Every finding on record at Medina Center for Rehabilitation and Nursing

Based on observation, interview, and record review, the facility failed to ensure Residents #46 and #68, on the secured dementia unit, were provided activities to meet their interests and psychosocial needs. This affected two residents (#46 and #68) and had the potential to affect 12 additional residents (#3, #14, #19, #21, #22, #28, #32, #40, #41, #43, #53, and #71) who resided on the memory care unit. The facility census was 71.Findings include: Observations made on 08/13/25 during the complaint survey revealed no organized activities nor any type of individual activities were available for any of the residents on the memory care unit.Review of the memory care unit's activity calendar for August 2025 revealed that on 08/13/25 the following activities should have been held at 11:00 A.M. an activity titled, Science Experiment, at 2:00 P.M. an activity titled, Parachute Popcorn, and at 3:30 P.M. an activity titled, Name that Tune. Interview on 08/13/25 at 1:20 P.M. with Family of Resident #46 revealed that she was pleased with the care provided by the facility but would like to see more activities for the residents. Interview on 08/13/25 at 1:41 P.M. with Certified Nursing Assistant (CNA) #343, verified activities staff rarely came to the memory care unit and stated between two and three residents would attend BINGO on the non-secured unit. CNA #343 stated residents residing on the memory care unit needed more activities.Interview on 08/13/25 at 2:49 P.M. with Resident #68 revealed he resided on the secured memory care unit. Resident #68 reported staff take care of his needs, but stated there was nothing to do. Interview on 08/13/25 at 3:00 P.M. with Registered Nurse (RN) #307 revealed that she did not see any activities on the memory care unit and felt there should be more stimulation for the residents. Interview on 08/13/25 at 3:09 P.M. with CNA #306 revealed that there used to be activities held in the memory care unit, but not in a long time. She stated that there are a couple of residents that would be taken off the unit to occasionally attend activities. Interview on 08/13/25 at 3:27 P.M. with Activity Assistant (AA) #308 revealed that she works 9:00 A.M. to 5:00 P.M. Monday through Friday and does not do activities in memory care. She does have one resident that she must see at least once a week for one-on-one visits that reside on the memory care unit. AA #308 stated that the memory care unit does not have a different activity calendar, and only three residents come to activities outside of memory care. AA #308 reported if residents from memory care get restless during activities, they are taken back to the memory care unit. AA #308 reported there was a dedicated activity staff member for the memory care unit, but she only works every other weekend.

Based on record review, review of an emergency squad run report, review of hospital records, facility policy and procedure review, review of the information contained on the Medscape website, resident and staff interviews, resident representative interview, and interview with pharmacy staff, the facility failed to ensure Resident #63 was free from significant medication errors, when Resident #63 who had a seizure diagnosis was not administered the anti-convulsant medication (Vimpat) as ordered by the physician. This resulted in Immediate Jeopardy and actual harm beginning on 03/31/25 when Resident #63 began having clonic tonic seizures (a type of seizure characterized by both a tonic phase (muscle stiffening) and a clonic phase (jerking movements), often accompanied by a loss of consciousness) at the facility which required the resident's transfer to the hospital for evaluation and treatment of seizures. While hospitalized the resident required multiple doses of intravenous anti-convulsant medications, was intubated (placed on life-support), and was subsequently life-flighted to a larger hospital as a result of the resident's medical needs following the significant medication error that occurred at the facility. Subsequently, the resident was admitted to the Neuro Intensive Care Unit (ICU) for ongoing care and treatment. In addition, the facility failed to ensure Resident #8 was free from significant medication errors when Resident #8 did not receive his Fentanyl patch as physician ordered for management of the resident's pain which placed the resident at potential risk for more than minimal harm that was not Immediate Jeopardy. This affected two residents (#8 and #63) of six residents reviewed for significant medication errors. The facility census was 70. On 04/10/25 at 3:52 P.M., the Administrator, Travel Administrator (TA) #277, [NAME] President of Clinical Operations (VPCO) #280, and Regional Director of Operations (RDO) #278 were notified Immediate Jeopardy began on 03/31/25 when Resident #63 did not receive the physician ordered medication Vimpat and subsequently was not administered the medication twice on 04/01/25 for the 7:00 A.M. dose and 4:00 P.M. dose. Consequently, on 04/01/25 at 7:10 P.M., Resident #63 began having seizure activity at the facility and was transferred to a local hospital for evaluation and treatment. At the local hospital, the resident was administered medications, was intubated, and ultimately life flighted to another hospital, where the resident was admitted to the Neuro ICU due to the significant medication error. The Immediate Jeopardy was removed on 04/10/25 when the facility implemented the following corrective actions: On 04/02/25 the facility pharmacy was contacted and delivered Resident #63's Vimpat to the facility. On 04/02/25 an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the root cause analysis of Resident #63 not receiving Vimpat, staff education, and ongoing medication audits. The Administrator, DON, ADON #234, Social Services #292, Minimum Data Set Nurse #293, and Medical Director #270 were in attendance. On 04/10/25 Regional Director of Clinical Services (RDCS) #279 educated the DON, ADON #234, and Unit Manager #700 on re-ordering resident medications. On 04/10/25 the DON and ADON #234 completed a whole house audit to ensure all in-house residents had all ordered medications available. On 04/10/25 the Administrator/designee educated the nurses who were currently working on re-ordering of medications and the procedure if the fax machine was not functioning properly. All remaining nurses would be educated prior to the beginning of their next shift. Nursing leadership (DON, ADON #234, Unit Manager position, and Night Shift Supervisor position) would add education to the nursing agencies the facility utilized to educate their staff on the facility's procedure of re-ordering medications and what to do if the fax machine was not working. Education would also be added to orientation for all new hire nurses. The facility also had a plan in place to hire a unit manager to begin employment on 04/21/25 for night shift supervision. On 04/10/25 the Administrator checked the facility fax machines and all three were in working order at this time. Beginning 04/10/25 the DON/designee would audit all resident medications three times weekly for four weeks then two times weekly for two weeks, then one time for two weeks to ensure all in-house residents have all ordered medications available. Any concerns identified would be reviewed in Ad Hoc QAPI by the interdisciplinary team. Beginning 04/10/25 nursing leadership would ensure all resident medications would be re-ordered when no less than five days remaining of the medication. Nursing leadership would be responsible for providing any prior authorization requests to the physician and/or nurse practitioner (NP) and following up to ensure the prior authorization request was returned to pharmacy timely. Beginning 04/10/25 staff would contact the Administrator or nursing leadership to inform them if the fax machine is not working. If a prescription was needed, the physician and/or NP would be contacted by staff or nursing leadership to request the prescription. Staff/nursing leadership would follow up with pharmacy to ensure the physician ordered was received. Although the Immediate Jeopardy was removed on 04/10/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not immediate jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1.Review of the medical record for Resident #63 revealed the resident was admitted to the facility on [DATE] with diagnoses including traumatic brain injury and unspecified epilepsy without status epilepticus. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was severely cognitively impaired. The assessment revealed Resident #63 had no impairment to the upper or lower extremities, used a walker, and required partial/moderate assistance with personal hygiene. Review of the physician orders for Resident #63 revealed a current order (initiated 05/05/24) for the anti-convulsant medication Vimpat (lacosamide) 200 milligrams (mg), one tablet by mouth two times a day. Review of the Medication Administration Record (MAR) for Resident #63 dated March 2025 revealed Vimpat was placed on the MAR to be administered at 7:00 A.M. and 4:00 P.M. Vimpat was not documented as administered on 03/31/25 at 4:00 P.M., the signature box for administration contained the number two (2), which indicated drug refused. Review of the progress note for Resident #63 dated 03/31/25 at 3:43 P.M. revealed Vimpat tablet 200 mg medication was not available. The progress note included the reason (for the medication not being administered) was different than what was documented on the MAR for 03/31/25. The MAR dated April 2025 for Resident #63 revealed Vimpat was included on the MAR to be administered at 7:00 A.M. and 4:00 P.M. On 04/01/25 Resident #63 did not receive the 7:00 A.M. or 4:00 P.M. dose of Vimpat. The signature box for administration contained the number nine (9), which indicated other/see nurses notes. The progress note dated 04/01/25 at 9:06 A.M. revealed Vimpat tablet 200 mg was on order. On 04/01/25 at 4:51 P.M., the facility was waiting on the pharmacy to deliver the Vimpat 200 mg. The progress note dated 04/01/25 at 6:43 P.M. revealed the nurse spoke to a representative (Representative #281) at the pharmacy and she stated Vimpat would be delivered to the facility that night (04/01/25). There was no documentation in the medical record from 03/31/25 through 04/01/25 at 4:00 P.M. of the physician for Resident #63 being notified of the three consecutive missed doses of Vimpat. The progress note dated 04/01/25 at 7:35 P.M. revealed a Certified Nursing Assistant (CNA) reported to the nurse that Resident #63 was observed on his back in bed with tremors. Resident #63 was unresponsive to verbal and tactile stimuli. Resident #63 did have a pulse and was breathing. The note indicated the resident's seizure started at 7:10 P.M. and tremors began at 7:18 P.M. Documentation included emergency 911 was called. Review of the emergency squad run report for Resident #63 dated 04/01/25 at 7:20 P.M. revealed the primary impression was seizures with status epilepticus (a life-threatening neurological emergency that occurs when a seizure lasts longer than five minutes). Upon arrival, Resident #63 was in clonic tonic (grand mal) seizure state. Resident #63 had been on Vimpat but had been out of the prescription for an unknown amount of time. Resident #63 was flushed, dry and warm, had elevated blood pressures, pulses from 104 to 140 (normal 60-100) ranges. Respiration rates from 30-34 (normal 12-20) with room air saturations from mid-70's to 91% (ideal 96 - 99%). Intravenous (IV) in right hand, nasal trumpet (nasopharyngeal airway) inserted into right nostril successfully, and oxygen six liters per minute. Initial 2.5 milligrams (mg) Versed (treatment of status epilepticus) given IV without affect, another 2.5 mg Versed given IV push after four minutes with eventual five mg Versed given IV push over the next 10 minutes. Seizure clonic tonic subsided once for about two minutes before returning to status epilepticus throughout the rest of the resident contact. The progress note dated 04/01/25 at 9:20 P.M. revealed the nurse called Hospital #275 for an update on Resident #63. The Power of Attorney (POA) for Resident #63 was at the bedside and called the facility nurse back with the hospital nurse on speaker. The facility nurse was advised Resident #63's seizures were unable to be controlled. Resident #63 was sedated and intubated and life-flighted to Hospital #276. Review of medical record information from Hospital #276 revealed Resident #63 presented to Hospital #275 on 04/01/25 with concerns for breakthrough seizure and status epilepticus. Resident #63 did not receive his prescribed dose of Vimpat for 48 hours. He was found to have continuous seizure on 04/01/25 and Emergency Medical Services (EMS) could not stop the seizures. In the emergency department at Hospital #275, Resident #63 was intubated for airway protection, Ativan (anti-anxiety medication) and Keppra (anti-convulsant) were administered and seizure then aborted. However, recurrent eye and left twitching recurring so was transferred to Hospital #276 on 04/01/25. The resident received continuous electroencephalogram (EEG) (measures electrical activity in the brain) monitoring and management of status. Resident #63 self-extubated on 04/04/25 and was stable. Resident #63 was discharged to the facility on [DATE]. Hospital discharge orders included oxygen administration one liter continuously via nasal cannula (NC) and Vimpat 200 mg twice daily. Interview on 04/09/25 at 11:30 A.M. with ADON #234 verified Resident #63 did not receive the medication Vimpat (ordered for seizures) for several doses. The ADON revealed this was due to the facility fax machines being down for several days (to send orders to the pharmacy). There were three fax machines in the facility, one on the east side, one on the west and one in the business office. The fax machine on the east side and the west side went down and the nurses were told the fax machine in the business office was still working. The residents who needed refills for their narcotics required a new prescription sent to the pharmacy for the refills. The physician would sign the prescription, then the nurse would fax it to the pharmacy. The nurse was supposed to call the pharmacy after faxing it to make sure the pharmacy got the prescription. The ADON revealed the nurse faxed Resident #63's prescription to the pharmacy from the business office. The nurse did not call the pharmacy to verify they received the prescription like they were supposed to and later found that the fax machine in the business office was not working either, so the pharmacy never received the new prescription for the Vimpat for Resident #63. The nurses also never notified the physician Resident #63 did not have his Vimpat. The ADON revealed the physician would have been able to fax the prescription from his office or call it in for an emergency three-day supply. ADON #234 stated Resident #63 had been stable and did not have any seizures for several months prior to this incident and never had a seizure this bad while at the facility. Interview on 04/09/25 at 11:55 A.M. with TA #277 confirmed he was at the facility at the time the fax machines went down. There were three fax machines that were down from 03/19/25 until 04/01/25 due to issues with the telephone lines. TA #277 stated he did not know what nurses were doing for faxes to and from the pharmacy or physician offices. TA #277 stated he was aware of Resident #63 running out of his medication. The family spoke with the DON, and it was his understanding there were fax machine issues and a lack of communication. TA #277 stated the facility was still looking into what exactly happened and waiting for reports to find out what happened. Interview on 04/09/25 at 1:05 P.M. with DON revealed the facility had not completed their investigation to determine what happened with Resident #63's Vimpat and why the pharmacy did not send his medication before he ran out. The DON revealed her first day of employment as the facility's DON was 03/31/25 and Resident #63 had his seizure on 04/01/25 which resulted in hospitalization . The DON revealed two house nurses, and two agency nurses failed to properly follow up on Resident #63's Vimpat not being on order. The DON stated Resident #63 did not need a prescription and she did not know why the pharmacy did not send the medication. The DON revealed nurses were educated on the ordering process on 04/02/25. Review of the in-service from 04/02/25 with the DON titled Learning Circle revealed course topic was medication reordering. Type of presentation revealed: All nursing staff and nursing staff management correctly re-order and notify physicians regarding missed medications. The form included six nurse's signatures: DON, ADON #234, Agency Nurse #283, Registered Nurse (RN) #269, Licensed Practical Nurse (LPN) #253, and LPN #258. The DON confirmed these were all the nurses in serviced and confirmed there was no other signature log. The DON revealed the Administrator had the in-service form that had the information on how to reorder the medication, she just had the signature log. During the interview, the DON verified Resident #63 had three missed doses of Vimpat on 03/31/25 4:00 P.M. and 04/01/25 7:00 A.M. and 4:00 P.M. Interview on 04/09/25 at 1:46 P.M. with Resident #63's legal guardian, (LG) #291 revealed Resident #63 was still in the hospital as of this date. LG #291 revealed the resident had a history of seizures that started seven years ago due to a brain injury from a vehicle accident. Resident #63 had been taking Vimpat since the accident to control the seizures. LG #291 reported Resident #63 had a small seizure while at the fair in August 2024, he was just staring off, there were no tremors, and he had not had any seizures since then. On 04/01/25, the nurse called her and told her Resident #63 was having seizures, and said he missed a couple of days of medications because they were not available. LG #291 stated she had told the facility if Resident #63 refused his medications they were supposed to notify the LG. LG #291 revealed the hospital told her that Vimpat had a 13-hour half-life, Resident #63 had no Vimpat in his system at all and that's why he had seizures. Resident #63 went to Hospital #275 then he was life-flighted to Hospital #276 because they could not get his seizures under control. They had to intubate him, and he was on the ICU. The LG revealed Resident #63 was never on oxygen before but now he may need to be on oxygen the rest of his life. Telephone interview on 04/09/25 at 2:12 P.M. with Facility Pharmacist (FP) #284 revealed the facility did not reorder Vimpat for Resident #63 before running out. The medication was not automatically refilled because it was a narcotic and required a new prescription. The pharmacy received the refill request on 04/01/25 at 6:44 P.M. FP #284 explained someone might miss two days of Vimpat and be fine, others might miss one dose and not be fine. There were variables, and the half-life for Vimpat was 13 hours, which was why the medication was given two times a day. Interview on 04/09/25 at 2:33 P.M. with Case Manager #271 at Hospital #276 revealed Resident #63 transferred from Hospital #275 on 04/01/25 to Hospital #276 with concerns breakthrough seizures and status epilepsy. On arrival Resident #63 had been intubated and sedated and was admitted to neuro ICU. He was found to have continuous seizure, Vimpat was given, and seizures were aborted. Resident #63 continued to receive impatient care at Hospital #276 but had no further seizures (since resuming the medication). Interview on 04/09/25 at 3:08 P.M. with RN #285 revealed she was an Agency Nurse. RN #285 revealed she would have to think about what she would do at her other job to know how to order residents narcotics at this facility. RN #285 stated she would order the narcotics in the electronic medical system then fax the pharmacy the order. Interview on 04/09/25 at 3:12 P.M. with LPN #258 revealed he was a facility staff nurse but he stated he did not know how to order a residents' narcotics. Interview on 04/10/25 at 8:35 A.M. with TA #277 revealed the nurses worked 12-hour shifts, there were typically three nurses on day shift and three nurses on night shift. A telephone interview on 04/13/25 at 9:06 P.M. with RN #269 revealed she was a facility nurse and worked the night shift. RN #269 confirmed she signed an in-service on 04/02/25 and confirmed the content of the in-service being only two pages, one signature page and one with three numbered instructions. RN #269 revealed the in-service was left at the nurse's station for staff to read and sign. RN #259 stated there were no further instructions with the in-service including what to do if the fax machine went out again. RN #259 revealed when the fax machine broke, the nurses took pictures on their personal cell phones of residents' laboratory results to send the results to the medical providers. Review of the website titled Medscape revealed withdraw Vimpat (lacosamide) gradually over one week; do not discontinue abruptly because of risk for increased frequency of seizures. Stopping Vimpat suddenly can cause serious problems. The elimination half-life of lacosamide was approximately 13 hours. Review of the facility policy titled Administering Medication revised April 2019 revealed medications were administered in a safe and timely manner, and as prescribed. Medication administration times were determined by resident need and benefit, not staff convenience. Factors that were considered include enhancing optimal therapeutic effect of the medication. 2. Record review for Resident #8 revealed an admitted [DATE] with diagnoses including stable burst fracture of fourth thoracic vertebra and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact. Resident #8 received routine scheduled and as needed (PRN) pain medications. Pain frequency was occasionally and occasionally pain interfered with activities of daily living (ADLs). Review of the physician orders for Resident #8 revealed an order dated 03/30/25 for Fentanyl transdermal patch (treats severe pain) 72-hour 25 micrograms (mcg), apply one patch transdermally every 72 hours for pain and remove per schedule. Review of the medication administration record (MAR) for April 2025 for Resident #8 revealed the Fentanyl transdermal patch was due to be applied on 04/08/25 at 9:00 P.M. The signature box for administration contained the number nine (9), which indicated other/see nurses notes. Review of the progress note for Resident #8 dated 04/09/25 at 12:49 A.M. revealed Fentanyl transdermal patch on order. The progress note dated 04/09/25 at 10:11 A.M. completed by Director of Nursing (DON) included the pharmacy was contacted regarding medication on order. The pharmacist indicated the prescription prior authorization was denied but would be submitted again for potential approval. The primary care physician (PCP) signed prior authorization to be filled. A verbal order was received from the PCP to apply the patch upon arrival. An additional physician order was written 04/09/25 for the Fentanyl patch to be on hold, due to awaiting arrival of the patch. Interview on 04/09/25 at 10:23 A.M. with Registered Nurse (RN) #289 revealed Resident #8 did not have his Fentanyl pain patch available. Interview on 04/09/25 at 11:30 A.M. with ADON #234 revealed Resident #8 was frequently running out of prescriptions for his narcotics because the nurses were not getting the prescriptions timely and sending them to the pharmacy. Interview on 04/10/25 at 10:43 A.M. with Resident #8 revealed he was hurting all over. Resident #8 rated his pain an 8.5 (pain scale from zero to no pain and ten being the most severe pain). Resident #8 stated the facility told him it was the doctor's fault because no one put the order in for his pain patch. Interview on 04/10/25 at 11:13 A.M. with RN #290 and the DON revealed RN #290 indicated the pharmacy was supposed to deliver Resident #8's Fentanyl patch the previous night, but they didn't. The DON stated the pharmacy was waiting on Resident #8's prior authorization, the insurance was not wanting to pay, and the insurance wanted prior authorization. The DON stated that was why Resident #8's Fentanyl patch did not get delivered to the facility. A telephone interview on 04/10/25 at 1:45 P.M. with Facility Pharmacist (FP) #284 revealed Resident #8 did need a prior authorization but that was not holding up Resident #8 receiving his Fentanyl patches from the pharmacy. FP #284 explained the facility never sent in the required prescription from the physician, but Resident #8 could still receive the medication. The pharmacy just needed the prescription because it was a narcotic medication. FP #284 confirmed the pharmacy could not send the Fentanyl patch because the facility never sent the required prescription. Review of the undated guidance from Medscape for the medication Fentanyl transdermal revealed Fentanyl was used for chronic pain in opioid-tolerant patients, severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate. Patients who were opioid tolerant were those receiving, for one week or longer, at least 25 mcg/day transdermal Fentanyl. Do not abruptly discontinue Fentanyl patch. It was unknown at what dose level transdermal may be discontinued without producing the signs and symptoms of opioid withdrawal. Review of the facility policy titled Administering Medication revised April 2019 revealed medications were administered in a safe and timely manner, and as prescribed. Medication administration times were determined by resident need and benefit, not staff convenience. Factors that were considered include enhancing optimal therapeutic effect of the medication. This deficiency represents non-compliance investigated under Master Complaint Number OH00164543 and Complaint Number OH00163962.

