Every finding on record at Mccrea Manor NSNG and Rehab CTR LLC

Based on interview, record review, and facility policy, the facility failed to ensure narcotic medications were administered per physician orders and reconciled properly. This affected one resident (Resident #71) of three residents reviewed for medications. The facility census was 65. Findings include:1.Review of the medical record for Resident #71 revealed an admission dare of 01/29/26 and a discharge date of 02/26/26 to home with diagnoses including but not limited to encephalopathy, low back pain, spinal stenosis cervical region and anxiety.Review of the care plan dated 01/29/26, revealed Resident #71 was at increased risk of adverse reactions related to taking opiates. Interventions included to administer medications as ordered by physician and monitor for side effects of medication.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had intact cognition. Review of physician orders dated for February 2026, revealed Resident #71 was ordered Klonopin (Clonazepam), 0.5 milligram (mg) give one (1) tablet by mouth (PO) two times a day (BID) for anxiety. Review of the medication administration records (MARS) and treatment administration records (TARS) for February 2026 revealed on 02/01/26 the morning dose (AM) dose, 02/02/26 the morning and evening dose, and on 02/16/26 the morning and evening dose for Clonazepam 0.5 mg had a number nine placed in the box to indicate not given and number nine was a code to Other/See Nurses Notes. Review of the narcotic sign out sheet for February 2026 revealed Clonazepam 0.5 mg was not signed out for the above doses. Review of Resident #71's progress notes revealed there was not a note for 02/01/26 regarding Klonopin 0.5 mg not being administered.Review of the progress note dated 02/02/26 at 9:02 A.M. revealed Klonopin 0.5 mg was not administered due to awaiting from pharmacy and the nurse practitioner was notified of the need for a refill.Review of the progress note dated 02/16/26 at 9:36 P.M. revealed Klonopin 0.5 mg was not administered due to waiting on new prescription.Interview on 03/23/26 at 1:44 P.M. with Interim Director of Nursing (DON) confirmed Resident #71 did not receive her Clonazepam 0.5 mg on 02/01/26 in the morning, 02/02/26 morning and evening dose, and on 02/16/26 morning and evening. Interim DON confirmed five doses of Clonazepam were missed.Review of facility policy, Administering Medications, revised 04/28/25, revealed medication shall be administered in a safe and timely manner, and as prescribed accordance with the orders.2. Review of the narcotic sign out sheet for Resident #71 revealed Clonazepam 1 mg available and order for Clonazepam 0.5 mg to be administered BID. The narcotic sign out sheet dated 02/18/26 at 10:00 A.M. revealed Registered Nurse (RN) #204 wasted Clonazepam 0.5 mg and signed for it. There was no second witness signature as required.Review of the Narcotic Sign out sheet for Resident #71 revealed Clonazepam 1 mg available and order for Clonazepam 0.5 mg to be administered BID. The narcotic sign out sheet dated 02/19/26 at 09:15 A.M. revealed RN #251 wasted Clonazepam 0.5 mg and signed for it. There was no second witness signature.Interview on 03/23/26 at 1:44 P.M. with Interim Director of Nursing (DON) confirmed Resident #71 was ordered Clonazepam 0.5 mg was to be administered BID. DON confirmed the narcotic sign out sheet for 02/18/26 at 10:00 A.M. and on 02/19/26 at 09:15 A.M. had only one signature for the wasted medication of Clonazepam 0.5 mg. DON confirmed the wasted narcotic medication was to have two witnesses and two signatures of the wasted narcotic medication.Interview on 03/24/26 at 9:49 A.M. via phone, with RN #251 confirmed Resident #71 had Clonazepam 1 mg available with an order for Clonazepam 0.5 mg. RN #251 confirmed there should have been two witnesses and two signatures when the medication was wasted. RN #251 reported she always had a witness and couldn't remember why there was only one and reported maybe the other nurse walked away and didn't sign. Interview on 03/24/26 at 1:56 P.M. with RN #204 confirmed Resident #71's Clonazepam 1 mg available and order for Clonazepam 0.5 mg. RN #204 confirmed there was only her signature when the medication was wasted but should have had two nurses witness the wasting of narcotic medication, with two signatures. RN #204 reported at the time she wasn't aware she needed 2 nurses to witness and sign.Review of the facility policy, Schedule 2 Controlled Substance Medication, undated, revealed the policy is to ensure adherence to state and federal laws related to the dispensing of Schedule 2 Controlled substance medications. Further stated waste of controlled dangerous substance will include all medication destruction in the facility shall be witnessed by at least two person, each of whom shall be registered professional nurse or a licensed practical nurse. A record of each drug destruction shall be maintained.

Based on interview, record review, and facility policy review, the facility failed to ensure physician orders were followed timely. This affected one resident (#70) of three residents reviewed for quality of care. The facility census was 65.Findings include:Review of the closed medical record for Resident #70 revealed an admission date of 02/19/25 and a discharge date of 03/04/26. Diagnoses included but not limited to age related osteoporosis, hypertensive heart and chronic kidney disease with heart failure stage 3, COPD, type 2 diabetes mellitus, multiple fractures of ribs, right side, of right ulna styloid process, nondisplaced fracture of shaft of right radios, and protein-calorie malnutrition.Review of the handwritten physician orders dated 02/17/26 for Resident #70 revealed an order for one (1) Liter (L) of Normal Saline (NS) 100 cubic centimeters per hour (CC/HR) of Intravenous fluids. The handwritten order was signed by Licensed Practical Nurse (LPN) # 202 and dated 02/18/26.Review of the medication administration records (MARS) and treatment administration records (TARS) for Resident #70 for 02/18/26 revealed an order for Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) use 1 liter IV every 24 hours for dehydration until 02/19/26 run at 100 milliliter (ML) per hour start date of 02/18/26 at 6:30 P.M. was administered by Registered Nurse (RN) #204.Review of the progress notes dated 02/18/26 at 6:38 P.M., authored by RN #204, for Resident #70 revealed the peripheral IV was initiated to resident's left antecubital space. NS running at 100 milliliter/hour (ML/HR), (ML/HR and CC/HR are used interchangeably), 22 gauge needle catheter in place. Interview on 03/18/26 at 2:01 P.M. with RN #204 revealed an order for IV fluids were to be hung for Resident #70 and the two nurses prior to her refused to hang the IV and the Director of Nursing (DON) told the nurse they had to hang it.Interview on 03/19/26 at 1:48 P.M. with DON denied any knowledge of instructing RN #204 or any nurse to put in IV for Resident #70. DON denied any knowledge of nurses refused to start an IV and administer IV fluids per physician orders. DON confirmed Resident #70's IV infusion order was not initiated timely on 02/18/26, but RN #204 had all day on 02/18/26 to start the IV and administer IV fluid per physician orders. Interview on 03/19/25 at 5:25 P.M. with LPN #202, via phone, revealed she might have taken the IV order for Resident #70, but dayshift nurse was to start the IV. LPN #202 confirmed she worked on 02/17/26 midnight shift from 7:00 P.M. to 7:00 A.M. on 02/18/26.Interview on 03/23/26 at 12:19 P.M. with Interim DON #300 confirmed Resident #70's IV of NS was not timely administered. Interim DON #300 confirmed timely IV administration would be a few hours after the order was received. Interview on 03/24/26 at 10:05 A.M. with Assistant Director of Nursing (ADON) #219 denied any knowledge of instructing a nurse to put in an IV for Resident #70. ADON #219 denied any knowledge of nurses refusing to start an IV and administer IV fluids per physician orders. ADON #219 confirmed Resident #70's IV infusion order was not initiated timely on 02/18/26. Review of the facility policy, Physician Orders Policy and Procedure, revised 05/2025, revealed the purpose of this policy is to provide guidance for licensed nurses to accurately document physician and provider orders. Further states, the nurse that takes the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse.This deficiency represents non-compliance investigated under Complaint Number 2798999.

Based interview, observation, record review, and facility policy, the facility failed to ensure smoking supplies were locked and secured. This affected one (Resident #62) out of three residents reviewed for smoking. The facility census was 65.Findings include:Review of the medical record for Resident #62 revealed an admission date of 03/04/21 with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, acute chronic respiratory failure with hypoxia, epilepsy, chronic obstructive pulmonary disease (COPD), alcohol abuse, cannabis use, and tobacco use.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #62 had intact cognition.Review of the care plan for Resident #62 dated 02/13/26 revealed he is at risk for injury related to smoking, cigarettes and electronic device. Interventions included supervision at all times while smoking, smoking apron to be worn while smoking, and smoking items to be kept at the nurses station. Observation on 03/18/26 at 10:49 A.M. of Resident #62 revealed he was in bed with oxygen on per nasal cannula. On his over the bed tray next to his bed was a metal red box opened and in it was a disposable e-cigarette called a vape. Resident #62 confirmed he keeps it in his room in the red box. Interview on 03/18/26 at 10:52 A.M. with Certified Nursing Assistant (CNA) #246 confirmed Resident #62 had his e-cigarette vape in his room in the opened red metal box. Interview on 03/18/26 at 10:53 A.M. with CNA #226 confirmed Resident #62 had his e-cigarette vape in his room and wasn't permitted to have in his room.Interview on 03/18/26 at 12:58 P.M. with Director of Nursing (DON) confirmed Resident #62 was not permitted to keep his e-cigarette supplies in his room. Review of the facility policy, Lionstone Smoking, revised 10/15/24 revealed no smoking materials are permitted with the resident or in their room. All smoking materials cigarettes, cigars, lighters, vapes etc, must be kept in lock boxes at the nurse station or designated area (Per State Regulations). This deficiency represents non-compliance investigated under Complaint Number 2797255.

Based on interview, record review, and policy review the facility failed to ensure Resident #26 and Resident #4 timely received COVID-19 vaccines and failed to develop a policy related to the administration of COVID-19 vaccines for residents. This affected two residents (Resident #4 and Resident #26) out of five residents reviewed for COVID-19 vaccinations and had the potential to affect all 58 residents in the facility. The facility census was 58. 1. Review of the medical record for Resident #26 revealed an admission date of 02/19/2025. Diagnoses included diabetes mellitus, muscle weakness, COPD, and anxiety. The resident was assessed to be cognitively intact.Review of Resident # 26's Covid-19 Vaccine Consent Form revealed the resident consented to receive the Covid-19 vaccine on 10/09/25.Review of Resident #26's Immunizations revealed she had not received any COVID-19 vaccines.Review of Resident #26's December 2025 physician orders revealed the facility had not yet ordered the COVID-19 vaccine for the resident.Interview on 12/18/25 at 9:15 A.M. Resident #26 reported she signed a consent in October stating she wanted the COVID-19 vaccine. She continued that she has asked nursing twice about when she will be receiving the vaccine, but they have not been able to give her an answer.A policy regarding COVID-19 vaccination was requested and not available for review.Interview on 12/18/25 at 11:40 A.M. with Director of Nursing (DON) revealed her expectation was after a resident signed a consent for a vaccination the vaccine should be ordered and administered within a week or two of receiving the signed consent. The DON verified Resident #26's COVID-19 vaccine had not been ordered and administered. The DON also verified the facility did not have a COVID-19 vaccine policy.2. Review of the medical record for Resident #4 revealed an admission date of 10/23/2024. Diagnoses included end stage renal disease, bipolar disorder, and diabetes mellitus. The resident was assessed to be cognitively intact.Review of Resident # 4's COVID-19 Vaccine Consent Form revealed the resident consented to receive the COVID-19 vaccine on 10/09/25.Review of Resident #4's Immunizations revealed he had not received any COVID-19 vaccines.Review of Resident #4's December 2025 physician orders revealed the facility had not yet ordered the COVID-19 vaccine for the resident.A policy regarding COVID-19 vaccination was requested and not available for review.Interview on 12/18/25 at 11:40 A.M. with DON revealed her expectation was after a resident signed a consent for a vaccination the vaccine should be ordered and administered within a week or two of receiving the signed consent. The DON verified Resident #4's COVID-19 vaccine had not been ordered and administered. The DON also verified the facility did not have a COVID-19 vaccine policy.

Based on record review and interview, the facility failed to ensure Resident #13 was provided appropriate dishware and silverware to promote the resident's dignity. This finding affected one (Resident #13) of three residents reviewed for dignity while dining.Findings include:Review of the dietary communication list revealed 11 residents currently received disposable utensils/dishes including Resident #9, #11, #13, #14 (requested), #21 (plastic spoon and fork only), #26, #35, #46 (plastic spoon and fork only), #51, #54 and #59. Review of Resident #13's medical record revealed the resident was admitted on [DATE] with diagnoses including major depressive disorder, essential hypertension and generalized anxiety disorder.Review of Resident #13's Diet Communication form dated 07/03/24 revealed the resident was to have disposables only on trays due to smokeless tobacco being discarded into mugs and bowls.Review of Resident #13's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #13's physician orders revealed an order dated 09/08/25 for a reduced carbohydrate diet, regular texture with a regular thin consistency; and an order dated 11/10/25 (discontinued 11/19/25) for contact isolation due to scabies.Review of Resident #13's care plans revealed the resident was at risk for malnutrition dated 09/23/25. A note dated 12/16/25 revealed the resident's disposable wares were discontinued.Interview on 12/17/25 at 8:38 A.M. with Resident #13 revealed she did not know why she was getting paper products and plastic utensils for meals.Interview on 12/17/25 at 9:00 A.M. with Certified Nursing Assistant (CNA) #641 confirmed both Residents #13 had been receiving paper plates/plastic utensils and she did not know why she was served meals on paper plates with plastic utensils.Interview on 12/17/25 at 1:05 P.M. with Dietary Director #618 confirmed Resident #13 was on paper plates from an intervention in 2024 and she was not reassessed to determine if she should have regular plates and silverware instead of paper plates.Review of the Use of Disposables revised 08/2008 revealed to enhance the dining experience, disposable dishware and utensils shall be used only in emergency situations.This deficiency represents non-compliance investigated under Complaint Number 2655538.

