Every finding on record at Maple Hills Skilled Nursing & Rehabilitation

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, review of a facility self reported incident form, and review of a facility job description, the facility failed to ensure staff implemented the assistance devices necessary to prevent accidents. This affected one resident (#35) of five sampled residents. The facility census was 34. Findings include:Review of the closed medical record for Resident #35 revealed an admission date of 05/22/26 and diagnoses including chronic obstructive pulmonary disease, diabetes, malignant neoplasm of the endometrium, and history of fracture of T11-T12 vertebrae. Review of the admission five day Minimum Data Set assessment revealed a brief interview for mental status score of 14, indicating intact cognition. It further documented the resident required supervision only with transfers and walking 10 feet. Review of a facility self reported incident form revealed on 06/01/26 Resident #35 was being transported to an appointment by Activities staff #23 in the facility van when a car pulled out in front of them. Activities staff #23 had to brake suddenly and Resident #35 came forward out of her wheelchair landing on her knees at approximately 8:45 A.M. The van was pulled over to the side of the road where Activities staff #23 opened the door to find the resident already attempting to get back into her wheelchair. Resident #35 stated she was fine, did not hit her head, and requested to continue on to her appointment so she got there on time. After the appointment, Resident #35 was returned to the facility and Activities staff #23 then reported the incident to nursing staff upon arrival (approximately 11:00 A.M.). The resident was assessed and determined to have abrased/bruised knees (right worse than left). X-rays were obtained and were negative for acute fractures. Upon questioning, Activities Staff #23 could not remember fastening the resident's seat belt upon leaving for the appointment. Interview with the Director of Nursing on 06/17/26 at 8:00 A.M. confirmed Resident #35 fell out of her wheelchair while being transported in the facility van to an appointment by Activities staff #23 on 06/01/26. She stated Activities staff #23 was also the Transportation Director. She confirmed Activities staff #23 did not notify nursing staff or 911 when the incident occurred on the van, and should have. She confirmed the resident should have been assessed for injury by medical personnel prior to getting up after falling out of the wheelchair. She confirmed the resident did not have a seatbelt on at the time of the incident and Activities staff #23 did not know if she had applied the required seat belt upon leaving the facility. Review of the undated job description for the position of transportation revealed the primary purpose of the position was to safely transport residents to medical appointments and recreational activities. The deficiency was corrected on 06/10/26 after the facility implemented the following corrective actions: On 06/01/26 Resident #35 was assessed for injuries by the Director of Nursing and Assistant Director of Nursing at 11:30 A.M. after returning to the facility from her appointment.On 06/01/26 X-rays of both knees and cervical, thoracic, and lumbosacral were completed for Resident #35 with no acute fractures noted. The physician was notified of the results on 06/01/26 with no new orders.On 06/01/26 all staff were trained on post fall interventions to include reporting immediately to nursing/calling 911 during transport and having resident assessed prior to moving resident off of the floor. Between 06/01/26 and 06/10/26, all staff who transport residents were re-trained on transportation safety by the Maintenance Director, including operation of security straps and safety/seatbelts with return demonstration. On 06/01/26 transportation staff was educated by the Director of Nursing to include clinical personnel to accompany on transports and at least two staff will document that the wheelchair is secured in the van and the resident is secured by seatbelt while being transported in the van. On 06/01/26 weekly audits of the van were started to ensure proper function, including seatbelts. This was being conducted by the Director of Maintenance. To be done weekly for four weeks then monthly for three months.On 06/02/26 a 30 day look back audit was completed by the Director of Nursing to identify any issues with previous transports. No other issues were identified besides Resident #35. On 06/02/26 the facility began audits of each transport by the facility to assess for proper seatbelt use by two staff prior to the resident being transported which was to continue for three months.On 06/03/26 weekly audits of all falls began by the Director of Nursing to determine if fall protocols were followed, including proper notification and timely assessment. To be done weekly for four weeks then monthly for three months.On 06/04/26 Activities staff/Transportation Director #23 was terminated from the facility. There were no identified accidents with resident transports between 06/02/26 and 06/17/26, the time of the onsite complaint investigation.This deficiency represents non-compliance investigated under Complaint Number 3032438.