Based on record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure resident meals were palatable and at a safe, appetizing temperature. This had the potential to affect all residents residing at the facility except for two residents, Resident #1 and #3 identified by the facility to receive nothing by mouth (NPO). The facility census was 70. Findings include: Observation on 04/07/25 at 11:30 A.M. of the meal tray line revealed residents tray were being prepared to serve. Interview on 04/07/25 at 11:47 A.M. with Resident #14 and Resident #58 revealed the chicken served was awful, it had a bad flavor and was like chewing jerky. Observation on 04/07/25 at 12:46 P.M. revealed a test plate of the lunch meal was served from the steam table and the food temperature was tested by the Dietary Manager (DM) #297. The test tray was served immediately after the last resident received their lunch tray from the food delivery cart. Observation of the test tray with DM #297 revealed the chicken appeared very small in portion size. DM #297 revealed the chicken shrinks in size after cooking and revealed it was not the correct proportion size, it was too small and revealed each piece should be at least four ounces and stated, There is no way that is four ounces. DM #297 confirmed the temperature of the chicken was 108.1 degrees Fahrenheit (F). The mashed potatoes were 125.4 degrees (F), the baked beans was 115.2 degrees (F) and the milk was 52.3 degrees (F). The appearance of the meal was unfavorable. The chicken tasted dry and not warm enough, the potatoes tasted instant and had a very strong garlic flavor and the baked beans were watery, not warm enough and had little to no flavor. DM #297 confirmed the food temperatures and revealed he heard several complaints from residents about the food and revealed he agreed with them. DM #297 revealed he was only permitted to order a few seasonings so all meals/food were seasoned with the same seasonings daily, no matter what the dish; all food items came frozen, nothing was fresh except some vegetables which frequently needed thrown out upon delivery due to mold. DM #297 revealed residents expressed the food was like prison food, it just tasted bad. Interview on 04/07/25 between 1:08 P.M. and 1:17 P.M. with Resident #27, #60, and #67 revealed the food served for lunch and in general was bland, dry, did not taste good and was not hot enough. Review of the Resident Council Minutes dated 03/20/25 revealed residents in attendance (Resident #14, #18, #73, #7, #52, and #36) voiced concerns the the mixed vegetables were full of water. Review of the facility undated policy titled, Food, Nutrition and Dietary Services Policy and Procedure revealed the purpose and policy was to ensure each resident of (the facility) was provided with a nourishing, palatable, well-balanced diet that meets his or her nutritional and special dietary needs, taking into consideration the preferences of each resident. Each resident shall receive, and the facility shall provide food prepared by methods that conserve nutritive value, flavor and appearance. The facility must serve food in appropriate quantity and at an appropriate temperature. Review of the facility undated policy titled, Record of Food Temperatures revealed hot foods would be held at 135 degrees (F) or greater. This deficiency represents non-compliance investigated under Complaint Number OH00163962. This is an example of continued non-compliance from the survey dated 02/25/25.

Based on observation, record review, facility policy review and resident and staff interview, the facility failed to ensure residents had comfortable water temperatures to bathe in, and maintain resident rooms in a clean and sanitary manner with adequate lighting. This affected two residents (#10 and #20) and had the potential to affect 18 additional residents (#2, #4, #7, #9, #15, #28, #30, #32, #37, #41, #45, #51, #56, #57, #64, #66, #69, and #71) who received a shower in the west shower room. The facility census was 70. Findings include: 1. Record review for Resident #10 revealed a re-admitted [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. The MDS revealed Resident #10 was dependent on staff for bathing. Interview on 04/15/25 at 8:34 A.M. with Resident #10 revealed when she was given a shower, the water felt cold, she did not like it, and it was miserable. Resident #10 was observed sitting in her wheelchair in her room. The carpeting was very warn and embedded with black dirt and stains and multiple liquid spills on top of spills throughout the entire carpet excluding the edges. The dresser and window blinds had dust build up and the floor molding was missing near the bathroom door. Resident #10 stated it was terrible, the staff does not dust, and they only sweep the carpet with a broom. Interview on 04/15/25 at 8:39 A.M. with Housekeeper #299 revealed the carpet in Resident #10's room was in that condition when they transferred her to the room. Housekeeper #299 stated the facility refused to rent a deep cleaner to clean the carpet and stated, We tell them all time, my manager, several Administrators, they don't do anything, it's not high on their list. Observation on 04/15/25 at 8:41 A.M. with Regional Director of Operations #278 confirmed the condition of Resident #10's room including the carpet. Interview on 04/15/25 at 9:21 A.M. with Housekeeping Supervisor #227 revealed Resident #10 was good at letting the staff clean her room, she never refused. Housekeeping Supervisor #227 confirmed the facility did not have a carpet scrubber. Interview on 04/15/25 at 10:46 A.M. with Maintenance Supervisor #230 revealed he tested the water temperatures monthly. Review of the water temperature log provided by Maintenance Supervisor #230 revealed on 03/12/25, he tested the water temperature for the west shower room and it was 87.6 degrees Fahrenheit (F). Maintenance Supervisor #230 stated after checking the water temperatures on 03/12/25, he turned the water temperature up. The next water temperature testing was completed and documented on 04/15/25 by Maintenance Supervisor #230 and revealed the west shower room tested at 99.9 degrees F. Subsequent interview on 04/16/25 at 12:21 P.M. with Maintenance Supervisor #230 revealed the water mixing valve broke and that was why the water was not getting warm enough on the west wing. Maintenance Supervisor #230 revealed he ordered the part on 04/15/25 and it should be in next week. The residents residing on the west wing would take showers in the memory care unit until the west wing shower/water temperature was fixed. Maintenance Supervisor #230 revealed the water temperature should be 105 degrees F to 120 degrees F. Interview on 04/16/25 with Certified Nursing Assistant (CNA) #254 revealed she gave Resident #10 her last shower on the west side shower room on 04/14/25. The water was cool to touch, she would let it run a while, it warmed up a little but then got cool again. CNA #254 verified residents complained of cold showers. 2. Record review for Resident #20 revealed an admitted [DATE] with diagnoses including major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Review of the care plan dated 03/17/25 revealed Resident #20 had a psychosocial well-being problem related to anxiety, inability to solve problems. Interventions included to increase communication between resident/family/caregiver about care and living environment. Observation on 04/09/25 at 9:52 A.M. revealed Resident #20 was sitting up in his chair in his room. The carpeting in Resident #20's room, excluding the edges was observed embedded with black dirt and grime. There were multiple large spills on top of spills covering greater than 50% of the carpet. The remainder carpet fibers excluding the edges, was flattened due to embedded dirt. The bathroom light did not turn on. The bathroom sink had dirt and grime on the inside and outside of the sink covering the entire sink. The faucets were also covered with grime. The toilet including the bowl and top and bottom of the lid had urine and stool throughout along with dirt and grime on the base of the bowl and floor. The bathtub floor and sides had a large black area under the faucet with visible dirt and grime throughout. At the time of the observation, interview with Resident #20 revealed, I use my shower, it's disgusting. Resident revealed staff did not offer to clean his room. Observation and interview on 04/09/25 at 9:57 A.M. with Administrator confirmed the flooring and bathroom conditions in Resident #20's room. Resident #20 stated his bathroom light had not worked for weeks. The Administrator revealed Resident #20 refused housekeeping. Resident #20 revealed he refused housekeeping sometimes but not all the time. Interview on 04/09/25 10:02 A.M. with Housekeeper #298 revealed Resident #20 has let housekeeping clean but he usually refused. In the past when Resident #20 refused housekeeping, the Administrator would go in and speak to him and then he would allow staff to clean his room. Interview on 04/09/25 at 10:12 A.M. with the Maintenance Supervisor #230 revealed he was not aware the light was not working in Resident #20's bathroom and stated he had only been at the facility for a month. Interview on 04/09/25 at 10:15 A.M. with the Administrator confirmed she was new and never been in Resident #20's room until today (04/09/25) and stated she was aware some Administrators had to go in there. Interview on 04/15/25 at 9:22 A.M. with Housekeeping Supervisor #227 revealed Resident #20 frequently refused housekeeping but he would usually allow her but at time also refused. Housekeeping Supervisor #227 stated in the past if he refused after three days, they would go to the old Administrator, and he would comply if the old Administrator went in. Review of the facility's undated policy titled Routine Cleaning and Disinfection revealed it is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Review of the facility's undated policy titled Quality of Life - Homelike Environment revealed comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and home-like environment. Review of the facility's undated policy titled Residents Rights Policy and Procedure revealed each resident has a right to a safe, clean, comfortable homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility shall provide a safe, clean, comfortable homelike environment. This deficiency represents non-compliance investigated under Complaint Numbers OH00163962 and OH00163963.

