Every finding on record at Mason Health Care Center

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure medications in the medication cart were labeled and stored in proper containers. This affected all of the residents residing in the facility. The facility census was 38 residents. Findings include: Observation on 05/12/25 at 9:00 A.M of the nurse two medication cart on the skilled care hallway revealed there were 19 loose pills of various shapes and colors in the bottom of the medication cart. Interview on 05/12/25 at 9:00 A.M. with Registered Nurse (RN) #221 confirmed there were 19 loose pills of various shapes and colors in the bottom of the nurse two medication cart on the skilled care hallway. RN #221 confirmed she was not able to identify the 19 pills nor to whom the 19 pills were prescribed. Observation on 05/12/25 at 9:26 A.M of the nurse two medication cart on the long-term care hallway revealed there were 92 loose pills of various shapes and colors in the bottom of the medication cart. Interview on 05/12/25 at 9:26 A.M with RN #221 confirmed there were 92 loose pills of various shapes and colors in the bottom of the nurse two medication cart on the long-term care hallway. RN #221 confirmed she was not able to identify the 92 pills nor to whom the 92 pills were prescribed. Observation on 05/12/25 at 9:32 A.M of the nurse one medication cart on the long-term care hallway revealed there were 130 loose pills of various shapes and colors in the bottom of the medication cart. Interview on 05/12/25 at 9:32 A.M with Licensed Practical Nurse (LPN) #224 confirmed there were 130 loose pills of various shapes and colors in the bottom of the nurse one medication cart on the long-term care hallway. LPN #224 confirmed she was not able to identify the 130 pills nor to whom the pills were prescribed. Review of the facility policy titled Medication Storage dated November 2021 revealed drugs should dispensed and stored in the manufacturer's original container. This deficiency represents noncompliance investigated under Complaint Number OH00165462.

Based on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted within 14 days. This affected two (Residents #401 and #402) of six residents reviewed for assessments. The facility census was 38 residents. Findings include: 1. Review of the medical record for Resident #401 revealed an admission date of 03/29/25 with diagnoses including cellulitis of the left finger, asthma, and type two diabetes mellitus and a discharged from the facility on 04/21/25. Review of the admission Minimum Data Set (MDS) assessment for Resident #401 dated 04/04/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the discharge return anticipated (DRA) MDS assessment for Resident #401 dated 04/19/25 revealed the MDS was in progress and had not been transmitted. Review of the progress note for Resident #401 dated 04/19/25 timed at 11:42 A.M. revealed the resident's representative called the urologist and was instructed to take the resident to the emergency room (ER). Resident #401 left the facility with two friends and his representative in an automobile. Review of the progress note for Resident #401 dated 04/20/25 timed at 7:18 P.M. revealed the resident returned to the facility at 6:50 P.M. Review of the DRA MDS assessment for Resident #401 dated 04/21/25 revealed the MDS was in progress and had not been transmitted. Review of the progress note for Resident #401 dated 04/21/25 timed at 11:55 A.M. revealed the resident had discharged home. Interview on 05/12/25 at 3:46 P.M with MDS Licensed Practical Nurse (LPN) #215 confirmed the DRA MDS assessments dated 04/19/25 and 04/21/25 for Resident #401 had not been transmitted within 14 days as required. 2. Review of the medical record for Resident #402 revealed an admission date of 07/11/24 with diagnoses including cerebral infarction, generalized anxiety disorder, major depressive disorder, and a discharge date of 04/30/25. Review of the admission MDS assessment for Resident #402's dated 01/16/25 revealed the resident was cognitively intact and required assistance with ADLs. Review of the quarterly MDS assessment for Resident #402 dated 04/18/25 revealed the MDS was in progress and had not been transmitted. Review of the DRA MDS assessment for Resident #402 dated 04/30/25 revealed the MDS was in progress and had not been transmitted. Review of the progress note for Resident #402 dated 04/30/25 timed at 7:38 P.M. revealed the resident was transported to the emergency room (ER). Interview on 05/12/25 at 3:46 P.M with MDS LPN #215 confirmed the quarterly MDS assessment dated [DATE] and the DRA MDS assessment dated [DATE] for Resident #402 had not been transmitted within 14 days as required.

Based on record reviews, staff interview, and policy review, the facility failed to monitor antibiotic use appropriately as part of an antibiotic stewardship plan. This had the potential to affect all 31 residents. The facility census was 31. Findings include: Review of documents dated January, February, March, April, and May 2023, provided by the Director of Nursing, (DON), revealed there was no documentation and analysis of appropriate indications for the use of antibiotics. Interview on 06/01/23 at 1:20 P.M., the Director of Nursing, (DON) stated the facility uses the McGeer monitoring criteria for the antibiotic stewardship program. The DON had no evidence of how the facility was monitoring antibiotic medications using the McGeer criteria. The DON verified there was no documentation of an antibiotic stewardship program. Review of the undated policy titled, Antibiotic Stewardship -Orders for Antibiotics, revealed antibiotics will be prescribed and administered to residents under the guidance of facility's antibiotic stewardship program, including appropriate indications for use. Indications of use included criteria must be met for clinical definition of an active infection and pathogen susceptibility.