Based on review of the facility's cycle menu, review of food temperature logs, staff interview, and policy review, the facility failed to ensure residents received food that was procured from their food service supply company and was prepared in the facility's kitchen to ensure proper food handling and preparation to safe guard it from possible food-borne illnesses. This affected eight (Resident #5, #6, #11, #20, #22, #24, #31, and #35) out of 36 residents who resided in the facility. Findings include: Review of the facility's cycle menu for Week #1 of the Spring and Summer Menu revealed the scheduled meal for lunch on 09/16/25 included chicken tortilla rice bowl as the main entree. They were also having seasoned black beans, corn, and a Mexican Wedding Cookie. The cycle menu did not include an alternate meal choice, other than what was on the facility's alternate/ always available menu. Review of a food temperature log for the meals served on 09/16/25 revealed the dietary staff obtained hot food temperatures of the food items served for the lunch meal. Temperatures were obtained for the main entree chicken tortilla rice bowl and for the black beans and creamed corn. Lasagna was included under the miscellaneous category despite it not being one of the food items on the cycle menu. There was no temperature recorded for the lasagna to show the dietary staff checked to ensure it was at the proper temperature before being served to residents. On 12/16/25 at 10:25 A.M., an interview with Certified Nursing Assistant (CNA) #121 revealed she used to work in the facility's kitchen, but was now working as a nursing assistant. She reported several months ago that she made lasagna in her home and brought it in to the residents to eat. She initially denied knowledge of any staff ever doing that and did not think that was something they were were able to do. It was not until she was directly asked, if she had cooked lasagna at home and brought in to the residents, that she admitted doing so. The residents had requested it as their special meal for the month and she could not tell them no. She stated she made a big old pan of it. She was told by the facility's previous Director of Nursing (DON) that she shouldn't do that, but did it anyway. On 12/16/25 at 10:56 A.M., an interview with RN #115 revealed there was one time that the residents asked for something special to be made for one of their meals. A staff member volunteered and brought in a lasagna that had been cooked at home for the residents. She confirmed CNA #121 was the staff member that brought the lasagna in and all residents that wanted it ate it. She was not sure what the facility's policy was on food brought in from outside sources. They allowed residents to do it (have food brought from home) and residents also had the right to order out for food from nearby restaurants, so she did not see what the difference was. On 12/16/25 at 12:34 P.M., an interview with Licensed Practical Nurse (LPN) #130 revealed there was one occasion a couple of months ago, when a staff member brought food in for the residents. It was a lasagna tray that had been cooked at home by CNA #121. She questioned if that was permitted to be done, but was told that someone there at the time had approved it. She had always been taught that no outside food could be brought in and shared with the residents. On 12/16/25 at 1:23 P.M., an interview with CNA #125 revealed she was aware of the special meal that was provided to the residents in the past couple of months or so. The residents picked what special meal they wanted each month. CNA #121 made two great big pans of lasagna at home and served it to the residents in the facility. She went into the kitchen and told the dietary staff they were not allowed to do that, but was told it had been approved. She then went to the Administrator, who told her that it had been approved and she was the one that approved it. The Administrator told her it was no different than the residents ordering out for food. She told the Administrator it was different, as those local restaurants the residents ordered food from were still inspected by the local health department and the aide's home where the lasagna was made was not inspected. On 12/16/25 at 3:08 P.M., an interview with Dietary Manager #108 revealed she had been the facility's Dietary Manager since March 2025. She was off the day a staff member cooked lasagna at home and brought into the facility for the residents. She did not find out about it until after it had already happened. She stated once she was aware, she put a stop to outside food being brought in, after that. It was not something the staff were able to do. Her dietary staff were not permitted to bring any outside food into the kitchen. The food they served had to come from the food service supply company the facility contracted with. She heard previous talk that an aide was talking about doing that, but nothing had been decided. She did an education with all her dietary staff during their next scheduled meeting that her rules and the State's rules were not to bring any outside food into the kitchen. She reported the residents had requested lasagna, as part of their special meal request during their Resident Council meeting. They usually prepared those special request meals in the facility's kitchen with the dietary staff preparing it. She informed the rest of the management team during the morning meeting that she had educated her dietary staff and that was not to happen again. She acknowledged the food temperature log for the lunch meal served on 09/16/25 did not show evidence that the dietary staff checked the temperature of the lasagna, after it had been prepared at a staff member's home, and before it was served to the residents. She acknowledged when food was obtained and prepared outside of the facility, they were not able to ensure food items used in the baking process was not expired and food was handled and prepared in a manner that protected the residents from any food-borne illnesses. Review of the facility's policy on Food Brought in from Outside Sources and Personal Food Storage obtained from a publication from [NAME] and Associates, Inc. Chapter 3: Food Production and Food Safety revealed it did not directly address food prepared and brought in by facility staff in their own home for resident consumption. The policy indicated food brought to the facility by family members or friends for a loved one or for a special event would be handled using safe food handling guidelines. Designated staff should monitor foods and beverages brought in from outside sources for storage in facility pantries, refrigeration units, or personal room refrigerator units. The procedure indicated families, volunteers, and others not employed by the facility would be educated on safe food handling and storage techniques by designated facility staff. Staff should examine food for quality (visual, smell, packaging) to identify potential concerns. The food and nutrition services department should ensure that once food was brought to the facility from an outside source that reheating and hot/ cold handling of leftovers was appropriate. This deficiency represents non-compliance investigated under Complaint Number 2692521.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a facility self-reported incident (SRI), and staff interview, the facility failed to ensure pre-operative laboratory testing was completed for a resident that was scheduled to have a surgical procedure performed to address kidney stones. This affected one (Resident #38) of two residents reviewed for pre-operative surgical procedures. Findings include: Review of Resident #38's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included acute pyelonephritis (a bacterial infection of the kidney), unspecified hydronephrosis (swelling of one or both kidneys due to the backup of urine often caused by a blockage in the urinary tract such as from kidney stones), and calculus of kidney (kidney stones). Review of Resident #38's progress notes revealed a nurse's note dated 10/03/25 at 10:27 A.M. by Licensed Practical Nurse (LPN) #113 that indicated the resident was complaining of lower abdominal discomfort. She had pallor (an unnatural lightness of the skin or mucous membranes often due to reduced blood flow or fewer red blood cells signaling conditions like anemia or shock) and her skin was clammy. The on-call physician was notified and a new order was received for the resident to be sent to the emergency room (ER) for an evaluation. A nurse's progress note dated 10/04/25 at 1:19 A.M. revealed the resident had been admitted to the hospital. She did not return to the facility until 10/15/25. Review of Resident #38's hospital records for her hospitalization between 10/03/25 and 10/15/25 revealed the resident was seen by urology while in the hospital for flank pain and taken to the operating room (OR) for further management. A cystocopy (a medical procedure where a thin, lighted scope was used to look inside the urethra and bladder to diagnose or treat urinary issues like pain, bleeding, or blockage) was performed in the OR on 10/08/25 with ureteral stent removal, ureteroscopy, laser lithotripsy, ureteroscopic renal evacuation, and stent replacement. She was diagnosed with left urolithiasis, staghorn calculus (kidney stone) and developed septic shock post procedure. The hospital progress note indicated urology would need the rest of the stone burden addressed and urology was holding off at that time. Review of Resident #38's After Visit Summary (AVS) for the hospital stay 10/03/25 through 10/15/25 revealed the resident had two appointments scheduled under the What's Next section on the AVS. On 10/28/25, she had a Cystolithotripsy with laser, ureteroscopy, steerable ureteral stone evacuation, and stent insertion scheduled. She also had another procedure with the urologist scheduled for 11/11/25 at 2:15 P.M. The latter did not specify what the procedure was planned on 11/11/25. Review of Resident #38's physician's orders revealed a telephone order had been received on 10/25/25 at 10:48 A.M. for a urinalysis (U/A) with a culture and sensitivity (C&S) to be collected for lab 10/27/25. The order indicated it must be done before surgery on 10/28/25. The resident's medical record was absent for any evidence of the U/A being completed as ordered and there was nothing documented in the resident's progress notes about her going out on 10/28/25 for her scheduled appointment. Further review of Resident #38's physician's orders revealed a telephone order had been received on 11/04/25 at 3:33 P.M. for a U/A and C&S being ordered for the following morning. The resident was indicated to have surgery on 11/11/25. Review of the U/A and C&S collected on 11/04/25 at 3:18 P.M. revealed the culture results were received on 11/07/25 (Friday) at 2:44 P.M. The culture results showed mixed pathology with greater than or equal to three organisms being isolated indicating probable contamination. There was instructions to contact the laboratory within 48 hours if identification was clinically indicated. Resident #38's medical record was absent for any evidence of the facility contacting the lab as instructed or to contact the urologist's office, who ordered the lab pre-operatively prior to her planned surgical procedure on 11/11/25, on 11/07/25 for further instructions. Review of a nurse's progress note by Registered Nurse (RN) #115 on 11/10/25 at 3:58 P.M. revealed the nurse made several calls to the urologist's office at the hospital where Resident #38 was supposed to have her procedure performed at to check on the schedule for surgery. She received a message earlier at 3:55 P.M. from the urologist's office that if they did not have the urine culture results within 30 minutes the resident was not going to be able to have her surgical procedure done on 11/11/25. Review of a nurse's progress note dated 11/11/25 at 1:35 P.M. indicated the previous U/A sample was contaminated and a new order was received for a U/A and C&S to be drawn on Wednesday 11/12/25. Resident #38 had been seen by her advanced level provider on 11/11/25 for hematuria (blood in urine) and dysuria (pain upon urination) That specimen was collected on 11/11/25 at 11:20 P.M. Review of a nurse's progress note dated 11/13/25 at 12:17 A.M. revealed Resident #38's nurse practitioner was made aware of blood being noted in the incontinent brief of the resident and indicated she would assess the resident while in the facility the next morning. The resident was seen at 10:32 A.M. and was transferred to the ER for an evaluation. Review of SRI #267413 with a discovery date of 11/11/25 revealed the SRI was being completed for an allegation of neglect. The involved resident was Resident #38 and the facility staff were indicated to be the alleged perpetrator. The initial source of the allegation was marked as being an unusual circumstance. A brief description of the allegation revealed a doctor's office was alleging neglect. The narrative summary of the incident revealed on 11/11/25, the DON was alerted by the nurse that they had received a call from the urology doctor's office for Resident #38 alleging neglect. The Administrator was notified and the investigation was initiated. Resident #38 was diagnosed with acute pyelonephritis, unspecified dementia, hydronephrosis, and tubulointerstitial nephritis. Upon interview, Resident #38 had not voiced any concerns related to her doctor's appointments. Review of her medical records and labs were completed and the labs were noted with contamination. The physician and urologist were made aware. A repeat draw was rescheduled. The lab (U/A) was obtained via straight catheterization and results were sent to the physician and the urologist for review prior to an upcoming appointment. Interview with staff revealed the lab results took longer to result, leading to rescheduling of the procedure. Upon obtaining the finalized U/A results, the urine had been contaminated resulting in the doctor's office requesting another draw before the rescheduled procedure. Interview with the doctor's office revealed they alleged neglect due to not receiving U/A results in the span of time that they thought that they should have. The doctor's office requested U/A be obtained day before the procedure. Upon interview with the lab, U/A results partially finalize within 24 hours and final results within 72 hours. As a result of the facility's investigation, they unsubstantiated the allegation, as the evidence did not show neglect occurred. Review of witness statements as part of the facility's investigation into the alleged neglect revealed statements were obtained from multiple nurses. A written statement from LPN #134 obtained 11/11/25 revealed when she came to work on the weekend of 10/25/25 and 10/26/25, it was passed on that an order had been found sitting on the fax machine Friday the 24th for a U/A to be collected for Resident #38. The urine had to be collected on Sunday the 26th, due to the lab coming at 12:00 A.M. Monday morning (27th) in order for it to be sent out in time for surgery. She had trouble getting the order into the lab server and after a couple of hours, she asked another nurse (LPN #130) for help. LPN #130 also had trouble, but was able to finally get the lab order in. Both of them forgot that they needed to print out a new list of all the labs needed for Monday, so when she reported to RN #124 that he needed to get a urine, he did not have a printed lab order. From her understanding, the lab refused to take the urine. Review of a witness statement from RN #124 revealed, on 11/09/25, he received report that Resident #38's surgery may have been moved to 11/11/25. On 11/10/25, he gave report that Resident #38's surgery may have been moved to 11/11/25, and he stated the lab had picked up Resident #38's urine specimen and that the appointment book had the resident's name written on the 11th (11/11/25) with no other information provided. Review of a written statement from the facility's Assistant Director of Nursing (ADON) revealed she phoned Resident #38's daughter in regards to the resident's surgery being canceled. She explained to the family that the facility was creating a time line of events to find out where the break down occurred. The family was informed that the facility had launched an investigation known as an SRI and what it was. It was explained to the family that the resident's urine was obtained, but came back contaminated and would be collected again. Review of a written statement from RN #115 (not dated) revealed on 11/10/25, the urologist's office called. A nurse tried to transfer the call to the first floor, but the call did not come. A return call was placed to the office of Resident #38's urologist on three separate occasions. A message was left at the second floor nurse's station that the urologist office would would call the Administrator and they wanted the results of the U/A C&S that had previously been ordered. She was told by a nurse in report that labs and U/A C&S results were sent to the urologist and they were good for Resident #38 to get her surgery. They received a call from the urologist office on 11/11/25 at 9:16 A.M. that the surgery had been canceled for that day, as they did not receive the results of the U/A C&S. On 12/16/25 at 10:56 A.M., an interview with RN #115 revealed she was familiar with Resident #38 and took care of her while she was in the facility. She described the resident as being a sick lady and had procedures done before she came to the facility. They had more procedures they wanted to do after she came to the facility. The resident had a scheduled procedure for her kidney stones. The facility had problems with the lab companies they used. They used four different ones in the past couple of months. The hospital did not accept what they had sent and they had to repeat the U/A. She was not sure why it had not been accepted and did not report any knowledge of the prior sample being contaminated. On 12/18/25 between 2:14 P.M. and 3:24 P.M., email correspondence with the facility's Director of Nursing verified concerns with Resident #38's pre-operative testing before her planned cystoscopies were not completed as ordered. She acknowledged there was no documented evidence in the resident's electronic medical record (EMR) that a U/A and C&S had been obtained as ordered prior to her scheduled cystoscopy on 10/28/25. She indicated that she had not had a copy of the AVS for the resident's hospital stay between 10/03/25 and 10/15/25 until 12/18/25, when it was requested for review. She acknowledged the order for the U/A and C&S was given via a telephone order on 10/25/25 and was supposed to be completed on 10/27/25, prior to the resident's scheduled procedure on 10/28/25. She confirmed there was an issue with the lab company the facility used not taking the urine sample, after it had been collected, due to there not being a lab order for a U/A on the updated lab requisition sheet. She confirmed the nurses entering that lab order did not print off the most recent lab slip that would have included all the labs that were to be done that morning, including the U/A and C&S. She acknowledged by not completing the U/A and C&S as ordered, Resident #38's scheduled procedure had to be rescheduled on 11/11/25. She further acknowledged there was no evidence of the urologist's office being notified on 11/07/25 (Friday) at 2:22 P.M., when the results of the U/A that had been collected on 11/04/25 at 3:18 P.M. came back as being probable contamination in the final report. It was not until 11/10/25 at 3:58 P.M. that the facility's nurses reached out to the urologist's office to check on the status of her scheduled surgery planned for 11/11/25. They were informed that the surgical procedure would not be performed unless they were able to provide the U/A C&S results in the next 30 minutes. She acknowledged if the facility's staff would have reached out to the urologist's office on 11/07/25, when it was known the prior U/A had been contaminated, they could have got a new order to repeat the U/A and C&S that evening and possibly could have had the final U/A and C&S report back on 11/10/25 preventing the scheduled procedure from being cancelled a second time. The deficient practice was corrected on 11/17/25 when the facility implemented the following corrective actions: Whole House Audit of all lab orders to ensure that they were completed as ordered and the results were reported to the physicians. DON/ Designee assessed the affected residents for adverse effects related to delayed lab draws. IDT met and discussed alternate measures for lab draws in the event the lab company did not come to the facility for the lab draw. All nurses were educated by 11/17/25 on their responsibility of entering, ensuring labs were obtained, and following up on lab results as ordered. DON/ Designee will audit orders/ lab draws daily in the clinical meeting. DON/ Designee will audit all labs three times a week for four weeks to ensure ongoing compliance. Medical Director was notified through Ad hoc QAPI process. Results of the daily/ weekly audits would be taken to the monthly QAA meeting and reviewed by the IDT for ongoing compliance. This deficiency represents non-compliance investigated under Complaint Number 2692521.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure fall interventions were in place per the plan of care and failed to ensure a fire blanket was available in the designated smoking area. This affected one resident (#8) out of the two residents reviewed for falls and had the potential to affect the seven residents (#1, #4, #8, #13, #17, #18, and #29) identified by the facility as smoking in the designated smoking area. The facility census was 32. Findings include: 1. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included dementia, COPD, and tobacco use. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/13/25, revealed the resident was assessed to have impaired cognition. Review of the care plan, dated 06/20/25, revealed the resident was at risk for falls. Interventions included a Call Do Not Fall Sign. Review of the nurses progress note, dated 05/06/25, revealed Resident #8 came to the nurses station and stated she fell in her room. The resident stated she fell putting her shoes on, then stated she fell back in the bed, then stated she fell on the floor in front of her bed rushing to go smoke. The root cause of the fall was determined to be the resident was in a rush to smoke and the intervention was to place a Call Don't Fall sign on the wall. Observation on 06/25/25 at 9:16 A.M. revealed there was not a Call Don't Fall sign present in Resident #8's room. Interview with Licensed Practical Nurse (LPN) #350 at the time of the observation confirmed there had been a Call Don't Fall sign on the residents wall by the mirror but it was no longer there. LPN #350 confirmed she would replace the sign immediately. 2. Observation on 06/24/25 at 9:19 A.M. revealed residents were outside in the designated smoking area smoking cigarettes. No fire blanket was present in the designated smoking area. Interview with Housekeeping Aide #190 and Housekeeping Aide #230 on 06/24/25 confirmed residents utilized the designated smoking area while smoking cigarettes. They confirmed there was not a fire blanket present in the designated smoking area. Observation on 06/24/25 at 1:24 P.M. revealed residents were outside in the designated smoking area smoking cigarettes. No fire blanket was present in the designated smoking area. Interview with Certified Nursing Assistant (CNA) #150 at the time of the observation confirmed there was not a fire blanket present in the designated smoking area. CNA #150 stated she would use clothing, her hand, or a smoking apron to extinguish flames if a resident were to catch on fire while smoking. Interview with Maintenance Director #490 on 06/25/25 at 10:30 A.M. confirmed he had ordered a fire blanket on 06/24/25 and had placed it in the designated smoking area on 06/25/25. Review of the facility policy titled Smoking Policy, revised 01/2025, revealed residents are to smoke in outside designated smoking areas if determined to be a safe smoker as assessed.