Based on resident and staff interviews, and review of the facility policy, the facility failed to honor residents' drink preferences to include caffeinated coffee. This had the potential to affect all residents residing at the facility except for two residents (#1 and #3) identified by the facility as being nothing by mouth (NPO). The facility census was 70. Findings include: Interview on 04/07/25 at 3:55 P.M. with Dietary Aide #220 revealed the facility did not have caffeinated coffee/tea to offer residents. Dietary Aide #220 stated the residents were not allowed to have regular coffee, it was a stimulant, and they can have decaffeinated. Interview on 04/09/25 at 9:32 A.M. with Medical Director #270 revealed he did not know residents could not have regular coffee and confirmed he was not aware of that. Medical Director #270 revealed there was no reason he knew of that they could not have regular caffeinated coffee. Interview on 04/09/25 at 10:19 A.M. with Resident #37 stated he preferred regular coffee but was told by the facility could not put it in the budget. Interview on 04/09/25 at 10:30 A.M. with Administrator confirmed the facility did not provide caffeinated coffee for the residents. The Administrator stated the previous Director of Nursing (DON) told them not to provide it to the residents. Interview on 04/09/25 at 10:45 A.M. with Resident #14 revealed he was the Resident Council President. Resident #14 stated the residents were not allowed to get caffeinated coffee. The nurse said it was because it interferes with medications. Resident #14 said trust me I wish we could have regular coffee. He stated he hated decaffeinated, and so does a lot of the residents. Resident #14 said the residents were recently told they were not allowed to have caffeinated coffee or tea. Review of the facility's undated policy titled Food, Nutrition and Dietary Services Policy and Procedure revealed the purpose and policy was to ensure each resident of (the facility) is provided with a nourishing, palatable, well-balanced diet that meets his or her nutritional and special dietary needs, taking into consideration the preferences of each resident. Each resident shall receive and the facility shall provide drinks including water and other liquids consistent with residents needs and preferences. This deficiency represents non-compliance investigated under Complaint Number OH00163962.

Based on record review, facility policy review and interview, the facility failed to timely fix a broken water mixing valve to ensure residents who utilized the west shower room were provided water at a comfortable temperature for showering/bathing. This affected one resident (#10) and had the potential to affect 19 additional residents, Resident #2, #4, #7, #9, #15, #20, #28, #30, #32, #37, #41, #45, #51, #56, #57, #64, #66, #69, and #71 who received a shower in the west shower room. The facility census was 70. Findings include: Record review for Resident #10 revealed a readmitted [DATE] with diagnoses including unspecified dementia, and spastic hemiplegia affecting the left nondominant side. Review of the care plan dated 05/14/24 revealed Resident #10 had an activity of daily living self-care performance deficit related to a history of cerebral vascular accident (CVA) with hemiparesis. Interventions included the resident preferred to have a shower on Mondays and Thursdays. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact and dependent on staff for bathing. Interview on 04/15/25 at 8:34 A.M. with Resident #10 revealed when she was given a shower, the water felt cold, she did not like it, it was miserable. Interview on 04/15/25 at 10:46 A.M. with Maintenance Supervisor #230 revealed he tested the water temperatures monthly. Review of the water temperature log provided by Maintenance Supervisor #230 revealed on 03/12/25 he tested the water temperature for the west shower room and it was 87.6 degrees Fahrenheit (F). Maintenance Supervisor #230 revealed after checking the water temperatures on 03/12/25 he turned the water temperature up. The next water temperature testing was completed and documented on 04/15/25 by Maintenance Supervisor #230 and revealed the west shower room tested at 99.9 degrees F. Interview on 04/16/25 at 12:21 P.M. with Maintenance Supervisor #230 revealed the water mixing valve broke and that was why the water was not getting warm enough on the west wing. Maintenance Supervisor #230 revealed he ordered a part on 04/15/25 and it should be in next week. The facility plan was for residents residing on the west wing to take showers on the memory care unit until the west wing shower/water temperature was fixed. Maintanance Supervisor #230 revealed the hot water temperatures should be maintained between 105 degrees F to 120 degrees F. Interview on 04/16/25 with Certified Nursing Assistant (CNA) #254 revealed she gave her last shower on the west side shower room on 04/14/25. The water was cool to touch, she would let it run a while, it warmed up a little but then got cool again. CNA #254 verified residents complained of cold showers. There was no evidence residents were provided another option for showering/bathing timely once it was identified the water in the [NAME] side shower room was not reaching a comfortable temperature. Review of the facility undated policy titled, Residents Rights Policy and Procedure revealed each resident had a right to a safe, clean, comfortable homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility shall provide a safe, clean, comfortable homelike environment. This deficiency represents non-compliance investigated under Complaint Numbers OH00163962 and OH00163963. This is an example of continued non-compliance from the survey dated 02/25/25.

Based on resident and staff interview, record review, and review of the facility policy, the facility failed to ensure residents were treated with respect and dignity. This affected one resident (#37) of three residents reviewed for respect and dignity. The facility census was 70. Findings include: Record review for Resident #37 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus (DM) with diabetic neuropathy, major depressive disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact. Review of the physician orders for April 2025 for Resident #37 revealed the resident had several medications to be administered in the morning. There were specific physician orders dated 01/02/25 for medications to be administered after breakfast which included: ferrous sulfate (vitamin) 325 milligrams (mg) mg one time a day, Jardiance 10 mg give one tablet by mouth in the morning, lisinopril five mg give one tablet in the morning for hypertension (HTN), pantoprazole sodium delayed release 40 mg in the morning related to epigastric pain, sertraline 50 mg give one tablet in the morning major depressive disorder, and torsemide 20 mg by mouth one time a day for HTN. Review of the Medication Administration Record (MAR) for Resident #37 from 04/01/25 to 04/07/25 revealed all of the morning medications (except ergocalciferol oral capsule scheduled 8:00 A.M.) were scheduled to be administered at 7:00 A.M.; The MAR for 04/07/25 at 7:00 A.M. revealed all the medications for 7:00 A.M. and 8:00 A.M. were documented as a two indicating the drug was refused and signed by Licensed Practical Nurse (LPN) #302. Resident #37 had not refused medications on any other of the six days. Interview on 04/07/25 at 2:20 P.M. with Resident #37 revealed the nurse (Licensed Practical Nurse (LPN) #302)came in with his medications at 6:57 A.M. Resident #37 told LPN #302 that he takes his medications after he eats. LPN #302 responded to him if you don't take your medications now, you will have to come find me (the nurse) later. Resident #37 told LPN #303 that if she read his medical record she would see that he receives his medications after meals. LPN #303 responded to him I don't have time to look at every expletive chart, I have 50 residents in here. LPN #303 walked out and slammed his door. The resident stated he reported this to the Administrator. The Administrator responded sorry (Resident #37), they don't always do their job around here. Resident #37 stated he also told Assistant Direct of Nursing (ADON) #234. Interview on 04/07/25 at 2:25 P.M. with ADON #234 revealed Resident #37 told her the nurse (LPN #302) was yelling at him because she told him to take his pills, he said he doesn't take them until after breakfast, LPN #302 said well then you will come find me because the nurse was not hunting him down, then she slammed his door. ADON #234 revealed she told Travel Administrator #277 and the Director of Nursing (DON). LPN #302 was from a staffing agency, and was recently placed on the do not return list with the agency because of her attitude. The new DON brought her back. Interview on 04/07/25 at 2:45 P.M. with Travel Administrator #277 revealed LPN #302 was an agency nurse and was previously on the do not return list by the previous DON who did not like her attitude. The new DON, who has been here about two weeks, said she worked with her before and brought her back. Regional Director of Operations (RDOP) #27 was present and revealed he talked to Resident #37 that morning (04/07/25). Resident #37 said there was a new girl, she was agency staff and he was afraid he was not going to receive his medications. He asked Resident #37 if he needed his medications now and Resident #37 said yes. They both went to the medication cart where LPN #302 gave him his medications. RDOP #27 revealed Resident #37 shared with him he did not feel abused, he felt not respected. Interview on 04/07/25 at 3:50 P.M. with the DON confirmed she was made aware of Resident #37's concerns. DON stated Resident #37 does a have a lot of complaints. Review of the facility's undated policy titled Residents Rights Policy and Procedure revealed every resident has the right to be treated with respect and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00163962.

Based on observation, record review, facility policy review and interview, the facility failed to ensure Resident #59 was free from an incident of neglect. This affected one resident (#59) of three residents reviewed for abuse/neglect. The facility census was 70. Findings include: Record review for Resident #59 revealed an admitted [DATE] with diagnoses including cerebral infarction, chronic obstructive pulmonary disease (COPD), and gastroesophageal reflux disorder (GERD). Review of the care plan dated 09/13/22 revealed Resident #59 had GERD. Interventions included to avoid lying down for at least one hour after eating. Keep head of the bed elevated. Resident #59 had shortness of breath related to COPD. Interventions included to elevate the head of the bed to alleviate shortness of breath while lying flat. Position resident for proper body alignment for optimal breathing pattern. Resident #59 had a pressure wound to the left heel. Interventions included to provide treatment to the left heel as ordered. Resident #59 was at risk for impaired skin integrity related to fragile skin, impaired mobility and incontinence. Interventions included a low air loss mattress to bed, and peri care after each incontinent episode. Resident #59 received hospice services related to end stage diagnosis, cererbral vascular accident, COPD, and acute respiratory failure. Interventions included to promote emotional support and comfort measures. Review of the physician orders for Resident #59 dated 02/28/25 included orders for the resident to wear bilateral heel protectors while in bed as tolerated. An order dated 03/11/25 for Resident #59 revealed left heel, clean with normal saline apply medihoney cover with ABD pad and wrap with kerlix every day shift for treatment and as needed. The treatment was scheduled 6:00 A.M.; An additional order dated 03/25/25 included lay pillowcase over left foot to keep dry every shift for preventative dated 03/25/25. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was moderately cognitively impaired. Resident #59 had impairment on one side of the upper extremity and both sides of the lower extremities. Resident #59 required set up or clean up assistance with eating, dependent on staff for toileting hygiene, dressing, personal hygiene, and bed mobility. Resident #59 was always incontinent of bowel and bladder. Resident #59 did not have a condition or chronic disease that may result in a life expectancy of less than six months. Observation on 04/07/25 at 2:00 P.M. revealed three Certified Nursing Assistants (CNA) #294, #295, and #296 and Assistant Director of Nursing (ADON) #234 were standing in the hall outside the nurse's station. Observation revealed a resident down the hall was overheard repeatedly yelling, Hello, I need help. No staff members were moving to assist or acknowledge the resident's repeated call for assistants. Observation while following the continued repeated yell, Hello, I need help revealed Resident #59 lying in bed. Resident #59's call light was also on, and the call light was blinking above Resident #59's door, but made no sound. Resident #59 stated, Please, I need help, I need changed. A foul strong odor of urine was present in the room. No staff were present. Resident #59 had tears in his eyes while asking for assistance. Observation revealed Resident #59 was on a low air loss mattress. The upper portion of the mattress was mostly deflated. Resident #59's head and shoulders were several inches lower than his body. Resident #59 had a t-shirt and brief on, no pants, blanket or sheet. The bottom sheet, bed pad and dressing on Resident #59's foot (that was contracted up to his peri area) were all saturated with urine. Resident #59's hair was unkept and oily, his facial hair was untrimmed. Resident #59 had dry flaky skin on his face and arms, his fingernails were long, uneven, and embedded with a dark substance. Resident #59 had no heel protectors on. Resident #59's again repeated, Please help me while audible respiratory gurgling could be heard in his voice as he spoke. The surveyor returned to the nurse's station to find the same staff members, CNA #294, #295, #296 and ADON #234 standing outside the nurse's station. Interview with ADON #234 confirmed they could hear Resident #59 yelling for help. ADON #234 stated, He yells all the time, the nurse who gave me report a few minutes ago said she just walked out, he only wanted a drink. Observation of Resident #59 on 04/07/25 at 2:09 P.M. with CNA #294, CNA #296 and ADON #234 confirmed Resident #59 had a foul strong odor of urine. Resident #59's low air loss mattress was deflated on the upper portion and Resident #59's head and shoulders were several inches lower than his body. CNA #294 stated, Oh that's the beeping I been hearing it all day. CNA #294 revealed she started her shift at 7:00 A.M. and Resident #59's bed, with his head lowered, was in that position since she started her shift. All staff present confirmed the sheet, bed pad and dressing on Resident #59's contracted foot were all saturated with urine. Resident #59's hair was unkept and oily, his facial hair was untrimmed. Resident #59 had dry flakey skin on his face and arms, his fingernails were long, uneven, and embedded with a dark substance. During observation of incontinence care for Resident #59 revealed a dark red area with a purple center on Resident #59's sacral area, the spinal area and left gluteal fold also had red areas. CNA #296 revealed she told the nurse this morning about the wound to the sacral area and stated, She said he had a patch on it, I told her there was no patch on it, she never came in to look at it. CNA #294 confirmed those wounds were there when she assisted CNA #294 to change Resident #59 that morning; ADON #234 entered the room and confirmed the wound to the sacral area and the gluteal fold were non-blanchable (an important sign of tissue damage). ADON #294 confirmed Resident #59 did not have any current treatment orders for the areas to the sacral wound or gluteal fold. Record review of the Change in Condition Evaluation for Resident #59 dated 04/07/25 at 3:09 P.M. completed by ADON #234 revealed Resident #59 had a skin wound or ulcer that started on 4/07/25. The area was a grade two or higher-pressure ulcer/injury on the sacrum that was red purple in color and measured three centimeters (cm) in length by three cm in width and was non-blanchable. The second new area was on the left gluteal fold, red, measured one cm in length by one cm in width and was non-blanchable. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting revised March 2018 revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility policy titled, Abuse and Neglect - Clinical Protocol revised March 2018 revealed Neglect as defined at 483.5 means the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. This deficiency represents non-compliance investigated under Complaint Numbers OH00163962 and OH00163963.