Based on record reviews, staff interviews, observations and policy reviews, the facility failed to ensure infection control logs were completed for tracking trends and patterns, complete tuberculous testing for newly hired employees, develop and follow a Legionella water management policy, and ensure hand sanitation was followed during resident care. This had the potential to affect all 31 residents. The facility census was 31. Findings include: 1. Review of the Infection Control Logs dated January, February, and [DATE] revealed the logs lacked tracking of the disease organism isolation type identification, and culture dates. For months January, March and [DATE], there was no organism mapping of the organism location in the facility. [DATE] logs revealed there were no date of infections, signs and symptoms appeared, date of culture, or isolation type. Review of the Infection Control Logs revealed no entries of infections for [DATE]. Interview on [DATE] at 1:20 P.M., with the Director of Nursing (DON) verified the Infection Control Logs of January, February, March, April, and [DATE], including facility organism mapping, was incomplete. The DON stated the infection control logs should have been completed to enable tracking of the infection's locations, identify isolation procedures and to monitor infection resolution. Review of the undated policy titled, Infection Control Policy and Procedure, revealed the facility policies and procedures surveillance shall include data to properly identify disease and infections before they spread. The policies and procedures include identifying the infection signs and symptoms, analysis of the number of residents who developed the infection and identification of infection trends and patterns. 2. Review of employee files revealed Business Office Manager, (BOM) #110 and Activity Director, (AD) #100 were hired in [DATE] and there was no evidence of Tuberculosis testing prior to hire and the second testing two weeks after hire. Interview on [DATE] at 12:06 P.M. with Scheduler #270 verified BOM #110 and AD #100 did not have evidence of tuberculosis testing prior to and after hiring. Scheduler #270 verified BOM #110 and AD #100 should have had tuberculosis testing completed prior to hire and two weeks after hire. Review of the facility Tuberculous Risk Assessment, dated [DATE], revealed the facility tests all health care workers upon hire. 3. Review Legionella notebook and documentation revealed evidence of a water management program which included control measures, testing protocols and corrective actions when control limits are not maintained. Interview on [DATE] at 10:35 A.M., with Maintenance Director (MD) #135 verified there was no Legionella water management policy. MD #135 stated he received no formal training. He studied on line how to manage Legionella. MD #135 was able to verbalize how to monitor for Legionella. Interview on [DATE] at 11:18 A.M., with the Administrator verified there was no policy or procedure for a Legionella water management program. 39703 4. Observation on [DATE] at 12:20 P.M., revealed State tested Nursing Assistant (STNA) #225 arrived on the unit to assist with passing room trays and donned gloves before taking Resident #7's tray off the cart. STNA #225 then delivered lunch trays to Residents #7 and #11. STNA #225 assisted residents with setting up their meal trays and ensuring they were appropriately positioned in bed. STNA #225 then entered Resident #24's and responded to her call light and assisted resident with repositioning. STNA #225 exited Resident #24 's room, and the Director of Nursing (DON) pointed to aide's gloves and gestured that the aide should remove the gloves. STNA #225 then doffed the gloves and continued with tray pass. STNA #225 was not observed performing hand hygiene at any time during passing trays and assisting residents. Interview on [DATE] at 12:26 P.M., with STNA #225 stated the last time she had washed her hands was after taking out the trash and just before entering the unit to assist with meal service. STNA #225 confirmed she had donned a pair of gloves before delivering trays and assisting Residents #7, #11, and #24. STNA #225 confirmed she did not remove gloves and/or wash or sanitize hands between resident contact. Interview on [DATE] at 1:12 P.M., with the DON confirmed she had witnessed STNA #225 wearing gloves in the hallway during lunch meal service and going from room to room wearing the same pair of gloves. DON confirmed staff should perform appropriate hand hygiene between each resident contact. Review of the policy titled Handwashing/Hand Hygiene dated [DATE] revealed the use of gloves did not replace hand washing/hand hygiene. Hand hygiene should be performed after removing gloves, after contact with items in the immediate vicinity of the resident, before and after direct contact with residents, before and after handling food, before and after assisting a resident with meals. 42731 5. Review of the medical record for Resident #130 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, chronic respiratory failure with hypoxia, major depressive disorder, generalized anxiety disorder, atrial fibrillation, and tracheostomy status. Review of the Medicare-Five Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #130 was not able to complete a Brief Interview for Mental Status (BIMS). This resident was assessed to require two-person total dependence with transfers, two-person extensive assistance with dressing, and one-person total dependence with eating, toileting, and bathing. Review of the care plan dated [DATE] revealed Resident #130 had a tracheostomy related to respiratory failure. Interventions included to ensure trach ties were secured at all times. Staff to administer humidified oxygen as prescribed. Staff to keep at bedside back up trach number six uncuffed Shiley and number four uncuffed Shiley. Staff monitor and document for restlessness, agitation, confusion, increased heart rate, and bradycardia. Staff use universal precautions and assist with coughing as needed. Observations on [DATE] between 11:18 A.M. and 11:27 A.M., revealed Licensed Practical Nurse (LPN) #265 perform trach care on Resident #130. LPN #265 applied gloves and then went to search for a trash can. LPN #265 located a trash can near the entrance to Resident #130's room and brought it to the bedside. LPN #265 then changed the glove of the hand utilized to carry the trash can and did not perform hand hygiene prior to applying the new glove. LPN #265 then opened a new container of trach supplies and proceeded to apply the sterile gloves from inside the container, over the gloves she was already wearing. LPN #265 then completed trach care on Resident #130. Interviews on [DATE] at 11:28 A.M. and 11:37 A.M., with LPN #265 verified she did not perform hand hygiene when changing her glove. LPN #265 further verified she applied sterile gloves over her regular gloves before performing trach care on Resident #130. LPN #265 verified hand hygiene should have been completed prior to donning the new glove and should not have placed the sterile gloves over another pair of gloves. Review of the policy titled, Tracheostomy Care, dated [DATE], revealed an aseptic technique should be utilized when providing care for the resident with a tracheostomy. Hand antisepsis should be performed before applying gloves.

Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure care conferences were held on a regular basis. This affected four (#01, #07, #12, and #23) of five residents reviewed for care conferences. The facility census was 31. Findings include: 1. Review of the medical record of Resident #01 revealed an admission 08/04/12. Diagnoses included cerebral palsy, chronic obstructive pulmonary disease, dementia without behavioral disturbance, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. The resident required supervision for all activities of daily living (ADLs). Interview on 05/30/23 at 11:52 A.M., with Resident #01 stated she could not recall having any recent care conferences. Review of the medical record revealed the most recent care conference was held 07/19/22. Interview on 06/01/23 at 1:24 P.M., with Social Service (SS) #280 verified Resident #01's last care conference documented was 07/19/22. 44412 2. Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included osteomyelitis of vertebra, sacral, and sacrococcygeal region, chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, major depressive disorder, atrial fibrillation, and generalized anxiety disorder. Review of the quarterly (MDS) assessment dated [DATE] revealed Resident #23 had moderate cognitive impairment. This resident was assessed to require two-person total dependence with transfers, one-person extensive assistance with dressing, supervision with eating, and two-person extensive assistance with toileting. Review of the care plan dated 02/22/23 revealed Resident #23 was at risk for skin breakdown related to admitted with osteomyelitis stage four to sacral, decreased mobility, decreased strength, preferred to stay laying on back, and refused to wear heel protectors. Interventions included administering medications as ordered and monitor/document for side effects and effectiveness. Staff to administer treatments as ordered and monitor for effectiveness. Staff to assess, record, and monitor wound healing. Staff to educate as to the causes of skin breakdown including transfer and positioning requirements, importance of good nutrition, and frequent repositioning. Staff provide diet and any supplements as ordered and monitor and record intake. Review of the care conferences for 2022 and 2023 revealed Resident #23 had no documentation of care conferences provided by the facility. Interview on 05/30/23 at 10:10 A.M. with Resident #23 revealed he had not had any care conferences since admission. Interview on 06/01/23 at 1:21 P.M., with Clinical Manager #230 verified there was no documentation to prove Resident #23 had any care conferences in the last 12 months. Interview on 06/01/23 at 1:23 P.M. with social services #280 verified there was no formal documentation for care conferences for Resident #23 for the last 12 months. 3. Review of the medical record for Resident #12 revealed an admitted [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, DM II, chronic kidney disease, stage four, dependence on renal dialysis, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 had moderate cognitive impairment. This resident was assessed to require one-person extensive assistance with transfers, dressing, and toileting, supervision with eating, and one-person total dependence with bathing. Review of the care plan dated 09/07/18 revealed Resident #12 had a potential for complications related to dialysis and chronic renal failure. Interventions included do not draw blood or take blood pressure in arm with graft. Staff to encourage resident to squeeze foam ball as tolerated in fistula arm. Staff to maintain fluid restriction as ordered. Staff to monitor intake and output. Staff to monitor labs and report to physician as needed. Staff to monitor and document peripheral edema. Staff to provide dialysis center with name and phone number of contact and other pertinent information for continuity of care. Review of the progress note dated 03/15/23 at 5:31 P.M., revealed the facility reached out to Resident #12's Power of Attorney (POA) to reschedule care conference on 03/16/23 at 11:00 A.M. Review of the care conferences for the last 12 months revealed only one care conference was completed on 03/16/23. Interview on 05/30/23 at 2:04 P.M., with Resident #12 revealed he could not recall if he had any care conferences in the last 12 months. Interview on 06/01/23 at 1:23 P.M., with SS #280 verified there was one care conference completed in March 2023 but completed phone interviews with POA without documentation. 39703 4. Review of the medical record for Resident #7 revealed an admitted [DATE], with diagnoses including cerebral infarction, diabetes mellitus (DM), lymphedema, major depressive disorder, anemia, and venous insufficiency. Review of the MDS assessment for Resident #7 dated 05/11/23 revealed resident was cognitively intact and required extensive assistance of staff with activities of daily living (ADLs.) Review of the medical record for Resident #7 revealed it did not include documentation of any care conferences held for residents in the previous 12 months. Interview on 05/30/23 at 1:51 P.M., with Resident #7 confirmed she had not had a care conference to discuss her care during her entire stay at the facility, and she had been admitted in April 2022. Interview on 06/01/23 at 1:45 P.M., with the Director of Nursing (DON) confirmed the facility had no documentation regarding any care conferences held for Resident #7. DON confirmed care conference should be held at least quarterly, and the resident and/or resident's representative should be invited to provide an opportunity for participation in care planning. Review of the policy titled Care Conference dated 02/02/06, revealed the facility would have regular interdisciplinary care conferences which would include the resident and/or resident's representative in order to facilitate communication regarding resident's condition and care interventions.