Based on interview, record review, and policy review the facility failed to ensure Resident #26 timely received the pneumococcal vaccine. This affected one resident (Resident #26) out of five residents reviewed for pneumococcal vaccinations. The facility census was 58. Findings include:Review of the medical record for Resident #26 revealed an admission date of 02/19/2025. Diagnoses included diabetes mellitus, muscle weakness, COPD, and anxiety. The resident was assessed to be cognitively intact.Review of Resident # 26's Pneumococcal Vaccine Consent Form revealed the resident consented to receive the pneumococcal vaccine on 10/09/25.Review of Resident #26's Immunizations revealed she has not received any documented pneumococcal vaccines.Review of Resident #26's December 2025 physician orders revealed the facility had not yet ordered the pneumococcal vaccine for the resident.Interview on 12/18/25 at 9:15 A.M. Resident #26 reported she signed a consent in October stating she wanted the pneumococcal vaccine. She continued that she has not yet received the vaccine.Interview on 12/18/25 at 11:40 A.M. with Director of Nursing (DON) revealed her expectation was after a resident signed a consent for a vaccination the vaccine should be ordered and administered within a week or two of receiving the signed consent. The DON verified Resident #26's pneumococcal vaccine has not been ordered and administered.Review of the facility policy, Influenza and Pneumococcal Disease Prevention dated 04/28/25 revealed in order to reduce the disease-mortality and mortality associated with influenza and pneumococcal disease, influenza and pneumococcal vaccines are offered to all residents.

Based on observation, record review, and interview the facility failed to ensure Resident #49's fall interventions were consistently implemented. This finding affected one (Resident #49) of five residents reviewed for accidents.Findings include: Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease, vascular dementia, and anxiety disorder.Review of Resident #49's Fall Care Plan revealed an intervention dated 06/25/25 to toilet (take to toilet to use restroom) the resident after meals.Review of Resident #49's Fall Risk Evaluation form dated 08/02/25 revealed the resident was at risk for falls.Review of Resident #49's progress note dated 09/03/25 at 12:54 P.M. revealed at approximately 11:40 A.M., the Certified Nursing Assistant (CNA) had witnessed a resident fall onto their bottom in the dining room. The nurse assessed the resident who denied pain and did not hit her head. The resident was able to get up with no injuries. The family and physician were notified.Review of Resident #49's progress note dated 09/14/25 at 6:28 A.M. revealed the resident was found lying on her right side in the hallway. The resident was not hurt and had no injuries from the fall. Vitals were obtained and the family and physician were notified.Review of Resident #49's progress note dated 10/15/25 at 11:20 A.M. revealed the resident was with staff in the A hall shower when the resident jerked away from staff and landed on her right side. The resident sustained a quarter sized knot on the posterior head. The resident's husband and nurse practitioner was notified.Review of Resident #49's Significant Change in Mental Status Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem; was frequently incontinent of bowel and bladder and was dependent for toileting.Attempted interview on 12/15/25 at 10:34 A.M. with Resident #49 and the resident was not interviewable.Observation on 12/15/25 at 12:51 P.M. revealed Resident #49 was in the dining room. CNA #626 took the resident to her room and provided incontinence care. The resident was not taken to the restroom toilet at this time to ensure the resident did not still need to void.Interview on 12/15/25 at 1:01 P.M. with CNA #626 revealed she was unsure if Resident #49 was on a toileting plan and did not know if the resident was continent or incontinent. CNA #626 confirmed she provided incontinence care to the resident but did not take the resident to the restroom for toileting. CNA #626 confirmed there was a book at the nurses' station that had resident care needs.Interview on 12/16/25 at 1:02 P.M. with the Director of Nursing (DON) revealed the fall interventions were put into the electronic health record (EHR) as orders for the nurses and on the report sheets for CNAs.Observation on 12/17/25 at 7:40 A.M. revealed Resident #49 was in the dining room for the breakfast meal.Observation on 12/17/25 at 8:35 A.M. revealed Resident #49 was taken back to her room and put in bed. No incontinence care or toileting was provided to the resident.Interview on 12/17/25 at 8:40 A.M. with CNA #610 revealed Resident #49 was not on a toileting program and she was not provided with incontinence care or toileting after breakfast. CNA #610 confirmed incontinence care would be completed after the other residents were out of the dining room because she allows time for the drinks to work through the residents. CNA #610 confirmed there was a book at the nurses' station with resident assistance needs and fall interventions for the staff.Interview on 12/17/25 at 9:36 A.M. with the DON stated the expectation for incontinence care was to be completed every 2 hours. She stated there were residents on a toileting program, including Resident #49 to assist in preventing falls. Regarding incontinence care after breakfast, the DON confirmed the care would be completed prior to breakfast and then completed after breakfast to stay within the two-hour timeframe. She stated even with the CNAs waiting to complete incontinence care after clearing the dining room would stay within the two-hour timeframe. She notified Assistant Director of Nursing (ADON) #608 to go to memory care to remind the CNAs to complete the toileting program for Resident #49.Review of the Fall policy, revised date 08/2024, revealed if underlying causes cannot be readily identified or corrected, staff may try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for continuation of the falling is identified as unavoidable. In conjunction with the attending physician/Nurse Practitioner (NP) as needed, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. Staff will monitor resident's response to interventions intended to reduce fall or the risks of falling. If interventions have been successful in preventing falling, staff will continue the interventions of reconsider whether these measures are still needed if a problem that required the intervention has resolved. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on medical records, review of manufacturer information, observation and interview, the facility failed to ensure opened insulin pens were dated for proper use and disposal. This affected four residents (Resident #28, #46, #68, and #71) from two of three medication carts observed for medication storage. Findings include: 1. During observation of medication preparation and administration on [DATE] between 10:28 A.M. and 10:38 A.M., Registered Nurse (RN) #105 was observed preparing and administering medication to Resident #68. RN #105 administered 24 units of insulin Lispro for a blood sugar level of 269. The Kwik-pen used did not have an open date recorded but was delivered to the facility on [DATE]. RN #105 was made aware the Kwik-pen did not have an open date on it prior to administration and the delivery date and acknowledged she agreed with the information shared. Review of manufacturer information for insulin Lispro revealed the Kwik-pen should not be used for more than 28 days after the pen use started. 2. On [DATE] at 10:28 A.M., RN #105 verified there was an undated opened insulin pen (Lantus) pen for Resident #46 and an undated opened Lantus Solostar pen for Resident #28 in the medication cart. 3. On [DATE] at 11:00 A.M., Licensed Practical Nurse (LPN) #145 verified there was an undated Lantus insulin pen in one of the medication carts for Resident #71. LPN #145 stated she did not know who Resident #71 was or how long ago he might have resided at the facility. LPN #145 indicated the insulin pen would need disposed of. Review of progress notes for Resident #71 revealed he expired [DATE]. Review of the facility's Medication Storage policy (not dated) indicated medications would be stored in the original, labeled containers received from pharmacy and expired, discontinued and/or contaminated medications were to be removed from the medication storage areas and disposed of in accordance with facility policy. This deficiency represents non-compliance investigated under Complaint Number OH00163930.

Based on review of menus with spreadsheets, policy review, observation and interview, the facility failed to ensure appropriate portion sizes were served. This affected 33 residents with the potential to affect 69 of 70 residents in the facility as one resident (Resident #24) had an order for no food by mouth. The census was 70. Findings include: Review of the menu spreadsheet revealed four ounces of the rice pilaf was to be served except for those residents on carbohydrate controlled diets who were supposed to receive three ounces. Observations of the tray line on 04/07/25 at 11:15 A.M. revealed the facility was serving two ounces of rice pilaf. This was verified by [NAME] #120 at the time of the observation. [NAME] #120 was referred to the spreadsheet and verified the incorrect amount of rice pilaf had already been served. The facility identified Residents #2, #5, #6, #8, #11, #13, #14, #18, #21, #22, #23, #25, #27, #31, #32, #34, #35, #37, #39, #40, #48, #50, #53, #54, #55, #57, #59, #60, #62, #64, #65, #67, and #68 as those residents who received the inappropriate portion sizes of the rice pilaf. Review of the facility diet list revealed Resident #24 received no food by mouth. Review of the facility's Portion Control Guidelines (revised August 2008) revealed portion control shall be used to ensure nutritional adequacy of standardized recipes, positive nutritional status and cost control. Portion sizes shall be written on recipes, spreadsheets and production sheets. Portion control utensils shall be used during food preparation and service. This deficiency represents non-compliance investigated under Complaint Number OH00164119.

Based on observation and interview, the facility failed to maintain the environment in a clean and sanitary condition. This affected twelve residents (Resident #4, #8, #10, #15, #18, #23, #24, #27, #28, #36, #38, and #57) of fifteen resident rooms observed for cleanliness. Findings include: 1. During observation of medication administration in Resident #27's room on 04/07/25 at 9:17 A.M., it was observed the floor was dirty. Resident #27 had a urinal on the floor under his bed. The stripping on the side of Resident #36's over bed table had pulled away from the surface on one long side of the table and 1/2 of one short side. On 04/07/23 at 9:23 A.M. Certified Nursing Assistant (CNA)/med tech #125 verified the table was in disrepair and stated the floor could be cleaner. On 04/07/25 at 9:50 A.M., the Administrator verified the environmental concerns identified in Resident #27's room. 2. During observation of medication administration in Resident #24's on 04/09/25 at 9:37 A.M., a used toothette was observed on the floor near the trash can. A disposable glove was noted on the floor inside of the closet. Observations under Resident #24's bed revealed a ball of dust, a plastic bottle and a crayon. Resident #24 had a hair bush and paper under her bed. There was a plastic bag on the floor by the oxygen concentrator and a white substance on the floor in front of the night stand. The bathroom floor had one lighter area of brown between the toilet and doors which appeared to be the original coloring of the floor. The remainder of the flooring was dark. There was build up of dirt around the bolts at the base of the toilet. On 04/07/25 at 9:45 A.M. the environmental concerns were brought to the attention of Registered Nurse (RN) #105 who did not dispute the findings. RN #105 stated she was unaware of the facility's cleaning schedule. On 04/07/25 at 9:50 A.M., the Administrator verified the environmental concerns identified in Resident #24's room. 3. On 04/07/25 at 10:57 A.M., Resident #15 stated she did not feel the room and bathroom floors were kept clean. Observations at that time revealed along the edges of the bathroom flooring, flooring under the sink in the room and along the edges of the room were discolored. 4. On 04/09/25 at 9:20 A.M. , a discoloration of the flooring between the beds and doors in Resident #38 and Resident #57's room was noted. The areas appeared to be a dried spill. In Resident #8's room there was one large piece and multiple smaller shredded pieces of an incontinence brief on the floor. On 04/09/25 at 9:50 A.M., the environmental concerns in Resident #38, Resident #57, and Resident #8's rooms were verified by the Administrator who stated housekeeping might not have cleaned those rooms yet. The Administrator verified staff should clean spills and pick up trash regardless of their titles. The Administrator called for a housekeeper. 5. On 04/09/25 at 10:17 A.M., an over-bed table was inside the doorway of Resident #23 and Resident #28's room with the strip on the side of the table taped. This was verified by the Administrator at that time, who instructed staff to remove and replace the table. It was unknown whose table was taped. 6. On 04/09/25 at 10:57 A.M. observation and interview with the Administrator verified the bathroom floor between Resident #8 and Resident #10's rooms were stained and there was a build up of dirt around the toilet bolts. This deficiency represents non-compliance investigated under Complaint Number OH00164119 and Complaint Number OH00163934.

Based on review of medical records, policy review and interview, the facility failed to ensure medical records were complete to accurately reflect medications being administered or not. This affected two (Residents #15 and #17) of three residents reviewed for medication administration. Findings include: 1. Review of Resident #15's open medical record revealed diagnoses including type two diabetes mellitus with a foot ulcer, generalized muscle weakness, gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), polyneuropathy, hyperlipidemia, morbid obesity, anxiety, depression, non-pressure chronic ulcer of the right foot, and protein-calorie malnutrition. Review of the March 2025 Medication Administration Record (MAR) revealed no documentation of morning medications being administered on 03/13/25. Ordered medications included mag ox (supplement) 400 milligrams (mg), Fluoxetine (antidepressant) 40 mg, Buspirone (anti-anxiety) 10 mg, Pantoprazole sodium (used to reduce stomach acid production) 40 mg, Metformin (anti-diabetic) 750 mg, Meloxicam (non-steroidal anti-inflammatory drug) 7.5 mg, Losartan Potassium (used to treat high blood pressure 50 mg, iron-vitamins 325 mg, Aspirin 81 mg, and Amlodipine Besylate (used to treat high blood pressure) 5 mg. During an interview with the Director of Nursing (DON) on 04/09/25 at 3:28 P.M., the DON reported there was an agency nurse, identified as Registered Nurse (RN) #110, scheduled to work 03/13/25. RN #110 worked until 4:56 P.M. (time card provided) and was observed administering medications. However, after she left it was discovered she had not signed off the administration of medications on the MAR. 2. Review of Resident #17's open medical record revealed diagnoses included multiple sclerosis, schizoaffective disorder, narcolepsy, chronic pain syndrome, protein-calorie malnutrition, obstructive sleep apnea, depression, dysphagia, epilepsy, seasonal allergic rhinitis, GERD, polyosteoarthritis, weakness and abnormal posture. Review of the February 2025 MAR revealed no documentation of morning medications including Riboflavin 100 milligrams ordered once a day, vitamin D 2000 units ordered every day, Zyrtec 10 milligrams ordered every day, Gauifenesin ER 600 milligrams ordered every 12 hours, Keppra (anticonvulsant) 500 milligrams ordered twice a day, Modafinil (central nervous system stimulant) 200 milligrams ordered twice a day, Senna S 8.6-50 milligrams (two tablets) ordered twice a day, Baclofen (skeletal muscle relaxant) 20 milligrams ordered three times a day, and Sucralfate (used to treat ulcers) 1 gram ordered three times a day) being offered or administered on 02/06/25. There was no documentation of medications scheduled to be administered on 02/06/25 at 2:00 and 3:00 P.M. being offered/administered, including Sucralfate 1 gram, Baclofen 20 milligrams, Senna S 8.6-50 mg (two tablets), and Modafinil 200 milligrams. There was no documentation indicating medications scheduled at bedtime on 02/11/25 were offered/administered, included Simvastatin used to treat high cholesterol) 10 milligrams (mg), Guaifenesin ER 600 mg, Keppra 500 mg, Baclofen 20 mg, and Sucralfate 1 gram. On 04/15/25 at 4:18 P.M., the DON stated she was unable to provide any additional details regarding why the medications were not documented as offered/administered. This deficiency represents non-compliance investigated under Complaint Number OH00164119.