Based on observation, record review, facility policy review and interview, the facility failed to ensure residents received timely, adequate and necessary staff assistance with activities of daily living (ADLs) to maintain proper grooming and hygiene. This affected three residents (#25, #15, and #39) of four residents reviewed for ADL care. The facility census was 70. Findings include: 1. Record review for Resident #25 revealed a re-admitted [DATE] with a diagnosis including Parkinson's disease. Review of the care plan dated 03/25/24 revealed Resident #25 had functional abilities impaired self-care and mobility deficit. Interventions included to assist with personal hygiene including combing hair and shaving. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was cognitively intact. The assessment revealed Resident #25 required substantial/ maximal (staff) assistance with personal hygiene. Observation on 04/07/25 at 1:20 P.M. revealed Resident #25 was sitting up in his chair in his room. Resident #25's face had dry flaky skin with long unkept facial hair present. An interview with the resident at the time of the observation revealed a concern that staff only shaved him once every week to two weeks. Resident #25 revealed he preferred to be clean shaved, but indicated staff reported they just didn't have time. Observation on 04/16/25 at 11:52 A.M. revealed Resident #25 was sitting up in his chair in his room. Resident #25's face had dry flaky skin and his long unkempt facial hair appeared the same. An interview with Resident #25 at the time of the observation revealed the staff still had not shaved him, he was still waiting. Interview on 04/07/25 at 11:44 A.M. with Certified Nursing Assistant (CNA) #300 revealed she assisted Resident #25 out of bed this A.M. CNA #300 confirmed Resident #25 had long facial hair and he was unkempt and his face had was dry and flaky. At the time of the interview, CNA #300 revealed she had not offered to wash Resident #25's face or shave him as part of his A.M. care on this date. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting revised March 2018 revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Record review for Resident #39 revealed an admitted [DATE] with diagnoses including dementia and muscle weakness. Review of the care plan for Resident #39 dated 04/03/23 revealed Resident #39 had an ADL self-care performance deficit related to dementia and limited mobility. Interventions included to encourage the resident to participate to the fullest extent possible with each interaction. Review of the annual MDS assessment dated [DATE] revealed Resident #39 was severely cognitively impaired. The assessment revealed Resident #39 required (staff) set up or clean up assistance for meals and supervision or touch assistance with oral hygiene, bed mobility, transfers and ambulation. Observation on 04/15/25 at 8:59 A.M. revealed Resident #39 was lying in bed. Resident #39 was observed to have a thick yellow build-up with food between her teeth. Interview on 04/15/25 at 9:01 A.M. with CNA #301 verified the condition of Resident #39's mouth and confirmed Resident #39 had not been offered or provided with oral care before or after breakfast on this date. 3. Record review for Resident #15 revealed an admitted [DATE] with diagnoses including Alzheimer's disease and muscle weakness. Review of the care plan for Resident #15 updated 04/21/24 revealed a plan related to the resident's oral care routine which included to brush teeth, clean gums with toothette and rinse mouth with wash. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 was rarely or never understood and dependent on staff for all ADL care. Observation on 04/09/25 at 8:52 A.M. with CNA #255 revealed Resident #15's teeth had a thick yellow build-up between the teeth. At the time of the observation, interview with CNA #255 revealed she had not offered or provided oral care, including cleaning Resident #15's teeth before or after breakfast on this date. CNA #255 revealed she does not always have time to do oral care for the residents she was assigned to care for, including Resident #15. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting revised March 2018 revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Numbers OH00163962 and OH00163963. This is an example of continued non-compliance from the survey dated 02/25/25.

Based on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized plan of care for Resident #15 related to the presence of bilateral hand contractures to prevent skin impairment. This affected one resident (#15) of three residents reviewed for quality of care and treatment. The facility census was 70. Findings include: Record review for Resident #15 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, muscle weakness, and disorders of bone density and structures. Review of the care plan dated 01/28/25 revealed Resident #15 was at risk for infection and or discomfort related to bilateral hand and finger contractures resulting in skin impairment to the resident's bilateral palms. No interventions were noted to be in place on the care plan. Review of the physician's orders for Resident #15 dated 01/29/25 revealed an order for treatment for the left palm. The order indicated to cleanse with normal saline, skin prep and wrap with Kerlix daily and as needed every day shift for wound treatment. The resident also had an order for treatment to the right palm, to cleanse with normal saline, skin prep, wrap with Kerlix under contractured fingers and secure to hand daily and as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was rarely or never understood and dependent on staff for all activities of daily living (ADLs). Review of the Treatment Administration Record (TAR) for April 2025 revealed the physician ordered treatments for the palms were not completed as ordered on 04/03/25, 04/07/25, or 04/10/25. Observation on 04/07/25 at 8:52 A.M. with Certified Nursing Assistant (CNA) #255 confirmed Resident #15's bilateral hands/fingers were contracted. Resident #15's nails that could be seen were long and uneven, the remaining nails were contracted into the palms of the resident's hands and not visible. Resident #15 did not have any dressings on either hand at the time of the observation. At the time of the observation, interview with CNA #255 revealed she worked full time three days a week, often with Resident #15. Per CNA #255 Resident #15 used to wear palm guards but the CNA stated the resident had not worn them or anything else for a very long time. CNA #255 then attempted to open Resident #15's fingers but was unable to Observation of Resident #15 on 04/07/25 at 11:13 A.M. with Assistant Director of Nursing (ADON) #234 confirmed Resident #15 did not have any dressings on either of of her contracted hands/fingers. ADON #234 confirmed Resident #15's visible nails were long and uneven. The third and fourth fingers on the right hand were contracted into the palm of the hand and the nails were not visible. The third, fourth, and fifth fingers on the left hand were contracted into the palm of the hand and the nails were not visible. ADON #234 attempted and verified she was unable to see if Resident #15's nails were embedded into her palm. ADON #234 confirmed Resident #15 was supposed to have her hands wrapped with gauze to prevent her nails from digging in to the palms of her hands causing wounds. ADON #234 revealed she had not seen them wrapped for a few weeks on the days/times she worked. ADON #234 revealed Resident #15 would no longer be able to remove the dressings on her hands herself but if she did, the nurses should have replaced the dressings. Review of the TAR and medical record with the ADON for April 2025 confirmed there was no documentation the dressings on Resident #15's hands came off after being applied, nor the as needed dressings re-applied if they were removed. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting revised March 2018 revealed residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00163963. This is an example of continued non-compliance from the survey dated 02/25/25.

Based on observation, record review, review of Centers for Disease Control and Prevention (CDC) guidance, facility policy review and interview, the facility failed to ensure staff maintained infection control practices including appropriate hand washing and the use of personal protective equipment (PPE) when required. This affected three residents (#44, #68, and #74) of 70 residents residing in the facility. Findings include: 1. Record review for Resident #74 revealed an admitted [DATE] with a diagnosis including multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #74 was cognitively intact. Resident #74 required assistance with activities of daily living (ADL's). Review of the care plan dated 03/18/25 revealed Resident #74 had multiple sclerosis. Interventions included to give medications as ordered. Observation on 04/07/25 at 10:36 A.M. of medication administration with the Director of Nursing (DON) revealed the DON prepared Resident #74's oral medications (13 pills) for administration. The DON did not wash her hands or use hand sanitizer prior to preparing the medication. The DON then entered Resident #74's room and assisted Resident #74 to take his medications. The DON then exited the room and returned to the medication cart without washing her hands or using hand sanitizer. The DON then began preparing Resident #44's medications. Observation on 04/07/25 at 11:14 A.M. of medication administration with the DON revealed the DON prepared Resident 74's topical medication patch (lidocaine patch 4 %) for application. The DON did not wash her hands or use hand sanitizer prior to opening and preparing the medication patch. The DON then entered Resident #74's room and applied the medicated patch topically. The DON then exited the room and returned to the medication cart without washing her hands or using hand sanitizer. Interview on 04/07/25 at 11:24 A.M. with the DON confirmed she never washed her hands or used hand sanitizer during the observations of medication administration for Resident #44 and #74. Review of the facility policy titled, Hand washing/Hand Hygiene revised October 2023 revealed the facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections. All personnel were expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene was indicated immediately before touching a resident; after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching a resident's environment; before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. 2. Record review for Resident #44 revealed an admitted [DATE] with a diagnosis including multiple sclerosis. Review of the care plan initiated 02/10/25 revealed Resident #44 had multiple sclerosis. Interventions included to give medications as ordered. Observation on 04/07/25 at 10:56 A.M. of medication administration with the DON revealed the DON prepared Resident 44's oral medications for administration. The DON did not wash her hands or use hand sanitizer prior to preparing the medication. The DON then entered Resident #44's room and assisted Resident #44 to take his oral medications. The DON then exited the room and returned to the medication cart without washing her hands or using hand sanitizer. The DON then began preparing Resident #74's topical medication patch (lidocaine patch 4 %) for application. The DON did not wash her hands or use hand sanitizer. Interview on 04/07/25 at 11:24 A.M. with the DON confirmed she never washed her hands or used hand sanitizer during the observations of medication administration for Resident #44 and #74. Review of the facility policy titled, Hand washing/Hand Hygiene revised October 2023 revealed the facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections. All personnel were expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene was indicated immediately before touching a resident; after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching a resident's environment; before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. 3. Record review for Resident #68 revealed an admitted [DATE] with diagnoses including local infection of the skin and subcutaneous tissue, chronic venous hypertension with inflammation bilateral lower extremity, and cellulitis of unspecified part of limb. Review of the Clinical Admission assessment dated [DATE] revealed Resident #68 was alert and oriented to person, place and time. Resident #68 had a pressure injury to the left lateral calf, right medial calf. Resident #68 also had a venous wound to the front of the right lateral lower leg, a skin tear to the left lateral foot, and a wound to the left medial foot. Review of the care plan for Resident #68 dated 04/01/25 revealed Resident #68 had signs and symptoms of wound infection. Resident #68 required use of intravenous (IV) for medications. Peripherally inserted Central Catheter (PICC) in the left upper extremity. Interventions included administering medications per the physician orders. Review of the physician orders for Resident #68 revised 03/31/25 revealed an order for Cefepime HCL solution two grams (gm)/100 milliliters (ml), use two gm IV every eight hours for infection. Normal saline flush solution, use 10 ml IV every shift for line patency. Observation on 04/09/25 at 2:45 P.M. revealed Resident #68's door to his room was open. On the outside of the door was a sign that revealed Resident #68 was on Transmission Based Precautions. Observation from the hall revealed Registered Nurse (RN) #289 was applying a new dressing on Resident #68's right lower leg. Observation revealed RN #289 was not wearing an isolation gown. Continued observation while in Resident #68's room revealed Resident #68 had a PICC line in the right upper arm. RN #289 continued with care and unwrapped the dressing on Resident #68's left lower leg. The dressing was heavily soiled with a brownish/serosanguinous drainage on the outside and inside of the dressing. RN #289. RN #289 did not wash her hands or use hand sanitizer after removing the soiled dressing and before applying the clean dressing. RN #289 completed wound care to Resident #68's bilateral lower extremities with no isolation gown. After completion of wound care, RN #289 confirmed Resident #68 was on transmission-based precautions and confirmed she did not wear the appropriate Personal Protective Equipment (PPE) to include an isolation gown. Review of the facility policy titled, Hand washing/Hand Hygiene revised October 2023 revealed the facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections. All personnel were expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene was indicated immediately before touching a resident; after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching a resident's environment; before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. Review of the facility policy titled, Isolation - Categories of Transmission - Based Precautions revised September 2022 included transmission-based precautions were initiated when a resident develops signs or symptoms of a transmissible infection; arrives on admission with symptoms of an infection, or is at risk for transmitting the infection to other residents. Transmission - based precautions are additional measures that protect staff, visitors and other residents from becoming infected. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Review of CDC guidance titled Clinical Safety: Hand Hygiene for Healthcare Workers found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html and dated 02/27/24 revealed hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of deadly germs to patients. Recommendations included on know when to wear (and change) gloves stated gloves are not a substitute for hand hygiene. If your tasks requires gloves, perform hand hygiene before donning gloves and touching the patient or the patients surroundings; always clean your hands after removing gloves. When to change gloves and clean hands included if gloves become soiled with blood or body fluids after a task, if moving from work on a soiled body site to a clean body site on the same patient or if clinical indication for hand hygiene occurs, and before exiting a patient room. This was an incidental finding during the course of the complaint investigation. This is an example of continued non-compliance from the survey dated 02/25/25.