Based on medical record review and staff interview, the facility failed to ensure the Ombudsman was notified of hospital transfers. This impacted one (#25) of one resident reviewed for hospitalization . The facility census was 31. Findings include: Review of the medical record of Resident #25 revealed an admitted [DATE]. The resident transferred to the hospital on 02/24/23, readmitted on [DATE], transferred to the hospital on 03/18/23, readmitted [DATE], transferred to the hospital on 03/29/23, readmitted [DATE], and transferred to the hospital on 04/29/23, and readmitted on [DATE]. Diagnoses included cerebral infarction, tracheostomy status, gastrostomy status, chronic respiratory failure with hypoxia, contractures of left hand, right elbow, right hand, dysphagia, acute kidney failure, severe sepsis with septic shock, pneumonia, essential hypertension, hyperlipidemia, and unspecified disorder of thyroid. Review of the medical record revealed no evidence of the Ombudsman being notified of Resident #25's transfers to the hospital on 02/24/23, 03/18/23, 03/29/23, and 04/29/23. Interview on 06/01/23 at 1:24 P.M., with Social Services (SS) #280 verified there was no evidence of Ombudsman notification of Resident #25's discharges to the hospital. SS #280 stated she was previously unaware of the need to notify the Ombudsman of discharges. Interview on 06/01/23 at 1:39 P.M., with the Administrator verified Ombudsman notification is required when residents transfer to the hospital.

Based on medical record review and staff interview, the facility failed to ensure a discharge summary was completed upon discharge from the facility. This affected one (#28) of two residents reviewed for discharge. The facility for census was 31. Findings include: Review of the medical record of Resident #28 revealed an admitted [DATE]. The resident transferred to another skilled nursing facility on 03/30/23. Diagnoses included malignant neoplasm of prostate, gout, chronic viral hepatitis C, obstructive sleep apnea, type 2 diabetes mellitus, morbid obesity, essential hypertension, gastro-esophageal reflux disease, and hypothyroidism. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the Multidisciplinary Discharge Summary dated 03/28/23 revealed the documentation was incomplete. Social Services and Nursing completed their sections on 03/28/23 and 03/30/23, respectively. Therapy, dietary, and activity sections were not completed. Interview on 05/31/23 at 2:23 P.M., the Director of Nursing verified the discharge summary was incomplete and should have been completed at the time the resident discharged .

Based on record review, observation, resident interview, and staff interview, the facility failed to ensure a resident who required assistance was provided assistance with hair washing. This affected one (#7) of 13 residents reviewed for activities of daily living (ADLs). The facility census was 31. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE], with diagnoses including cerebral infarction, Diabetes Mellitus (DM), lymphedema, major depressive disorder, anemia, and venous insufficiency. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 05/11/23 revealed resident was cognitively intact and required extensive assistance of staff with ADLs. Review of the care plan for Resident #7 dated 06/16/22 revealed resident was resistive to care related to preference of taking bed baths. Residents would refuse showers and state she had a bad experience at another nursing facility with her showers. Interventions included the following: allow resident to make decisions about treatment regime, to provide sense of control, educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care, encourage as much participation/interaction by the resident as possible during care, if resident resists ADLs reassure resident, leave and return, praise resident when behavior is appropriate, provide consistency in care to promote comfort with ADLs, maintain consistency in timing of ADLs, caregivers and routine, as much as possible, provide resident with opportunities for choice during care provision. Review of the care plan for Resident #7 dated 07/13/22 revealed resident had an ADL self-care performance deficit and required assistance with ADLs related to activity intolerance, decreased mobility, impaired balance, and incontinence. Interventions included the following: resident requires extensive assistance with bathing, resident prefers to only have bed baths, staff participation with hygiene and personal care. Review of the Kardex for Resident #7 undated revealed resident was to have bed baths only. Review of the shower sheets for Resident #7 revealed resident received a bed bath on the following dates in the month of May 2023: 05/03/23 05/06/23, 05/10/23, 05/13/23, 05/17/23, 05/20/23, 05/24/23 05/27/23. Shower sheets did not indicate the resident had her hair washed on any of these dates. Observation on 05/30/23 at 12:34 P.M., of Resident #7 revealed resident's hair was [NAME] length and appeared greasy and unwashed. Interview on 05/30/23 at 12:34 P.M., with Resident #7 confirmed she was unsure of the last time staff offered assistance to wash her hair. Resident #7 confirmed she preferred bed baths, and there had been times in the past when staff were able to wash her hair while she was on bed, but this had not occurred during the month of May 2023. Resident #7 confirmed she felt her hair was dirty, and she would like to have her hair washed during her bed bath at least once per week. Interview on 05/30/23 at 2:06 P.M., with Licensed Practical Nurse (LPN) #265 confirmed Resident #7's hair looked greasy and appeared unwashed. LPN #265 reviewed Resident #7's shower sheets for the month of May 2023 and confirmed resident had only received bed baths for the month. LPN #265 confirmed the only way resident could get her hair washed was if she allowed the staff to take her to the shower room. Interview on 05/31/23 at 12:55 P.M., with the Director of Nursing (DON) confirmed the facility had no rinse shampoo on hand and available to wash hair for residents who either could not get out of bed or preferred not to get out of bed to have their hair washed.

Based on medical record review and staff interview, the facility failed to ensure a pressure ulcer was adequately monitored. This affected one (#25) of one resident reviewed for pressure ulcers. The facility census was 31. Findings include: Review of the medical record of Resident #25 revealed an admitted [DATE]. The resident transferred to the hospital on 02/24/23, readmitted on [DATE], transferred to the hospital on 03/18/23, readmitted [DATE], transferred to the hospital on 03/29/23, readmitted [DATE], and transferred to the hospital on 04/29/23, and readmitted on [DATE]. Diagnoses included cerebral infarction, tracheostomy status, gastrostomy status, chronic respiratory failure with hypoxia, contractures of left hand, right elbow, right hand, dysphagia, acute kidney failure, severe sepsis with septic shock, pneumonia, essential hypertension, hyperlipidemia, and unspecified disorder of thyroid. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition could not be assessed. The resident exhibited inattention and an altered level of consciousness continuously during the survey period. The resident was dependent on two staff for bed mobility, transfers, and toileting. Review of the nursing progress note dated 05/09/23 at 3:28 P.M., revealed the resident readmitted to the facility from the hospital. A head-to-toe assessment was completed, and identified a deep tissue injury to the bottom of the left great toe, measuring 2.5 cm (centimeters) by 1.5 cm. The area was painted with betadine and the resident was to follow up with wound care. Review of the plan of care dated 05/11/23 revealed the resident was at risk for skin breakdown related to decreased mobility, decreased strength, and incontinence. The resident was noted on 05/09/23 to have been readmitted to the facility with skin breakdown on her right great toe. Interventions included to monitor, document, and report to the physician PRN (as needed) changes in skin status including appearance, color, and signs/symptoms of infection. Review of physician orders revealed an order dated 05/10/23 to paint area to bottom of right great toe with betadine BID (twice per day). Review of the medical record revealed no evidence of skin rounds, wound progress notes, nor measurements noted after identification of the area on the right great toe on 05/09/23. Interview on 05/31/23 at 3:28 P.M., with the Director of Nursing (DON) verified there were no wound progress notes nor measurements present in Resident #25's chart since identifying the area on 05/09/23.