Based on observation and interview, the facility failed to ensure food was served at a palatable, safe temperature. This affected one (Resident #37) of seven residents interviewed regarding the lunch meal served on 04/07/25. Findings include: On 04/07/25 between 11:15 A.M. and 12:02 P.M., the lunch tray line was observed. Incorrect information was provided to the surveyor regarding carts that had been served. At 12:02 P.M., the cook indicated she only had three trays lift to serve but they were waiting on residents to indicate if they were going to the dining room or eating in their rooms. Meals were prepared and placed in the warmer. On 04/07/25 at 12:03 P.M., a test tray was prepared directly from the steam table. The temperature of the fish was 111 degrees Fahrenheit. [NAME] #120 stated the fish should have been 145 degrees when served. The fish tasted cool. On 04/07/25 at 1:53 P.M., Resident #37 reported she did not like the fish served for lunch. It was cold and did not taste good. Review of the facility's Food Temperature Guidelines (revised August 2008) revealed hot foods should be greater than 135 degrees at point of service. This deficiency represents non-compliance investigated under Complaint Number OH00164119.

Based on observation, review of physician orders, review of manufacturer information, policy review and interview, the facility failed to administer medication as ordered and/or in accordance with manufacturer guidance. Four medication errors out of 31 opportunities for error were identified resulting in a 12.9% error rate. This affected two (Residents #31 and #68) of six residents observed for medication administration. Findings include: 1. Review of Resident #31's physician orders revealed Clopidrogel bisulfate 75 mg was ordered once a day in the morning. The start date was 02/15/25. Review of physician orders indicated an order dated 02/18/25 for one multivitamin every day in the morning, with no indication for minerals. On 04/09/25 Licensed Practical Nurse (LPN) #100 was observed preparing medication for administration to Resident #31 at 8:45 A.M. During the preparation, LPN #100 stated she had no Clopidrogel bisulfate (anti-platelet) 75 milligrams (mg) available for administration. LPN #100 verified she was preparing one multivitamin with mineral for administration. LPN #100 administered the multivitamin with mineral along with other medications. This resulted in two medication errors. 2. Review of Resident #68's physician orders revealed an order dated 01/18/25 for one multivitamin every day. Resident #68 had orders for insulin Lispro dated 02/27/25 for 18 units before meals on a routine basis and for six units for a blood glucose level of 251-300. On 04/09/25 at 10:28 A.M., Registered Nurse (RN) #105 was observed preparing and administering medication to Resident #68. Among the medication administered was one multivitamin with mineral tablet. During the preparation stage, RN #105 verified she was preparing a multivitamin with mineral. At 10:38 A.M., RN #105 administered 24 units of insulin Lispro for a blood sugar level of 269. The Kwik-pen used did not have an open date recorded but was delivered to the facility on [DATE]. RN #105 was made aware the Kwik-pen did not have an open date on it prior to administration and the delivery date but administered it regardless. This results in two medications errors, to equal four total errors. Review of manufacturer information revealed the Kwik-pen should not be used for more than 28 days after the pen use started. Review of the facility's Medication Dispensing System policy (not dated) revealed instructions prior to medication administration, it should be verified the medication was the right drug, at the right dose, the right route, the right rate, the right time and for the right customer. This deficiency represents non-compliance investigated under Master Complaint Number OH00164409, Complaint Number OH00164119, and Complaint Number OH00163930.

Based on medical record review and interview, the facility failed to honor Resident #3's choice in showers. This affected one (Resident #3) of three residents reviewed for resident rights Finding include: Review of Resident #3's open medical record revealed diagnoses including chronic kidney disorder, bipolar disorder, major depressive disorder, generalized muscle weakness, need for assistance with personal care and contracture. A care plan initiated 01/09/23 indicated Resident #3 needed assistance from staff to meet Activities of Daily Living (ADL) needs related to impaired mobility with decreased physical functioning and general debility following hospitalization with lymphedema and multiple wounds. Interventions included assisting Resident #3 with bathing as needed per resident's preference. A nursing note dated 03/15/25 at 11:51 P.M. indicated Resident #3 was offered a shower by staff during the shift. Resident #8 refused. The nurse spoke with Resident #3's Power of Attorney (POA) via Resident #3's personal cell phone about Resident #3 continuously refusing care and showers. The nurse explained to the POA that because Resident #3 continued to refuse showers/care his bed and linens had become extremely soiled. The nurse explained the POA/family would not be happy about Resident #3 being left in the condition he was in. The nurse went on to explain to the POA that staff would be getting Resident #3 up to be showered unless the POA stated otherwise. The nurse explained that if the POA were to say not to shower Resident #3 because he was refusing the nurse would chart the information. The POA stated she did not want it on the record that she was okay with Resident #3 laying in bed in his current stated and gave permission for the nurse and staff to shower Resident #3, clean and sanitize his mattress and change Resident #3's linen. A nursing note on 03/16/25 at 12:28 A.M. indicated Resident #3's shower was completed. Resident #3 tolerated the shower well. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was able to make himself understood and was able to understand others. Resident #3 was assessed as cognitively intact. Disorganized thinking was present and did not fluctuate. A resident preference evaluation dated 04/03/25 at 11:44 A.M. indicated Resident #3 reported it was somewhat important to him to choose the type of bath he received. Resident #3 preferred a sponge bath. Resident #3 also indicated it was somewhat important to have his brother involved in discussion about his care. On 04/10/25 at 6:23 P.M., the nursing note from 03/25/25 regarding Resident #3 refusing a shower and the nurse reaching out to the POA to get permission to give a shower against his wishes when he was assessed as cognitively intact were discussed with the Administrator and Director of Nursing (DON). Neither voiced concerns regarding the note. The Administrator indicated staff could not just leave Resident #3 in bed unclean. The Administrator verified the power of attorney did not over-ride a resident's ability to make choices as long as the resident was able to make his own decisions. The Administrator stated Resident #3 had psychiatric diagnoses and might not be able to make good decisions. It was verified Resident #3 had not been deemed incompetent and did not have a guardianship assigned. On 04/10/25 at 8:40 A.M., Resident #3 was interviewed. When asked if he had any concerns about his care or how he was treated he stated he was taught by his parents at a young age not to report bad things against other people. This deficiency represents non-compliance investigated under Complaint Number OH00163934.

Based on observation, medical record review, and interview, the facility failed to ensure ordered medication was available for administration. This affected three residents (Resident #15, #31, #32) of three residents reviewed for pharmacy services. Findings include: 1. On 04/09/25 at 8:45 A.M., Licensed Practical Nurse (LPN) #100 was observed administering medication to Resident #31. As LPN #100 was preparing the medications she verified Resident #31 did not have Clopidrogel (anti-platelet) available for administration. 2. Review of Resident #15's open medical record revealed diagnoses including type two diabetes mellitus with a foot ulcer, generalized muscle weakness, gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), polyneuropathy, hyperlipidemia, morbid obesity, anxiety, depression, non-pressure chronic ulcer of the right foot, and protein-calorie malnutrition. Review of the March 2025 Medication Administration Record (MAR) revealed an electronic MAR note on 03/12/25 indicating Losartan Potassium, Amlodipine and another unspecified medication was not administered and waiting on pharmacy delivery. During an interview with the Director of Nursing (DON) on 04/09/25 at 3:28 P.M., the DON reported she had only worked at the facility for one week and she was unable to provide an explanation to those specific medications. However, she had been made aware of problems with the pharmacy. 3. Review of Resident #32's medical record revealed diagnoses including epilepsy. Electronic MAR notes dated 02/09/25 at 10:45 P.M. 02/11/25 at 4:29 A.M., 02/12/25 at 6:49 A.M. and 02/12/25 at 8:31 A.M. indicated Phenobarbital (barbiturate) was not administered because it was not available. The note on 02/12/25 at 8:31 A.M. revealed the physician was aware and the facility was awaiting delivery from the pharmacy. On 04/15/25 at 4:20 P.M., the DON stated she was unable to explain why the Phenobarbital was not available during the time frame. This deficiency represents non-compliance investigated under Complaint Number OH00164119.