Based on observation, interviews and completion of a facility provided meal test tray the facility failed to provide palatable meals at the appropriate temperature. This affected all thirty-one residents who receive their meals from the kitchen with the exception of one resident (#20), who does not receive them. The facility census was 32. Findings include: Review of resident concern logs and resident council minutes on 06/24/25 revealed multiple entries of food temperature complaints. Test tray completed on 06/25/25 at 01:05 P.M. and included one beef enchilada, black beans, Mexican corn, and fruit punch. All food items were cool to taste with varying temperatures including corn temperature of 109 degrees Fahrenheit and black bean temperature of 108 degrees Fahrenheit. Both items cool to taste. Interview with Dietary Manager #699 on 06/25/25 at 1:10 P.M. verified both items did not have an appropriate temperature after being the last meal tray served. Interview with Resident #29 on 06/25/25 at 1:40 P.M. revealed her meals are served cool sometimes once she is served her meal tray in her room. Interview with Resident #185 on 06/25/25 at 1:45 P.M. revealed her food is served cold sometimes. This deficiency represents noncompliance for Complaint Number OH00166168.

Based on observation and interviews the facility failed to maintain all kitchen equipment in a clean, serviceable, and operational manner. This affected all residents who received meals from the kitchen with the exception of one resident (#20) who did not receive them. The facility census was 32. Findings include: Observation of the kitchen on 06/23/25 at 09:13 A.M. revealed the lift up door for the ice machine was broken and falling off when gently lifted. The overhead stove hood was visibly soiled with heavy layer of dust and multiple cobwebs hanging over the cooking area. The gas stove range was also visibly soiled with heavy dry burnt on foods from accidental spills. Interview with Dietary Manager #699 on 06/23/25 09:35 AM. verified she did not know how to remove the hood vents to clean them, and that someone was supposed to show her the process before he left but never did. Also stated the ice machine has been broken for as long as she has worked here. She also verified the stove top was visibly soiled and that there were multiple substances that had been burned onto it.

Based on interviews, record review, and facility policy, the facility failed to ensure dialysis communication forms were utilized to ensure communication between the facility and the dialysis center. This affected one resident (#16) of one resident reviewed for dialysis. Facility census was 32. Review of Resident #16's medical record revealed an admission date of 07/23/24. Medical diagnoses included osteomyelitis, diabetes mellitus type 2, severe calorie malnutrition, alcoholic cirrhosis of liver without ascites, end stage renal disease, anxiety, anemia, dependence on dialysis, right below the knee amputation, thrombocytopenia, and atrial fibrillation. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact, dependent for toilet and tub/shower transfers, and required assistance for mobility and was wheelchair dependent. Review of Resident #16's care plan dated 06/06/25 revealed Resident #16 will experience no complications related to dialysis through review date. Interventions included checking for new orders upon return from dialysis and coordinating care with dialysis center. Review of Resident #16's physician orders for 05/14/25 revealed dialysis days on Monday, Wednesday, Friday, pick up time 05:00 A.M. with return time 12:30 P.M. Review of Resident #16's physical chart for April 2025, May 2025, and June 2025 revealed missing Dialysis Communication Forms for 04/02/25, 04/23/25, 05/12/25, 05/14/25, 05/16/25, 05/28/25, 06/04/25, 06/06/25, 06/13/25, and 06/18/25. Interview with staff nurse #350 on 06/25/26 at 12:05 P.M. confirmed some communication forms are missing from Resident #16's chart and sometimes dialysis does not send forms back with resident post dialysis appointment. Staff Nurse #350 stated that dialysis center will call facility if there are any changes. Interview with Director of Nursing (DON) on 06/25/25 at 04:08 P.M. confirmed all forms for each dialysis encounter should be in resident's chart and if they are not staff should call dialysis center for communication. Facility policy titled Dialysis care dated 08/21 (reviewed 08/24) stated It is the policy of this facility to ensure residents that receive dialysis treatment are safe, well assessed, and that the facility collaborates care with the dialysis center. Policy further stated Upon return from dialysis, the nurse will review the communication form sent to dialysis center. If the dialysis center fails/refuses to provide communication, document on the form.

Based on observations, staff interviews, resident record reviews, and review of facility policy, the facility failed to ensure residents dignity was maintained while providing assistance with consuming meals. This affected one resident (#19) observed during dining experiences. The facility census was 32. Findings include: Record review for Resident #19 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, dementia, and dysphagia. Review of the annual Minimum Data Set (MDS) assessment, dated 04/04/25, revealed the resident was assessed to have severely impaired cognition. Observation on 06/25/25 at 9:10 A.M. revealed Resident #19 was lying in bed asleep with the lights off. Certified Nursing Assistant (CNA) #160 entered the residents room, turned on the lights, and asked Resident #19 if she was hungry. CNA #160 then set up the residents breakfast meal tray and began feeding the resident the meal while standing over her. Interview with CNA #160 at the time of the observation confirmed Resident #160 had to be assisted by staff to consume meals. Observation on 06/25/25 at 1:26 P.M. revealed CNA #160 entered the room of Resident #19 and began assisting the resident to consume the lunch meal. The residents bed was lowered to the floor and CNA #160 was standing, bent over at the waist, feeding the resident. Interview with the Director of Nursing (DON) on 06/25/25 at 4:00 P.M. confirmed staff should not be standing over residents while assisting them to eat. Review of the facility policy titled Dignity, reviewed most recently on 04/28/25, revealed the facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and promoting resident independence and dignity in dining.

Based on record reviews and interviews, the facility failed to ensure a baseline care plan was implemented for a resident with a tracheostomy or requiring respiratory care. This affected one resident (Resident #186) out of twelve residents reviewed for baseline care plans. The facility census was 32. Findings include: 1. Record review for Resident #186 revealed the resident was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of the supraglottis, tracheostomy, bipolar disorder, anxiety, muscle weakness, abnormalities of gait and movement, dysphagia, acute embolism and thrombosis, dyspnea, obesity, and diseases of the larynx. Review of the admission Minimum Data Set (MDS) assessment, dated 06/10/25, revealed this resident was assessed to have intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 out of 15. Review of physician orders revealed this resident had a tracheostomy upon admission to the facility with orders for daily care including: wear stoma vent at all times, may clean with warm water or may use one-half strength Hydrogen peroxide to loosen crusted blood or secretions from stoma vent, suction and clean stoma as needed to clear secretions that resident cant cough up, monitor stoma for any signs and symptoms of infection every shift, and cover neck wound with Xeroform daily, may wrap with gauze if needed to keep in place. Interview with the Director of Nursing on 06/25/25 at 02:00 P.M. verified a baseline care plan was not in place for respiratory or tracheostomy care for this resident. She stated a care plan was created on 06/25/25 during the annual survey.

Based on observations, staff interviews, and record reviews, the facility failed to ensure comprehensive care plans were accurately completed for residents who smoked. This affected two residents (#4 and #8) reviewed for smoking. The facility identified seven residents (#1, #4, #8, #13, #17, #18, #29) who resided in the facility and smoked. The facility census was 32. Findings include: 1. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hemiplegia and hemiparalysis, dementia, and Chronic Obstructive Pulmonary Disorder (COPD). Review of the annual Minimum Data Set (MDS) assessment, dated 04/16/25, revealed the resident was assessed to have intact cognition. Review of the facility Smoking and Safety assessment, dated 01/14/25, revealed the resident was not assessed to require the use of a smoking apron while smoking. Review of the care plan, dated 06/19/25, revealed the resident was at risk for injury related to smoking. Interventions included a smoking apron was to be worn when smoking. Observation on 06/24/25 at 1:24 P.M. revealed Resident #4 was in the designated smoking area smoking a cigarette. The resident was not wearing a smoking apron. Interviews with Resident #4 and Certified Nursing Assistant (CNA) #150 at the time of the observation confirmed Resident #4 did not wear a smoking apron while smoking. Interview with the Director of Nursing (DON) on 06/25/25 at 4:00 P.M. confirmed Resident #4 had been assessed to not require a smoking apron to be worn while smoking. The DON confirmed the care plan for the resident was not accurately completed. 2. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included dementia, COPD, and tobacco use. Review of the quarterly MDS assessment, dated 05/13/25, revealed the resident was assessed to have impaired cognition. Review of the facility Smoking and Safety assessment, dated 05/13/25, revealed the resident was not assessed to require the use of a smoking apron while smoking. Review of the care plan, dated 06/20/25, revealed the resident was at risk for injury related to smoking. Interventions included smoking apron to be worn while smoking. Observation on 06/24/25 at 9:22 A.M. revealed Resident #8 was in the designated smoking area smoking a cigarette. The resident was not wearing a smoking apron. Interviews with Housekeeping Aide #190 and Housekeeping Aide #230 at the time of the observation confirmed Resident #8 did not wear a smoking apron while smoking. Interview with the Director of Nursing (DON) on 06/25/25 at 4:00 P.M. confirmed Resident #8 had been assessed to not require a smoking apron to be worn while smoking. The DON confirmed the care plan for the resident was not accurately completed. .