Based on record review, observation, staff interview, and review of policy, the facility failed to ensure fall prevention/management interventions were in place for a resident assessed at risk for falls. This affected two (#9 and #24) of three residents reviewed for accidents. The facility census was 31. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE], with diagnoses including: cerebral infarction, diabetes mellitus (DM), alcoholic cirrhosis of the liver, traumatic subarachnoid hemorrhage, aphasia, dysphagia, hypertension (HTN), hyperlipidemia, spinal stenosis, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 04/20/23 revealed resident was cognitively impaired and required extensive assistance of one staff with bed mobility and ambulation and extensive assistance of two staff with transfers. Review of the fall risk assessment for Resident #9 dated 04/14/23 revealed resident was at risk for falls. Review of the care plan for Resident #9 dated 04/14/23 revealed resident was at risk for falls related to falls at home, impulsivity, care plan, non-compliant with safety recommendations, antihypertensive medications, decreased mobility, impaired cognition, poor balance secondary to right hemiparesis. Interventions included the following: anticipate and meet resident needs, educate about safety reminders and what to do if a fall occurs, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure call light is within reach and encourage resident to use it for assistance as needed, nonskid footwear, staff to ensure wheels of the bed are locked at all times for safety, therapy evaluation as needed. Review of the undated Kardex for Resident #9 revealed the resident should have fall mats to both sides of the bed for fall prevention/management. Review of the nurse progress note for Resident #9 dated 05/19/23 (Friday) revealed the hospice nurse would be ordering fall mats for resident which would be delivered over the weekend. Review of the hospice nurse assessment for Resident #9 dated 05/26/23 revealed the resident was at risk of falling. Review of the hospice nurse visit note for Resident #9 dated 05/27/23 revealed fall precautions would be initiated to minimize the incident of falls which included the following: keep bed in lowest position and locked with fall mats in place, instruct caregivers in safety precautions to prevent injury, review hospice plan of care with facility staff. Observation on 05/30/23 at 10:23 A.M., revealed the resident was resting in bed on a low air loss mattress with a fall mat on the floor to the right side of resident's bed. There was another fall mat which was propped up against the wall on the other side of the room away from resident's bed. Interview on 05/30/23 at 10:25 A.M., with State tested Nursing Assistant (STNA) #270 confirmed Resident #9 did not have a fall mat to the floor to the left side of his bed. STNA #270 confirmed Resident #9 was supposed to have fall mats to both sides of the bed at all times because resident was at risk for falls. Interview on 05/31/23 at 11:57 A.M., with Licensed Practical Nurse (LPN) #250 confirmed Resident #9 should have fall mats to both sides of his bed when he was in bed because he was at high risk for falls out of bed. LPN #250 confirmed Resident #9 was unable to ambulate by himself and/or remove the fall mats. 2. Review of the medical record for Resident #24 revealed an admitted [DATE], with diagnoses including: multiple sclerosis (MS), metabolic encephalopathy, chronic respiratory failure with hypoxia, and quadriplegia. Review of the care plan for Resident #24 dated 11/01/22 revealed resident was at risk for falls related to decreased mobility, poor balance, poor safety awareness, use of diuretic med secondary to diagnosis of MS, encephalopathy, muscular dystrophy. Interventions included the following: anticipate and meet resident needs, educate about safety reminders and what to do if a fall occurs, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, encourage use of call light/EZ pad call button in reach, fall mats to both sides of bed for safety, follow facility fall protocol, therapy to evaluate and treat as ordered, review information on past falls and attempt to determine cause of fall, record possible root causes, alter/remove any potential causes if possible, staff to ensure wheels of the bed are locked at all times for safety. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 05/18/23 revealed resident was cognitively impaired and required extensive assistance of two staff with bed mobility and was totally dependent on assistance of staff with transfers. Resident #24 was non-ambulatory. Review of the fall risk assessment for Resident #24 dated 05/22/23 revealed resident was at risk for falls. Review of the undated Kardex for Resident #24 revealed resident should have fall mats to both sides of the bed for safety. Observation on 05/30/23 at 12:08 P.M., of Resident #24 revealed resident was resting in bed on a low air loss mattress with a fall mat in place on the floor to the left side of the bed. There was no fall mat on the right side of the bed. A fall mat was folded up and stored underneath the bed. Interview on 05/30/23 at 12:26 P.M., with STNA #225 confirmed Resident #24's fall mat was folded up and being stored underneath the bed. STNA #225 confirmed Resident #24 was a fall risk and should have fall mats on both sides of the bed. Observation on 05/30/23 at 12:26 P.M., revealed STNA #225 pulled fall mat which was folded up and stored under Resident #24's bed. STNA #225 used her foot to pull the fall mat out from under the bed and positioned the mat next to the right side of the resident's bed after discussion with the surveyor. STNA #225 did not unfold the mat after positioning to the right side of the bed. The mat was folded into three sections. Interview on 05/30/23 at 12:29 P.M., with LPN #160 confirmed Resident #24 was at high risk for falls and should have fall mats to both sides of the bed at all times while in bed. LPN #160 confirmed the fall mat on the right side of the bed was folded up and should be unfolded to provide fuller coverage and minimize the risk of injury in the event of a fall. Review of the undated policy titled Fall Risk Education revealed the facility would ensure appropriate communication methods to ensure direct care staff and management are aware of residents who are at risk for falls and will communicate fall interventions via the following: 24-hour report, the resident's care plan, nurse aide assignment sheets, visual cues.

Based on record review, observation, staff interview, and review of policy, the facility failed to ensure gastrostomy tubes (g-tubes) ands supplies were maintained in a sanitary manner. This had the potential to affect one (#24) of one residents reviewed for tube feedings. The facility identified three residents with g-tubes. The facility census was 31. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE], with diagnoses including: multiple sclerosis (MS), metabolic encephalopathy, chronic respiratory failure with hypoxia, and quadriplegia. Review of the Minimum Data Set (MDS) for Resident #24 dated 05/18/23 revealed resident was cognitively impaired and required extensive assistance of one staff with eating. Review of the care plan for Resident #24 dated 12/19/22 revealed resident required tube feeding related to dysphagia and aspiration risk. Resident may have pureed foods for pleasure, and tube feed remains primary source of nutrition. Interventions included the following: check for tube placement and gastric contents/residual volume per facility protocol and record, discuss with me/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications, follow physician orders for tube feeding and water flushes, keep head of bed elevated during and thirty minutes after tube feeding. Review of May 2023 monthly physician orders for Resident #24 included an order dated 01/09/23 for a continuous tube feeding at 43 milliliters (ml) per hour and to flush tube with 160 ml of water every four hours. Observation on 05/30/23 at 12:05 P.M., of Resident #24 revealed the resident had a continuous tube feeding of Fibersource running via pump at 43 ml per hour. There was a bag of water running via pump set to flush 160 ml of water every four hours. There was a tube feeding syringe at Resident #24's bedside which was not dated. Interview on 05/30/23 at 12: 29 P.M., with Licensed Practical Nurse (LPN) #160 confirmed she had used the syringe hanging at resident's bedside for medication administration that morning and it was undated. LPN #160 further confirmed she was unsure how long the syringe had been at the bedside because it was undated. LPN #160 confirmed g-tube syringes should be changed daily and should be dated upon opening. Interview on 06/01/23 at 8:44 A.M., with the Director of Nursing (DON) confirmed g-tube syringes should be replaced daily and the staff should write the date it was placed at the bedside on the syringe or the plastic bag in which it was stored. Review of the policy titled Enteral Tube Medication Administration dated November 2021, revealed the facility would assure safe and effective administration of enteral formulas and medications via enteral tubes. The nurse will use a 60 ml enteral syringe for flushing the tube, checking the tube for appropriate placement, checking tube for residual, and administration of medications and enteral formulas.