Based on observation, medical record review, review of Self-Reported Incident, review of witness statement, policy review and interview, the facility failed to ensure staff provided appropriate dementia care when Resident #57, who had a diagnosis of dementia with mood disturbance/other behavioral disturbances and resided on the secured memory care unit, began to display resistive-to-care behaviors. This affected one (Resident #57) of three residents reviewed for dementia care. Sixteen residents (Residents #66, #62, #55, #52, #40, #57, #37, #49, #15, #68, #21, #45, #47, #41, #28 and #23) had a diagnosis of dementia and resided in the secured memory care unit. The census was 70. Findings include: Review of the medical record for Resident #57 revealed an admitted [DATE] with diagnoses of Alzheimer's disease, dementia with mood disturbance, dementia with other behavior disturbances, and anxiety disorder. Resident #57's power of attorney (POA) was his wife. Resident #57 resided on the secured memory care unit. Review of Resident #57's care plan for impaired cognition dated 10/18/23 revealed Resident #57 had impaired cognitive function/dementia or impaired thought process with an intervention to communicate with Resident #57 and/or family/caregivers regarding his capabilities and needs. Review of Resident #57's care plan for inappropriate behaviors updated 02/13/24 revealed Resident #57 had verbally and physically aggressive behaviors at times related to diagnoses of Alzheimer's disease and dementia with behaviors. Behaviors included urinating in trash can, resistance to personal care, verbally and physically assaulting staff, removing clothing and wanting to walk around nude in the hallways with staff redirecting and assisting resident to redress. Inventions included approaching Resident #57 in a slow, calm manner, bringing resident to a quiet environment as needed, providing support and encouragement and allowing resident to make choices with daily care when possible. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #57 was severely cognitively impaired, had continuous inattention and disorganized thinking, utilized a wheelchair for mobility and required partial/moderate assistance with toileting and walking 150 feet. Review of the nursing note dated 01/25/25 timed 11:17 P.M. revealed Resident #57 was aggressive with staff and other residents. It took three nurse aides to get Resident #57 back into his room as Resident #57 continued to try to hit, scream and yell. Resident #57 was taken into shower and continued to scream in shower with high pitched scream. Resident #57 took medications well after shower and was able to get calmed down and to room with no further incidents. Review of the Psychiatry Nurse Practitioner Note dated 01/30/25 revealed Resident #57 was last seen on 01/16/25 with a new order to discontinue Seroquel (an antipsychotic medication) 175 milligrams (mg) at bedtime and start Seroquel 150 mg at bedtime for seven days then 125 mg at bedtime. Nursing staff reported on 01/25/25 that Resident #57 was combative, and it took multiple nurses to get Resident #57 to room and his shower. The Assessment/Plan for anxiety/depression/dementia with behaviors indicated Resident #57 was to continue Namenda (a medication for treatment of Alzheimer's disease) 10 mg twice a day, paroxetine (an antidepressant) 20 mg, Depakote Sprinkles (used to treat mood conditions) 250 mg twice a day, Buspar (an antianxiety medication) 10 mg three times a day, Ativan (an antianxiety medication) 0.5 mg at bedtime and Ativan 0.5 mg every 24 hours as needed. At the last visit, gradual dose reduction (GDR) of Seroquel began. The note further indicated to continue decreasing Seroquel to 100 mg for seven days then to 75 mg. Resident #57 had an as needed available (Ativan), and would encourage use of as needed medication. Review of the physician orders from February 2025 revealed Resident #57 was ordered Ativan oral tablet 0.5 mg give one tablet by mouth every 24 hours as needed for agitation/anxiety. Review of the electronic medication administration record (eMAR) medication administration note dated 02/04/25 timed 9:50 A.M. revealed Resident #57 raised his fist and tried to hit the nurse when attempting to administer medications. Resident #57 refused and yelled, get the [expletive] out of here. Review of the nursing note dated 02/04/25 timed 7:04 P.M. revealed Resident #57 was going in and out of other resident rooms and got into an argument with another male resident. Resident #57 was hitting the nurse and nurse aides and was being very aggressive. Review of the eMAR medication administration note dated 02/10/25 timed 2:03 A.M. revealed Resident #57 began hitting and trying to bite an aide as she was trying to direct him to bed. The nurse interrupted and advised aide to step out of the room. Resident #57 was calm towards nurse and agreed to lay down in bed and let the nurse cover him up. Resident #57 stayed in bed with no further issues. Review of the Psychiatry Nurse Practitioner Note dated 02/13/25 revealed Resident #57 was last seen on 01/30/25 with a new order to decrease Seroquel to 100 mg for seven days then to 75 mg. Nursing staff reported Resident #57 had an incident with another resident and had been consistently having behaviors. The Assessment/Plan for anxiety/depression/dementia with behaviors indicated Resident #57 was utilizing Buspar 15 mg three times a day, Ativan 0.5 mg at bedtime and every 24 hours as needed, Namenda 10 mg twice a day, Seroquel 50 mg at bedtime and Depakote Sprinkles 250 mg at morning and 375 mg at bedtime. The note indicated the psychiatry nurse practitioner would continue to titrate Seroquel down because Resident #57 did not have the supporting diagnosis for the Seroquel medication. GDR of Seroquel 25 mg for seven days then discontinue. The note further indicated the nurse practitioner would like to increase Depakote Sprinkles to 250 mg three times a day. Review of the eMAR medication administration note dated 02/24/25 timed 3:44 A.M. revealed Resident #57 was wandering into other resident rooms. Resident #57 became agitated and tried to punch aides when they attempted to redirect. Resident #57 was directed to bedroom, medicated with bedtime medications, assisted to lay in bed, covered up, and bedroom door closed. Resident #57 stayed in room and eventually fell asleep. Review of the late entry health status note dated 02/28/25 timed 1:10 A.M. revealed Resident #57 was evaluated by the nurse to determine if any bruises or injuries were noted. No bruising/injuries were noted to resident face, neck or arms. Resident #57 would not allow the nurse to remove his shirt or pants to look for any bruising or injury. When asked if he had any pain anywhere, he replied, well no, nothing is bothering me. Review of the eMAR medication administration note dated 02/28/25 timed 4:07 A.M. revealed Resident #57 was wandering in other resident rooms, yelling at staff and was violent and aggressive with staff - hitting, punching and trying to bite staff. Interventions were one-to-one, reduction of stimulation and medication with bedtime medications that included Ativan. The note further indicated Resident #57 improved some, and would be violent and aggressive with staff whenever hands on care provided. Review of the February 2025 Medication Administration Record (MAR) revealed Resident #57 was not administered the as needed Ativan during the month. Review of the eMAR medication administration note dated 03/01/25 timed 2:08 A.M. revealed Resident #57 was fighting staff, trying to hit, kick and bite staff while they attempted to give him care. Resident #57 was wandering into other resident rooms and yelling at other residents. Resident #57 was directed to his room, bedtime medications were given and staff were able to get Resident #57 to lay down in his room and provided a quiet room with door shut. The note further indicated Resident #57 did calm down when left alone in room but continued to get up in the room, moved things around in room, urinated on the floor and tried to hit, kick and bite whenever staff tried to provide hands-on care. Review of the Psychiatry Nurse Practitioner Note dated 03/03/25 revealed psychiatric evaluation at the request of the facility staff for worsening of behaviors at bedtime and medication management. Wife reported Resident #57 told her, he is going to die. The note indicated Resident #57 was compliant with medications and review of the Medication Administration Record (MAR) indicated no use of as needed Ativan in over four weeks. Review of the nursing progress note dated 03/03/25 timed 8:40 P.M. revealed Resident #57 was walking around on unit searching for his room when he opened a door belonging to another resident. The other resident became angry and yelled at Resident #57 causing Resident #57 to go farther down the hall where he entered a different resident's room and that resident proceeded to tell him to get out and Resident #57 responded by telling the resident he would snap her neck. Review of the eMAR medication administration note dated 03/04/25 timed 12:54 A.M. revealed Resident #57 was wandering into other resident rooms, tried to lay in their beds, urinated all over his bedroom floor, and became violent with attempts of hands-on care. When staff was trying to redirect him out of another resident's room, Resident #57 became angry, started yelling, hitting and tried to bite staff. Other staff members took over care which did help Resident #57 calm down and they were able to get Resident #57 into bed to lay down. The note further indicated Resident #57 was currently asleep in bed and every 15 minute checks remained ongoing. Review of the March 2025 MAR revealed Resident #57 was not administered the as needed Ativan. Review of the February and March 2025 nursing and social services progress notes and assessments revealed there was no evidence the facility attempted to coordinate an interdisciplinary team meeting with Resident #57's wife regarding his increasing behaviors. Review of the Self-Reported Incident dated 02/27/25 revealed there was an allegation of physical and verbal abuse involving Resident #57. The MDS Nurse stated that a nurse aide who was training with two fell ow nurse aides accused the other two nurse aides of holding down Resident #57 and covering his mouth with their hand/hands. Review of the witness statement dated 02/27/25 authored by Certified Nurse Aide (CNA) #4 revealed, so at 8:40 P.M., myself and [CNA #3] and [CNA #2], we went into [Resident #57's] room and trying to change him but he was fighting us .and [CNA #3] was trying to put his brief on and [Resident #57] was fighting his legs . Interview on 03/03/25 at 2:15 P.M. with CNA #4 revealed on 02/27/25, it was her third day orienting with other CNAs and CNA #4 had been shadowing CNA #12 earlier in the day then began shadowing CNA #2 and CNA #3 on the memory care unit. At 8:40 P.M., Resident #57 was exiting his bedroom when CNA #2 and CNA #3 assisted him back into his bathroom within his bedroom. Resident #57 was yelling/screaming standing in front of the toilet saying get off of me while CNA #3 was behind him trying to apply an incontinence brief with CNA #4 assisting. CNA #2 or CNA #3 told Resident #57 to cooperate, we're trying to put your brief on then CNA #2 put her hand in front of his mouth so Resident #57 would not bite CNA #4. Interview on 03/03/25 at 2:51 P.M. with CNA #3 revealed on 02/27/25 around 9:30 P.M., CNA #4 asked for assistance to change Resident #57 because Resident #57's was wet/soiled and had incontinent odor so the CNAs assisted Resident #57 into his bathroom. At that time, Resident #57 grabbed CNA #4's wrists and tried to bite or hit her. CNA #3 held her hand between his mouth and shoulder to prevent him from biting CNA #4. The CNAs got his incontinence brief changed and assisted him to bed then notified Licensed Practical Nurse (LPN) #10 of what happened. CNA #3 stated that Resident #57's behaviors had been bad lately and he screamed when the staff tried to do any kind of care. Resident #57 would yell and reject care. Observation on 03/03/25 at 4:05 P.M. revealed Resident #57 was pleasantly sitting in a wheelchair in the dining room. Interview, during the observation, with Resident #57 revealed Resident #57 was unaware he was residing at a nursing home and unaware of the town where he resided. Interview on 03/03/25 at 4:20 P.M. with CNA #6 revealed Resident #57 had violent tendencies and was very violent. Interview on 03/04/25 at 8:15 A.M. with LPN #8 revealed Resident #57 would often bite CNA #3 and LPN #8 had to patch up CNA #3's arms after being bit. Resident #57 sundowns (when behaviors occur in the afternoon and evening hours in people with dementia) and searched for his wife. Resident #57 got mad when redirected and re-approaching later did not work. However, if he was left alone and left to deescalate himself, he would lay down in bed. He got violent/yelled anytime the staff tried to perform care which was his way of acting out. Observation on 03/04/25 at 9:25 A.M. revealed Resident #57 was peacefully lying in bed with his eyes closed. Interview on 03/04/25 at 10:35 A.M. with CNA #2 revealed Resident #57 did not like to be touched, went into fight mode and would bite staff. On 02/27/25, the CNAs had been trying to assist him for five minutes in the bathroom beforehand when CNA #4 grabbed both his arms and pulled his sleeves over his hands then Resident #57 started swinging and biting CNA #4's arm stating, keep her away from me. Interview on 03/04/25 at 12:05 P.M. with Social Services Designee (SSD) #13 revealed Resident #57's wife used to come visit him from the morning into the afternoon every other day then the wife went on vacation for the last two to three weeks. Resident #57's behaviors had increased since the wife had not been coming in to visit. SSD #13 verified there had not been any documented formal interdisciplinary team meetings with Resident #57's wife to discuss his behavior management and dementia care. Interview on 03/04/25 at 12:45 P.M. and 3:05 P.M. with the Administrator verified there had not been an interdisciplinary team meeting including Resident #57's wife to discuss interventions that might be more successful in managing Resident #57's dementia related behaviors. The Administrator also verified Resident #57 was not administered as needed Ativan during February and March 2025 as suggested in the nurse practitioner progress note dated 01/30/25. Review of the facility's undated Dementia and Behavioral Health Guidelines policy revealed agitation referred to a range of behaviors associated with dementia, including irritability, sleeplessness and verbal or physical aggression. Agitation could be triggered by a variety of things, including environmental factors, fears and fatigue. Most often, agitation was triggered when the person experienced control being taken from him or her. Interventions included reducing noise, clutter or the number of people in the room. The policy indicated to try gentle touch, soothing music, reading or walking to quell agitation. Speak in a reassuring voice. Do not try to restrain the person during a period of agitation. This deficiency represents noncompliance investigated under Control Number OH00163161.

Based on observation and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary condition. This had the potential to affect 110 of 111 residents receiving food from the kitchen. Resident #45 was identified as receiving no food from the kitchen. The facility census was 68. Findings include: Initial tour of the kitchen on 08/25/24 from 8:10 A.M. to 8:32 A.M. with Dietary Manager (DM) #238 revealed the floor was dirty with food splatter, pieces of paper, and dried food debris especially underneath equipment. The microwave had food splatter on all sides of the microwave and had burnt food on the bottom. The grill had food residue on it and the grill pan was filled with french fries and food pieces. The prep table that the grill was sitting on had food debris on it. Dietary Manager (DM) #238 stated that the grill was electric and there was no power for it, so they did not use it for cooking. Observation inside the walk-in refrigerator revealed an undated food container on the floor with no label to identify what was inside of it. In addition, there was a container of soup, black olives and sliced tomatoes that were not labeled or dated. DM #238 verified the findings at time of observation. Observation inside the walk-in freezer revealed a bag of pepper steak that was open, not labeled, dated or wrapped properly. There was bag of breaded patties that was not labeled or dated. DM #238 verified the findings at time of observation. Review of the undated policy Food Safety and Sanitation Review revealed a checklist to ensure the kitchen was clean and sanitary. The policy indicated the checklist should always be followed in the dietary department. Review of the checklist revealed it was divided in the subgroups by food procurement, food storage, food preparation, and general sanitation. Under the food storage section it indicated that all food must be covered, label, and dated. The general sanitation subgroup indicated all equipment must be cleaned either after use or daily basis. Review of a list provided by the facility revealed Resident #45 received no food from the kitchen.