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure residents who were dependent on staff for nail care and meal assistance received care in a timely and appropriate manner. This affected two residents (#2 and #19) out of the three residents reviewed for Activities of Daily Living (ADLs). The facility census was 32. Findings include: 1. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hemiplegia and hemiparalysis affecting the left side, dementia, and chronic pain. Review of the quarterly Minimum Data set (MDS) assessment, dated 05/07/25, revealed the resident was assessed to have impaired cognition. Review of the care plan, dated 06/10/25, revealed the resident was at risk/had an ADL self-performance deficit. Interventions included the resident was dependent for personal hygiene. Observation of Resident #2 on 06/23/25 at 1:25 P.M. revealed the resident was lying in bed. The residents fingernails were long and had light brown colored debris caked underneath them. Observation of Resident #2 on 06/25/25 at 8:40 A.M. revealed the resident was lying in bed. The residents fingernails continued to be long with light brown colored debris caked underneath them. Interview with Resident #2 at the time of the observation confirmed the resident wanted his nails to be trimmed and cleaned. Observation of Resident #2 on 06/25/25 at 3:18 P.M. revealed the resident was lying in bed. The residents nails continued to be long with light brown colored debris caked underneath them. Interview with Licensed Practical Nurse (LPN) #350 at the time of the observation confirmed Resident #2's fingernails were long and dirty and needed to be trimmed and cleaned. LPN #350 confirmed nail care was to be completed on residents shower days and as needed in between. Review of the facility policy titled Dignity, most recently reviewed on 04/28/25, revealed residents would be groomed as they wished including nails being clean and clipped. 2. Record review for Resident #19 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, dementia, and dysphagia. Review of the annual Minimum Data Set (MDS) assessment, dated 04/04/25, revealed the resident was assessed to have severely impaired cognition. Review of the care plan, most recently revised on 06/23/25, revealed the resident was at risk for malnourishment/alteration in nutritional status. Interventions included to assist with meals as needed. Observation on 06/25/25 at 8:50 A.M. revealed Resident #19 was lying in bed asleep with the lights off. The residents breakfast meal tray was lying on the tray table several feet away from the residents bed and had not been set up. No staff were present in the residents room. Observation on 06/25/25 at 8:55 A.M. revealed Resident #19 continued to be asleep in bed with the breakfast meal tray lying on the tray table several feet away from the residents bed with the lights off. The meal tray continued to not be set up or offered to the resident. Observation on 6/25/25 at 9:07 A.M. revealed Resident #19 continued to be asleep in bed with the breakfast meal tray lying on the table several feet away from the residents bed with the lights off. The meal tray continued to not be set up or offered to the resident. Observation on 06/25/25 at 9:10 A.M. revealed Resident #19 continued to be asleep in bed with the breakfast meal tray lying on the table several feet away from the residents bed with the lights off. The meal tray had still not been set up. Interview with Certified Nursing Assistant (CNA) #160 at the time of the observation confirmed the breakfast meal tray had been placed in the residents room earlier and had not been set up or offered to the resident. CNA #160 confirmed the resident had to be assisted to consume meals. CNA #160 then entered the residents room, turned on the lights, and asked Resident #19 if she was hungry. CNA #160 then set up the residents breakfast meal tray and began feeding the resident the meal while standing over her. Observation on 06/25/25 at 12:41 P.M. revealed CNA #160 entered Resident #19's room carrying the residents lunch meal tray. CNA #160 set the lunch meal tray down on the residents tray table and exited the room. Observation on 06/25/25 at 12:46 P.M. revealed Resident #19 was sitting up in bed asleep. The residents meal tray was sitting on the tray table in front of her and the food had not been set up or offered to the resident. Observation on 06/25/25 at 12:57 P.M. revealed Resident #19 continued to be asleep in her bed with the lunch meal placed in front of her on the tray table. The food still had not been set up or offered to the resident. Observation on 06/25/25 at 1:00 P.M. revealed CNA #160 entered the room of Resident #19 and opened the residents food containers. CNA #160 assisted the resident to consume some of the lunch meal tray then exited the room. Observation on 06/25/25 at 1:26 P.M. revealed CNA #160 again entered the room of Resident #19 and began assisting her to consume more of the lunch meal tray. CNA #160 again exited the room Observation on 06/25/25 at 1:33 P.M. revealed CNA #160 again entered the room of Resident #19 and began assisting the resident to consume more the lunch meal tray. CNA #160 finished assisting the resident, moved the tray table containing the lunch meal away from the resident, then exited the room. Interview with Licensed Practical Nurse (LPN) #350 on 06/25/25 at 1:45 P.M. confirmed Resident #19 had experienced a decline in condition and was dependent on staff to assist her with consuming meals. Review of the facility policy titled Dignity, most recently reviewed on 04/28/25, revealed residents independence and dignity in dining was to be promoted.

Based on observation, review of an invoice from an outside plumbing company, review of maintenance temperature logs, and staff interview, the facility failed to ensure hot water temperatures were maintained between 105 degrees Fahrenheit (F.) and 120 degrees F. as required and did not pose a potential burn risk for the residents. This had the potential to affect seven residents (#2, #7, #10, #18, #20, #21, and #26), who the facility identified as having the use of the first floor shower room and five residents (#8, #9, #22, #25, and #28), who the facility identified as having the ability to utilize the sinks in their rooms on the second floor, without staff assistance. Findings include: On 04/17/25 at 9:20 A.M., an observation of the facility's boiler room located in the basement revealed there were three hot water tanks for providing hot water throughout the facility. Two of the three hot water tanks were of the same size and were a standard electric water heater. The third hot water tank was larger in size and was a hybrid energy efficient hot water tank with a display screen on the top of it that indicated what the temperature of the hot water was inside the tank and what operating set up temperature was. The tank temperature was indicated to be 125 degrees F. on the display screen and the operating set up temperature was also 125 degrees F. On 04/17/25 at 9:44 A.M., hot water temperature readings were obtained from various areas of the facility, as there had been concerns about the facility's hot water being too cold for residents during their showers. Temperatures of the hot water was checked on both the first floor and the second floor. The temperatures were obtained from the resident rooms on both ends of the hall and from the shower rooms on each floor that were centrally located on each hall. The first floor was noted to have hot water temperatures that exceeded 120 degrees F. in room [ROOM NUMBER] and room [ROOM NUMBER]. room [ROOM NUMBER] was noted to have a hot water temperature from the sink in the residents' room at 133 degrees F. room [ROOM NUMBER] was noted to have hot water from the sink at 129.7 degrees F. The shower room on the first floor located in the middle of the hall was noted to have a hot water temperature from the sink at 136.2 degrees F. On 04/17/25 at 10:04 A.M., hot water readings were obtained from the second floor, again testing rooms on each end of the hall and in the centrally located shower room. The hot water temperature in room [ROOM NUMBER] was noted to be 126.3 degrees F. and room [ROOM NUMBER] was 129 degrees F. The shower room on the second floor had a hot water temperature reading of 114.8 degrees F, which fell within the required temperature ranges for hot water. Findings were verified by Maintenance Director #100 at the time of the observations. Review of a work invoice from an outside plumbing company dated 03/25/25 revealed the plumbing company had been out to the facility on that date at the request of the facility to check a water heater circulation pump. It was reported at the time that the facility was not getting any hot water to their shower room. The circulation pump and mixing valve were checked and the technician asked about showers and a mop sink. It was discovered that the mop sink had recently been installed the day prior and the faucet to the mop sink was letting water mix. The technician turned off the water to the mop sink and hot water was restored to the showers. The customer was instructed to only turn the water back on to the faucet for the mop sink only when using. Review of the facility's maintenance temperature logs for the past three months revealed the last recorded temperatures for hot water checks was for 04/08/25. There was no evidence any hot water was being checked between 04/09/25 and 04/17/25. On 04/17/25 at 10:14 A.M., an interview with Maintenance Director #100 revealed he had only worked at the facility for four days now. He was still trying to learn about the facility and it's operations. He indicated he would have to determine which of the three hot water tanks were controlling what part of the building so he could adjust the hot water temperatures accordingly. On 04/17/25 at 12:30 P.M., a follow up interview with Maintenance Director #100 revealed all three hot water tanks fed into the same water line. He found a mixing valve that was off those lines that he was able to adjust to bring the hot water temperatures down to where they were required to be. The mixing valve adjusted how much cold water was being added to the heated water from the hot water tanks to reach the appropriate temperature levels of the hot water before it reached the rest of the building. He indicated he would have to do some additional monitoring to ensure the hot water temperatures remained in acceptable ranges. He stated it could take up to 24 hours for the temperature to be maintained at a consistent level, after adjustments had been made. He confirmed he had not checked the hot water temperatures as part of his maintenance log monitoring since he started four days ago. It was his understanding that they needed to be checked twice weekly, which had not been done to that point of time. On 04/17/25 at 2:04 P.M., an interview with Certified Nursing Assistant (CNA) #150 revealed she did not have any concerns with the facility's water temperatures. If it was too hot, she cooled it down by adding more cold water. She had not heard any residents complain that their water during showers was too cold. She has noted the hot water to be too hot at times. She stated when that happened she just adjusted it by turning the cold water on more. She acknowledged residents with cognitive impairment or decreased sensory perception may not be able to do that and were at risk for burns. On 04/17/25 at 2:19 P.M., an interview with CNA #200 revealed she had not known the hot water in the facility to be too hot. If it got hot, but not hot hot, she would leave the water run for a couple of minutes then adjust it from there to the desired temperature. She denied any of the residents took their showers on just straight hot water. She indicated, if only the hot water was turned on, it would be too hot for them to take a shower. She acknowledged the hot water should not exceed 120 degrees F. and confirmed, if the water was all the way on hot, it would be hotter than that. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00164664.