Based on record review, resident interview, staff interview, and review of policy, the facility failed to ensure staff administered medications as ordered by the physician. This affected three (#5, #7, and #21) of six residents reviewed for medications. The census was 31 residents. Findings include: 1. Review of the medical record for Resident #7 revealed an admitted [DATE], with diagnoses including: cerebral infarction, diabetes mellitus (DM), lymphedema, major depressive disorder, anemia, and venous insufficiency. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 05/11/23 revealed resident was cognitively intact and required extensive assistance of staff with ADLs. Review of eye doctor visit note for Resident #7 dated 11/10/22 revealed the resident had primary glaucoma to both eyes. The eye doctor made a recommendation for the resident to add brimonidine eye drops to her treatment regime. Review of the May 2023 monthly physician orders for Resident #7 revealed an order dated 11/13/22 for resident to receive brimonidine tartrate 0.2% solution eye drops with instructions to instill one drop in each eye twice daily for glaucoma. Review of the May 2023 Medication Administration Record (MAR) for Resident #7 revealed the 8:30 A.M. and 4:30 P.M. doses of brimonidine were not signed off as administered on 05/02/23, 05/03/23, and 05/04/23. Review of nurse progress notes for Resident #7 dated 05/02/23 timed at 10:16 A.M., 05/02/23 at 4:36 P.M., 05/03/23 at 4:30 P.M., 05/04/23 at 10:41 A.M., and 05/04/23 timed 5:37 P.M., revealed the resident did not receive brimonidine eye drops which were scheduled to be administered twice daily at 8:30 A.M. and 4:30 P.M., due to eye drops were not available for administration. Interview on 05/30/23 at 12:34 P.M., with Resident #7 confirmed she had been diagnosed with glaucoma and was followed by the facility eye doctor. Resident #7 confirmed the facility had run out of her brimonidine eye drops earlier in the month of May and she went several days without receiving her medication. Interview on 06/01/23 at 1:12 P.M., with the Director of Nursing (DON) confirmed Resident #7 did not receive brimonidine eye drops on 05/02/23, 05/03/23, and 05/04/23. DON confirmed the bottle of brimonidine got lost or accidentally discarded so she had to give approval for the facility to provide a new bottle. 42731 2. Review of the medical record of Resident #05 revealed an admitted [DATE]. Diagnoses included unspecified sequalae of unspecified cerebrovascular disease, hemiplegia affecting right dominant side, type 2 diabetes mellitus, chronic obstructive pulmonary disease, aphasia, dementia with behavioral disturbance, major depressive disorder, arthroplasty, and mood disorder. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required extensive assistance of two for bed mobility and toileting and was dependent on two for transfers. Review of a physician order dated 01/30/23 revealed an order to decrease Seroquel to 50 milligrams (mg) by mouth twice per day, then, on 02/13/23, decrease Seroquel to 25 mg by mouth twice per day. Review of physician orders revealed a completed physician order dated 01/31/23 and discontinued the same date for Seroquel-50 mg by mouth twice per day and an active order dated 01/30/23 for Seroquel 25 mg by mouth twice per day. Interview on 05/31/23 at 10:54 A.M., with Licensed Practical Nurse (LPN) #345 verified the Seroquel order dated 01/30/23 was not entered correctly. 44412 3. Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, congestive heart failure, chronic kidney disease, stage three A, and major depressive disorder. Review of the Admission MDS assessment dated [DATE] revealed Resident #21 had moderate cognitive impairment and was assessed to require one-person extensive assistance with transfers, dressing, and toileting, supervision with eating, and one-person total dependence with bathing. Review of the care plan dated 05/09/23 revealed Resident #21 had a nutritional problem related to CHF, depression, anxiety, significant weight decreases for last 30 days on 05/09/23. Interventions included administering medications as ordered and monitoring and documenting side effects and effectiveness. Staff to assist with developing a support system to aid in weight loss efforts. Staff to encourage healthy eating habits. Staff to monitor weight per protocol. Staff provide a calm and quiet setting at mealtimes with adequate eating time. Dietician to evaluate and make diet change recommendations as needed. Review of the physician order dated 04/21/23 revealed Resident #21 was ordered Megestrol Acetate oral suspension 40 milligrams (mg)/milliliter (ml), give 10 ml by mouth two times a day related to adult failure to thrive. Review of the progress notes dated 05/23/23 through 05/30/23, for Resident #21, revealed Megestrol Acetate was not available for administration and awaiting from pharmacy. Review of the medication administration record (MAR) for May 2023 revealed Resident #21 did not receive Megestrol Acetate on 05/23/23, 05/24/23, 05/26/23, 05/27/23, 05/28/23, and 05/30/23. Interview on 05/30/23 at 9:01 A.M., with LPN #160 verified Resident #21 had been out of his Megestrol Acetate since last Tuesday or Wednesday. LPN #160 reported pharmacy had not been notified, but the facility had still not received the medication. Review of the policy titled, Medication Administration - General Guidelines, dated November 2021 revealed medications were prepared only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to prepare and administer medications. If a dose of regularly scheduled medications was withheld, refused, not available, or not given at a time other than the scheduled time, the space provided on the front of the MAR for that dosage administration was initialed and circled. An explanatory note was entered on the reverse side of the record. If three consecutive doses or per facility protocol, of a vital medication were withheld, refused, or not available, the physician was notified. Nursing documented the notification and physician response.