Based on observation, medical record review, interview, and review of facility policy, the facility failed to ensure Resident #9's wound related treatments were implemented as ordered; Resident #18's skin was assessed and treatments were applied as ordered; Resident #34's thrombo-embolic deterrent (TED) hose and geriatric sleeves were implemented as ordered; and Resident #45's percutaneous endoscopic gastrostomy (PEG) tube dressing was implemented as ordered. This affected three (Residents #9, #18 and #34) of three residents reviewed for general skin conditions; and one (Resident #45) of one resident reviewed for PEG tube care. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus with other circulatory complications, diabetic neuropathy, intervertebral disc degeneration of the lumbar region, fibromyalgia, depressive disorder, and stage three kidney disease. Review of the active diagnoses further revealed an additional diagnosis added on 07/15/24 of a left foot ulcer with fat layer exposed, and additional diagnoses added on 08/05/24 of a left foot ulcer with bone involvement and an unspecified wound to the left lower leg. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 08/07/24 revealed Resident #9 had intact cognition. Further review of the MDS assessment revealed Resident #9 had a diabetic foot ulcer and skin tears and received applications of non-surgical dressings to his feet and to a site other than his feet. Review of the physician orders revealed an order dated 08/07/24 to cleanse the left foot with normal saline solution (NSS), pat dry, apply Medihoney and a foam dressing at bedtime every other day. Further review of the orders revealed skin assessments were to be completed on night shift weekly every Saturday and if any new skin areas were noted, the nurse was to complete a N Adv-skin only evaluation. Another order, dated 08/05/24, revealed Resident #9 was to wear an offloading shoe to his left lower extremity. Review of the care plan with date span of 05/30/23 through 10/09/24 revealed Resident #9 had the potential for altered skin integrity with development of a diabetic foot ulcer on 05/22/24, a vascular ulcer on the left medial great toe on 07/08/24, and a skin tear of the leg on 08/05/24. Interventions included adherence to enhanced barrier precautions, floating heels when in bed, inspection of skin during routine daily care, and application of treatments as ordered. Review of the weekly skin assessments revealed no documentation of assessment outcomes between 12/11/23 and 08/08/24. The three weekly documented skin assessments completed on 08/08/24, 08/15/24, and 08/22/24 revealed Resident #9 had fair to poor skin turgor, bilateral edema (unspecified upper, lower, or generalized), and no new skin areas of concern. Review of the N Adv - Skin only evaluation created on 02/02/24, 04/04/24, 04/18/24, 04/25/24, 05/02/24, 05/09/24, 05/16/24, 06/06/24, and 07/11/24 revealed each note stated that Resident #9's skin was warm and dry, skin color was within normal limits (WNL), skin turgor was normal, there were no external devices, and no skin issues. No other assessment criteria or details were included on these forms and there was no indication as to what new skin area, if any, was noted on the dates listed. Further review of the N Adv - Skin only evaluation forms revealed no documentation of the new skin areas noted per the care plan that developed on 05/22/24, 07/08/24, or 08/05/24. Review of the wound consultant progress note completed by Certified Nurse Practitioner (CNP) #206 on 05/22/24 revealed an initial evaluation of a left lateral diabetic foot ulcer measuring 1.4 centimeters (cm) by 0.9 cm by 0.1 cm with a small amount of serous drainage and orders to cleanse with NSS, apply collagen to the wound bed, cover with a foam dressing, and change three times a week and as needed. Interventions recommended by CNP #206 included offloading and repositioning. Review of the wound consultant progress note completed by Certified Nurse Practitioner (CNP) #206 on 07/08/24 revealed the left lateral diabetic foot ulcer measured 1.5 cm by 1.3 cm by 0.1 cm with a moderate amount of serous drainage and new orders to cleanse with NSS, apply Medihoney, silver alginate, and abdominal pad (ABD), and wrap in Kerlix daily and as needed. Further review of the wound note revealed a new vascular ulcer to the left great toe with orders for the nurse to apply Skin Prep (barrier film) every shift. Review of the wound consultant progress note completed by CNP #206 on 07/15/24 revealed the left lateral diabetic foot ulcer measured 1.5 cm by 2 cm by 0.1 cm with a moderate amount of serous drainage and the vascular wound to the left great toe measured 0.5 cm by 0.5 cm with zero depth. Review of the wound consultant progress note completed by CNP #206 on 07/22/24 revealed the left lateral diabetic foot ulcer had worsened and measured 2.1 cm by 2.4 cm by 0.7 cm with purulent drainage. A wound culture was obtained, treatment orders were updated, and Resident #9 was ordered Doxycycline (antibiotic) 100 milligrams (mg) by mouth twice daily for seven days pending results of the wound culture. The vascular ulcer to the left great toe was assessed as stable during the wound CNP's visit on this date. Review of the wound culture lab report dated 07/23/24 revealed the following growth of organisms: - high growth of Enterococcus faecalis - high growth of Morganella morganii - high growth of Bacteroides fragilis - high growth of Proteus miribilis/Proteus vulgaris - high growth of Staphylococcus aureus Review of the wound care visit notes from the new facility wound Nurse Practitioner (NP) #208 dated 08/05/24 revealed NP #208 provided wound assessment and care on 07/29/24 and on 08/05/24. Review of the visit note dated 08/05/24 revealed Resident #9's left lateral diabetic foot ulcer was improving after debridement performed on 07/29/24 and measured 1.16 cm by 1.29 cm by 0.1 cm with moderate serosanguinous drainage. Further review of the visit note revealed identification of a wound to the left anterior lower leg measuring 8.82 cm by 3.11 cm by 0.1 cm with an order to cleanse the left lower extremity wound with NSS, pat dry, apply Medihoney, and cover with a dry sterile dressing daily and as needed. Further review of the note revealed continued use of shoes could delay wound healing and the treatment plan moving forward was to discontinue footwear to the left foot and provide a surgical shoe for offloading. Observation on 08/26/24 at 8:23 A.M. revealed a bandage to Resident #9's left leg dated 08/23/24 with a large amount of light brown dried drainage soaked through the dressing. Further inspection of the left leg revealed one small open skin lesion just above the sock line seeping serous drainage just below the edge of the tape from the dressing and dried serosanguinous drainage the size of a nickel on his sock just below the anterolateral aspect of his ankle. An interview with Resident #9 at the time of the observation confirmed it had been a few nights since a nurse changed the dressing. Interview on 08/26/24 at 8:38 A.M. with Registered Nurse (RN) #219 confirmed the date on the dressing was 08/23/24 and it was soiled. At this time, Resident #9 stated the dressing only got changed when one nurse was on shift (Licensed Practical Nurse #232). Interview on 08/27/24 at 9:20 A.M. with the facility wound nurse, Assistant Director of Nursing (ADON) #218 confirmed the advanced skin assessments (N ADV - Skin only Evaluations) were to be opened and completed by the nurse whenever a new skin concern was found and should include location of the wound, wound type, and assessment of the wound status, including measurements. ADON #218 further confirmed this form would serve as the facility's initial wound assessment and if the complete wound assessment was not documented on this form, the facility did not have record of the initial wound assessment so the wound information would only be found by reviewing the Nurse Practitioner's visit progress notes. Observation on 08/27/24 at 10:29 A.M. with Resident #9 confirmed he was wearing his brown tie-up casual dress shoes on both feet and no offloading shoe. An interview conducted with Resident #9 during this observation confirmed he had no special shoe on his left foot, was wearing a regular shoe on his left foot, and did not have a surgical offloading shoe in his possession, as he also pointed out all his pairs of shoes that he stored under his bed. Interview on 08/27/24 at 10:41 A.M. with RN #219 confirmed he was unaware of the order for the offloading shoe and had not seen an offloading shoe being worn by Resident #9. Interview on 08/27/24 at 5:05 P.M. with ADON #218 confirmed there were two weeks another company provided wound care services and there were two weeks there was no wound physician or Nurse Practitioner following the residents with wound care needs. ADON #218 further confirmed that she had no knowledge of Resident #9 having an offloading shoe per orders. Interview on 08/28/24 at 10:4 A.M. with Physical Therapist (PT) #252 confirmed she had not seen Resident #9 in an offloading shoe for therapy sessions and had no knowledge of the order but assumed it could have been ordered to keep the pressure off the wound on his foot. Interview on 08/28/24 at 12:15 P.M. with ADON #218 confirmed wound NP #208 recommended Resident #9 should not wear shoes on his left foot and ordered an offloading shoe during the visit rendered on 08/05/24. ADON #218 further confirmed she did not know who put the order into the medical record or why nobody followed through by ordering the surgical offloading shoe but would follow-up with the new wound care practitioner. Review of the policy titled Wound Care last reviewed in August 2024 revealed wounds were to be cleansed, dressings applied per orders, and wound care related treatments applied as ordered. The policy further revealed treatments were to be documented in the electronic medical record, along with resident refusals and reasons for the refusal. 2. Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses including respiratory failure with hypoxia, constipation, cognitive impairment of unknown etiology, protein-calorie malnutrition, anxiety disorder, unspecified dementia, hypertension, atherosclerotic heart disease, and depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment completed on 08/12/24 revealed Resident #18 had intact cognition and required supervision or touching assistance with bathing and personal hygiene. Further review of the MDS assessment revealed Resident #18 was not receiving dressings or wound care but did have applications of ointments to locations other than her feet. Review of the care plan dated 04/06/20 through 09/30/24 revealed Resident #18 had the potential for altered skin integrity due to decreased mobility, incontinence, and age-related fragile skin. Interventions included minimizing irritation and dryness, keeping skin clean and dry, linens clean, dry and wrinkle free, minimizing moisture exposure, observing for signs of skin breakdown, and alerting the charge nurse and notifying the physician as needed for treatment orders. Review of the physician orders revealed an order dated 03/03/24 for Resident #18 to have skin assessments completed weekly every Sunday night and if any new skin areas were noted, the nurse was to complete a N Adv-skin only evaluation. Further review of the orders revealed an order dated 08/06/24 for Telfa, Kerlix, and Coban to Resident #18's right lower leg once daily for blisters. There were no orders for cleansing the blisters or for any ointments. Another order, dated 08/21/24, revealed Resident #18 was to have all cotton elastic (ACE) wraps applied to her bilateral lower extremities from her toes to her knees every morning and removed every evening at bedtime. Review of the weekly skin assessments in the electronic medical record revealed the last assessment had been documented on 11/20/23. Review of the shower sheets from 07/11/24 through 08/27/24 revealed the state tested nurse aide (STNA) performing showers on those dates noted blisters on 08/06/24, 08/08/24, 08/11/24 and the shower sheets were co-signed by a nurse. No nursing assessment was provided on the shower sheets. The shower sheet dated 08/21/24 was filled out by the wound care nurse/Assistant Director of Nursing (ADON) #218, which noted a scab to the right LE. With no other accompanying wound details. The shower sheet dated 08/27/24 revealed the STNA providing Resident #18's shower noted a scab to the right LE which was co-signed by a nurse. Review of the progress notes revealed a note dated 08/04/24 with the following note text: Resident concerned about right lower leg. states its painful and not healing. blisters noted to leg oozing purulent drainage. leg cleansed well. The note further revealed the physician was aware and there was no redness or warmth to the touch. Further review of the progress notes revealed there were no other notes regarding the blisters on Resident #18's right lower leg. Review of the progress notes revealed Resident #18 refused her bilateral ACE wraps on 08/27/24 and on 07/22/24. Review of the documents in the electronic medical record revealed no wound care provider progress notes related to the blisters on Resident #18's right lower leg. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for the month of August 2024 revealed nurses documented wound care had been completed as ordered daily each morning from 08/06/24 through 08/27/24 and the ACE wraps were applied daily from 08/01/24 through 08/28/24 except for no documentation on 07/07/24 and a noted resident refusal on 08/27/24. Observation on 08/25/24 at 12:34 P.M. revealed Resident #18 had a black, dried dime-sized scab on her right shin and a pea-sized open lesion just below the scab. Further observation revealed the right lower extremity was slightly more edematous than the left lower extremity. An interview conducted with Resident #18 at the time of the observation confirmed she was supposed to have cream to her right shin wounds, but never got it. Resident #18 further stated she felt it had been infected at one point, but nobody would take a swab to rule it out. Resident #18 further stated her right shin burned at times, more so at night. There were no ACE wraps noted at the time of this observation and interview. Observation on 08/26/24 revealed Resident #18 had a dressing wrapped in Coban to her right shin, but no ACE wraps to either lower extremity. Interview on 08/27/24 at 10:49 A.M. with Registered Nurse (RN) #219 after observing Resident #18 with no dressing to her right lower leg confirmed Resident #18 had an order for a dressing because she preferred her wound to be covered. RN #219 further stated it was his assessment the healing blisters should be left open to air and confirmed when nurses did apply a dressing, Resident #18 yelled to have the dressing removed after a few hours because she was non-compliant and dangled her legs all day, causing increased fluid retention. During the interview, RN #219 was unable to say what the etiology was for the blisters. Interview on 08/27/24 at 9:20 A.M. with the facility wound nurse, Assistant Director of Nursing (ADON) #218 confirmed the advanced skin assessments (N ADV - Skin only Evaluations) were to be opened and completed by the nurse whenever a new skin concern was found and should include location of the wound, wound type, and assessment of the wound status, including measurements. ADON #218 further confirmed this form would serve as the facility's initial wound assessment. Interview on 08/27/24 at 5:05 P.M. with ADON #218 confirmed there were two weeks another company provided wound care services and there were two weeks there was no wound physician or Nurse Practitioner following the residents with wound care needs. ADON #218 further confirmed that she was uncertain of the date of onset or the etiology of Resident #18's skin concern. Observation on 08/28/24 at 7:47 A.M. of Resident #18 revealed she was sitting in her wheelchair with no ACE wraps to her bilateral lower legs and her blisters were open to air. Resident #18 confirmed she was not approached about having her ACE bandages applied on this date and pointed to her dresser, which contained a roll of Coban and padded foam, stating she did not have ACE wraps in her room. Interview on 08/28/24 at 8:14 A.M. with STNA #247 confirmed Resident #18 was not wearing her bilateral ACE wraps and she did not know where the ACE wraps were kept. Interview on 08/28/24 at 8:09 A.M. with Licensed Practical Nurse (LPN) #315 confirmed she did not receive report that Resident #18 refused application of her ACE wraps and was unaware she was not wearing them. A follow-up interview with LPN #315 on this date at 8:28 A.M. confirmed Resident #18 was not wearing her bilateral ACE wraps as ordered and the Medication Administration Record reflected documentation they had been applied. Interview on 08/28/24 at 12:03 P.M. with ADON #218 revealed she just learned about Resident #18's blisters today or late yesterday and was uncertain as to the etiology or date of onset. During the interview, ADON #218 confirmed the order did not indicate the reason for the bilateral ACE wraps and she did not know why they were to be worn. ADON #218 confirmed Resident #18 had not been seen on weekly wound rounds and she was never made aware when the new skin concern was found. During the interview, ADON #218 confirmed staff had been reeducated on not signing off on treatments they had not administered, and it had been an ongoing concern that the facility was addressing. Review of the policy titled Wound Care last reviewed in August 2024 revealed wounds were to be cleansed, treatments applied, and dressings applied per orders. The policy further revealed treatments were to be documented in the electronic medical record, along with resident refusals and reasons for the refusal. 33019 3. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, asthma, dementia, diabetes mellitus, congestive heart failure, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/05/24, revealed Resident #34's Brief Interview for Mental Status (BIMS) score was 14, which indicated intact cognition. There were no behaviors or rejection of care. The assessment indicated the resident had skin tears. Review of the Care Plan, dated 10/16/23, revealed Resident #34 was at risk for impaired skin integrity related to impaired mobility, diabetes mellitus, edema of the lower extremities, and age-related fragile skin with the intervention to apply geriatric (geri) sleeves (skin protection sleeves). Review of physician order, dated 10/24/23, revealed the order for thrombo-embolic deterrent hose (TED) hose to be applied to bilateral lower extremities, to be on in the A.M. and off in the P.M. Further review revealed the physician order, dated 01/15/24, for geri sleeves to be worn on the bilateral upper extremities to protect against skin tears, to be on in the A.M. and off in the P.M. Observations on 08/27/24 at 9:10 A.M. and again at 11:00 A.M. revealed Resident #34 was not wearing geri sleeves on his upper extremities or TED hose on his lower extremities as ordered by the physician. During interview on 08/27/24 at 11:01 A.M., State-tested Nursing Assistant (STNA) #300 confirmed Resident #34 was not wearing his geri sleeves or TED hose. STNA #300 stated would apply both as soon as possible. During interview on 08/27/24 at 11:02 A.M., Licensed Practical Nurse (LPN) #269 confirmed Resident #34 was not wearing geri sleeves on his upper extremities or TED hose on his lower extremities as ordered by the physician. During interview on 08/28/24 at 11:07 A.M., the Director of Nursing confirmed Resident #34 should be wearing geri sleeves and TED hose as ordered by the physician. 34297 4. Review of Resident #45's physician orders revealed an order dated 04/25/23 for the percutaneous endoscopic gastrostomy (PEG) site t-drain dressing to be changed twice daily every shift. Observation on 08/26/24 at 8:42 A.M. with Licensed Practical Nurse (LPN) #269 of Resident #45's PEG tube medication administration revealed a PEG tube t-drain dressing was not in place. Interview on 08/26/24 at 8:50 A.M. with LPN #269 confirmed Resident #45's PEG tube t-drain dressing was not in place as ordered. Review of the Gastrostomy/Jejunostomy Site Care policy revised October 2011 revealed the purpose of the procedure was to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection.