Based on observation, record review, facility policy review and interview, the facility failed to ensure Resident #24, a resident dependent on staff, was safely secured in the wheelchair in the facility bus when transporting to outside appointments to prevent a fall with injury. Actual harm occurred on 12/12/24 when Bus Driver (BD) #118 failed to properly secure Resident #24 in her wheelchair during a facility bus transport resulting in the resident being propelled out of her chair approximately three feet, onto the bus floor when Bus Driver #118 stopped abruptly. The resident sustained a right humerus (arm) fracture as a result of the incident. This affected one resident (#24) of three residents reviewed for accidents. Additionally, the facility failed to ensure a non-flammable protective cover was provided to a resident known to drop cigarette ashes during smoking, placing the resident at risk for more than minimal harm which did not rise to Actual Harm. This affected one resident (#30) of 11 residents reviewed for smoking. The facility census was 73. Findings include: 1. Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified, muscle wasting and atrophy, major depressive disorder, and other lack of coordination. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] noted Resident #24 had intact cognition. The assessment revealed Resident #24 required maximum (staff) assistance for activities of daily living and utilized an electric wheelchair for mobility. Review of the undated plan of care revealed Resident #24 was at risk for falls and had an activity of daily living self-care deficit. Review of nurse progress notes dated 12/06/24 through 01/01/25 revealed no documentation indicating Resident #24 had experienced a change in condition. Review of a progress note dated 12/12/24 indicated Resident #24 returned to the facility wearing a brace on her right arm. No additional progress notes were provided that indicated Resident #24 had sustained a significant injury, a fracture of the right humerus, on 12/12/24. Review of emergency room documentation dated 12/12/24 noted Resident #24 sustained a shoulder, leg, and head injury. Resident #24 received a computed tomography scan (CT) of the brain, cervical, right elbow and shoulder. The results of the CT's noted a fracture to Resident #24's right humerus. Review of the statement from Resident #24 dated 12/12/24 revealed BD #118 had to stop abruptly causing her to fall out of her wheelchair. Resident #24 stated she needed to be secured facing 90 degrees from the front of the bus (facing sideways) because it allowed her to have her leg rest on the electric wheelchair fully extended as her leg was in a brace and the electric wheelchair did not fit facing forward. Review of the written statement from BD #118 dated 12/12/24 revealed he had slammed on the brakes to prevent hitting a vehicle who was in front of him. BD #118 stated Resident #24 came out of her chair, he called emergency services who then transported Resident #24 to the hospital. Review of an undated folder provided by the Administrator for bus training and information noted a training packet titled Sure-Lok, Safe and Secure. The training consisted of pre-trip assessment, sensitivity training, securing the wheelchair, securing the occupant, system care and maintenance, and hands-on training. The Securing the Wheelchair, section of the training indicated correctly securing the wheelchair is extremely important for the safety and comfort of the passenger as well as for your peace of mind. Injury or death may result from improper securement. The section indicated residents should be facing the front of the vehicle. Review of the Securing the Occupant, section of the training indicated to attach the lap belt around the passenger by threading the belt through the opening between the side panel or the seat back and the seat cushion. Position the lap belt around the occupant's pelvis zone near the hip, with the buckle of the lap belt placed opposite to the side where the shoulder belt is attached to the wall. Review of a facility investigation file following the 12/12/24 incident, provided by the Administrator, contained a certificate for Bus Driver (BD) #118 titled Defensive Driving Training, dated 04/15/22, an electronic receipt indicating the facility purchased an online course titled Passenger Assistance Safety and Sensitivity, (PASS), dated 12/16/24 for BD #118 and #119, a certificate of completion for the PASS program dated 01/15/25 for BD #118, and a written statement from Resident #24. The investigative file contained no additional staff interviews, interviews with residents who used a wheelchair and were transported on the facility bus, and no additional staff training records. There was no evidence the bus had been audited or inspected for proper harness functioning following the 12/12/24 incident. Review of personnel file revealed BD #118 was hired on 05/01/21. Further review noted no evidence BD #118 received training related to resident safety when transporting residents. A document titled Risk Management, policy, Driving/Vehicle Fleet Safety Program consisting of driver responsibilities indicated BD #118 reviewed and signed the training 04/15/22 and again on 02/11/25. No documentation was provided to indicate BD #118 received the Sure-Lok, Safe and Secure training. Review of personnel file noted BD #119 was hired on 09/17/24 in housekeeping. BD #119 stated started driving the facility bus in November 2024. Further review noted no evidence BD#119 received training related to resident safety when transporting residents. A document titled Risk Management, policy, Driving/Vehicle Fleet Safety Program consisting of driver responsibilities indicated BD #119 reviewed and signed the initial training 02/11/25. No documentation was provided to indicate BD#118 and #119 received the Sure-Lok, Safe and Secure training. An interview on 02/09/25 at 10:35 A.M. with Resident #24 revealed (on 12/12/24) she was on the facility bus heading for a pre-operative appointment. The bus driver slammed on the brakes, she flew out of her wheelchair, and fractured her right arm. Resident #24 reported BD #118 did not secure her wheelchair correctly in the bus causing it to fall on its side allowing her to fall out during the transport. Following the incident, Resident #24 stated her right arm fracture was deemed non-surgical. She received occupational therapy to treat and utilized oral pain medication to control the right arm pain. An interview on 02/10/25 at 8:54 A.M. with BD #118 revealed (on 12/12/24) he was taking Resident #24 to an appointment when he had to slam on the brakes to prevent hitting a vehicle in front of him due to icy road conditions. BD #118 stated Resident #24 fell out of her wheelchair and he called emergency services who transported Resident #24 to the hospital. BD #118 stated Resident #118 was facing sideways in the facility bus. BD #118 reported the wheelchair was difficult to secure due to the width and he had to figure out a way to secure the harness because the harness would not tighten. BD #118 stated in a joking manner that he could have jimmied out of the harness. An interview on 02/10/25 at 11:21 A.M. with the Administrator revealed she was notified of the incident (on 12/12/24) with Resident #24 and the facility bus after being alerted by the [NAME] President of the company, who was driving down the road and observed the facility bus pulled over on the side of the road. The Administrator stated the bus driver called emergency services to transport Resident #24 to the hospital. Following the incident, the facility interviewed the bus driver and Resident #24. The Administrator reported she arranged online driver safety training for BD #118 and the one other facility bus driver, BD #119. An interview on 02/10/25 at 3:28 P.M. with BD #119 revealed she started driving (the facility bus) in November 2024 and she always positioned residents facing forward. A follow-up interview on 02/11/25 at 9:17 A.M. revealed BD #119 stated she was unsure if she received formal training related to driving the facility bus. BD #119 stated she did receive hands-on training from BD #118, who showed her how to secure residents in wheelchairs in a perpendicular position (facing the side of the bus). BD #119 stated she placed residents forward-facing as she did not feel comfortable positioning residents in the perpendicular position. BD #119 confirmed she had not yet completed the online PASS training yet. An interview on 02/11/25 at 10:35 A.M. with the Administrator revealed she did not think the bus drivers received formal training, rather the new staff were just trained by other staff. The Administrator stated the Risk Management policy should be reviewed and signed yearly by the bus drivers, and verified BD #118 did not review and sign an acknowledgement of the policy in 2024. The Administrator also verified BD #119 did not review and sign acknowledgement of the policy before moving into a bus driver role. During an interview on 02/11/25 at 4:04 P.M., the Regional Director of Operations (RDOO) #206, [NAME] President of Clinical Operations (VPCO) #202, and [NAME] President of Operations (VPO) #116, were informed of the survey team's concerns related to the fall incident, lack of fall investigation, lack of training, failure to report the incident to the State Agency, and the lack of documentation in Resident #24's medical record related to the 12/12/24 incident. VPO #116 verified the findings and shared the facility had begun to implement corrective action. Observation of the facility bus and interview on 02/12/25 at 8:22 A.M. with Regional Maintenance Director (RMD) #205 revealed there is no safe way to secure a wheelchair or the resident when it is placed perpendicular to the front of the bus. I would never transport a resident placed perpendicular to the front of the bus. Observation of the facility bus and interview on 02/12/25 at 9:35 A.M. with BD #118, who was called into the facility to complete driver training, revealed he was learning a lot with the training. BD #118 stated he never knew he was not supposed to transport residents facing sideways. BD #118 demonstrated the hands-on steps he took to secure Resident #24 in a perpendicular position. BD #118 stated he used the shoulder straps and noted they were difficult to use due to the resident's size, wheelchair, and position of the wheelchair. BD #118 proceeded to illustrate where Resident #24 fell and slid. Further observations of the bus indicated Resident #24 fell forward approximately three feet before hitting the floor and then slid an additional four feet, landing in the aisle on her right side. An interview on 02/12/25 at 10:00 A.M. with Paramedic #201, who responded to the scene on 12/12/24, revealed Resident #24's wheelchair was upright and secured to the floor of the bus. Upon arrival, Resident #24 was positioned on her right side on the floor of the bus. Review of the facility policy titled Abuse Prohibition Policy and Procedure, dated 2023 defined neglect as failure to provide goods and services necessary to avoid physical harm, mental-anguish, or mental illness. Review of the facility policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation, dated 2023 noted the facility would investigate any allegations made alleging abuse, neglect, and exploitation of residents. The facility would ensure that any suspicion of resident abuse, or neglect was coordinated with the facilities Quality Assurance and Performance Improvement (QAPI) program. 38523 2. Resident #30 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia affecting the left non-dominant side, contracture of unspecified hand, and nicotine dependence. Review of Resident #30's physician's orders revealed an order dated 05/05/24 for the resident to be supervised while smoking. Resident #30's smoking assessment dated [DATE] revealed the resident was noted to have cognitive loss. Resident #30 was referenced to have a dexterity problem. Resident #30 was noted to smoke between five and ten cigarettes per day and smoked in the morning, afternoon, evening and night. Resident #30 was not able to light his own cigarettes and required supervision. The assessment noted the facility stored the resident's lighter and cigarettes. Review of Resident #30's MDS annual assessment dated [DATE] revealed the resident was cognitively intact. Resident #30 was noted to have a functional limitation in range of motion with an impairment on one side of both the upper and lower extremities. Resident #30 was noted to use a wheelchair and was dependent on staff for activities of daily living. Review of Resident #30's smoking care plan dated 02/04/25 revealed he was at risk for injury related to smoking. Interventions included maintaining a safe environment during smoking, provide supervision at all times for smoking and smoking items are to be kept at the nurses station. Observation on 02/19/25 at 1:46 P.M. of Resident #30 revealed many burn holes in his blanket, when the blanket was removed by staff, there were numerous burn holes in his sweatpants. An interview at the time of observation with Agency CNAs #211 and #212 confirmed the burn holes present in the resident's sweatpants and blanket. Observation on 02/19/25 at 4:00 P.M. during the smoke break revealed Resident #30 and 10 other Residents (#06, #14, #35/#169, #45, #46, #51, #52, #59, #68 and #174) were supervised by Dietary Aide #135. During the smoke break, Resident #30 was observed dropping hot ashes from his cigarette onto his blanket. Resident #51 proceeded to wipe the ashes off of Resident #30, onto the ground. Resident #06 noticed and thanked Resident #51 for swiping the hot ashes off Resident #30's blanket as she was going to swipe them off too. Resident #06 was observed to have burn holes in her coat. Interview on 02/19/25 at 4:04 P.M. with Dietary Aide #135 verified no residents were wearing a smoking apron, blanket, or other non-flammable protective cover to protect from hot ashes or burns. Dietary Aide #135 also verified multiple burn holes in the blanket of Resident #30 from hot ashes falling from his cigarette. She stated Resident #30 needed a smoking apron, but she did not know where they were kept, or which residents required a smoking apron She also verified two other Residents (#06 and #52) were also noted with burn holes in their clothing and/or coat. Smoking observation on 02/20/2025 at 9:15 A.M. revealed Housekeeper #143 was supervising the smoke break. Hot ashes were observed to fall from Resident #30's cigarettes, onto his blanket, which had numerous burn holes present. When the surveyor pointed out the hot ashes landing on Resident #30's blanket, Housekeeper #143 proceeded to brush the ashes off of Resident #30's blanket. Housekeeper #143 revealed there were no smoking aprons available but there was a smoking blanket inside the building. Interview with the [NAME] President of Clinical Operations #202 on 02/20/2025 at 12:30 P.M. revealed the facility did not have a policy addressing smoking safety including residents wearing smoking aprons for residents who require them per their smoking assessment. This deficiency represents non-compliance investigated under Complaint Number OH00161426.

Based on record review and staff interview, the facility failed to timely address and respond to voiced concerns regarding resident care and life in the facility identified by residents in resident council and food committee meetings. This had the potential to affect all residents residing in the facility. The facility census was 73. Findings include: Review of the resident council meeting minutes revealed the following documented concerns regarding staffing: - During the meeting dated 11/30/23, residents reported nightshift could be nicer. - During the meeting dated 01/25/24, residents reported call lights need answered faster. - During the meeting dated 04/25/24, residents reported nurses need to be nicer and more caring. - During the meeting dated 06/27/24, residents reported nurses need to be more caring and night aides need to do their jobs. - During the meeting dated 07/25/24, residents reported night aides need to do their jobs. - During the meeting dated 08/29/24, residents reported night shift needed to get better, and the staff on night shift do whatever they want. The notes additionally mentioned the aides come in the room too aggressive when answering call lights. - During the meeting dated 09/09/24, residents reported there was no consistency with night shift aides and nurses. Residents reported they were missing their medications and were being dressed in soiled clothing. - During the meeting dated 10/31/24, residents reported wanting to discuss the aides, referring to the aides as rude and nasty. Review of food committee meeting minutes from July 2024 through present day revealed residents had concerns related to cold food and coffee, the facility not using hot packs to keep food warm, and food palatability. The facility was unable to provide evidence that any of the concerns or issues brought forth by residents in resident council and/or food committee meeting minutes had been investigated, reviewed, or followed up on by any facility staff member. Interview on 02/09/24 at 8:45 A.M. with Resident #3 revealed concerns related to sufficient facility staffing, notably on the weekends and night shift. Interview on 02/09/25 at 10:30 AM with Resident #46 revealed the food in the facility is bland and usually not warm. Interview on 02/09/25 at 11:15 A.M. with Resident #51 revealed the food in the facility does not taste good and is cold. Interview on 02/09/25 at 01:57 P.M. with Resident #36 revealed the food in the facility is nasty. Interview on 02/09/24 at 2:02 P.M. with Resident #44 revealed concerns related to sufficient facility staffing. Resident #1 further stated that he had past instances where he had missed medications due to insufficient facility staffing and believed many of his skin issues could have been solved by increased staffing levels. Interview on 02/10/24 at 9:12 A.M. with Resident #1 revealed concerns related to sufficient facility staffing. Resident #1 stated call lights can take up to four hours to be answered after being activated. Interview on 02/19/24 at 2:30 P.M. with a family member of Resident #54 revealed the facility staffing levels were horrible. Interview on 02/19/25 at 3:00 P.M. with Licensed Practical Nurse (LPN) #701 revealed first shift workers often complain about night shift failing to complete standard job duties. Interview on 02/19/25 at 3:24 P.M. with Certified Nursing Assistant (CNA) #800 revealed night shift workers are not nearly as productive as day shift workers. Interview on 02/19/25 at 4:10 P.M. with Resident #52 revealed call lights are often never answered and night shift is extremely understaffed. Interview on 02/19/25 at 4:12 P.M. with Resident #6 revealed the facility is in desperate need of more staff. Interview on 02/20/25 at 9:00 A.M. with Licensed Practical Nurse (LPN) #702 revealed she works both day and night shift and during night shift no one is ever here. Interview on 02/20/25 at 9:12 A.M. with Resident #25 revealed you can't get anything done at night due to lack of staff. An interview during the completion of the resident council portion of the annual recertification survey on 02/11/25 between 2:58 P.M. and 3:30 P.M. with Residents #6, #25, #44 and #51 revealed numerous concerns related to sufficient facility staffing and staffs ability to meet their needs timely. A test tray on 02/09/25 at 6:00 P.M. was completed after half of the room trays were served. The meal consisted of a barbeque (BBQ), pork sandwich and baked beans. The BBQ pork sandwich was noted to be 115 degrees Fahrenheit (F) and the baked beans were noted to be 113.7 degrees F. Both the BBQ pork and baked beans tasted lukewarm and unappetizing. The BBQ pork had a white color and was extremely overcooked and had mushy texture and was very difficult to chew. The baked beans had no seasoning and were very bland. The temperatures and condition of the food were verified with Dietary Manager (DM) #114 at the time of the test tray. An interview on 02/19/25 at 10:10 A.M. with Regional Administrator (RA) #203 verified the facility had no evidence of any follow-up from any of the concerns or issues brought forth by residents during any of the resident council or food committee meetings minutes reviewed.

Based on record review, resident interview, staff interview, review of the resident council meeting minutes, review of the grievance log, and facility policy review, the failed to be adequately staffed to meet the needs of its residents. This had the potential to affect all residents. The facility census was 73. Findings include: 1. Interview on 02/09/24 at 8:45 A.M. with Resident #3 revealed concerns related to sufficient facility staffing, notably on the weekends and night shift. 2. Interview on 02/09/24 at 2:02 P.M. with Resident #44 revealed concerns related to sufficient facility staffing. Resident #1 further stated that he has missed medications due to insufficient facility staffing and is of the belief many of his skin related to issues could have been solved by increased staffing levels. 3. Interview on 02/10/24 at 9:12 A.M. with Resident #1 revealed concerns related to sufficient facility staffing. Resident #1 stated call light response time is often up to four hours. 4. Interview on 02/19/24 at 2:30 P.M. with the family member of Resident #54 revealed staffing is horrible. 5. Interview on 02/19/25 at 3:00 P.M. with Licensed Practical Nurse (LPN) #701 revealed first shift workers often complain about night shift completing standard job duties. 6. Interview on 02/19/25 at 3:24 P.M. with Certified Nursing Assistant (CNA) #800 revealed night shift workers are not nearly as productive as day shift workers. 7. Interview on 02/19/25 at 4:10 P.M. with Resident #52 revealed call lights are often never answered and night shift is extremely understaffed. 8. Interview on 02/19/25 at 4:12 P.M. with Resident #6 revealed the facility is in desperate need of more staff. 9. Interview on 02/20/25 at 9:00 A.M. with Licensed Practical Nurse (LPN) #702 revealed she works both day and night shift and during night shift no one is ever here. 11. Interview on 02/20/25 at 9:12 A.M. with Resident #25 revealed you can't get anything done at night due to lack of staff. 12. Review of the minutes from the resident council meeting revealed the following documented concerns about staffing ratios and/or quality of staff during the resident council meetings held on 11/30/23, 01/25/24, 04/25/24, 06/27/24, 07/25/24, 08/29/24, 09/09/24, and 10/31/24. 13. An interview during the completion of the resident council portion of the annual recertification survey on 02/11/25 between 2:58 P.M. and 3:30 P.M. with Residents #6, #25, #44 and #51 revealed numerous concerns related to sufficient facility staffing and staffs ability to meet their needs timely. 14. Review of the grievance log revealed Resident #44 filed a formal grievance on 09/09/24 regarding concerns related to night shift staffing. No resolution was noted on the log. 15. Review of the quality assurance performance improvement report from the facilities Human Resources/Staffing Coordinator and/or the Administrator from 03/27/24, 06/26/24, 07/11/24, 08/21/24, 09/20/24,10/23/24, 11/13/24, and 01/16/25 revealed concerns/goals of the facility to hire more staff, reduce staff turnover and increase customer service from staff. Review of the policy entitled Staffing, Sufficient and Competent Nursing dated 08/01/22 revealed the facility provides sufficient numbers of nursing staff with appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The policy further noted minimum staffing requirements imposed by the state, if applicable, are adhered to when determining staff ratios. This deficiency represents non-compliance investigated under Complaint Number OH00161426 and OH00161390.