Based on record review, review of the administrator's job description, observations, review of the facility vendor and supplier bills, and interviews, the facility failed to ensure the facility was administered in a manner that enabled it to use it's resources effectively and efficiently including compliance with all financial obligations for the delivery of care to attain and maintain the highest practicable well being of each resident. This affected 33 of 33 residents residing in the facility. Findings included: 1. Review of information received from an anonymous complainant on 03/18/25 revealed the facility owed over $10,000 for their water bill, but due to it being a nursing facility the water department was either unable to or refused to issue a shut off notice. a .)Review of an invoice dated 04/06/24 from Stockmeister (plumbing, heating, and cooling repair company) revealed the facility owed $110 at the time of receipt for a service call related to the garbage disposal not working. Review of an invoice dated 04/24/24 from Stockmeister revealed the facility owed $2,427.63 for miscellaneous services at the time of receipt. Services included materials, tools, and labor to replace approximately 20 feet and one inch of galvanized pipe which was leaking in the basement ceiling above the water heaters with one inch copper pipe and press fittings. Review of an invoice dated 04/25/24 from Stockmeister revealed the facility owed $706.25 for the water heater tripping the breakers and not functioning correctly. The payment was due at the time of receipt. Review of an invoice dated 12/30/24 from Stockmeister revealed the facility owed $241.25 for the dishwasher drain being clogged. The payment was due at the time of receipt. Review of an invoice dated 12/30/24 from Stockmeister revealed the facility owed $190 due to the hot water tank having a low gas pressure warning being repaired. The payment was due at the time of receipt. Review of an invoice dated 12/30/24 from Stockmeister revealed the facility owed $918.76 for repairs to a floor drain backing up in basement. The payment was due at the time of receipt. Review of an invoice dated 12/30/24 from Stockmeister revealed the facility owed $660.43 for repairs to a heater in room [ROOM NUMBER]. The payment was due at the time of receipt. Review of an invoice dated 12/30/24 from Stockmeister revealed the facility owed $477.50 for repairs to water in the basement and the kitchen drain which was not draining properly. Payment was due at the time of receipt. Review of an invoice dated 01/20/25 from Stockmeister revealed the facility owed $1,941.11 for repairs to a circulating pump for the water heater. The payment was due at the time of receipt. Review of an invoice dated 02/12/25 from Stockmeister revealed the facility owed $351.50 for repairs to heating unit and starting the boiler. Payment was due at the time of receipt. Review of an invoice dated 02/13/25 from Stockmeister revealed the facility owed $458.50 for repairs to a toilet in room [ROOM NUMBER]. Payment was due at the time of receipt. Review of an invoice dated 02/13/25 from Stockmeister revealed the facility owed $2,586.85 for repairs to a water leak on the main line in the basement. Payment was due at the time of receipt. Review of an invoice dated 02/13/25 from Stockmeister revealed the facility owed $1,061.48 for repairs for sewage backing up into drains in the basement. Payment was due at the time of receipt. Review of an invoice from 02/13/25 from Stockmeister revealed the facility owed $320.60 due to replacing a one-inch valve in basement. Payment was due at the time of receipt. Review of an invoice from 02/13/25 from Stockmeister revealed the facility owed $1,160.50 for a gas leak on 02/08/25. The carbon monoxide detectors were going off. The gas company checked for leaks, there were none. The gas company red-tagged the boiler and said the boiler was the issue and it was unsafe to run. Everything was turned back on and the pilot lights were re-lit. Everything was working properly at the time of services. Payment was due upon receipt. The total of the invoices came to $13,612.36. Interview on 03/20/25 at 12:32 P.M. with Stockmeister Representative (SR) #722 revealed the facility had several open invoices which were not paid. SR #722 stated payment is due at the time of receipt or within 30 days. SR #722 stated the facility is often behind on payments, but due to it being a nursing facility, they will not refuse services. b.) Interview on 03/20/25 at 9:11 A.M. with Water Department Representative (WDR) #717 revealed the facility owed $10,848.92 for their water bill which was over due. The WDR #717 stated the last payment made was $1,608.89 in December 2024. The WDR #717 stated the water department bills monthly. The WDR #717 stated the facility had been in arrears for a while because they pay a little bit at a time. The WDR #717 stated the facility was in arrears since 04/2024 and the amount continually goes up. The WDR #717 stated the facility used 460,000 gallons of water in 03/2025 which was a lot of water totaling to approximately $5,000 worth of water in one month. The WDR #717 stated she has called and left messages for someone at the facility and has received no call back. The WDR #717 stated they are not allowed to turn off the water because it is a nursing facility. c.) Interview on 03/20/25 at 12:24 P.M. with Fire Chief (FC) #713 revealed the fire department had to respond to the facility twice in 02/2025: once for a potential gas leak which ended up being due to the boiler and once due to the sprinkler system being down due to the boiler not working. FC #713 stated when they responded to the first incident on 02/08/25, the facility was unable to find a report regarding the boiler because it needed services but there was a deficiency with the bill. There was a tag dated 08/12/24 which stated boiler needs serviced. The assumption was the person who services the boiler left the tag there without telling anyone due to nonpayment. Interview on 03/20/25 at 1:37 P.M. with Licensed Practical Nurse (LPN) #380 revealed she was made aware the boiler has been tagged out for nonpayment and it would not be repaired until the company received payment. On 03/20/25 at 3:21 P.M., observation and interview with Maintenance Staff (MS) #338 revealed the boiler is still out of service. Interview on 03/27/25 at 8:47 A.M. with Director of Nursing (DON) revealed she was not able to confirm or deny anything related to billing because she does not take care of billing. The DON stated she would let the surveyor know who to talk to regarding bills, but the DON did not ever provide a contact person to the surveyor. Review of an undated document titled Job Description for Administrator revealed it is the responsibility of the Administrator to ensure the building and grounds are maintained in good repair, ensure the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring necessary equipment and supplies are maintained to perform such duties and services, and ensure adequate supplies and equipment are on hand to meet the day-to-day operational needs of the facility and residents. Additionally, the administrator should assist in the establishment and maintenance of an adequate accounting system that reflects the operating cost of the facility, review and interpret monthly financial statements, keep abreast of the economic condition and situation and make adjustments as necessary to assure the continued ability to provide quality care. This deficiency represents non-compliance investigated under Complaint Number OH00163810. This deficiency is evidence of continued non-compliance from the survey dated 02/19/25.

Based on observation, policy review, and interview, the facility failed to ensure the facility provided a safe, sanitary and comfortable environment for residents. This affected 33 of 33 residents residing in the facility. Findings included: Continuous observations on 03/20/25 from 8:39 A.M. to 8:49 A.M. revealed trash throughout the yard, parking lot and woods surrounding the facility. Trash including plastic grocery bags, cigarette butts, and Styrofoam food containers. There was an empty flower pot with three inches of standing water and a Styrofoam container in it with a black mold-like substance. There was a sidewalk next to the building leading to the back where the resident smoking area is. At the back corner of the building, there was a hole which appeared to be created from a water drip. The drop off into the hole was approximately three feet and the hole was starting to go underneath the sidewalk. There was no hand rail for the residents to use. Interview on 03/20/25 at 1:37 P.M. with Licensed Practical Nurse (LPN) #380 revealed she had concerns about a section of the ceiling in the laundry room in the basement falling in, the handrail off the back porch was loose and you cannot put weight on it, there was a crack in the concrete out front, a large hole near the sidewalk at the back corner of the building from a water drip and the sidewalk goes over it a little bit. LPN #380 stated some residents' wheelchairs are right at the edge of the sidewalk near the hole. LPN #380 stated there is a slab of concrete which raises up on the sidewalk when the ground expands due to cold weather. LPN #380 stated there is a large area of mold in the laundry room and there had been mold behind the nurses station but they just put new trim right over top of it. Interview and observations on 03/20/25 at 2:09 P.M. with Certified Nursing Assistant (CNA) #304 revealed she was concerned about an area in the laundry room by the dryers due to mold and the ceiling, filters not being cleaned in units causing them to stop working, the grab bars in the upstairs shower room were loose, the drain was broken, the shower was dirty and covered with mildew. A facility tour completed with Maintenance Staff (MS) #338 on 03/20/25 starting at 3:21 P.M. revealed the laundry room had a six-foot long span of wall which was covered with a black mold-like substance, an area on the ceiling approximately four feet by four feet was collapsing in; the boiler room was observed and the boiler was out of service; the first floor shower room was observed with a sharps container overflowing with razors, there were three missing tiles on the shower floor as well as a broken drain; the shower had a build up of grime and mildew on the walls and floors in the grout; the second floor shower room had loose grab bars around the toilet, a missing drain, mildew streaks on the shower walls and floors; room [ROOM NUMBER] had a missing transition strip; a call light in room [ROOM NUMBER] (which was empty) was not working; the back porch, used only by staff, was unstable and wobbling; there was trash throughout the property including plastic bags, Styrofoam containers, and cigarette butts; a large hole next to the sidewalk from a water drip starting to corrode under the sidewalk. MS #338 confirmed all findings and stated he has made multiple efforts to make repairs in the facility but has not been provided with payment for tools and supplies required for improvements. Interview on 03/27/25 at 9:09 A.M. with LPN #380 revealed corporate staff came to the facility and attempted to improve the second floor nurses' station by adding a wooden trim. The trim was observed to have splinters at the far right side, the screws were sharp, and the left corner piece had fallen off leaving a sharp edge. LPN #380 also showed concern over a door handle which falls off when you grab it, leading into a room [ROOM NUMBER]. Interview on 03/27/25 at 10:15 A.M. with Corporate Nurse #101 regarding the trim revealed she felt the trim, but when asked if she had any concerns, she walked away without answering. Interview on 03/27/25 at 10:39 A.M. with MS #338 revealed he had concerns with the trim that was applied to the nurses' station because the edges were sharp and a piece had already fallen off. MS #338 stated he has a cut from the trim and showed a cut on her right, middle knuckle. MS #338 stated he was sent upstairs and instructed to remove the trim. Review of an undated policy titled Quality of Life- Homelike Environment revealed residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to extent possible. This deficiency represents non-compliance investigated under Complaint Number OH00163080. This deficiency is evidence of continued non compliance from the survey dated 02/19/25.