Based on observations, interview and record review, the facility failed to ensure residents were provided activities on the memory care unit. This affected 15 ( #8, #11, #16, #24, #26, #27, #35, #42, #44, #47, #49, #52, #53, #55, and #57) of 16 residents residing on the memory care unit. Resident #31 was identified as a resident taken off the memory care unit for activities. The facility census was 68. Findings include: Observation on 08/26/24 at 3:02 P.M. of the memory care dining room revealed the television was on the music channel, few residents were sitting at the tables, and agency State tested Nursing Assistant (STNA) #500 was sitting at a table eating potato chips, drinking pop, and looking at her phone. STNA #500 stated she was on a small break and not there to do activities. Observation and interview on 08/26/24 at 3:30 P.M. revealed STNA #236 was coming out of a male resident's room and standing near the doorway. STNA #236 stated that she was trying to redirect a female resident out of the male resident's room. STNA #236 stated that she was standing at the doorway to keep an eye on the female resident and would reapproach in a few minutes. STNA #236 verified that there were no activities going on, but she was taking care of residents. Interview on 08/26/24 at 3:45 P.M. with the Director of Nursing (DON) revealed that one STNA was supposed to do activities at 3:00 P.M. because the residents got antsy before dinner, while the other STNA took care of the residents that were not in activities. Agency staff should find out their responsibilities from the facility staff. Interview on 08/27/24 at 10:59 A.M. with Activity Assistant (AA) #212 revealed she organized and completed the activities for the skilled residents and tracked the activities for all residents. AA #212 stated that there was not a specific time for movies to be shown in the memory care unit, but she assumed that the staff put a movie on the television which was their activity. AA #212 verified that music was played in the memory care unit from 10:00 A.M. through 3:30 P.M. and although she documented the residents participated in a movie activity no movie was provided for the residents to watch. AA #212 also documented all residents participated in reading and reality orientation because she delivered daily chronicles to the memory care unit and the STNAs were supposed to go over it with the residents and she assumed they did. The daily chronicles were documented as reading and reality orientation because they included the day and date on them. Interview on 08/27/24 at 11:40 A.M. with the DON revealed that the activity department documented activities as completed, not the STNAs but the DON did not know how the STNAs communicated with the activity department regarding what activities were completed and when. The DON also indicated morning care could hinder activities from being completed. Review of the staff in-service dated 02/27/24 revealed STNAs were to complete activities with the residents at 9:30 A.M. and 3:00 P.M. Interview with the Director of Nursing on 08/26/24 at 3:45 P.M. verified that the in-service was provided to STNAs. Review of the memory care unit activity calendar revealed that there were only two activities scheduled daily at 9:30 A.M. and 3:00 P.M. There were no evening activities on the memory care unit. Review of the current resident census revealed Residents #8, #11, #16, #24, #26, #27, #31 #35, #42, #44, #47, #49, #52, #53, #55, and #57 resided on the memory care unit.

Based on medical record review, interview, and review of facility policy, the facility failed to ensure resident comprehensive care plans were updated and individualized, or that staff were aware of the resident's current smoking status and interventions. This affected four residents (#9, #13, #17 and #31) of six residents (#9, #13, #17, #31, #52, and #59) who were reviewed for smoking. The facility also failed to ensure Resident #53 was free of accidents hazards. This affected one out of three residents reviewed for falls ( #8, #53, and #59). The facility census was 68. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus with other circulatory complications, diabetic neuropathy, intervertebral disc degeneration of the lumbar region, fibromyalgia, depressive disorder, diabetic foot ulcer, unspecified wound to the left lower leg, and stage three kidney disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 08/07/24 revealed Resident #9 had intact cognition and was on a scheduled pain regimen. Further review of the MDS assessment revealed Resident #9 had no impairments of his upper or lower extremities limiting his range of motion and he used a walker and a wheelchair to aid in mobility. Review of the physician orders revealed an order dated 05/26/23 stating it was permitted for Resident #9 to sign himself out and go to the resident smoking area to smoke as needed. Review of the [NAME] Manor Resident Smoking Agreement signed 03/22/24 revealed Resident #9 had permission to leave the building for personal smoke breaks by signing out at the nurse's station leave of absence (LOA) binder and signing back in upon return from the smoke break. Resident #9 was to return his lighter and smoking materials to the nurse upon his return from LOA and he understood he was not allowed to keep the smoking materials in his room or on his person. The document further stated no LOAs were permitted after 10:00 P.M. without the administrator's approval. Review of the document titled [NAME] Manor LOA Smoking Rules dated 08/19/24 revealed Resident #9 agreed to the following rules: - Sign-out in the LOA binder each visit - Smoke in designated area only (near the picnic tables) - No smoking on walkway or sidewalks - Always dispose of cigarettes in the ashtray - Sign-in in the LOA binder each visit Review of the care plan dated 05/30/23 through 10/09/24 revealed Resident #9 used tobacco. Interventions included conducting smoking safety evaluations on admission and as needed, providing Resident #9 with education on the smoking policy, and orienting Resident #9 to the facility's smoking times and procedures. The care plan goal was for Resident #9 to adhere to the smoking policies of the facility. The care plan did not specify smoking times, whether Resident #9 was deemed safe for independent or unsupervised smoking, Resident #9's history of noncompliance with the smoking policy, or that storage of Resident #9's smoking materials was permitted in his room. Interview on 08/26/24 at 8:23 A.M. with Resident #9 confirmed he was a smoker, kept his lighter and his cigarettes in his room, and could go out front and smoke by the picnic tables whenever he wanted, if he signed the LOA book at the front desk first. Observation during this interview revealed a red lockbox inside a clear drawer of a storage dresser where Resident #9 revealed he kept his smoking materials. Interview on 08/27/24 at 9:50 A.M. with Social Services Director/Activity Coordinator #279 confirmed smoking materials were kept in individual lockboxes and that all the lock boxes, including the one for the residents she referred to as LOA smokers were to be locked in a designated cabinet near the smoking area, which was maintained and kept secured by facility staff. Observation on 08/27/24 at 10:10 A.M. of the cabinet used to store all resident smoking materials did not contain the lockbox or smoking materials for Resident #9. When informed the lockbox was observed to be in Resident #9's room, Social Services Director #279 confirmed Resident #9 liked to take multiple smoke breaks within an hour, and perhaps the Administrator gave him permission to keep his own smoking materials so he would not have to wait on facility staff to get his supplies each time. She further verbalized no knowledge whether Resident #9's care plan permitted the storage of Resident #9's smoking materials in his room. Interview on 08/27/24 at 10:58 A.M. with Interim Activities Coordinator #263 confirmed all resident smoking materials were to be kept in the locked cabinet by facility staff and was unaware of any individualized resident care plan that directed otherwise. Review of the policy titled Resident Smoking Policy for Resident Signature revealed residents were permitted to smoke in designated areas, at designated times, and with supervision. Further review of the policy revealed no smoking materials were permitted to be with the residents, either on their person or in their rooms. The policy further revealed reeducation on facility smoking procedures would occur after the first infraction of the rules, but subsequent infractions could result in involvement of the Ombudsman, one to one supervision, or the potential of an immediate or 30-day discharge notification. 2. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), protein-calorie malnutrition, alcohol abuse, right shoulder pain, nicotine dependence, depression, anxiety disorder, polyneuropathy, colostomy status, and syncope and collapse. Review of the admission Minimum Data Set (MDS) 3.0 assessment revealed Resident #13 had moderate cognitive impairment, had no range of motion limitations in his upper or lower extremities and used a wheelchair for mobility. Further review of the MDS assessment revealed Resident #13 used tobacco. Review of the physician orders revealed no orders related to smoking. Review of the admission smoking assessment completed on 07/16/24 revealed no concerns related to safe smoking. Review of the updated smoking and safety assessment completed on 08/26/24 revealed Resident #13 followed policy on location and time of smoking and was capable of lighting own cigarettes & smoking safely, ok with LOA's [leave of absence] to smoke. Review of the care plan focus dated 08/06/24 revealed Resident #13 was at risk for injury related to smoking. Interventions included verbalization of adherence to the facility's smoking policy and keeping all smoking materials at the nurse's station. There were no care plan interventions related to rolling his own cigarettes, nor did the care plan specify whether Resident #13 was in independent smoker or required additional supervision or interventions. Observation on 08/25/24 at 10:40 A.M. revealed Resident #13 had a pack of cigarettes laying on his bedside table in his room and he was holding an unlit cigarette. During this observation, Resident #13 confirmed he kept his cigarettes and lighter in the drawer by his bed. Interview on 08/27/24 at 9:50 A.M. with Social Services Director/Activity Coordinator #279 confirmed smoking supplies were kept in individual lockboxes and that all the lock boxes, including the one for the residents she referred to as LOA smokers were to be locked in a designated cabinet near the smoking area, which was maintained and kept secured by facility staff. At the time of the interview, Social Services Director #279 was uncertain whether Resident #13 was considered an LOA smoker. Observation on 08/27/24 at 10:10 A.M. of the cabinet used to store all resident smoking materials did not contain the lockbox for Resident #13 but did contain two bags of tobacco and boxes of rolling paper. During the observation, Social Services Director #279 verbalized no knowledge of any care plan interventions involving storage of smoking materials in Resident #13's room. Further interview revealed Resident #13 was permitted to roll his own cigarettes while sitting at a table in the activity hall, then, to her knowledge, was to store them in the designated cabinet with all the other smoking materials. Interview on 08/27/24 at 10:58 A.M. with Interim Activities Coordinator #263 confirmed all resident smoking materials were to be kept in the locked cabinet by facility staff and was unaware of any individualized resident care plan directing otherwise. Review of the policy titled Resident Smoking Policy for Resident Signature revealed residents were permitted to smoke in designated areas, at designated times, and with supervision. Further review of the policy revealed no smoking materials were permitted to be with the residents, either on their person or in their rooms. 3. Review of the medical record for Resident #17 revealed an admitted [DATE] with diagnoses including spondylolysis of the cervical region, hypertension, migraines, major depressive disorder, schizophrenia, need for assistance with personal care, type two diabetes mellitus, neuropathy, nystagmus, chronic obstructive pulmonary disease (COPD), and nicotine dependence. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 06/06/24 revealed Resident #17 had intact cognition, no behaviors, and no wandering. Further review of the MDS assessment revealed Resident #17 had no limitations related to range of motion in her upper or lower extremities and was ambulatory with use of a cane or crutch. Review of the orders revealed a physician order dated 12/11/23 that it was ok for resident to have LOA smoking breaks. Review of the LOA Smoking Agreement signed on 03/22/24 revealed Resident #17 was permitted to sign-out on LOA for smoke breaks, but she was not to take any LOA smoke break after 10:00 P.M. and was to return her lighter and smoking materials to the nurse. This document contained Resident #17's acknowledgement she could not keep the smoking materials in her room. Review of the [NAME] Manor LOA Smoking Rules document, signed by Resident #17 on 08/19/24 revealed she agreed to the following rules: - Sign out in LOA binder each time - Smoke only in designated area (near picnic tables) - No smoking on walkways or sidewalks - Dispose of cigarettes in the ashtray - Sign-in LOA binder each time There was no verbiage permitting the storage of smoking materials in Resident #17's room. Review of the care plan last revised on 08/26/24 revealed Resident #17 was at risk for injury related to smoking and needed frequent reminders where the designated smoking area was. Care plan interventions included verbalization of safe smoking practices, adherence to the smoking policy, and keeping smoking items at the nurse's station. The care plan did not identify whether Resident #17 was deemed safe as an independent smoker or if she required supervision or other safe smoking interventions. Observation and interview on 08/25/24 at 11:15 A.M. with Resident #17 revealed all other smoking residents had specific smoking times and a designated area, but she and one other male resident were allowed to smoke out front whenever they wanted and kept their smoking materials in a lockbox in their rooms. At the time of the interview, Resident #17 pointed to a lockbox sitting on top of her dresser and stated that was where she was told she needed to keep her lighter and cigarettes. Interview on 08/27/24 at 9:50 A.M. with Social Services Director/Activity Coordinator #279 confirmed smoking supplies were kept in individual lockboxes and that all the lock boxes, including the one for the residents she referred to as LOA smokers were to be locked in a designated cabinet near the smoking area, which was maintained and kept secured by facility staff. Observation on 08/27/24 at 10:10 A.M. of the cabinet used to store all resident smoking materials did not contain the lockbox for Resident #17. During the observation, Social Services Director #279 verbalized no knowledge of any care plan interventions involving the storage of smoking materials in Resident #17's room. Interview on 08/27/24 at 10:58 A.M. with Interim Activities Coordinator #263 confirmed all resident smoking materials were to be kept in the locked cabinet by facility staff and was unaware of any individualized resident care plans directing otherwise. Review of the policy titled Resident Smoking Policy for Resident Signature revealed residents were permitted to smoke in designated areas, at designated times, and with supervision. Further review of the policy revealed no smoking materials were permitted to be with the residents, either on their person or in their rooms. 39333 4. Medical record revealed Resident #31 was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses including but not limited to dementia, anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 had severely impaired cognition and required physical assistance from staff for activities of daily living. Review of the care plan dated 04/04/22 for Resident #31 revealed Resident #31 had the potential for smoking safety issues related to being an active smoker. Interventions included but were not limited to providing a smoking apron during smoking to prevent accidental injury. Observation on 08/26/24 at 1:07 P.M. revealed Resident #31 was smoking during a supervised smoke break. Dietary Manager (DM) # 238 was observing the smokers. DM #238 stated Resident #31 required one on one supervision when smoking because she was an elopement risk. DM #238 verified that Resident #31 was not wearing a smoking apron. Interview on 08/28/24 at 10:12 A.M. with Business Office Manager (BOM) #293 verified Resident # 31's care plan indicated she should wear a smoking apron. 5. Medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including but not limited to dementia, restlessness, and agitation. Review of Resident #53's care plan dated 11/08/23 revealed Resident #53 was at risk for falls and potential injury related to impaired balance and poor decision-making skills. Interventions included but were not limited to nonskid socks to be worn at all times. may be removed for hygiene. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had severely impaired cognition and required physical assistance from staff for activities of daily living (ADL). Observation on 08/25/24 at 10:47 A.M. revealed Resident #53 sitting at a table with socks on his feet, the socks were not nonskid. Interview with State tested Nursing Assistant (STNA) #247 verified Resident #53 was not wearing non skid socks at the time of observation. Review of the facility policy with a revision date of August 2024 titled, Falls and Fall Risk Managing, revealed that resident-centered approaches would be implemented to manage falls and fall risk.