Based on record review and staff interview the facility failed to ensure the service of a Registered Nurse (RN) for at least eight hours a day seven days a week as required. This had the potential to affect all residents. The facility census was 73. Findings include: Review of the staffing schedule and posted nursing staff information for 12/21/24 revealed the facility did not have eight hours of Registered Nurse (RN) coverage as required. The facility had evidence of only four total hours of RN coverage on 12/21/24. Interview with Scheduler #111 on 02/19/25 at 11:11 A.M. verified the lack of required RN hours. This deficiency represents non-compliance investigated under Complaint Number OH00161426 and OH00161390.

Based on observation, resident interview, and record review revealed the facility failed to provide palatable food to residents. This had the potential to affect all residents residing in the facility. The facility census was 73. Findings include: Review of food committee meeting minutes from July 2024 through February 2025 revealed residents had concerns related to cold food and coffee, the facility not using hot packs, and food palatability. Review of grievance logs between August 2024 and February 2025 revealed on 08/26/24, Resident #56 reported there were no hot plates (to keep food warm) provided and that residents were unhappy with their meals. On 09/09/24, Resident #10 reported their food was cold. On 01/30/25, Resident #6 reported the meat is trash. Interview on 02/09/25 at 10:30 AM with Resident #46 revealed the food is bland and usually not warm. Interview on 02/09/25 at 11:15 A.M. with Resident #51 revealed the food does not taste good and is cold. Interview on 02/09/25 at 01:57 P.M. with Resident #36 revealed the food is nasty. An observation and interview on 02/09/25 at 6:00 P.M. revealed a test tray was completed after half of the room trays were served. The meal consisted of a barbeque (BBQ), pork sandwich and baked beans. The BBQ pork sandwich was noted to be 115 degrees Fahrenheit (F) and the baked beans were noted to be 113.7 degrees F. Both the BBQ pork and baked beans tasted lukewarm and appeared unappetizing. The BBQ pork had a white color, was overcooked, had a mushy texture yet was difficult to chew. The baked beans had no seasoning and tasted bland. The temperatures and condition of the food were verified with Dietary Manager (DM) #114 at the time of the test tray. Interviews conducted with residents during the completion of the resident council portion of the annual survey on 02/11/25 between 3:00 P.M. and 3:30 P.M. with Residents #6, #8, #28 and #51 revealed multiple food quality concerns. An observation and interview on 02/18/25 at 12:24 P.M. revealed a test tray was completed after all room trays were served. The meal consisted of pasta, brussels sprouts, and crushed pineapple. The pasta was noted to be 121 degrees F, the brussels sprouts were noted to be 127.2 degrees F, and the crushed pineapple was noted to be 51.6 degrees F. The temperatures were verified with DM #114 at the time of the test tray. This deficiency represents non-compliance investigated under Complaint Number OH00161426.

Based on observation, interview, and review of facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all 73 residents. Findings include: 1. Observation and interview on 02/09/25 between 8:52 A.M. and 9:35 A.M. with [NAME] #118 during a kitchen tour revealed the following: a. One bottle of vanilla with expiration date of 02/10/24. b. The shelf under tray line had rust, food debris, and crumbs on it. c. The ice machine had noticeable rust on the door hinge. d. Significant areas of crumbs and food debris were observed on the floor in the dry storage area. e. The air vent next to the food preparation area was rusted and had a thick layer of grime on it. f. A large brown stain and crack on ceiling above the three-compartment sink was noted. g. The seal on the refrigerator door was falling off and not attached to door. h .The walk-in freezer had an ice cream tub wedged underneath a pipe. The pipe had dripped water onto the ice cream tub and a large ice chunk had formed on the lid. The ice cream tub was unable to be opened. The walk-in freezer was observed to have large ice chunks on the floor from the pipe. An interview at the time of observation with [NAME] #118 confirmed the above findings. [NAME] #118 stated he had worked at the facility for eight years, and the walk-in freezer had always been in that condition. 2. Observation and interview on 02/11/25 at 2:45 P.M. with Dietary Manager #114 and Dietician #193 revealed the dementia unit kitchen was noted to have splatter and food debris on kitchen cabinets and the microwave was soiled with food debris. A resident's slippers were in the kitchen next to the trash can with a broom and dust pan placed on top of them. The findings were confirmed at the time of observation with Dietary Manager #114 and Dietician #193.

Based on observation and staff interview, the facility failed to maintain its garbage disposal area in a clean and sanitary condition. This had the potential to affect all 73 residents in the building. Findings include: Observation on 02/09/25 at 9:10 A.M. revealed one of two outside dumpsters did not have a lid and there were multiple latex gloves, a large cardboard box near the woods and other miscellaneous trash on ground around the dumpster. Additional trash and debris was observed to have blown into the grass and woods behind the dumpster. Observation and interview on 02/09/25 at 3:48 P.M. with Dietary Manager (DM) #114 verified that the dumpster did not have a cover and confirmed observation of trash around dumpster.

Based on observation, interview, record review, and review of facility policy, the facility failed to maintain an infection prevention program to prevent, recognize, and control transmission of communicable disease. This affected two residents (#32 and #33) of four residents sampled and had the potential to affect all facility residents. The facility census was 73. Findings include: 1. Review of the medical record for Resident #32 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included cognitive communication deficit, moderate intellectual disabilities, abnormalities of gait and mobility, anxiety, and muscle weakness. Review of Resident #32's physician orders revealed the resident was to attend an outside adult day program Monday through Friday. An order dated 12/26/24 revealed the resident was to have skin sweeps performed twice daily, every day and night shift for monitoring for three days. Review of an email dated 12/19/24 at 2:03 P.M. from the adult day program to the Director of Nursing (DON) revealed Resident #32 was exposed to scabies at the adult day program. The local health department had recommended the day program reach out to potential exposures and close contacts. The email reported to contact the resident's provider to discuss the need for a cream to treat. The email communicated Resident #32 would not be able to return to the adult day program until 24 hours after the first treatment as a precaution. Review of the facility assessment dated [DATE] under Part 1 Our Residents Profile indicated infectious diseases/conditions that require complex medical care and management include skin and soft tissue infections, respiratory infections, tuberculosis, urinary tract infections, infections with multi-drug resistant organisms, septicemia, viral hepatitis, clostridium difficile, influenza, scabies, legionellosis. Review of Resident #32's plan of care revised on 01/13/25 revealed the resident had impaired cognitive function/dementia or impaired thought processes related to developmentally delayed and impaired decision making. Interventions included to keep the resident's routine consistent and to provide consistent caregivers as much as possible in order to decrease the resident's confusion. Interview on 02/10/25 at 12:12 P.M. with the guardian for Resident #32 revealed they had been notified that the resident had been exposed to scabies by a close contact at the resident's adult day program. The program manager reported the potential exposure to the facility DON on 12/19/24. The guardian stated the DON was not going to treat the Resident #32 and stated the physician had instead ordered skin assessments twice daily. The guardian confirmed the exposure letter, and recommended treatment, was provided to the DON. The guardian further stated the Resident #32 was unable to return to the day program for six weeks if not treated and a request was made to transfer the Resident #32 to a facility that would treat Resident #32 for scabies exposure. Interview on 02/10/25 at 3:25 P.M., the DON verified she spoke with the legal guardian of Resident #32 and was notified of the Resident #32's close contact Sarcoptes scabiei (scabies) exposure at outside day program. The DON stated the guardian demanded the Resident #32 be treated for scabies. The DON stated she verbally reported the information to the Nurse Practitioner and an order was placed for skin checks twice daily for three days. The DON confirmed three out of six skin checks had not been completed per the physician order. The DON confirmed no documentation of a physician assessment or clinician progress notes were available regarding the scabies exposure. The DON further confirmed the reported scabies exposure was not reported to the infection control designee, staff, or Resident #32's roommate. The DON stated no additional investigation, follow up, or infection surveillance was performed. The DON stated, we are not going to treat what a resident does not have. Interview on 02/11/25 at 1:43 P.M. of the outside day Program Manager #860 revealed the program had sent recommendations to the facility, from the local health department, regarding direct contact exposure to scabies and treatment. The program manager stated the Resident #32's facility refused to treat her and Resident #32 was unable to return to the day program until treated or six weeks post-exposure. Interview on 02/11/25 at 2:02 P.M. with the outside day program Operations Manager #910 revealed on 12/19/24, Resident #32 was sent home with a letter stating the Resident #32 was in direct contact to another individual who was positive for scabies. The operations manager stated the local health department advised treatment based on close scabies exposure and the Resident #32 was not able to return to the day program until 24 hours after treatment. On 12/26/24, the guardian contacted the operations manager and stated the facility would not treat the Resident #32 or prescribe medication to treat exposure. Interview on 02/11/25 at 3:10 P.M. with Assistant Director of Nursing (ADON) #102 revealed the Resident #32's guardian had reported the scabies exposure to the nurse on duty. The ADON #102 verified she was the facility Infection Preventionist and stated a nurse had reported the exposure to her. The ADON #102 was unable to identify the nurse who reported the exposure and further verified no additional infection control or surveillance was initiated. Review of the Resident #32's discharge order revealed a discharge was initiated on 12/27/24 and the Resident #32 was discharged to another skilled nursing facility on 12/30/24. Review of the facility policy titled Scabies Identification, Treatment and Environmental Cleaning dated August 2016 revealed the purpose of the policy was to treat residents infected with and prevent the spread of scabies to other residents and staff. Scabies is an itching skin irritation caused by the microscopic human itch mite, which burrows into the skin's upper layers and eventually causes itching, tiny irregular red lines just above the skin, and an allergic rash. The incubation period can range between 2-6 weeks before onset of symptoms. Affected residents should remain on contact precautions until 24-hours after treatment. Family and friends of residents who have had close contact should be notified and given instructions regarding self-examination and treatment. 2. Review of the medical record for the Resident #33 revealed an admitted [DATE]. Diagnosis included Alzheimer's Disease, abnormalities of gait/mobility, depressive disorder, hearing loss, and falls. Review of the physician orders dated 01/29/25 revealed to cleanse Resident #33's wound to right buttocks with Normal Saline and apply a wet-to-dry dressing every shift until healed. Resident #33 also had an order to empty Foley (urinary drainage) bag every shift and as needed. Observation of wound care on 2/12/25 at 2:58 P.M. with ADON #102 revealed she gathered wound supplies and placed them directly on Resident #33's side table next to a styrofoam cup with straw without disinfecting the side table or creating a barrier for aseptic technique. Observation of urinary catheter care on 2/12/25 at 3:00 P.M. with ADON #102 revealed after draining the urine from the drainage bag, the ADON #102 did not wipe the drain with an antiseptic wipe per protocol. Interview on 02/12/25 directly following the observations, the ADON #102 confirmed the above findings. Review of the facility policy titled Wound Care revealed a disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. Review of the Certified Nurse Aide (CNA) training on emptying urinary catheters included after draining urine into the graduated cylinder until bag is empty, close the drain, and wipe the drain with an antiseptic wipe after the drainage bag is empty. Review of the facility policy titled Introduction: Infection Prevention and Control in Long-Term Care, revised on 12/2023 revealed the purpose of Infection prevention and control programs (IPCP) should fulfill essential functions and also be flexible enough to fit a facility's specific environment, pertinent to residents' potential and actual problems, and able to accommodate new issues or requirements. The elements of the IPCP should include the following: o Coordination and Oversight o Policies and Procedures o Surveillance and Data Analysis o Antibiotic Stewardship o Prevention of Healthcare Associated Infections o Outbreak Management o Influenza and Pneumococcal Immunization o Employee Health and Safety This deficiency represents non-compliance investigated under Master Complaint Number OH00161888.

Based on record review, interview, and review of facility policy, the facility failed to designate a certified infection preventionist responsible for the infection control and prevention program. This affected one resident (Resident #32) of four residents sampled and had the potential to affect all facility residents. Facility census was 73. Findings include: Review of the Infection Preventionist certification from The Centers for Disease Control and Prevention (CDC) revealed the Assistant Director of Nursing (ADON) #102 completed the Nursing Home Infection Preventionist Training Course, (#WB4448R) on 02/10/25. Review of the facility staffing records during the annual survey revealed a part-time qualified infection control preventionist was not present in the building as required. Review of the quarterly Quality Assurance and Performance Improvement (QAPI) committee meeting documentation revealed an Infection Preventionist was not in attendance on 10/23/24, 11/6/24, 01/16/25. No other documentation was provided. Interview on 02/20/25 at 12:09 P.M., the VP of Clinical Operations #202 confirmed no additional documentation of a qualified infection control preventionist working part-time at the facility was available from date of last annual survey, 04/24/23 until 02/10/25. Interview on 02/20/25 during the annual survey, Regional Administrator #203 confirmed the infection preventionist was not documented at the QAPI committee meetings as required. Review of the facility policy titled Introduction: Infection Prevention and Control in Long-Term Care, revised on 12/2023 revealed the purpose of Infection prevention and control programs (IPCP) should fulfill essential functions and also be flexible enough to fit a facility's specific environment, pertinent to residents' potential and actual problems, and able to accommodate new issues or requirements.