Based on medical record review and staff interview, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected two (#05 and #13) of five residents reviewed for unnecessary medications. The facility census was 31. Findings include: 1. Review of the medical record of Resident #13 revealed an admitted [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, frontal temporal neurocognitive disorder, type 2 diabetes mellitus, dysphagia, major depressive disorder, attention-deficit hyperactivity disorder, post-traumatic stress disorder, dementia without behavioral disturbance, and hypothyroidism. Review of the annual Minumum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident required extensive assistance of one staff for bed mobility, limited assist of one staff for transfers, toileting, and ambulation, and supervision for eating. Review of a list titled, Consultant Pharmacist's Medication Regimen Review, for recommendations created between 01/01/23 and 06/01/23 revealed the following recommendations: a. Recommendations dated 03/03/23 and 05/05/23 revealed the resident was taking levothyroxine 75 micrograms (mcg) daily. No recent TSH (thyroid stimulating hormone)/thyroid panel was able to be located in the medical record. Recommendations were made to consider monitoring a TSH/thyroid panel on the next lab day, then yearly thereafter if within normal limits. b. Recommendation dated 03/03/23 revealed the resident was receiving insulin and a recent A1c was unable to located in the chart. Recommendations were made to check the A1c every three months. c. Recommendation dated 03/03/23 revealed the resident was receiving atorvastatin (Lipitor) for dyslipidemia and a recent fasting lipid panel was unable to be found in the record. Recommendations were made to consider monitoring a fasting lipid panel on the next lab day and then yearly after that if within normal limits. Review of the medical record revealed no evidence of A1c, TSH/Thyroid panel, nor lipid panel being completed as recommended. Interview on 06/01/23 at 10:25 A.M., with the Director of Nursing (DON) verified the resident did not have any of the labs completed as recommended by pharmacy. 2. Review of the medical record of Resident #05 revealed an admitted [DATE]. Diagnoses included unspecified sequalae of unspecified cerebrovascular disease, hemiplegia affecting right dominant side, type 2 diabetes mellitus, chronic obstructive pulmonary disease, aphasia, dementia with behavioral disturbance, major depressive disorder, arthropathy, and mood disorder. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required extensive assistance of two for bed mobility and toileting and was dependent on two for transfers. Review of a list titled, Consultant Pharmacist's Medication Regimen Review, for recommendations created between 01/01/23 and 06/01/23 revealed a recommendation dated 04/06/23 indicating Resident #05 was receiving Lipitor (atorvastatin) 20 milligrams (mg) daily for dyslipidemia. The most recent serum lipid profile noted was normal (124). Recommendations were made to evaluate the continued need and consider taper to Lipitor 20 mg every other day and do follow up lipids in three months. Review of the medical record revealed no evidence of a serum lipid panel being obtained following the pharmacy recommendations dated 04/06/23. Interview on 06/01/23 at 11:49 A.M., with the DON verified lab work had not been completed as recommended by the pharmacy recommended.

Based on record review, staff interview, and review of policy, the facility failed to ensure physician's orders for as needed anti-anxiety medications included a stop date or duration for the order. This affected two (#9 and #18) of six residents reviewed for medications. The facility census was 31. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses including cerebral infarction, diabetes mellitus, alcoholic cirrhosis of the liver, traumatic subarachnoid hemorrhage, aphasia, dysphagia, hypertension, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 04/20/23 revealed resident was cognitively impaired and required extensive assistance of one staff member with activities of daily living (ADLs.) Review of the May 2023 monthly physician orders for Resident #9 revealed orders dated 05/18/23 for resident to receive Ativan tablets 1 milligram (mg) or 2 mg every two hours as needed for anxiety. There was no stop date or duration indicated for the Ativan order. Interview on 06/01/23 at 1:12 P.M., with the Director of Nursing (DON) confirmed Resident #9's as needed Ativan orders dated 05/18/23 did not include stop dates. 44412 2. Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, generalized anxiety disorder, atrial fibrillation, and pneumonia. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #18 had intact cognition and assessed to require one-person extensive assistance with transfers, dressing, and toileting, supervision with eating, and one-person total dependence with bathing. Review of the care plan dated 04/21/23 revealed Resident #18 used anti-anxiety medications related to anxiety disorder. Interventions included to give anti-anxiety medications ordered by physician and monitor and document side effects and effectiveness. Staff to monitor for drowsiness, dizziness, tiredness, muscle weakness, and headache. Staff to educate about risks, benefits, and side effects and/or toxic symptoms. Review of the physician order dated 05/29/23 revealed Resident #18 was ordered Lorazepam two milligrams (mg)/milliliter (ml), give 0.25 ml by mouth every six hours as needed for anxiety. The physician order revealed there was no end date. Interview on 06/01/23 at 1:12 P.M., with the Director of Nursing (DON) verified Resident #18 did not have an end date for the Lorazepam order. Review of the policy titled, Medication Monitoring and Management, dated January 2018 revealed residents do not receive as needed (PRN) medications unless necessary to treat a diagnosed specific condition which must be documented in the record. PRN orders for psychotropic medications which were not antipsychotic medications were limited to 14 days. The attending physician may extend the order beyond 14 days if he or she believes it was appropriate. If the attending physician extended the PRN for the psychotropic medication, the medical record must contain a documented rationale and determined duration.

Based on record review, observation, resident interview, and staff interview, the facility failed to ensure residents were examined by a dentist. This affected one (#7) of 13 residents sampled. The facility census was 31. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnoses including cerebral infarction, diabetes mellitus, lymphedema, major depressive disorder, anemia, and venous insufficiency. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 05/11/23 revealed resident was cognitively intact and required extensive assistance of staff with activities of daily living (ADL). Review of the care plan for Resident #7 dated 07/13/22 revealed resident had an ADL self-care performance deficit and required assistance with ADLs related to activity intolerance, decreased mobility, impaired balance, and incontinence. Interventions included staff should assist residents with oral hygiene. The care plan did not include documentation regarding dental consult and/or resident's missing teeth. Review of the medical record for Resident #7 revealed the record did not include documentation regarding dental consultations for resident during her stay at the facility. Observation on 05/30/23 at 12:34 P.M., revealed Resident #7 had natural teeth with a few missing teeth on the bottom front section of her mouth. Interview on 05/30/23 at 12:34 P.M., with Resident #7 confirmed she was missing several bottom front teeth due to decay. Resident #7 confirmed she had occasional mouth pain which did not inhibit her ability to consume adequate nutrition, and she would like to be seen by a dentist. Resident #7 confirmed she had been a resident of the facility since April 2022 and had not been offered the opportunity to be examined by a dentist. Interview on 06/01/23 at 1:12 P.M., with the Director of Nursing (DON) confirmed Resident #7 had not been examined by a dentist during her stay at the facility, and resident had been admitted on [DATE].

Based on record review and staff interview, the facility failed to complete annual employee evaluations for State tested Nurse Aides (STNA) #180 and #155. This had the potential to affect all 31 residents in the facility. The facility census was 31. Findings include: Record review of employee files for STNA #180 and #155 revealed the STNAs had dates of hire greater than one year. There were no annual evaluations for STNA #180 for the years 2021, and 2022. There were no annual evaluations for STNA #155 for the years 2021, 2022 and 2023. Interview on 05/31/23 at 12:06 P.M., with Scheduler #270 verified STNA #180 should have had an annual performance evaluation for the years 2021 and 2022 and STNA #155 should have had an annual performance evaluation for the years 2021, 2022 and 2023. Scheduler #270 also verified the annual performance evaluations for all STNA, who had been hired greater than a year, had not been completed for the years 2021, 2022 and those evaluations due in 2023.