Based on closed record review and interview, the facility failed to ensure adequate assessment/monitoring was completed and the attending physician was promptly notified for Resident #55 following an acute change in condition. Actual harm occurred on 01/03/23 when Resident #55, who was assessed to have an acute change in condition (new onset inability to feed herself/diet downgrade) was not comprehensively assessed, provided timely medical treatment and the attending physician was not notified resulting in a delay of treatment. On 01/04/23 the resident was admitted to the hospital for treatment of weakness, encephalopathy, hypoxia and pneumonia. The resident did not return to the facility following the hospitalization . This affected one resident (#55) of three residents reviewed for a change in condition. Findings include: Review of Resident #55's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. Resident #55 had diagnoses including unspecified dementia, major depressive disorder and anxiety disorder. Resident #55 resided on the secured memory care unit (SMCU). Review of Resident #55's Minimum Data Set (MDS) 3.0 assessment, dated 11/22/22 revealed the resident had intact cognition and required limited one person assist for bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #55 required supervision setup assistance with meals and was assessed to be occasionally incontinent of urine and bowel. Review of Resident #55's progress note, dated 12/30/22 at 7:00 A.M., authored by Licensed Practical Nurse (LPN) Unit Manager #804, revealed the State tested Nursing Assistant (STNA) notified the nurse of the resident being on the floor. The resident was assessed with no injuries and was noted to be attempting to take herself to the bathroom. The fall was unwitnessed and neurological checks were in place. Review of Resident #55's progress note, dated 01/03/23 at 12:23 P.M., authored by LPN #805, revealed the resident was incontinent as of this date and unable to feed herself. Labs were to be drawn on this date and the resident was to transfer with one assist. The note revealed the resident's vital signs were within normal limits. However, review of the medical record revealed no evidence a comprehensive assessment was completed related to the change in condition (identified in the 01/03/23 12:23 P.M.) note. The medical record contained no information related to what vital signs were actually taken and what they were. In addition, there was no assessment related to the resident's neurological status or a respiratory assessment (including oxygen saturation) completed at that time. Review of Resident #55's progress note, dated 01/03/23 at 12:31 P.M., authored by LPN #805, revealed the resident's diet was downgraded to mechanical soft per nursing judgement. The note indicated physician and power of attorney (POA) aware. The medical record did not reflect any type of follow up assessment/monitoring related to this new onset change in condition. Review of Resident #55's progress note, dated 01/04/23 at 6:28 A.M., authored by LPN #807, revealed the STNA reported changes to this nurse and Resident #55 was assessed. The resident's eyes opened when her name was called but she was nonverbal with very sweaty lips which were purplish. The certified nurse practitioner (CNP) was called, and the resident was transferred to the hospital. Review of Resident #55's progress note, dated 01/04/23 at 2:55 P.M. revealed the resident was admitted with weakness, encephalopathy, hypoxia and pneumonia. Interview on 02/09/23 at 9:41 A.M. with LPN #807 revealed on 01/04/23 at 6:28 A.M. she was working as an STNA and was with the midnight nurse when the STNA on the SMCU said Resident #55 was not doing well. She stated she called the Certified Nurse Practitioner (CNP) who wanted the resident sent to the emergency room and she contacted the emergency contact. Interview on 02/09/23 at 11:09 A.M. with Physician #803 revealed he was not aware of any changes in condition or phone calls involving Resident #55. Physician #803 revealed his last day with the facility was on 12/31/22. Email interview on 02/11/23 at 1:16 P.M. with the Administrator indicated LPN #805 reported she informed Physician #803 of Resident #55's downgraded diet due to her change in her baseline and her inability to feed herself. Interview on 02/09/23 at 1:34 P.M. with CNP #888 revealed her first call from the facility related to Resident #55 was on 01/04/23. She indicated she was first made aware of a change in condition on this date and ordered the facility to send the resident to the emergency room . She stated she received a call sheet daily and did not have any other notifications from the facility between 01/01/23 to 01/04/23 related to Resident #55. Interview on 02/13/23 at 9:22 A.M. with Registered Nurse (RN) Unit Manager #865 revealed the facility would call Physician #803 on multiple occasions and he would not return the call. She indicated she usually waited until the return call to document any interventions implemented for a resident's care. Interview on 02/13/23 at 9:35 A.M. with the Director of Nursing (DON) revealed LPN #805 noted Resident #55 had a change in condition when she was no longer able to feed herself (on 01/03/23). The DON verified the medical record lacked evidence a thorough assessment/comprehensive monitoring or treatment was initiated at that time. The DON also verified the lack of evidence to support the resident's vital signs were obtained or that neurological or respiratory assessments were completed. The DON also confirmed LPN #805 had attempted to notify the facility previous medical director (Physician #803) for the change in Resident #55's condition instead of the resident's current physician (Medical Director #965). An additional interview on 02/13/23 at 11:11 A.M. with Physician #803 with the Administrator and DON present revealed his last day with the facility as the medical director was 12/31/22 and he did not overlap with the new medical director at any point. Review of a facility notification form, dated 01/02/23 revealed Medical Director #965 and CNP #888 would be providing medical services as of this date. This deficiency represents non-compliance investigated under Complaint Number OH00139807.

Based on medical record review, resident interview and staff interview the facility failed to timely obtain and administer pain medications to Resident #47 as ordered by the physician. Actual Harm occurred when Resident #47 waited over 24 hours to receive ordered pain medication which affected her sleep and limited her activity level. This affected one of three residents reviewed for medications. Findings include: Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on 09/24/21 to another facility. Review of the hospital discharge orders revealed Resident #47 was sent to the nursing facility with medication orders including oxycodone/acetaminophen 5 milligrams (mg)/325 mg, a narcotic pain reliever, [MEDICATION(S)] 75 mg an anti-[CONDITION(S)] medication, and acetaminophen 1000 mg, a non-narcotic pain reliever. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse's notes revealed there were no notes documented for 09/17/21 to indicate what time Resident #47 was admitted . The first nursing note was dated 09/18/21 at 2:45 A.M. Review of the plan of care dated 09/19/21 revealed Resident #47 was at risk for alteration in comfort related to her left ankle fracture. Review of the Medicare 5-day Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #47 was alert, oriented and had intact cognition. She required extensive assistance with all activities of daily living, received scheduled pain medication, received as needed pain medication, received non-medication intervention for pain, received an opioid. The assessment revealed Resident #47 reported her pain was frequent, had made it hard to sleep at night over the last five days, had limited her day-to day activities, and she rated the pain a seven out of ten, with zero being no pain and 10 being the worst pain ever. Review of the September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for a pain level of seven out of ten with ten being the worst pain possible. Review of the nurse note dated 09/18/21 at 3:13 P.M. revealed Resident #47 was upset that some of her pain medications had not been sent timely from the pharmacy. Review of the pharmacy delivery slip dated 09/18/21, which had no time listed, revealed a delivery of 10 tablets of oxycodone/acetaminophen, 5 mg/325 mg were delivered to the nursing facility for Resident #47. According to the September 2021 MAR, Resident #47 was not given any of her ordered narcotic pain reliever, oxycodone/acetaminophen 5 mg/325 mg, until 09/19/21 at 1:07 A.M. for a pain level she rated at nine. Review of the emergency medication supply list revealed oxycodone/acetaminophen 5-325 mg was available to be administered if needed by residents. Review of the Starter Kit replacement forms revealed no documentation oxycodone/acetaminophen, 5 mg/325 mg was pulled to be administered for Resident #47 while she waited for the medication supply to be delivered to the nursing facility from the pharmacy. Review of the nurse's notes dated 09/19/21 at 1:07 A.M. revealed Resident #47 was administered one oxycodone/acetaminophen tablet, 5 mg/325 mg for a pain level of nine for her fractured ankle. This was over 24 hours after admission to the facility on [DATE]. Interview on 10/06/21 at 9:47 A.M. with Family Member #400, family of Resident #47, revealed the facility did not have Resident #47's pain medication available for her complaints of pain. She stated they were giving her Tylenol for pain and it was not helping. She said it took a whole day to get her [MEDICATION(S)] (oxycodone/acetaminophen) for Resident #47. She stated they took her to another facility because of the poor care she received. Interview on 10/06/21 at 4:00 P.M. with Registered Nurse #311 indicated he did not know why the oxycodone/acetaminophen was not pulled from the starter kit and administered to Resident #47 for her complaints of pain. This deficiency substantiates Complaint Number OH 152.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of the facility's Coronavirus (COVID-19) policy, review of the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-38-NH, and review of the Centers for Disease Control and Prevention (CDC) guidelines, observations, interviews, and record review the facility failed to implement appropriate infection control practices related to resident testing, personal protective equipment (PPE) for residents on COVID-19 quarantine and isolation precautions and use of recommended face coverings. This resulted in Immediate Jeopardy on 09/29/20 after all residents in the facility were not tested for COVID-19 following a staff member testing positive on 09/29/20, the 22 residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, and Resident #23) exposed to the positive staff member were not quarantined according to CDC guidelines, and the facility failed to implement universal use of N95 masks in the facility due to the COVID-19 outbreak. In addition, rapid COVID-19 testing showed Resident #1 was positive for COVID-19 on 10/02/20 and Resident #2 and Resident #3 were positive for COVID-19 on 10/05/20. The facility failed to implement proper PPE procedures when exiting resident rooms with confirmed COVID-19. The lack of effective infection control practices placed all residents at the facility at risk for serious life-threatening harm, complications and/or death related to the facility ' s failed practice of infection control. The facility census was 49. The Administrator and Director of Nursing (DON) were notified on 10/08/20 at 5:36 P.M. that an Immediate Jeopardy began on 09/29/20 when the facility failed to implement appropriate and recommended infection control practices after a facility employee tested positive for COVID-19. After the staff tested positive for COVID-19, 19 of the 22 residents exposed to the positive employee were not quarantined properly as staff were not using full PPE (gowns, gloves, face shield, and N95 masks) in quarantine rooms. Interviews on 10/08/20 with facility employees revealed all residents were not tested after the employee tested positive and staff did not properly use N95 masks throughout the facility, as staff were using the same N95 in all resident rooms and throughout the facility, including those resident rooms (Resident #1, Resident #2, and Resident #3) with COVID-19. The Immediate Jeopardy was removed on 10/08/20 when the facility implemented the following correction actions: · On 10/08/20 by 11:00 P.M. all residents were tested for COVID-19 via rapid BP Veritor by Registered Nurse (RN) #104 and Licensed Practical Nurse (LPN) #105. Resident #4 tested positive for COVID-19 and was asymptomatic. · On 10/08/20 by 7:00 P.M. all 19 residents (Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, and Resident #23) who had exposure to COVID-19 who should have been on quarantine starting 09/29/20 were quarantined starting 10/08/20 through 10/13/20. · On 10/08/20 at 9:00 P.M. the four asymptomatic positive residents (Resident #1, Resident #2, Resident #3, and Resident #4) were moved to a unit where they would be separated from all other residents to limit further exposure. · On 10/08/20 at 10:00 P.M. all applicable facility policies and procedures pertaining to COVID-19 were reviewed by Director of Nursing (DON) to ensure CDC recommendations were in place. · On 10/08/20 by 8:00 P.M. all staff were given education by the DON via phone and in person pertaining to: Definition of COVID-19 quarantine (residents exposed to COVID-19 placed in quarantine for 14 days), the proper personal protective equipment (PPE) necessary when caring for quarantined residents, and proper procedures when entering the facility that include a mask. Staff unavailable via phone or in person will be educated by the Administrator, DON or Assistant Director of Nursing (ADON) #104 before their next shift. · On 10/08/20, the facility indicated the DON or designee will oversee infection prevention and control education for all new hires · Starting 10/08/20 at 7:00 P.M., the infection preventionist or designee will monitor staff on all shifts to ensure they are utilizing a mask upon entrance into the facility three times a week for one month and then weekly for three months. · Starting 10/08/20 at 10:00 P.M., the infection preventionist or designee will monitor quarantine procedures daily to ensure proper quarantine policies are followed if residents become exposed to COVID-19. · Starting 10/08/20, the Administrator implemented a Quality Assurance and Performance Improvement Performance Improvement Plan (QAPI PIP) as means to gather and process information from the audits/monitoring processes. Findings will be reported at the monthly Quality Assurance (QA) meetings for a minimum of three months. · On 10/08/20 at 4:55 P.M., the DON received PCR COVID-19 test results that Resident #3 was negative for COVID-19. · On 10/08/20 at 11:34 P.M., DON received PCR COVID-19 test results that Resident #1 was negative for COVID-19. · On 10/09/20 at 3:13 A.M., the DON received PCR COVID-19 test results that Resident #2 was negative for COVID-19. · On 10/09/20 by 3:00 P.M., all staff were tested COVID-19 via rapid BD Veritor by ADON #104 and Licensed Practical Nurse (LPN) #105. · On 10/12/20 by 2:00 P.M. all staff and residents were retested via PCR test by ADON #104 and LPN #105. · On 10/13/20 at 4:30 P.M., the Administrator and DON were counseled on the COVID-19 policy and procedure, Transmission Based Precautions, Testing of Residents and Staff, Quarantine policy and procedure by Corporate Regional Nurse #103. · On 10/13/20 by 4:45 P.M., all staff were re-educated via phone or in person by the DON on donning and doffing PPE when coming out of COVID-19 unit or rooms and quarantine rooms. Any staff member that could not be reached will be educated by the Administrator, ADON #104, and/or the DON before their next shift. Although the Immediate Jeopardy was removed on 10/08/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 ' s Nurses Note dated 10/02/20 revealed the resident tested positive for COVID-19 during resident testing. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2 ' s Progress note dated 10/05/20 revealed the resident tested positive for COVID-19 via rapid detection, the resident was asymptomatic, and droplet isolation precautions were initiated. Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3 ' s Progress Note dated 10/05/20 revealed the resident tested positive for COVID-19 via rapid detection, and the resident was asymptomatic. Observation on arrival to the facility on [DATE] at 10:50 A.M. revealed Receptionist #108 was sitting at the front desk with a blue surgical mask on. There were no N95 masks readily available at the receptionist desk for staff or visitor use. Interview on 10/08/20 at 11:09 A.M. with the DON and Administrator revealed on 09/29/20 LPN #100 tested positive for COVID-19. She last worked on 09/26/20 in the facility on night shift, caring for residents on B wing. The facility identified 22 residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, and Resident #23) reside on B wing, and they were all tested via rapid BD Veritor System test on 09/29/20 and all were negative for COVID-19. On 10/02/20, all staff were tested again and were negative for COVID-19. On 10/02/20, only the 22 residents residing on B wing were retested , and Resident #1 was positive for COVID-19. Resident #1 was asymptomatic, resided in a private room with a private bathroom. On 10/05/20, all 22 residents were retested using the rapid test, with two more resident ' s positive for COVID-19, Resident #2 and Resident #3. Both residents were asymptomatic and resided in private rooms with private bathrooms. The DON revealed on 10/05/20, N95 masks were required everywhere in the building and when entering Resident #1, Resident #2, and Resident #3 ' s room gown, gloves, face shield, and a surgical mask over the N95 should be worn. The DON revealed the 22 residents were placed in quarantine on B-wing which included the residents staying in their rooms. Other than the N95 mask, staff did not have to wear additional PPE in the quarantined resident rooms. Interview on 10/08/20 at 11:37 A.M. with the DON revealed the facility implemented N95 masks when the first resident tested positive on 10/02/20, and initially staff were taking the N95 masks home and bringing them back to the facility for use. On 10/08/20, the facility began implementing a paper bag storage system for the N95 masks, but staff had to walk down the halls through resident areas to get the N95 mask at the nurse ' s station. Observation on 10/08/20 at 12:05 P.M. revealed Resident #1, Resident #2, and Resident #3 were in their rooms with signs to see the nurse before entering. There was a cart with PPE available outside of the door, but additional N95 masks were not available in the carts for use. There was no indication anywhere on B wing to indicate the other 19 residents (Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, and Resident #23) were quarantined or that additional PPE was required in the quarantined resident rooms. Interview on 10/08/20 at 2:08 P.M. with State tested Nursing Assistant (STNA) #102 revealed in rooms of residents who are positive for COVID-19 she wears the same N95 mask and blue surgical mask that she wears throughout the facility in the room and when leaving the room she keeps that same N95 mask on. At no point does the STNA discard or replace the N95 mask or surgical mask used in the room where a resident was positive for COVID-19. Interview on 10/08/20 at 2:13 P.M. with LPN #100 revealed staff should wear a N95 with a blue surgical mask on over the N95 throughout the entire facility. LPN #100 was observed to only be wearing a Kn95 mask, and she indicated she has yet to get a new blue surgical mask to put over the Kn95 mask. LPN #100 revealed in rooms of residents who are positive for COVID-19 she wears the same N95 mask that she wears throughout the facility in the room and when leaving the room, she keeps that same N95 mask on. At no point does the LPN discard or replace the N95 mask used in the room where a resident was positive for COVID-19. LPN #100 revealed prior to the first resident testing positive 10/02/20, the residents were not quarantined and were able to come out of their rooms, despite the nurse employee testing positive on 09/29/20. Observation on 10/13/20 at 2:22 P.M. revealed LPN #106 was leaving the designated COVID-19 unit. LPN #106 discarded her gown, gloves, and sanitized her face shield, but did not discard or replace her N95 mask and blue surgical mask she had worn over the N95 mask. LPN #106 began to exit the unit. Interview with LPN #106 revealed she was unaware she had to discard or change her mask and thought there were no additional masks available. The DON joined the interview and pointed out there were additional N95 masks available for use. Interview on 10/13/20 at 3:03 P.M. with LPN #106 revealed she was not educated to change her mask when coming off the COVID-19 unit, and that she is caring for residents on and off the COVID-19 unit. STNA #107 joined the interview and revealed she wears the same N95 mask and blue surgical mask in and out of quarantined resident rooms as well as COVID-19 positive resident rooms. STNA #107 also stated she was not educated on discarding or changing masks. Review of the local health department email correspondence dated 09/29/20 revealed the facility should have immediately quarantined the residents that LPN #100 cared for. Review of the facility policy, titled Coronavirus Testing revealed an outbreak is a new COVID-19 infection in any healthcare personnel or any onset of COVID-19 infection in a resident. All staff and residents will be tested upon identification of a single new case of COVID-19 infection in any staff or residents. Review of the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-38-NH revealed all staff and residents will be tested upon identification of a single case of COVID-19 infection in any staff or residents. Review of the CDC guidance updated 04/30/20, revealed the facility should determine which residents received direct care from and which health care person had unprotected exposure to HP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset. Residents who were cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCP COVID-19 testing are known. If the HCP is [DIAGNOSES REDACTED]. Review of the CDC guidance updated 07/15/20, revealed PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: respirator or facemask. Disposable respirators and facemasks should be removed and discarded after exiting the patient's room or care area and closing the door unless implemented extended use or reuse. If reusable respirators are used, they should be removed after exiting the patient's room or care area. They must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use.