Based on observation, medical record review, facility policy review and interviews with Resident #02, facility staff and the Physician Assistant (PA), the facility failed to provide adequate monitoring, appropriate treatment and follow-up for a non-functioning suprapubic catheter (a thin, flexible tube that drains urine from the bladder through a small incision in the lower abdomen) for Resident #02. Actual Harm occurred beginning on 03/05/24 when staff documented Resident #02 had no output from her suprapubic catheter. Documentation between 03/05/24 and 10/02/24 noted the suprapubic catheter continued to malfunction, resulting in decreased urinary output, urinary retention, and increased pain and discomfort during this time with no evidence of adequate follow-up or interventions. An interview with Resident #02 revealed she reported daily pain (rated at times a seven on a scale of one to 10 with 10 being the most severe pain) and/or really bad pain as a result of the catheter not functioning properly during this time period. The non-functioning suprapubic catheter placed Resident #02 at increased risk of complications including infection, sepsis and, if the catheter was unable to be removed, surgery. This affected one resident (#02) of one resident identified by the facility with a suprapubic catheter. The facility census was 60. Findings include: Review of Resident #02's medical record revealed an admitted [DATE]. Diagnoses included multiple sclerosis and neuromuscular dysfunction of the bladder. The resident had a suprapubic catheter in place. Review of the care plan, initiated 11/04/18, noted Resident #02 required an indwelling catheter as evidence by urinary retention. The goal included bladder elimination would be maintained through an indwelling suprapubic catheter with no signs or symptoms of a urinary tract infection (UTI). Interventions included to change the suprapubic catheter per orders and drainage bag as needed for blockage, leakage, signs and symptoms of a UTI or when the closed system had been compromised. Additional interventions included intake and output (I & O - amount of fluids consumed and the amount of urine output) every shift, observe for clinical signs and symptoms of a UTI, monitor urine color, hematuria (red blood cells in urine), flank or abdominal pain, elevated temperature or absence of urine daily. Report positive findings to the physician. Review of a nursing progress note dated 03/05/24 at 9:00 P.M. and completed by Licensed Practical Nurse (LPN) #404 revealed Resident #02 was wet and there was no output in the foley. The note indicated the nurse changed the resident's catheter. Review of a nursing progress note dated 03/15/24 at 7:00 P.M., and completed by Registered Nurse (RN) #419, revealed Resident #02 was wet and the catheter was not draining. Attempt to irrigate the catheter was unsuccessful. Review of a physician order, dated 03/18/24, revealed Resident #02 had appointment at the Urology Clinic (UC) #470 on 04/10/24 at 9:00 A.M. with Urologist #471. Review of a nursing progress note dated 03/20/24 at 8:20 A.M., and completed by LPN #472, revealed Primary Physician (PP) #473 was in to see Resident #02. No new orders were obtained regarding the resident's suprapubic catheter. Per PP #473, urology to address Resident #02's suprapubic catheter at the appointment next month (scheduled for 04/10/24 per the medical record). New orders were obtained for labs to be drawn on 04/17/24. Review of a physician order, dated 03/20/24, revealed laboratory (lab) orders for a complete blood count (CBC) and a comprehensive metabolic panel (CMP) to be drawn on 04/17/24 and every three months thereafter. Review of a nursing progress note dated 03/20/24 at 10:24 P.M., and completed by LPN #404, revealed Resident #02's catheter was changed due to no urinary output in the drainage bag and the resident was wet. Review of a nursing progress note dated 03/26/24 at 1:35 A.M., and completed by RN #419, revealed Resident #02's brief and bed were wet. The nurse was unable to irrigate the catheter. The catheter was changed. Review of a physician order, dated 04/08/24, revealed Resident #02 had an appointment at UC #470 on 05/15/24 at 9:30 A.M. with the PA. Review of a nursing progress note dated 04/12/24 at 3:29 P.M., and completed by RN #365, revealed Resident #02 continued to urinate large amounts via what appears to be the vaginal area. Further review of the medical record revealed no evidence the resident's suprapubic catheter function was checked or the physician (MD) was notified of the change in condition. Review of Resident #02's electronic medical record (EMR) and hard chart revealed no lab results for 04/17/24 or any lab results thereafter. Review of physician orders for Resident #02, dated 04/22/24, revealed to flush foley catheter with 60 milliliters (ml) of normal saline (NS) or distilled water everyday shift for patency, change suprapubic catheter and drainage bag every four weeks and as needed for blockage, leakage, signs and symptoms of urinary infection or when closed system has been compromised with a 20 French (FR), 30 cubic centimeter (cc) balloon. Review of a physician order, dated 04/24/24, revealed intake and output (I & O) every day and night shift. Review of Resident #02's medical record from 04/24/24 through 09/30/24, including the Medication Administration Record (MAR) and the Treatment Administration Record (TAR), revealed the TAR included check marks documented for I & O, but no fluid or urine output amounts were documented. Review of a nursing progress note dated 05/18/24 at 11:15 A.M., and completed by LPN #472, revealed Resident #02 was provided incontinence care twice so far during the shift and the resident had been shouting I need checked and changed repetitively all morning. Redirection, reeducation, and all non-pharmacological interventions exhausted and ineffective. Further review of the medical record revealed no evidence the resident's suprapubic catheter function was checked or the MD was notified of the change in condition. Review of a physician order, dated 06/18/24, revealed Resident #02 had an appointment at UC #470 on 06/20/24 at 2:40 P.M. with the physician assistant (PA). Review of a physician order, dated 06/20/24, revealed Resident #02 had an appointment at UC #470 on 07/03/24 at 11:10 A.M. with the PA. Review of a physician order, dated 07/19/24, revealed Resident #02 had an appointment at UC #470 on 07/26/24 at 11:00 A.M. Review of the annual Minimum Data Set (MDS) assessment, dated 09/06/24, revealed Resident #02 was cognitively intact. Resident #02 had progressive neurological conditions, had impairment to both sides of the lower extremities, was (staff) dependent for toileting and bed mobility and had an indwelling catheter. Review of Resident #02's medical record from 04/10/24 through 10/02/24 revealed no evidence the facility arranged transportation for the resident's appointments with UC #470 on 04/10/24, 05/15/24, 06/20/24, 07/03/24 or 07/26/24. Additionally, there was no evidence Resident #02 received follow-up care for the malfunctioning suprapubic catheter and no further urology appointments were scheduled after 07/26/24. Review of Resident #02's medical record from 04/12/24 through 09/29/24 revealed no evidence the MD was notified of any changes in condition related to Resident #02's suprapubic catheter malfunction or follow-up with urology. Observation on 09/24/24 at 4:27 P.M. revealed Resident #02 was lying in bed. A catheter bag was hanging on the side of the bed. Continued observation revealed there was no urine in the catheter bag or tubing. Interview on 09/25/24 at 1:03 P.M. with LPN #456 revealed Resident #02's suprapubic catheter had not functioned for a long time, stating it would not even flush. LPN #456 revealed Resident #02 had follow-up urology appointments scheduled, but she was told they kept getting canceled or rescheduled. LPN #456 stated since the catheter was not functioning, staff rolled Resident #02 side to side to release the urine from the urethra (carries urine from the bladder out of the body). Observation on 09/25/24 at 1:05 P.M. of suprapubic catheter care for Resident #02, and provided by LPN #456, revealed the dressing removed from the insertion site had a small amount of serosanguinous (fresh blood) and mucous drainage. The insertion site had hyper granulating tissue (a condition where there is too much tissue in a wound bed) present. The tissue surrounding the catheter was red. Continued observation revealed there was no urine in the suprapubic catheter tubing or drainage bag. Concurrent interview with Resident #02 revealed the suprapubic catheter was placed several years ago because she was unable to urinate on her own. Resident #02 stated the suprapubic catheter had not worked in five months. Resident #02 stated follow-up appointments had been scheduled with UC #470; however, UC #470 required she come to her appointments on a stretcher and the appointments kept getting canceled because the facility had no stretcher transportation available. Coinciding interview with LPN #456 verified the observation of the suprapubic catheter and insertion site. LPN #456 confirmed nurses were not monitoring Resident #02's I & O and stated they just know she urinates. LPN #456 further confirmed there were no bladder assessments completed for Resident #02 to determine urine retention. Interview on 09/30/24 at 3:55 P.M. with LPN/MDS Nurse #308 revealed the floor nurses scheduled physician follow-up appointments for all residents, including Resident #02. LPN/MDS Nurse #308 revealed she scheduled all transportation to those appointments. LPN/MDS Nurse #308 stated Ambulance Service (AS) #474 was the only contract the facility had for stretcher transportation and UC #470 required Resident #02 to arrive via stretcher for her appointments. LPN/MDS Nurse #308 stated AS #474 always had an excuse as to why they could not provide transportation. LPN/MDS Nurse #308 went on to state Resident #02 required a Hoyer lift for transfers and she always had some urine in the catheter drainage bag. LPN/MDS Nurse #308 stated she was still working on getting Resident #02 another appointment at UC #470 and she was going to contact PP #473 to see what they could do in the interim. LPN/MDS Nurse #308 stated she did not know when Resident #02's catheter initially malfunctioned, stating the floor staff did not always tell her when there were problems. LPN/MDS Nurse #308 stated she had been at the facility for one year and Resident #02 had not followed-up with urology during that time. LPN/MDS Nurse #308 stated she just scheduled transportation for appointments, and she wrote down when transportation could not take Resident #02 to her appointments. LPN/MDS #308 confirmed there was no documentation in Resident #02's medical record indicating reasons why the resident's appointments with UC #470 were canceled or rescheduled. LPN/MDS Nurse #308 stated transportation schedules were documented in a book and the previous medical records staff took the book when she left so the facility had no evidence of transportation scheduled for Resident #02's urology appointments. Interview on 09/30/24 at 4:07 P.M. with Regional Clinical Director (RCD) #447 revealed she had been the acting Director of Nursing (DON) at the facility for approximately one month. RCD #447 stated it had never been reported to her Resident #02's suprapubic catheter had no urinary output. A follow-up interview on 09/30/24 at 4:21 P.M. with Resident #02 revealed she could tell when she had to urinate because her bladder felt full and uncomfortable. Resident #02 stated she would call staff to turn her from side to side, which would allow urine to release from her bladder. Resident #02 stated she experienced pain at a level of seven out of a scale of one to ten when her bladder was full. Resident #02 stated she experienced pain daily as a result of her suprapubic catheter not functioning and her bladder not emptying. Resident #02 stated once staff rolled her, and she urinated, the pain would be relieved. Resident #02 stated if she had to wait any amount of time for assistance with rolling to cause urination, the pain got really bad. Interview on 09/30/24 at 4:21 P.M. with RN #475 verified Resident #02's suprapubic catheter had not functioned in a long time (unable to determine when the malfunction began). RN #475 confirmed the nurses did not measure Resident #02's I & O and further confirmed there was no way for the staff to measure or know the amount of residual urine left in the resident's bladder after urination. RN #475 confirmed there were no bladder assessments completed for Resident #02. Review of a progress note dated 09/30/24 at 9:45 P.M. and completed by LPN/Minimum Data Set (LPN/MDS) Nurse #308 revealed the nurse attempted to change Resident #02's suprapubic catheter. Balloon deflated as per protocol. Attempt to remove catheter from ostomy site was met with resistance. The resident requested for this nurse to stop the procedure and leave the catheter in place. The balloon was reinflated. Resident tolerated the procedure fair. Interview on 10/01/24 at 8:17 A.M. with [NAME] President of Operations (VPO) #451 revealed the nursing staff attempted to change Resident #02's suprapubic catheter the previous night (09/30/24) but could not get the catheter out. When asked about the transportation schedule book, VPO #451 stated she saw the transportation schedule book on LPN/MDS Nurse #308's desk. VPO #451 retrieved the transportation schedule book and revealed she was not able to find where transportation for Resident #02 was scheduled for the urology appointments. A follow-up interview on 10/01/24 at 10:00 A.M. with RCD #447 verified the labs (CBC and CMP) ordered by the physician for Resident #02 on 03/20/24, to be drawn on 04/17/24 then every three months thereafter, were not completed. RCD #447 also verified Resident #02's I & O were not documented as ordered. Review of an electronic mail (e-mail) communication dated 10/01/24 at 3:31 P.M. from Director of Business Operations (DBO) #465 with AS #474 verified the facility never scheduled transportation for Resident #02's appointments at UC #470 on 04/10/24, 05/15/24, 06/20/24, 07/03/24 or 07/26/24. Interview on 10/02/24 at 9:14 A.M. with LPN #324 revealed she frequently worked with Resident #02. LPN #324 stated she had not been able to flush Resident #02's suprapubic catheter for greater than 3 months. LPN #324 stated Resident #02 was supposed to go to the urologist, but the appointments were canceled, and she was unsure why. LPN #324 revealed Resident #02 urinated when she was turned, stating, Turn her one way she goes then turn her the other way she goes. There is no way to tell if she empties (her bladder). Interview on 10/02/24 at 10:25 A.M. with Receptionist #476 at UC #470 revealed Resident #02 was seen at the clinic in 2018 and 2019 and had not been seen for any follow-up since. A telephone interview on 10/02/24 at 2:34 P.M. with urology PA #477 revealed the facility should have called and ensured follow-up as soon as Resident #02's suprapubic catheter malfunctioned. PA #477 revealed multiple complications could occur when urine stops flowing from the suprapubic catheter or when the catheter was no longer functioning properly, including an increased risk for infection, sepsis and, if the catheter was unable to be removed, the resident may require surgery. Review of the facility policy titled, Catheter Care, Urinary, revised August 2022, revealed to observe the resident's urine level for noticeable increases or decreases, report it to the physician or supervisor. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately if the resident indicates that his or her bladder is full or that he or she needs to urinate, or if signs or symptoms of urinary retention occur. This deficiency represents non-compliance investigated under Complaint Number OH00157492 and OH00157355.