Based on medical record review, observation, and staff interview, the facility failed to monitor a resident's non-pressure skin breakdown. This affected one (#22) of three reviewed for wound care. The census was 29. Findings include: Review of Resident #22's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #22 was assessed as being severely cognitively impaired, requiring extensive assistance with activities of daily living (ADL's), and being always incontinent of bowel and bladder in am admission Minimum Data Set (MDS) assessment dated [DATE]. Review of Resident #22's comprehensive care plan revealed no documentation of any skin alteration to the right buttocks. Review of progress notes dated 03/01/22 at 11:33 A.M. revealed a new order was obtained for [MEDICATION(S)] (wound treatment) cream and barrier (skin protectant) cream to an area of suspected moisture associated skin damage (MASD) to the right buttock. Review of progress notes dated 03/21/22 at 7:55 A.M. revealed Resident #22 has an open area to the right buttocks, scant amount of blood noted on brief, wound bed is beefy red, and no signs or symptoms of infection noted. Physician was notified and awaiting a follow-up response. Review of progress noted dated 04/05/22 at 11:17 A.M. revealed a treatment was in place for right buttock. No signs or symptoms of infection were noted. Review of weekly skin assessments dated 03/02/22, 03/09/22, 03/24/22, and 04/06/22 revealed no documentation of the area to Resident #22's right buttock. Review of a weekly skin assessment dated [DATE] revealed Resident #22 was documented with a skin tear to the right buttock measuring 3.0 centimeters (cm) x 1.0 cm. Review of Wound Nurse Practitioner (WNP) noted dated 04/19/22 documented Resident #2 had a superficial area of mechanical irritation/moisture associated skin damage on the right buttock. Area measured 3.0 cm x 1.0 cm x 0.1 cm with 75 percent (%) granulation and 25% epithelial tissue. Area likely developed secondary to extreme difficulty in repositioning patient due to severe contracture of right knee, and secondary to mixed incontinence and [CONDITION(S)] ([CONDITION(S)] skin condition). Healing will likely be slowly secondary to incontinence and difficulty repositioning. Observation of Resident #22's skin on 04/19/22 at 2:18 P.M. revealed an oval shaped shaped open area to right buttocks. Wound was red in color with no drainage or odor noted. During an interview on 04/20/20 at 2:39 P.M. the Director of Nursing (DON) confirmed when Resident #22 was identified with a skin alteration to the right buttock on 03/01/22 the skin alteration was not assessed again until 03/21/22. The DON confirmed after 03/21/22 the skin alteration to Resident #22's right buttock was not assessed again until 04/19/22. The DON confirmed that the skin alteration was not documented on wound round documentation dated 04/01/22, 04/07/22, and 04/14/22. This deficiency substantiates Complaint Number OH 659.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL, review of the COVID-19 staff vaccination status and staff roster, review of the facility's list of COVID-19 positive residents, review of the Centers for Disease Control and Prevention (CDC) guidance, review of a vaccination card, review of the list of COVID positive residents, staff interview, and review of the facility's policy, the facility failed to ensure the staff COVID-19 vaccination rate was 100%. The facility's COVID-19 vaccination rate was 96.2%. The facility census was 32. Findings include: Review of the undated facility COVID-19 staff vaccination status revealed the facility had a total of 26 employees. There were 25 employees fully vaccinated for COVID-19 or with exemptions. There was one employee (Laundry Aide #19) who was partially vaccinated against COVID-19 and did not have an exemption, indicating a staff vaccination rate of 96.2%. Review of the undated facility's staff roster revealed Laundry Aide #19 was hired by the facility on 01/15/14. Review of Laundry Aide #19's COVID-19 vaccination card revealed Laundry Aide #19 received her first Pfizer COVID-19 vaccine on 12/01/21. There was no second dose recorded on the vaccination card. Review of the facility's undated list of COVID-19 positive residents revealed there had not been any residents diagnosed with COVID-19 in the past four weeks. Interview with the Administrator on 04/08/22 at 1:18 P.M. verified Laundry Aide #19 did not receive her second Pfizer vaccination and Laundry Aide #19 was not fully vaccinated. The Administrator also confirmed Laundry Aide #19 continued to work at the facility without being fully vaccinated for COVID-19 or have an exemption. Interview with Laundry Aide #19 on 04/08/22 at 1:22 P.M. revealed Laundry Aide #19 received her first vaccine at a pharmacy in the community in December 2021 and she had a second appointment to get her second COVID-19 vaccine, but she did not go and get it because of personal reasons. Laundry Aide #19 stated she did not have a medical or religious exemption at the facility. Review of the Centers for Disease Control and Prevention (CDC) guidance titled COVID-19 Vaccine Interim COVID-19 Immunization Schedule for Ages Five Years and Older dated 03/11/22, revealed a recipient age of [AGE] years and older who received the Pfizer-BioNTech product should get the second dose by at least three to eight weeks after the first dose. Review of the facility's vaccination policy dated 08/16/21 revealed all current employees are encouraged to receive the COVID-19 vaccination within 30 days of the effective date of the policy unless otherwise exempted from the policy by an approved accommodation pursuant to the interactive process. Fully and properly vaccinated under the policy included all individuals who have received two doses of a two dose vaccine series such as Pfizer. Review of the Centers for Medicare & Medicaid Services (CMS) memorandum, QSO-22-09-ALL regarding COVID-19 health care staff vaccination, dated 01/14/22, revealed CMS expected all providers' and suppliers' staff to have received the appropriate number of doses by the time frames specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by the Centers for Disease Control (CDC). Facility staff vaccination rates under 100% constituted non-compliance under this rule. Within 60 days after issuance of the memorandum, if less than 100% of all staff have received at least one dose of a single-dose vaccine, all doses of a multiple-dose vaccine series, have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the CDC, the facility is non-compliant under the rule.