Based on observation, record review, staff interviews, resident interviews, Ombudsman electronic communication, and policy review, the facility failed to provide sufficient staff to meet residents' needs. This affected three residents (#24, #28, and #30) of three residents reviewed for personal care needs and had the potential to affect all 33 of 33 residents in the facility. Findings include: 1. Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including unspecified dementia and hypertension. Review of a nursing note dated 03/13/25 at 4:32 P.M. by Director of Nursing (DON) revealed she was made aware Resident #30 was outside, when she went outside to check, the first floor nurse was with Resident #30. Resident #30 had wandered out the side door with construction workers because she wanted to take a walk. Resident #30 was immediately assessed and had no injuries, she was taken back into the facility, and her wander-guard was checked and working properly. All wander-guards were checked and working properly. The elopement assessment was updated. Review of an Elopement Evaluation dated 03/14/25 at 12:41 P.M. by the DON revealed Resident #30 did not have a history of eloping while at home, she did have a behavior pattern of wandering, she wanders aimlessly, and wandering behavior was likely to affect the safety of herself/others. Resident #30's wandering was likely to affect the privacy of others and she was a recent admission. She had an elopement score of seven. Interview on 03/20/25 at 2:09 P.M. with Certified Nursing Assistant (CNA) #304 revealed she was concerned because Resident #30 eloped in the previous week and the DON lied to her husband. CNA #304 stated there are not enough staff in the facility to meet the needs of residents because the unit she is assigned to, she has 22-25 residents by herself and when she requests additional help, she is told the nurse is considered help. CNA #304 stated there was a time where she and the nurse were caring for a resident in their room and they heard the door alarms go off and a resident had made it into a stairwell because there was no one to provide additional supervision. CNA #304 stated most of the residents on her unit require the use of a hoyer lift, which requires two staff to operate. CNA #304 stated there are times call lights go unanswered for an extended period of time due to lack of staff. Interview on 03/20/25 at 4:01 P.M. with Registered Nurse (RN) #355 revealed she was working on 03/13/25 when Resident #30 left the building unsupervised. RN #355 stated she was downstairs and two agency staff and an agency nurse were working upstairs, the alarms began to go off. The aide downstairs had to go upstairs and check both doors because the agency staff did not. RN #355 stated she was approached a few minutes later by an agency aide who asked, is that a resident?. RN #355 stated she saw Resident #30 about 50 yards away from the building in a grassy area between the driveway and the trees near the road. RN #355 stated she took off running to get to Resident #30. RN #355 stated the elopement was not witnessed, but since the alarms for the stairwells had gone off, the resident had likely walked down the stairs and out the side staff exit, which did not lock or have an automatic locking system for residents wearing wander-guards. RN #355 stated the DON took care of documentation for the incident. Interview on 03/20/25 at 4:10 P.M. with CNA #395 revealed when Resident #30 got out of the facility, the construction workers were already gone, so they did not let her out. CNA #395 stated Resident #30 wandered out alone because the staff entrance does not lock, so once someone is in the stairwell, they are able to leave. CNA #395 stated she was in a resident room on the first floor, when she came out she was told to check the stairwells because the alarms were going off. CNA #395 stated she walked upstairs and turned off the alarm and told the agency staff the alarm was due to a wander-guard. CNA #395 stated when she came back downstairs, RN #355 had Resident #30 back in the building. Interview on 03/27/25 at 2:36 P.M. with the DON revealed when Resident #30 eloped, she made it to the end of the parking lot. DON stated the construction workers saw her leave the building. The DON stated Resident #30's family was notified, she was assessed and she was wearing a functioning wander-guard. The DON stated there was another resident having a medical emergency at the time of the incident, so all upstairs staff were in the other residents room and did not hear the alarms. Interview on 03/27/25 at 3:18 P.M. with CNA #404 revealed she is agency staff. CNA #404 stated she and the agency nurse were in a room with a resident having a medical emergency, but she was not sure where the other agency aide was. CNA #404 stated due to the room being on the opposite end of the hallway, they were not able to hear the door alarming and the doors open after being pushed for 15 seconds. CNA #404 stated Resident #30 could only have been outside for about five or six minutes because she was found by the other agency aide (CNA #416) when she went outside for break. CNA #404 stated the facility does not have enough staff because the second floor has about six residents who require a hoyer lift and they have one aide working the floor. CNA #404 stated the aide who works downstairs is supposed to come up to help, but doesn't have time to very often. CNA #404 stated the DON does help when she can due to call-offs. Interview on 03/27/25 at 3:23 P.M. with CNA #416 revealed she was headed outside to her break when she saw an older lady outside who did not look right. CNA #416 stated the lady was walking towards the street, stopped, then sat down in the grass. CNA #416 went back inside and grabbed RN #355 to ask if it was a resident, then RN #355 began running to the lady and told CNA #416 to get the DON. CNA #416 stated she is agency staff and it was her first time working at the facility and she did not realize the resident was missing from the second floor where she had been working. CNA #416 stated she was in a room with CNA #404 and a nurse with a resident who was having a medical emergency so she did not see or hear Resident #30 leave. 2. Record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including dementia and hypertension. Review of an email from Ombudsman #101 dated 03/20/25 at 10:04 A.M. revealed she had investigated and verified complaints related to call lights taking greater than 30 minutes and up to three hours to get assistance from staff. Interview on 03/20/25 at 2:09 P.M. with Certified Nursing Assistant (CNA) #304 revealed she had three residents on the unit, including Resident 28, who had excoriated bottoms due to delayed incontinence care. CNA #304 stated there are not enough staff in the facility to meet the needs of residents because the unit she is assigned to, she has 22-25 residents by herself and when she requests additional help, she is told the nurse is considered help. CNA #304 stated there was a time where she and the nurse were caring for a resident in their room and they heard the door alarms go off and a resident had made it into a stairwell because there was no one to provide additional supervision. CNA #304 stated most of the residents on her unit require the use of a hoyer lift, which requires two staff to operate. CNA #304 stated there are times call lights go unanswered for an extended period of time due to lack of staff. Interview on 03/20/25 at 4:10 P.M. with CNA #395 revealed there is absolutely not enough staff to meet resident needs and there were several residents upstairs with raw butts and Resident #28 stays bright red. Interview on 03/24/25 at 8:02 A.M. with CNA #304 revealed she would have to get an aide from the first floor to assist her with Resident #28's incontinence care because she required a two-person assist. CNA #304 confirmed Resident #28 did not have incontinence care yet since her arrival at 6:05 A.M. Interview on 03/24/25 at 8:04 A.M. with CNA #150 revealed she had worked all night on the second floor. CNA #150 stated she last provided incontinence care to Resident #28 at about 5-5:15 A.M. Observation on 03/24/25 at 8:05 A.M. of incontinence care for Resident #28 revealed the skin on the resident's front perineal and groin area was red. Both aides, CNA #304 and #150, stated the redness was typical for Resident #28 and barrier cream was applied after incontinence care. Resident #28's buttocks was also reddened and there was a pinpoint open area to her coccyx, which CNA #304 and #150 confirmed. Both aides also confirmed there is one aide upstairs and one aide downstairs. Interview on 03/27/25 at 2:36 P.M. with DON revealed she completes the schedules and it is based on PPD of 2.5. The DON stated she does aim for 2.75 contact hours per resident to account for acuity. The DON stated there were ten residents on the first floor and 22 on the second floor. The DON stated if staff are busy, management will step in to assist as needed. The DON confirmed she had spoken with Ombudsman #101 and was informed it took up to one hour for a call light to be answered, but was unaware of a call light going unanswered for three hours. Interview on 03/27/25 at 3:45 P.M. with Resident #24 revealed she was upset because she had her call light turned on for staff to remove her lunch tray, but no one had come yet. Resident #24 stated lunch was over hours ago and the tray should already be removed because it takes up space in her room. Resident #24's call light was not on during the interview. Review of a policy dated 08/2024 titled Staffing revealed the facility should provide sufficient staffing numbers with the skills necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Staffing numbers and the skill requirements are determined by the needs of the residents. This deficiency represents non-compliance investigated under Complaint Number OH00163080.

Based on record review and interview, the facility failed to ensure resident medical record documentation was accurate and not falsified. This affected three residents (#24, #26, and #28) of three sampled residents reviewed for accurate medical records. Findings included: Review of medical records for Residents #24, #28, and #26 revealed the director of nursing (DON) entered notes on 02/08/25 which stated Resident assessed noted no signs or symptoms of dizziness, nausea, headache, shortness of breath, confusion, or chest pains. Vital signs obtained and within normal limits. Family and MD (medical director) notified. Interview on 03/20/25 at 10:15 A.M. with the DON revealed she was on the phone with a nurse manager during the time of the gas leak incident (on 02/08/25), but she did not come to the facility. The nurse manager who was at the facility was who completed resident assessments on paper regarding the incident. Interviews on 03/20/25 with Licensed Practical Nurse (LPN) #380 and Registered Nurse (RN) #355 at 1:21 P.M. revealed they did not look into it, but did hear the DON had entered false assessments into the resident notes regarding an incident she was not in the building for. Interview on 03/27/25 at 8:47 A.M. with the DON confirmed she entered resident assessments into notes. The DON confirmed she did not complete the assessments and she was not in the facility when the nurse who completed the assessments was physically in the building. This deficiency represents non-compliance investigated under Complaint Number OH00163080.