Based on medical record review, observations, policy reviews, resident and staff interviews, the facility failed to ensure adequate supplies were provided to a resident with urinary retention that required straight catheterization; provide proper care and service to ensure self-catheterization was being completed as needed and implement physician orders to encourage fluid intake and straight catheterized as needed and implement measures to prevent urinary tract infections. This affected one (Resident #09) of one resident reviewed for straight catheterization supplies. The facility census was 59. Actual Harm occurred on 11/30/23 when Resident #09 became frustrated with the facility from not having catheter supplies began self- restricting fluid intake to prevent the bladder from filling up and becoming enlarged and feeling full, resulting in the resident self-catheterizing and developing an acute change in condition with cloudy, foul-smelling urine which resulted in the resident being diagnosed with a urinary tract infection (UTI) requiring an antibiotic treatment. Findings include: Record review for Resident #09 revealed an admitted [DATE]. Diagnosis included neuromuscular dysfunction of the bladder and paraplegia. Review of the Admission Minimum Data Set assessment dated [DATE] revealed Resident #09 was cognitively intact. Resident #09 had impairment on both sides of lower extremities. Resident #09 required substantial/maximum assist with toileting, bathing, personal hygiene, supervision with bed mobility, and partial moderate assist with transfers. Resident #09 used a wheelchair. Resident #09 had an external (Texas) catheter and was always incontinent of bowel. Review of the care plan for Resident #09 from 10/24/23 through 11/04/23 revealed there was no care plan for Resident #09 regarding a straight catheterization or care and treatment. There was no care plan to encourage fluids or monitor Resident #09's output. Review of the History and Physical for Resident #9 dated 10/25/23 completed by Primary Care Physician/Medical Director #315 revealed the resident had a chronic Foley due to neurogenic bladder. The resident was here for further care. Review of the physician orders dated 11/15/23 revealed Primary Physician #315 gave orders to straight catheterization PRN (as needed) for the diagnosis of neurogenic bladder. Review of the medical record from 11/15/23 through 12/04/23 revealed no documentation of the PRN straight catheterization occurring or Resident #09 being assessed for the need. There was no evidence of fluid intakes or outputs being recorded or obtained. Review of the progress note for Resident #09 dated 11/30/23 at 6:16 P.M., completed by Licensed Practical Nurse (LPN) #286 revealed UA (urinalysis) obtained for cloudy, foul-smelling urine. Review of the physician order per Primary Care Physician/Medical Director #315 dated 12/01/23 revealed Resident #09 received an order for a UA and Culture and Sensitivity (C&S) if needed. The orders included: Push Fluids. Review of the UA with culture if indicated report for Resident #09 dated 12/01/23, collected 11/30/23, revealed urine clarity was abnormal, cloudy. The protein, nitrates, leukocytes, red blood cells, and white blood cells, in the urine was abnormal along with many bacteria which was also abnormal. The urine was verified, and a culture was indicated. The urine culture returned and was reported to the facility on [DATE] at 1:55 P.M. Review of the physician order for Resident #09 dated 12/05/23 per Primary Care Physician/Medical Director #315 revealed an order for the antibiotic cefdinir 300 milligrams (MG) given 300 mg by mouth two times a day for UTI. Review of the medical records for Resident #09 from 12/01/23 through 12/05/23 revealed no documentation of staff encouraging or monitoring fluid intake for Resident #09. Interview on 12/04/23 at 10:35 A.M. and 11:50 A.M., with Resident #09 stated he was frustrated. Resident #09 revealed he had been at the facility for over a month, and they still did not have his straight catheter supplies. Observation revealed Resident #09 was wearing a Texas catheter attached to a catheter bag. Resident #09 stated he wore the Texas external catheter to prevent overflow of urine. Resident #9 revealed he straight catheterized himself three times a day due to retention, the Texas catheter was only to prevent overflow. Resident #09 revealed the staff told him they ordered the straight catheter supplies, but the corporation decided what he needed and canceled the order. Resident #09 stated he had urinary retention, he was paralyzed from the chest down but when his bladder got full, he could feel the pressure in his abdomen. Resident #09 revealed he had to order his own supplies for the straight catheters online while at the facility. Observation revealed there were three straight catheter kits sitting on the nightstand near Resident #09. Resident #09 revealed he ordered the straight catheter supplies himself twice so far while at the facility because he had to straight catheterization himself three times a day to empty his bladder. Resident #09 revealed he had been asking since admission for the straight catheter supplies, but they were never provided. Resident #09 revealed he only had three left from what he ordered himself then he was out and had no more money to order any more. Resident #09 provided an order statement confirming he ordered the catheter kits online on 11/11/23 and they were delivered on 11/14/23 to the facility for him. Resident #09 revealed he was trying not to drink much because he only had three straight catheters left. Resident #09 stated the facility has not taught him how to self-cathe, he learned to straight cathe himself from an inmate while he was incarcerated in the hospital for inmates. Resident #09 revealed he had to save the catheters he had left for as long as he could because the facility would not assist him with getting more and he didn't have the money to buy anymore so if he didn't drink much, he wouldn't have to cathe himself as much and he could make the three he had last longer. Resident #09 revealed he didn't know what else to do, this has been very stressful for him, and he was worried constantly about it. Resident #09 revealed after his motor vehicle accident (MVA) he had a Foley (internal) catheter, when it was removed, he was bleeding from the trauma. Resident #09 stated he opted to straight cathe three times a day rather than getting the permanent catheter. Interview and observation on 12/04/23 between 10:54 A.M. and 11:10 A.M., with Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #285 and Central Supply #242 confirmed Resident #09 straight catheterized himself. Observation of the facility supply room with ADON LPN #285, and Central Supply #242 confirmed the facility had no straight catheter supplies. ADON LPN #285 and Central Supply #242 revealed the corporate office reviewed every order and they canceled resident supply orders in the past. ADON LPN #285 stated, They do it all the time. Central Supply #242 stated maybe they will send the straight catheter supplies on next shipment. Interview on 12/04/23 at 11:55 A.M., with the Director of Nursing (DON) verified the facility had no straight catheter supplies. DON confirmed Resident #09 was the only resident who required straight catheters. DON requested the surveyor ask the Administrator why there were no straight catheter supplies for Resident #09. DON stated Resident #09 was never observed straight catheterizing himself to assure the correct procedure was being done; Resident #09 had no care plan for straight catheterization; there was no monitoring of output, and there was no documentation of intake for pushing fluids per the physician's orders. DON revealed Resident #09 should have had education provided with return observation for straight catheterization prior to straight catheterizing himself at the facility. Interview on 12/04/23 at 11:59 A.M., with Administrator revealed the facility ordered the straight catheters from the company they order supplies from. The straight catheter supplies did not come from that company because they were a Part B item (paid for by the residents insurance, not by the facility) and should be ordered under Part B for billing purposes. Administrator confirmed the supplies were not ordered under Part B either yet. Administrator revealed he would get that done today. Administrator confirmed Resident #09 had no straight catheter supplies yet provided by the facility. Interview on 12/06/23 at 7:31 A.M., with Primary Care Physician/Medical Director #315 revealed Resident #09 had an order to straight catheterized as needed due to a neurogenic bladder and urinary retention. Primary Care Physician/Medical Director #315 revealed he spoke with the team at the facility from the beginning of Resident #09's admission about getting Resident #09's supplies; stating they should have had the supplies. Primary Care Physician/Medical Director #315 revealed he was not aware Resident #09 did not receive his straight catheter supplies. Primary Care Physician/Medical Director #315 revealed Resident #09 not drinking enough fluids could cause dehydration and not emptying the bladder could cause infection. Review of the policy titled, Resident Hydration and Prevention of Dehydration, dated 2001, revealed Nurse Aids will provide and encourage intake of bedside, snack, and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aids will report intake of less than 1200 milliliters per day to the nursing staff. Review of the policy titled, Catheterization, Intermittent, Male Resident, revised October 2010, included to maintain an accurate record of the resident's daily intake and output. This deficiency represents the noncompliance investigated under Complaint Number OH00148172.

Based on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer management program to ensure the identification of pressure ulcers, to ensure physician's orders were obtained timely for treatments and to ensure physician ordered treatments were provided as ordered. This affected three residents (#23, #11 and #12) of four residents reviewed who were at risk for pressure ulcer development. Actual harm occurred on 04/14/22 when Resident #23, who was severely cognitively impaired was identified to have an unstageable pressure ulcer to the coccyx. Resident #23 was admitted on [DATE] with intact skin, on 04/05/22 the resident was noted to have a Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer to the coccyx. The facility failed to notify the physician and obtain a treatment order at that time. On 04/14/22 (nine days later) the area was identified to have declined and was an unstageable pressure ulcer. Findings include: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] indicated Resident #23 was severely cognitively impaired, at risk of pressure ulcers, and had no unhealed pressure ulcers or arterial ulcers. Review of the plan of care related to being at risk for skin impairment dated 03/22/22 indicated to provide a barrier cream after each incontinence episode, encourage fluids, inspect skin with routine daily care and provide pressure reduction devices if ordered. Review of the progress notes revealed on 04/05/22 at 7:06 P.M. Resident #23 had three episodes of diarrhea and was identified to have a Stage II pressure ulcer to the coccyx. The wound bed was white and the surrounding tissue nonblanchable. The pressure ulcer was cleansed with soap and water, [MEDICATION(S)] (antibacterial and bacteria resistant ointment) was applied and border foam dressing. The note indicated monitoring would continue. However, there were no additional progress notes regarding the coccyx pressure ulcer and no evidence the physician or responsible party were notified. Review of the wound assessment dated [DATE] indicated the date of origin of the Stage II pressure ulcer was 04/07/22. However, the progress note identified the area was present on 04/05/22. The assessment did not indicate if the pressure ulcer was community acquired or in house acquired. It was noted the pressure ulcer measured two centimeters (cm) in length by two cm width with 0.1 cm depth with white adherent slough (material in the wound bed which consists of dead cells that accumulate in wound exudate). There was no evidence the physician was notified at that time or that a pressure ulcer treatment was in place. The note did reflect the resident often did not drink the nutritional supplement Review of Resident #23's physician orders revealed no indication a treatment was ordered. In addition, review of Resident #23's April 2022 treatment administration record revealed no indication a treatment had been completed to the pressure ulcer. Review of Resident #23's weight records revealed the resident was 62 inches tall and weighed 100.2 pounds on 03/12/22, 102.2 pounds on 03/17/22 and 93.8 pounds on 03/18/22. Review of the dietary note, dated 03/31/22 indicated Resident #23 was at moderate nutritional risk due to being underweight and having suboptimal oral intake. Observation of Resident #23's pressure ulcer treatment on 04/14/22 at 9:20 A.M. with Registered Nurse (RN) #199 revealed the pressure ulcer to the coccyx area measured three cm in length by by two cm width with 0.1 cm depth. RN #199 reported the area had declined and was now unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) because you could not see the wound bed. RN #199 verified there was not physician ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] At the time of the observation, interview with RN #199 verified there was no physician ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The lack of physician ordered treatment resulted in the deterioration of the ulcer. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission note dated 11/22/21 indicated Resident #12 had a scab to her left knee, bruise to her top left foot, multiple bruises to the left leg, a left medial leg wound, right heel wound, right lower leg wound times two, multiple bruises on the right leg, right foot two plus pitting [CONDITION(S)], right second two wounds and a right fifth toe blister. Review of the wound assessment dated [DATE] indicated wound measured two cm by two cm. Review of the MDS 3.0 comprehensive assessment dated [DATE] indicated Resident #12 was severely cognitively impaired, displayed other behavioral symptoms not directed toward others on four to six days of the assessment period, required the extensive assistance of two plus staff for bed mobility, transfers, toileting and the extensive assistance of one staff for personal hygiene. Resident #12 was always incontinent of bowel and bladder, was at risk for the development of pressure sores and had one unstageable pressure ulcer present upon admission. Resident #12 was noted to have two venous or arterial ulcers. Review of Resident #12's weights revealed she lost six pounds since January 2022. The last dietary assessment was dated 01/25/22 indicating she had lost 4.9 pounds over seven days. It was noted that her weight was trending down significantly. Her average intake was 25-50% and her supplement was accepted between 50-100%. Weights were to be monitored daily. Review of the wound assessment dated [DATE] revealed the right heel wound measured four cm by four cm and a second wound measuring four cm by four cm. On 03/23/22 the right heel wound measured four cm by four cm with necrotic (dead) tissue noted as well as worse pain. Review of the physician orders dated 04/06/22 indicated heel boots bilaterally, wash right heel with Dial (antibacterial) soap and water rinse and pat dry. Apply Dakin's (bleach solution) moistened 1/2 inch packing strip to the wound base. Cover with ABD (large bulky padded dressing) and heel cup and secure with stretch gauze and paper tape. Change daily and as needed. Review of the treatment administration record for April 2022 revealed blanks for 04/07/22 and 04/08/22 indicating no treatment was completed. Observation of wound care on 04/13/22 beginning at 7:45 A.M. for Resident #12's right heel revealed RN #199 was assisted by Licensed Practical Nurse (LPN) #206 who held up Resident #12's leg. Physician #209 was present to observe the wound. RN #199 cut off a bandage from the right heel revealing two wounds. One on the heel and another on the back of the heel under the achilles. The physician reported the right heel wound was healing nicely and all of the necrotic (dead) tissue had been removed. RN #199 measured the right heel wound indicating it was five cm by five cm then re-measured indicating it was 4.5 cm x 4.5 cm. RN #199 did not measure the second wound under the achilles but reported it was much smaller. RN #199 then applied Dakin's solution half strength to sponge like pads, applied the pads to both wounds, applied an ABD then wrapped the entire foot with stretchy gauze. Interview with RN #199 on 04/13/22 at 12:45 P.M. verified she did not cleanse the heal with Dial soap before dressing the heel wound and did not apply the heel cup. RN #199 reported the heel cup was not available and did not consult the wound clinic to either provide the heel cup or to recommend another device to protect the wound. RN #199 reported Resident #12 had an appointment with the wound clinic today, 04/13/22. Review of the nurses note dated 04/13/22 at 8:23 P.M. revealed Resident #12 was being admitted to the hospital from the wound care appointment. There was no documentation related to why the resident was being admitted to the hospital. Interview with RN #199 on 04/14/22 at 10:00 A.M. reported Resident #12 was sent to the hospital for wound debridement and foot x-ray. 3. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care related to skin impairment initiated on 10/14/21 indicated to apply barrier cream after each incontinence episode, inspect skin during routine daily care, and pressure reduction devices if ordered. Review of the skin risk assessment dated [DATE] indicated Resident #11 was high risk for pressure sores. Review of the MDS 3.0 comprehensive assessment dated [DATE] indicated Resident #11 was severely cognitively impaired and wandered four to six days of the assessment period. Resident #11 was not at risk for pressure ulcers and had no unhealed pressure ulcers. Review of the physician order dated 03/28/22 indicated treatments to Resident #11's left and right buttocks were discontinued on 03/28/22 Review of the progress notes revealed no information or notification of the physician or responsible party regarding the left and right buttocks. Interview with RN #199 on 04/14/22 at 10:06 A.M. revealed last night a skin sweep was conducted and found Resident #11 had an open area to her right buttock. RN #199 indicated nursing updated her and she informed them to pad the area until she observed it on 04/14/22. Observation of the open area to Resident #11's right buttock on 04/14/22 beginning at 10:06 A.M. with RN #199 revealed there there was no pad in place as she had directed. RN #199 described the area as having a thin white line around the edge rim, redness around the edges and the base of the wound was beefy red. RN #199 determined the area was a Stage II pressure ulcer. RN #199 indicated they waited until this morning to update the CNP because it was a recurring wound. RN #199 stated they had to get better at identifying, assessing and getting treatments in place. There was no documentation or assessment of the area noted in the clinical record. There was no notification of the physician of the pressure ulcer. Review of the wound care policy dated October 2010 indicated staff were to verify there was a physician's order for the procedure, review the care plan and assessment for any special needs, document the type of wound care given, any changes in condition and the assessment (wound bed color, size, drainage etc.) and how the resident tolerated the procedure. This deficiency substantiates Complaint Number OH 532.

Based on record review and interview the facility failed to maintain side rails in a safe operating condition for one resident (Resident #53). Actual harm occurred when Resident #53's unsecured side rail failed causing Resident #53 to fall and sustain a [MEDICAL CONDITION] hip. This affected one of three residents reviewed for falls. The facility census was 53. Findings include: Medical record review revealed Resident #53 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #53's Minimum Data Set 3.0 (MDS) assessment dated [DATE] indicated she needed extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. The MDS indicated Resident #53 was unsteady when moving from seated to standing position, walking, turning around and facing the other direction, moving off the toilet and transfer from bed to chair or wheelchair. Resident #53 used a walker or wheelchair for mobility. Review of a fall assessment dated [DATE] indicated Resident #53 had a high risk for falls. Review of Resident #53's MDS dated [DATE] indicated a discharge from the facility and the MDS indicated on 11/11/19 Resident #53 was readmitted to the facility. Review of a nursing progress note dated 11/07/19 at 10:24 P.M. indicated at 6:10 P.M. Resident #53's son-in-law was assisting Resident #53 with walking and assisted her to her bed. Resident #53 sat on the bed and leaned on the side rail that was in the upright position. The side rail fell and Resident #53 rolled off the bed and fell to the floor. Resident #53's family member ran to get a staff member. A review of an incident report dated 11/07/19 indicated Resident #53's son-in-law informed the licensed nurse that Resident #53 had a fall in her room. Resident #53 was found lying on her right side facing the window by the bed. The report indicated Resident #53 attempted to sit on the bed as Resident #53's son-in-law was making the bed and she rolled off the bed. Resident #53 complained of left hip pain. The incident report indicated the 1/2 side rail was not locked in position. A review of Resident #53's hospital record indicated on 11/07/19 Resident #53 was admitted to the hospital with [REDACTED]. The summary of hospital care included a repair hemiarthroplasy hip [MEDICAL CONDITION] surgery procedure on 11/08/19. Resident #53 was admitted to the hospital from 11/07/19 to 11/11/19 and was discharged back to the long term care facility on 11/11/19. A review of Resident #53's readmission nursing progress note dated 11/11/19 indicated Resident #53 was readmitted from the hospital with a left [MEDICAL CONDITION] with surgical repair. An interview with State tested Nurse Aide (STNA) #9 on 11/26/19 at 6:05 [NAME]M. indicated Resident #53 fractured her hip after sustaining a fall in the facility. STNA #9 indicated the 1/2 side rail on Resident #53's bed broke when she attempted to use the 1/2 side rail for bed mobility. On 11/26/19 at 1:44 P.M. the Assistant Director of Nursing verified the above findings. This deficiency substantiates Complaint Number OH 394.