Based on observation, staff interview, review of online resources per the Centers for Disease Control (CDC) and the Center for Medicare and Medicaid Services (CMS), and review of facility policy, the facility failed to ensure staff wore eye protection in resident areas to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 35 residents residing in the facility. The census was 35. Findings include: Observation on 10/22/21 at 9:21 A.M. of Registered Nurse (RN) #200, at 9:35 A.M. of State tested Nursing Assistant (STNA) #300, at 9:40 A.M. of Licensed Practical Nurse (LPN) #400, at 9:55 A.M. of STNA #350 revealed the staff were working in resident areas and were not wearing eye protection. Interviews on 10/22/21 at 9:21 A.M. of RN #200, at 9:35 A.M. of STNA #300, at 9:40 A.M. of LPN #400, at 9:55 A.M. of STNA #350 confirmed they were working in resident areas and were not wearing eye protection. Interview on 10/22/21 at 10:00 A.M. with the Director of Nursing (DON) confirmed staff were supposed to be wearing eye protection in resident areas due to the current positivity rate for COVID-19 in the county in which the facility was situated. Review of the facility policy titled COVID-19 undated revealed the facility would follow current guidelines and recommendations to ensure the facility is prepared to respond to the threat of COVID-19. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data-Test-Positivity-Rates/q5r5-gjyu/ revealed the county in which the facility was situated was experiencing a high spread of COVID-19 with a positivity rate of 13.0 percent (%) and was identified as red for the week ending in 10/12/21. Review of an online resource per the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19). at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review and staff interview, the facility failed to ensure the accuracy of resident assessments regarding hearing deficit and use of hearing aids. This affected three (#22, #32, and #36) out of three residents sampled for hearing deficits and/or who utilize hearing aids. The census was 35. Findings include: 1. Review of the medical record for Resident #22 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 07/26/21 revealed resident had adequate hearing and did not require hearing aids. Review of the care plan for Resident #22 revealed it contained no documentation regarding hearing deficit or the use of hearing aids. Observation on 10/22/21 of Resident #22 at 12:09 P.M. revealed the resident was hard of hearing and was wearing bilateral hearing aids. Interview on 10/22/21 at with Resident #22 confirmed she was hard of hearing and wore bilateral hearing aids. 2. Review of the medical record for Resident #32 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS assessment for Resident #32 dated 08/12/21 revealed resident had adequate hearing and did not require hearing aids. Review of the care plan for Resident #32 revealed it contained no documentation regarding hearing deficit or the use of hearing aids. Observation on 10/22/21 of Resident #32 at 12:11 P.M. revealed the resident was hard of hearing and was wearing bilateral hearing aids. Interview on 10/22/21 at with Resident #32 at 12:11 P.M. confirmed she was hard of hearing and wore bilateral hearing aids. 3. Review of the closed medical record for Resident #36 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment for Resident #36 dated 08/13/21 revealed resident had adequate hearing and did not require hearing aids. Review of the care plan for Resident #36 dated 09/18/19 revealed resident was at risk for a communication problem related to a hearing deficit. Interventions included to ensure resident had access to her hearing aids/batteries. Interview on 10/22/21 at 5:00 P.M. with the Director of Nursing (DON) confirmed Resident #22, #32, and #36 had hearing deficits and utilized hearing aids. DON further confirmed the MDS assessments for Residents #22, #32, and #36 were not accurate regarding resident hearing status. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, staff and resident interviews, and policy review the facility failed to protect residents from physical abuse. The facility failed to recognize an escalation in behavior of one employee. This resulted in harm to resident (#24) who received a small bruise and complained of pain after a staff member pulled on her arm. Three residents were sampled. The census was 44. Findings include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] revealed Resident #24 was assessed as moderately impaired for cognitive function was an extensive one person assist with ambulation and personal hygiene and a one person physical assist with bathing. Resident # 24 was assessed as not steady with ambulation. Review of the nurses note dated 05/29/15 at 6:08 P.M., revealed the nurse was standing in the nurses ' station and witnessed State tested Nurse Aide (STNA) #48 pulling on Resident # 24's right upper extremity. At the time Resident #24 was sitting in a recliner in the bird room watching TV and her hair was wet. STNA #48 was attempting to have Resident #24 go with her to get a shower. Resident #24 was stating she already had a shower; she was yelling and cursing, telling STNA #48 to stop. STNA #48 continued to pull on Resident #24's arm. A nurse and two other STNA's intervened and separated STNA #48 and Resident #24. The resident was taken to a safe place, her room and a head to toe skin assessment was completed by the nurse. No redness or skin issues were noted and the resident denied any pain or discomfort. Review of the nurse ' s note dated 05/30/15 at 4:48 A.M. revealed Resident # 24 told the nurse her right arm was sore and pointed to her elbow. Upon assessment a small quarter sized bruise on the outer side of elbow was noted. Resident #24 indicated her arm was sore from STNA #48 pulling on her arm. Active and passive range of motion (ROM) performed without issue. On 06/15/15 at 12:39 P.M. an interview with Resident #24 revealed STNA #48 hurt her arm when she pulled it. Resident #24 stated she had told STNA #48 to leave her alone and that STNA #44 had already assisted her with a shower, but STNA #48 would not listen. Resident #24 stated STNA #48 started a fight with STNA #44 in the hall and Resident #24 almost fell . STNA #44 helped the resident and STNA #48 followed them into the bird room. All the nurses came to the bird room to help Resident #24. A review of STNA #48's employee file review revealed she was hired on 03/25/15, was from another country and English was a second language. The nurse aide registry report dated 02/23/15 revealed she had received her certification in 02/2015 and was in good standing. The facility had completed former employee reference checks and a background check with no issues. The employee file was silent for any write ups or verbal warnings. On 06/15/15 at 12:50 P.M., an interview with Licensed Practical Nurse (LPN) #55 revealed she was working on the day of the incident but was at the desk when she saw STNA #48 trying to get Resident #24 to go to the shower room. Resident #24 was sitting in a recliner in the bird room. STNA #48 was pulling on Resident #24's arm saying, shower, shower, shower, over and over. LPN #55 stated sometimes she had to Google Spanish in order to communicate care needs of the residents with STNA #48. She stated sometimes she had to pull up her high school Spanish to get her point across to STNA #48. On 06/15/15 at 12:57 P.M., an interview with STNA #44 revealed she was working at the computer in the hall when she saw STNA #48 come out of Resident #24's room with Resident #24. STNA #44 stated she called the name of STNA #48, but STNA #48 did not respond so she placed her hand on STNA #48's shoulder to get her attention. STNA #48 screamed at her in front of Resident #24. STNA #48 let go of Resident #24 and shoved STNA #44. STNA #44 assisted the resident to the bird room and sat her in a recliner. STNA #44 indicated she reported the incident of STNA #48 shoving her to the nurses on the unit and told them she had already showered Resident #24. The Director of Nursing (DON) took both of the STNA's into her office and discussed the issue with them. After this STNA #48 went into the bird room and started to pull on Resident #24's arm. Resident #24 told her she already had a shower and she kept telling STNA #48, no, but STNA #48 kept pulling at her arm. The nurses came running into the bird room and STNA #44 backed up out of the area. STNA #44 indicated this occurred close to the end of her shift which was 3:00 P.M. STNA #44 stated when STNA #48 first started working at the facility she did well with communication, but she got worse at understanding direction. STNA #44 stated she would tell STNA #48 the correct way to do something and she felt STNA #48 thought she was being bossed around. STNA #44 stated she did know what time STNA #48 left the building. On 06/15/15 at 1:15 P.M., an interview with STNA #40 revealed she had adjusted the shower assignment to make it more equal for staff. STNA #48 was assigned to care for Resident #24, except for her shower. STNA #44 was assigned to shower Resident #24. STNA #48 was observed next to the shower room with Resident #24, STNA #44 informed STNA #48 she had already completed Resident #24's shower. STNA #48 continued to insist Resident #24 go to the shower room. STNA #44 assisted Resident #24 to the bird room and sat her in a recliner. STNA #48 went into the bird room and started to pull on Resident #24's arm. STNA #44 intervened and told STNA #48 to stop doing that. STNA # 40 said she also told STNA #48 to stop but she would not listen. The nurse on the unit was able to get her to stop pulling on Resident #24's arm. STNA #40 indicated this occurred around 3:00 P.M. She further indicated they had to adjust the evening assignment and pull an STNA from the dining room to pass trays in the hall for STNA #48. On 06/15/15 at 1:26 P.M. during an interview with Licensed Practical Nurse (LPN) #50 she stated she was at the computer and she heard Resident #24 yelling, stop, stop When she looked up she saw a nurse and a couple of STNA's trying to separate STNA #48 from Resident #24. LPN #50 was the nurse assigned to care for Resident #24 that day so she took her into her room and did an assessment. LPN #50 indicated there was a little redness around her right elbow but at that time Resident #24 denied any pain. The DON, another nurse on duty and LPN #50 removed STNA #48 from the facility. The DON and LPN #50 reenacted the incident for STNA #48 to help her understand why she was being removed from the facility. STNA #48 was saying LPN #50 was a liar and the incident did not happen the way LPN #50 said it did. The other nurse attempted to explain to STNA #48 what the concern was. LPN #50 stated the entire incident from start to the time STNA #48 exited the building was approximately 3:30 P.M. to about 5:15 P.M. LPN # 50 stated she saw a quarter size bruise on Resident #24's elbow area the day after the incident. On 06/15/15, a review of the Self-Reported Incident # the facility investigation and the employee statements from 05/29/15 revealed there were issues with STNA #48 not answering call lights during other staff lunch breaks prior to the incident. These concerns were reported to the DON. The issues with STNA #48 screaming at STNA #44 in front of Resident #24 was also reported to the DON prior to STNA #48 pulling on Resident #24's arm. A review of the facility Abuse, Neglect, Misappropriation and Injury of Unknown Source Policy dated 05/16/14 revealed number 13 part C of the policy Interpretation and Implementation revealed the facility staff were educated on how to recognize signs of burnout, frustration and stress that may lead to abuse. This deficiency substantiates Control Number OH 485.