Based on observation, interview and record review, the the facility failed to notify the physician of a decline in appearance, and presence of drainage and odor of a pressure ulcer for Resident #12 resulting in delay of an effective treatment plan. This affected one of three residents reviewed for pressure ulcers. The facility census was 65. Findings include: Review of the medical record for Resident #12 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the minimum data set comprehensive quarterly assessment (MDS) 3.0 dated 01/20/12 revealed the resident had moderate cognitive impairment with long and short term memory problems. Review of a care plan dated 01/04/12 and updated through 05/07/12 revealed the resident had altered skin integrity and impaired skin areas on her bilateral heels. Interventions included observe areas on heels for signs or symptoms of infection and alert the physician of changes. Review of the medical record revealed that Resident #12 fell on [DATE] in the facility and suffered a left [MEDICAL CONDITION]. She was discharged to the hospital, returning on 01/15/12 following surgical repair of her [MEDICAL CONDITION]. The nursing readmission skin assessment dated [DATE] revealed dark purple areas on both of her heels. The areas progressed to large blood filled blisters by 01/18/12 and the facility podiatrist was consulted. He continued to follow the progression of the pressure areas, last seeing the resident on 03/13/12. The note from his visit on that date indicated that both heels had black devitalized tissue with the ulceration on the right heel measuring 2.5 centimeters (cm) by 1.5 cm full thickness. His note indicated the left heel ulceration measured 4.0 cm by 2.5 cm. The note also indicated there was no drainage, no odor and no signs of acute infection. Review of the skin assessment for both heels dated 03/20/12 described the heels as purple/red. The assessment indicated there was no drainage present for either ulceration. Review of the assessment skin grid dated 03/28/12 revealed the right heel measured 1.5 cm by 2.8 cm, a slight increase in size, with the wound described as purple/black and the left heel measured 6.0 cm by 3.0 cm, an increase of 2 cm in length and 0.5 cm in width. The left heel was also described on 03/28/12 as red/black with drainage noted. Prior to a dressing change observation on 03/29/12 at 9:40 A.M. Licensed Practical Nurse (LPN) #8 stated that she had noticed an odor lately to the left heel wound, and was going to notify the podiatrist the following day (03/30/12), when he would be in for his weekly visit to see the resident. She stated that he did not see the resident the previous week due to emergency surgery. During observation of the dressing change on 03/29/12 the dressings to both the left and right heel wounds were observed sticking to the wound bed upon removal. The old dressings contained reddish brown drainage and a foul odor was noted emitting from the wounds. After the dressing change was complete, LPN #8 stated that she had first noticed the odor to the left heel on 03/26/12, but did not call the physician. She stated that she did not work on 03/27/12. She stated that she "thought about" calling the podiatrist on 03/27/12, but knew he was coming in on 03/30/12 to see the resident. She verified that an odor was a change in condition that could be a sign of infection and that the physician should have been notified. LPN #8 stated she notified the physician on 03/29/12 at 11:15 A.M. of the odor and drainage to Resident #12's pressure ulcers. At 3:30 P.M. LPN #8 stated the physician had returned the call and ordered a culture of the left heel to check for infection and he had changed the treatment to [MEDICATION NAME] Ag, an ointment that kills wound bacteria, absorbs wound fluid and bacteria, maintains a moist environment and aids in the removal of non-viable tissue from the wound (autolytic debridement). Interview with the corporate nurse, Registered Nurse (RN) #1 on 03/29/12 at 4:00 P.M. verified the change in condition, including increase in size of the areas and odor and drainage noticed on 03/26/12, signified a possible infection, and had not been reported to the physician until after surveyor intervention on 03/29/12.

Based on observation, interview and record review, the facility did not ensure Resident #12 was free from pain during a dressing change. This affected one of three residents observed for dressing changes. In addition, the facility failed to ensure all staff followed the plan of care related to fall interventions for Resident #68. This affected one of three residents reviewed for falls. The facility census was 65. Findings include: 1. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the minimum data set comprehensive quarterly assessment (MDS) 3.0 dated 01/20/12 revealed Resident #12 had moderate cognitive impairment with impaired long and short term memory. The assessment also indicated that the resident received scheduled and as needed (prn) pain medication. Review of the care plan for alteration in comfort, dated 12/13/11 and updated through 05/07/12 revealed Resident #12 had a potential for pain related to [MEDICAL CONDITION] and a history of a [MEDICAL CONDITION]. Interventions included alternative pain relief measures such as relaxation, guided imagery or distraction. Review of a care plan dated 01/04/12 and updated through 05/07/12 revealed the resident had altered skin integrity and impaired skin areas on her bilateral heels. Interventions included to observe the areas on her heels for signs or symptoms of infection and to alert the physician of changes. The care plan for skin integrity did not indicate interventions related to pain of the impaired area. Review of the medical record revealed that Resident #12 fell on [DATE] in the facility and suffered a left [MEDICAL CONDITION]. The nursing admission assessment dated [DATE], after a hospital stay for surgical repair of the left hip, revealed the resident had dark purple areas to both of her heels. These areas progressed to large blood filled blisters by 01/18/12 and were being treated as Stage 2 pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough). Review of the of skin grid dated 03/28/12 revealed the right heel measured 1.5 centimeters (cm) by 2.8 cm with the wound described as purple/black. The left heel measured 6.0 cm by 3.0 cm and as red/black with scant drainage noted. Review of the pain evaluation dated 01/15/12 indicated the resident could have pain in her left hip and thigh with movement related to surgery and the fall. The evaluation indicated the resident would express pain by moaning and that [MEDICATION NAME], a narcotic pain medication, would be used prn to relieve the pain. A pain evaluation dated 01/20/12 again indicated pain in the left leg and hip due to the surgery. The pain was described as aching and tender and was exhibited by grimacing. [MEDICATION NAME] and Tylenol, a non-narcotic pain reliever, were indicated as the treatment for [REDACTED]. Review of the MAR for March, 2012 revealed the resident did not receive any Tylenol during the month of March through 03/29/12 and received 11 doses of [MEDICATION NAME]. The resident received the [MEDICATION NAME] on 03/24/12 at 12:15 P.M., 03/25/12 at 9:30 A.M., 03/26/12 (two doses) 9:00 A.M. and 9:00 P.M. and on 03/28/12 at 9:30 A.M. Review of a nursing note dated 03/24/12 at 9:00 A.M. revealed the resident was "very uncooperative with dressing change" and was "yelling." Review of the pain assessment on the treatment record for that date indicated the resident did not have pain on day shift. Prior to the dressing change observation for Resident #12 on 03/29/12 at 9:40 A.M., Licensed Practical Nurse (LPN) #8 stated to the surveyor that the dressing change was painful for the resident and that she may "yell out" during the dressing change. She also stated that the facility podiatrist followed the resident for the wounds and that they had recently been debrided. LPN #8 entered the room with the surveyor, washed her hands and applied gloves. She cut away thick wrappings on both heels and began to remove the old dressings, that were lightly stuck to each impaired area. As the old dressings were being removed, the resident yelled out "ouch." LPN #8 stated to resident "I am almost done." She then cleansed the area by patting the wounds with a four by four that had been soaked with normal saline. Resident #12 was yelling out during that time saying "what are you doing down there?" As LPN #8 applied the new treatment, she held it against the resident's heel and wrapped the heel with a roll of [MEDICATION NAME] gauze, the resident called out again expressing pain. LPN #8 continued to state to the resident, "We are almost done." On 03/29/12 at 9:50 A.M., after completion of the dressing change, LPN #8 confirmed she had stated to the surveyor that Resident #12 would have pain during the procedure. The resident was last medicated for pain on 03/28/12 at 9:30 A.M., the day prior to the treatment. LPN #8 stated that she used to medicate the resident prior to therapy, but the narcotic would make her sleepy, so she did not administer the medication for pain frequently. She stated that Resident #12 only had pain when the pressure area was touched. LPN #8 verified she had touched the pressure area several times during the procedure and that Resident #12 had called out in pain. LPN #8 and the director of nursing approached the surveyor again at 3:30 P.M. and stated that she had asked the resident if she wanted pain medication earlier that morning when she received her other morning medications. She stated that the resident had declined her offer of pain medication. LPN #8 verified that Resident #12 had memory problems and was cognitively impaired. She further verified that she did not ask the resident about pain medication immediately prior to the dressing change and she was aware that the resident had pain during the procedure. Interview with the corporate nurse, Registered Nurse (RN) #1 on 03/29/12 at 4:00 P.M. verified that the record did not contain an assessment or interventions related to pain during dressing changes. RN #1 confirmed the resident had suffered pain during the dressing change on 03/29/12. 2. Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care for fall risk initiated on 04/05/09 and current through 06/17/12 revealed the resident was at risk for falls due to impaired cognition and impaired balance. Interventions included an alarming self-release seatbelt and a low bed. Review of nursing notes revealed Resident #68 sustained falls on 03/04/12, 03/15/12 and 03/19/12. Review of the fall investigations revealed the alarming self-release seatbelt was sounding with each incident and new interventions were implemented that included a physical therapy evaluation, non-skid footwear and a three-day bowel and bladder tracking. On 03/29/12 at 10:45 A.M. Resident #68 was observed ambulating with Physical Therapist Assistant (PTA) #10. At 10:55 A.M. Resident #68 was observed standing unassisted in the hallway attempting to push another resident in her wheelchair. The self-releasing seatbelt was not alarming. Registered Nurse (RN) #9 assisted the resident back to her wheelchair and discovered the alarm had not been turned on. On 03/29/12 at 12:15 P.M. interview with PTA #10 revealed she had assisted Resident #68 back to her wheelchair after ambulation and had secured the self-release seatbelt. She revealed she must have forgotten to turn on the alarm. Interview with Registered Nurse (RN) #1 on 03/29/12 at 2:45 P.M. confirmed the self-release seatbelt had not been alarmed.