Based on observation, record review, review of the Administrator job description and personnel file and interview, the facility failed to employ a qualified administrator to ensure the facility was effectively and efficiently administered to allow all residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being and to ensure staff were knowledgeable of who the administrator was. This had the potential to affect all 34 residents residing in the facility. Findings Include: On [DATE] between 10:45 A.M. and 12:41 P.M. interviews with Certified Nursing Assistant (CNA) #216, Licensed Practical Nurse (LPN) #223, and Registered Nurse (RN) #220 revealed none of the staff knew who the current facility Administrator was. The staff revealed they were not familiar with Interim Administrator (IA) #260 or Administrator #275. During the interview with the CNA, the CNA revealed she had not met IA #260 or Administrator #275. She stated she was aware there had been a new administrator hired but had not yet been introduced. The CNA revealed she had not been provided with any education related to who she should report to should she need an Administrator. During the interview with the LPN, the LPN indicated if there was a concern or issue, she would go to the Director of Nursing (DON); however, the LPN revealed she did not know who to contact if for some reason the issue involved the DON. The staff interviewed denied any contact information or chain of command information being available for staff. An interview on [DATE] at 11:14 A.M. with IA #260 via telephone and Administrator #275 revealed Administrator #275 identified herself as the facility incoming Administrator. However, during the conversation, Administrator #275 revealed she was not a Licensed Nursing Home Administrator (LNHA) in the State of Ohio. On [DATE] at 11:05 A.M. interview with the Director of Nursing (DON) revealed IA #260 started in the facility on [DATE] and worked between this facility and a sister facility. Then Administrator #275's first day working at the facility as the Administrator was on [DATE]. Administrator #275 was the only administrator present/working in the facility on [DATE] when the survey investigation started. Review of Administrator #275's application dated [DATE] revealed the applicant's address was in [NAME] Virginia. Administrator #275 was hired as the facility Administrator on [DATE] with a start date on [DATE]. Review of an Administrator offer letter dated [DATE] revealed Administrator #275 was offered an Administrator position on [DATE] with a start date on [DATE]. On [DATE] at 2:47 P.M. a telephone interview with Director of Operations (DOO) #270 revealed she was responsible for hiring the facility Administrator. DOO #270 confirmed she was aware Administrator #275 did not have a current Licensed Nursing Home Administrator's license (LNHA) in the State of Ohio at the time she was hired. However, DOO #270 stated Administrator #275 was working under the supervision of IA #260 (who was licensed in the State of Ohio as an LNHA). DOO #270 confirmed Administrator #275 was on-site at the facility on [DATE] and [DATE] without IA #260 present. Concerns investigated during the onsite investigation related to administrative oversight were identified related to the facility boiler system as noted: Review of the boiler inspection dated [DATE] revealed Certificate of Operation expired: The Certificate of Operation is expired due to either a non-passed inspection within the last 12 months or non-payment of fees. Please contact the Division of Industrial Compliance support staff within 30 days of this order. Observation on [DATE] at 11:58 A.M. of the boiler room revealed the boiler had a red tag on it dated [DATE]. Boiler needs serviced was written on the tag. There was no further evidence of attempts by the facility to follow up on the expired Certificate of Operation for the boiler until [DATE], following surveyor intervention. On [DATE] at 2:47 P.M. during the interview with DOO #270, the DOO confirmed the boiler was not certified for use in [DATE] and stated this was due to unpaid fees from 2018. However, DOO #270 revealed she was not aware of the issue prior to the surveyors entering the facility to investigate a complaint related to the boiler. DOO #270 confirmed it was the Administrator's responsibility to ensure bills/invoices were paid in a timely manner. Review of the undated Administrator Job Description revealed the primary purpose of the position was to direct the day-to-day functions of the facility in accordance with federal, state, and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Furthermore, duties included to ensure the building and grounds are maintained in good repair. Ensure that the facility was maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies were maintained to perform such duties and services. Keep abreast of the economic condition and situation and make adjustments as necessary to assure the continued ability to provide quality care. Qualifications included the individual must possess a current, unencumbered Nursing Home Administrator's license or meet the licensure requirements of this State. This deficiency is an incidental findings identified during the investigation of Complaint Number OH00162507.

Based on observation, record review, facility policy review and staff interview, the facility failed to ensure all essential mechanical equipment (boiler) was maintained in a functional and safe operating condition. The had the potential to affect all 34 residents residing in the facility. Findings Include: Review of the boiler inspection dated [DATE] revealed Certificate of Operation expired: The Certificate of Operation is expired due to either a non-passed inspection within the last 12 months or non-payment of fees. Please contact the Division of Industrial Compliance support staff within 30 days of this order. Observation on [DATE] at 11:58 A.M. of the boiler room revealed the boiler had a red tag on it dated [DATE]. Boiler needs serviced was written on the tag. There was no further evidence of attempts by the facility to follow up on the expired Certificate of Operation for the boiler until [DATE], following surveyor intervention. On [DATE] at 1:17 P.M. information provided via email from Regional Maintenance (RGM) #208 revealed the boiler failed inspection in [DATE] due to unpaid fees from 2018. On [DATE] at 2:47 P.M. interview with Director of Operations (DOO) #270 confirmed the boiler was not certified for use in [DATE] and stated this was due to unpaid fees from 2018. However, DOO #270 revealed she was not aware of the issue prior to the surveyors entering the facility to investigate a complaint related to the boiler. DOO #270 confirmed it was the Administrator's responsibility to ensure bills/invoices were paid in a timely manner. Review of the facility policy, Resident Environmental Quality, dated ,d+[DATE], revealed the facility would be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility shall maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. The deficiency represents non-compliance investigated under Complaint Number OH00162507.

Based on observation, record review, facility policy review and interview, the facility failed to maintain a safe, functional and comfortable environment for all residents and failed to timely address an alarming carbon monoxide detector to ensure resident safety. This had the potential to affect all 34 residents residing in the facility. The facility census was 34. Findings Include: Review of the Fire Department Run Report dated 02/08/25 revealed the fire department was dispatched to the facility at 9:10 A.M. for a possible gas or carbon monoxide (CO) leak at the facility. There was no gas detected on the first floor of the facility but upon entering the basement, the multi-gas meter started alarming with carbon monoxide level at 87 parts per million (ppm) (normal/average levels 0.5-5.0 ppm). Evacuation and ventilation procedures were started. The gas was shut off at the meter by the fire department. Gas and CO level began falling rapidly once the gas was shut off and normal readings were restored. The facility's HVAC company isolated the boiler. The residents and staff were cleared to return into the building once normal readings were maintained. The Maintenance Director was instructed not to use the boiler under any circumstances until it had been inspected and/or repaired by a boiler technician and also inspected and approved b the Ohio Department of Commerce State Boiler Inspector. One worker was transported to the hospital due to possible exposure to CO and natural gas. Interview on 02/12/25 at 11:42 A.M. with Maintenance Director (MD) #206 revealed he was called in to the facility on [DATE] at approximately 8:00 A.M. by the floor nurse due to the carbon monoxide detector in the boiler room alarming. MD #206 arrived at the facility at approximately 8:30 A.M. and residents were already being evacuated from the facility. The Fire Department arrived at the facility and were directed to the boiler room. MD #206 stated the boiler was supposed to be serviced but it was not serviced by the HVAC company. They just turned it on. MD #206 was responsible for testing carbon monoxide detectors but had not been keeping any documentation of the tests he conducted. MD #206 stated the Fire department and the gas company shut down the boiler quickly and shortly after allowed residents and staff to return inside the building. There was no evidence of any carbon monoxide on the first or second floors where the residents resided, it was only found in the basement. Observations during the initial tour on 02/12/25 from 11:58 A.M. to 12:30 P.M. revealed the boiler had a red tag dated 08/12/24 with the written indication, boiler needs serviced. The boiler was also tagged by the local gas company dated 02/08/25 that stated, Danger. The boiler was not currently in use and was being serviced by the facility's Heating, Ventilation, and Air Conditioning (HVAC) company. There was a carbon monoxide detector observed inside the boiler room. The detector was tested and was in good working condition. Observations of resident rooms on the first and second floor revealed the rooms were supplied heat through packaged terminal air conditioning (PTAC) units. There were not any carbon monoxide detectors observed on the first or the second floors of the facility. Interview on 02/12/25 at 12:30 P.M. with MD #206 confirmed there were not any CO detectors installed on the first or second floors where residents resided. Interview on 02/12/25 at 2:34 P.M. with Housekeeping Aide (HKA) #204 revealed she had arrived to the facility approximately one hour before her shift started, at approximately 6:00 A.M. HKA #204 stated as soon as she arrived she heard an alarm going off in the basement. HKA #204 and HKA #210 found the alarm was in the boiler room. HKA #210 informed the floor nurse. Two nurses changed the batteries in the CO detector and it stopped alarming for ten to 15 minutes and then started alarming again. The nurse was notified again of the alarm going off. HKA #204 stated then the fire department was called and everyone was evacuated out into the parking lot until it was cleared. HKA #210 was transported to the emergency room (ER) due to feeling light headed, dizzy, and short of breath. She was treated in the ER for about three hours with 100% oxygen and was told she had carbon monoxide poisoning. There were not any residents who were transported to the hospital that she was aware of. HKA #204 stated approximately two hours and 30 minutes had passed between when the detector was first alarming and when the fire department was contacted. Interview on 02/12/25 at 4:14 P.M. with HKA #210 revealed he arrived for his shift at approximately 5:30 A.M. on 02/08/25. Upon arriving he heard an alarm sounding in the basement but was not able to determine exactly where it was coming from until HKA #204 arrived at approximately 6:00 A.M. and found the alarm was coming from the boiler room. The floor nurse on the first floor was notified. Two nurses changed the batteries in the detector and it did stop alarming for approximately ten to 15 minutes but then started alarming again. The floor nurse was notified again. HKA #210 stated then the building was evacuated to the parking lot until the fire department and the gas company confirmed it was safe to return inside the building. HKA #210 reported having a headache and was evaluated by the paramedics but declined to go to the hospital. Interview on 02/12/25 at 4:48 P.M. with Licensed Practical Nurse (LPN) #214 confirmed she started her shift at approximately 6:00 A.M. on 02/08/25. LPN #214 first notified MD #206 at approximately 8:00 A.M. that a CO detector was alarming in the boiler room. MD #206 did not answer and LPN #214 attempted again at approximately 8:30 A.M. At approximately 8:50 A.M., LPN #214 notified the Assistant Director of Nursing (ADON) who instructed to call the fire department. LPN #214 attempted to call the fire department but there was no answer so she then dialed 911 at approximately 9:00 A.M. The dispatcher instructed LPN #214 to start evacuating the building. By approximately 10:00 A.M., the fire department and other companies who had responded had assessed and cleared the building to be safe and the residents and staff were allowed to go back inside. LPN #214 stated she and another nurse changed the batteries in the CO detector in the boiler room between 6:30 A.M. and 7:00 A.M. and the beeping stopped. LPN #214 stated she was not notified again that the alarm was going off again until approximately 8:00 A.M. Review of the boiler inspection reports revealed the facility's boiler had been red tagged due to non-payment of fees from 2018 at the time of the inspection on 08/12/24. The inspection did not indicate there was any need for repairs to be made to the boiler at that time. Review of facility undated policy titled Emergency Preparedness Program, revealed within zero to two hours, the facility should initiate the Incident Briefing of all appointed staff. Include the following: nature of the problem and safety of staff, residents, and visitors. Review of the facility policy titled Resident Environmental Quality, dated 08/2023 revealed the facility would be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility shall maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. The deficiency represents non-compliance investigated under Complaint Number OH00162507.

Based on observation, staff interview, and policy review, the facility failed to ensure food was prepared and served in a sanitary manner. This had the potential to affect all residents that received meals from the facility's kitchen. The facility's census was 30. Findings include: On 11/01/23 at 11:02 A.M., a visit to the facility's kitchen was made to observe the pureed food process, obtain food temperatures prior to tray line and to observe the meal process. During the pureed food process, Dietary Cook #177 was observed to pull her N-95 mask down by grasping the outside of her mask with her bare hands. She would then raise her mask after talking to re-cover her mouth and nose. She would then handle food equipment such as pans and food processing equipment with her same bare hands without performing hand hygiene. She was also noted to touch the outside of her N-95 mask when she had gloves while handling trays used to place the residents' food on. She did not remove her gloves or performing hand hygiene before she continued with the serving of the residents' food. Findings were verified by Dietary Manager #200. On 11/01/23 at 12:36 P.M., an interview with Dietary Manager #200 revealed she was not aware of Dietary Cook #177 touching the outside of her N-95 mask without performing proper hand hygiene during the preparation and serving of food during the lunch meal process. She acknowledged the outside of the N-95 mask was considered contaminated and hand hygiene should have been performed after each contact the dietary cook had with the outside of her N-95 mask. A review of the facility's policy on Handwashing Guidelines for Dietary Employees (undated) revealed handwashing was necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees should keep their hands and exposed portions of their arms clean. Dietary employees shall clean their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils. They should also wash their hands after they had touched anything unsanitary, after hands had touched bare human body parts other than clean hands such as the face, nose, hair etc.

Based on observation, record review, resident and staff interview, the facility failed to ensure a resident, who was displaying signs of a depressed mood, received an antidepressant as ordered by the physician. This affected one (Resident #78) of two residents reviewed for mood and behaviors. Actual harm occurred to Resident #78 when the facility failed to administer ordered antidepressant medication and antianxiety medication resulting in the resident expressing thoughts of being depressed, sleeping for extended periods of time, and being tearful when being conversed with. Findings include: A review of Resident #78's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #78's hospital records revealed they included a patient instruction sheet dated 12/01/21 for an admitted [DATE]. The resident's chronic problems included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient instructions included medications the resident was to stop taking, start taking and continue taking. The only medication the resident was to stop taking was [MEDICATION(S)] ([MEDICATION(S)]) 5 milligrams (mg) three times a day for muscle spasms. Under the continue taking medications, the resident was directed to continue to take [MEDICATION(S)] (an antidepressant) 150 mg every day. The discharge instructions from the local hospital included a list of medications Resident #78 was to take after her discharge. The medications were divided up between new medications, continued medications and discontinued medications. It too indicated the only medication the resident was to stop taking was the [MEDICATION(S)] that was ordered three times daily on an as needed (prn) basis for muscle spasms. The medications that were to be continued included [MEDICATION(S)] 150 mg orally daily. A review of Resident #78's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence of the resident receiving any antidepressants since she had been admitted to the facility on [DATE]. A review of Resident #78's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 12/16/21, no antidepressants had been given to the resident despite her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #78's baseline care plans revealed the resident was known to have mental health needs. Depression was marked as being an issue for the resident. A review of a life event checklist for Resident #78 dated 12/02/21 revealed the resident's past experiences included a physical and sexual assault. The resident reported having had therapy/ counseling services in the past but was not interested in speaking with a therapist or counselor at the present time. A review of Resident #78's progress notes revealed her discharge plan was to return home after receiving therapy services. A nurse's progress note dated 12/10/21 revealed the social worker had spoke with the resident's sister. The resident wasn't aware but it was determined her home she was previously living in was deemed not livable. The sister was her only family member and lived 12 hours away. The resident did not have an alternate placement at that time and the sister wanted the resident to stay there or find another nursing facility for permanent placement. The resident was not safe to live alone and had no means to support herself. She did not have a car and needed assistance with her activities of daily living. A nurse's progress note dated 12/11/21 revealed Resident #78 verbalized she did not like it at the facility and had requested to get something for anxiety. On 12/13/21 at 3:00 P.M., an observation of Resident #78 noted her to display signs of a depressed mood. She became tearful when conversed with and reported she felt isolated while on a 14 day isolation period as part of her 14 day quarantine following her recent admission. She related it to the same feelings of being in jail and felt she was being punished as she could not leave her room. She denied she was on an antidepressant that she was aware of. On 12/16/21 at 9:20 A.M., an interview with Certified Nursing Assistant (CNA) #7 revealed she had worked in the facility for about six months now and was familiar with Resident #78. She reported the resident did tend to sleep a lot during the day but she did not correlate that with her being depressed. She denied she had known the resident to be tearful or appear sad. She knew the resident did not like to be on isolation precautions mainly because she could not go outside to smoke. The resident tended to watch a lot of TV in her room when she was not sleeping or talking on the phone with her sister. She felt the resident has done a little better since they got her an E-cigarette to keep in her room. On 12/16/21 at 9:34 A.M., an interview with Registered Nurse (RN) #16 revealed she had only worked in the facility for about two weeks now, which was about as long as Resident #78 had been in the facility. She reported the resident was not happy to be there but she has not seen her be tearful or show other signs of being depressed. She was asked what psychoactive medications the resident was on and stated she thought she was on an antidepressant. When asked to check the electronic health record and the electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . She was then asked if the resident had any psychoactive medications ordered on an as needed (prn) basis and reported she did not see any prn's ordered other than Tylenol for pain. She did not identify [MEDICATION(S)] ([MEDICATION(S)]) as one of the prn psychoactive medications ordered for the resident. When [MEDICATION(S)] was pointed out to the nurse as being one of her prn medications and also a psychoactive medication, she confirmed it was being given on an as needed basis for itching. She acknowledged [MEDICATION(S)] was classified as an antihistamine but was also known to be used for anxiety as it had anti-anxiety properties. She was asked if that was something available to the resident if she complained of anxiety. She denied she would be able to give it to the resident since her orders specified it was to be used on a prn basis for itching. She stated she would have to check with the Director of Nursing (DON) if that was something they could use for anxiety. She verified the resident's hospital discharge orders did include [MEDICATION(S)] 150 mg by mouth daily as one of her medications she should have continued when released from the hospital and admitted to the facility. She also verified the discharge instructions from the hospital did specify the resident was to receive [MEDICATION(S)] 25 mg by mouth four times a day prn for anxiety. On 12/16/21 at 10:02 A.M., an interview with the DON confirmed Resident #78's hospital records and discharge instructions did show she was to receive [MEDICATION(S)] 150 mg by mouth daily and the resident had not received it while in the facility following her admission on 12/01/21. She also confirmed the discharge instructions from the hospital included the use of [MEDICATION(S)] ([MEDICATION(S)]) 25 mg four times a day prn for anxiety and the facility staff had written it up as being ordered on a prn basis for itching. She confirmed Resident #78 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she would have to clarify the reason the [MEDICATION(S)] was ordered for.

Based on record review and interview the facility failed to ensure Resident #12 received the appropriate level of assistance needed during transferring and ambulation resulting in a fall. Actual Harm occurred when staff did not maintain contact with and did not provide two staff for Resident #12 while assisting her with ambulation and transfer. The resident fell and sustained a laceration below her left eye that required sutures. This affected one (Resident #12) of two residents reviewed for accidents/supervision. Findings include: A review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident #12's care plan revealed she was at risk for falls and injury related to her [DIAGNOSES REDACTED]. The goal was to minimize potential risk factors related to falls. A review of Resident #12's nursing progress notes revealed a fall occurred on 04/13/19 at 4:45 P.M. The note indicated the resident had a fall in front of the nurses' station with State tested Nursing Assistant (STNA) #323 present. The nurse's note did not provide any information as to the circumstances of the fall or any injuries sustained but indicated the physician was notified and an order was received to send the resident to the emergency room for evaluation and treatment. A review of Resident #12's immediate needs post fall care plan indicated the resident did have a fall with injury to her face. Interventions on the immediate care plan indicated the resident was sent to the emergency room for an evaluation and staff education had been provided to make sure the resident's chair was in place prior to transferring the resident. A review of Resident #12's fall investigation dated 04/13/19 revealed the resident was being set up for dinner and was standing while the STNA moved the chair. The resident fell forward after losing her balance while she was standing and waiting for the STNA to reposition her chair. The new intervention added as a result of the fall was to educate the staff to reposition the chair before transferring the resident. A review of STNA #323's witness statement revealed the STNA was setting Resident #12 up for her dinner at the nurses' station. The STNA stated she was trying to get the wheelchair closer to her for her to sit down when the resident lost her balance. The STNA stated she could not get around the wheelchair fast enough to catch the resident before she hit the floor. She called for the other STNA to get the nurse while she remained with the resident. A nurse's progress note dated 04/13/19 at 8:45 P.M. revealed Resident #12 returned from the emergency room with five sutures below her left eye. The left eye was bruised and the sclera was red. Her left arm was wrapped with a dressing due to skin tears she sustained to her left elbow as a result of her fall. A review of Resident #12's fall risk evaluations revealed she did not have a fall risk assessment completed until 04/23/19. Fall risk assessments were completed on 04/23/19, 05/03/19, and 06/04/19. The assessments were marked as being completed for other when indicating what type of assessment it was. The fall risk evaluation for 04/23/19 indicated the resident's fall risks under cognition included impaired decision making, delusions and [MEDICAL CONDITION]. Her risk factors under physical functioning indicated she needed assistance with her activities of daily living self performance and unsteady gait. She was identified on that evaluation as having had a history of [REDACTED]. A review of Resident #12's most recent Minimum Data Set 3.0 (MDS) assessment, an assessment tool used by the facility to identify a resident's level of care for reimbursement purposes, dated 04/23/19 revealed the resident had adequate vision with the use of corrective lenses. She had no communication issues. Her cognition was severely impaired. She had no behaviors. She required the extensive assist of two persons for bed mobility, transfers, ambulation, locomotion, and toilet use. The resident was identified as having had two or more falls since her prior MDS assessment. One of the falls was indicated to have resulted in injury that was not a major injury. Her prior MDS assessment (Medicare 5 day assessment) also indicated the resident required extensive assist of two for transfers but she was only an extensive assist of one for ambulation. On 07/17/19 at 1:50 P.M. the Director of Nursing (DON) confirmed Resident #12 had an avoidable fall on 04/13/19 that resulted in a laceration under her left eye that required suture repair. She stated the fall occurred when an STNA was walking the resident from her room to a chair in the hall by the nurses' station. They were setting the resident up for dinner and the STNA let go of the resident to reposition the chair. The resident lost her balance and fell forward. The DON said the STNA was educated to reposition the chair first before assisting the resident with ambulation from her room. The DON confirmed Resident #12 required extensive assist of one person for ambulation and two persons for transfer at the time the fall occurred, and the STNA should not have let go of her to reposition the chair.