Every finding on record at Mentor Ridge Health and Rehabilitation

Based on record review, interview, and facility policy review, the facility failed to notify the physician of a significant weight gain for a resident with a diagnosis of fluid overload. This affected one resident (#22) of three residents reviewed for nutrition. The facility census was 98.Findings include:Review of the medical record for Resident #22 revealed an admission date of 01/05/26 with a primary diagnosis of fluid overload and other diagnoses including unspecified fracture of the right tibia shaft, effusion of the right knee, type two diabetes, morbid (severe) obesity, hypertension (high blood pressure), and hyperlipidemia (high levels of fat in the blood).Review of Resident #22's Medication Administration Record (MAR) for January 2026 revealed an order dated 01/06/26 for a low concentrated sweet and no added salt diet, and a fluid restriction of 1500 milliliters (ml) per day, 480 ml for day shift, 300 ml for night shift, and 720 ml for dietary. Review of the MAR for January 2026 and February 2026 revealed an order dated 01/06/26 for furosemide (a diuretic) 80 milligrams (mg) twice daily for edema. On 02/13/26, the order was changed to furosemide 80 mg twice daily for fluid overload.Review of the dietary assessment progress note dated 01/12/26 at 3:29 P.M. revealed the weight for Resident #22 of 268 pounds (lbs.) at admission was a significant weight gain of 26 lbs. (10.7%).Review of Resident #22's care plan dated 01/14/26 revealed potential for alteration in nutrition and hydration related to risk for malnutrition, obesity, significant weight gain upon admission, and fluid restriction. The resident's goal was for the resident to maintain weight in range of plus or minus five percent and an intervention for weights per protocol.Review of Resident #22's recorded weights revealed an admission weight on 01/05/26 of 268.4 lbs. (gain of 26 lbs., 10.7% upon admission), on 01/13/26 of 278 lbs. (gain of 9.6 lbs., 3.6% since admission), on 01/20/26 of 278 lbs., on 01/26/26 of 289 lbs. (gain of 11 lbs., 7.7% since admission), on 02/02/26 of 286 lbs., and on 02/17/26 of 285 lbs. Interview on 02/18/26 at 10:51 A.M. with the Director of Nursing (DON) revealed residents were weighed weekly for all skilled stays throughout their stay, and monthly for long-term care residents. Weights were recorded on a sheet and given to the dietitian. Interview on 02/18/26 at 11:05 A.M. with Registered Dietician (RD) #701 revealed when a resident was admitted , the resident was weighed weekly for the first four weeks. If the weight was stable, then the resident was weighed monthly. Further, there was one caregiver that did the weights every week on the weekend. The caregiver gave the dietician a paper copy of the weights in her mailbox and then the dietician reviewed and entered the weights in the medical record followed by notifying the physician as appropriate. RD #701 verified Resident #22 had significant weight gain on 01/20/26 of 10.7% upon admission and again on 01/26/26 of 7.7% after admission. The RD confirmed there was no evidence that the physician or nurse practitioner was notified of Resident #22's significant weight gain.Review of the dietitian progress note dated 02/18/26 at 11:36 A.M. revealed Resident #22 had a significant weight gain of 20.6 lbs. and a 7.7% increase within the facility with a comparison weight on 01/05/26 of 268.4 lbs.Review of the progress note by Certified Nurse Practitioner (CNP) #523 dated 02/18/26 at 1:34 P.M. revealed Resident #22's weights were reviewed and stable over the last month.Interview on 02/18/26 at 5:13 P.M. with Resident #22 revealed he was on a fluid restriction diet and only drank the fluids provided to him by the facility. Interview on 02/19/26 at 10:35 A.M. with CNP #523 regarding Resident #22's significant weight gains in January 2026 revealed that she spoke with the dietician during morning meetings about every resident, reviewed notes, and saw weights that popped up. CNP #523 stated she possibly could have been notified, but if it was not in the notes, then the weight gain was not addressed. CNP #523 added that Resident #22 was seen weekly by the primary physician or CNP and monitored for signs of fluid overload. The resident's breathing was fine and his labs were stable.Review of facility policy labeled, Weight Monitoring, dated 02/14/24, revealed a weight monitoring schedule was developed upon admission for all residents. Newly admitted residents' weights were monitored as close to weekly as possible for the initial four weeks and at least monthly thereafter. A significant weight change was defined as a 5% change in one month, 7.5% change in three months, and 10% change in six months. Significant changes in weight were reported to the practitioner.

Based on record review, observation, interview, review of the facility policy and Centers for Disease Control and Prevention (CDC) informational sheet, the facility failed to ensure appropriate testing was completed to rule out multi-drug resistant organisms (MDROs) and use appropriate enhanced barrier precautions (EBP) for MDROs. This affected one Resident (#11) of four residents reviewed for urinary tract infections (UTIs). The facility census was 98.Findings include:Review of the medical record for Resident #11 revealed an admission date of 08/15/23 with diagnoses including dementia with behavioral disturbance, chronic obstructive pulmonary disease, diabetes mellitus, and anemia. Resident #11 was on hospice services.Review of the progress note dated 10/22/25 revealed Resident #11 was making unusual comments to the nurse practitioner (NP). The NP ordered a urinalysis with culture if indicated.Review of the physician order dated 10/25/25 revealed order to collect an urinalysis with culture if indicated. The sample may be collected via straight catheter.Review of progress note dated 10/30/25 revealed a partial urinalysis with culture and sensitivity results showed Resident #11 was positive for Escherichia Coli (E-coli) Extended-Spectrum Beta-Lactamases (ESBL) producing organism. The NP was notified and ordered Macrobid (antibiotic) 100 milligrams (mg) by mouth twice per day for 10 days. Resident #11's daughter was notified of the UTI. Resident #11 was placed on contact precautions.Review of the physician orders dated 10/30/25 revealed Resident #11 was ordered Macrobid 100 mg by mouth two times per day for E-coli ESBL producing organism UTI. Resident #11 was placed on contact precautions for E-coli ESBL producing organism UTI. The orders were completed as of 11/08/25.Review of a lab result dated 10/31/25 revealed a specimen for urinalysis with culture if indicated was collected on 10/27/25. Urinalysis results indicated turbid clarity, positive for leukocytes, and white blood cells greater than 50. A culture was indicated. Culture revealed greater than 100,000 colony-forming units per milliliter (CFU/ml) of E Coli. It was noted there was possible ESBL producing organism and it was recommended caution and monitoring of the resident during and after therapy.Observations on 02/17/26, 02/18/26, and 02/19/26 revealed Resident #11 was not on EBP or any other transmission-based precautions (TBP).Interview on 02/18/26 at 3:09 P.M. with Registered Nurse (RN) #706 confirmed Resident #11 was not on EBP.Interview on 02/19/26 9:12 A.M. with Assistant Director of Nursing (ADON) #804 revealed she was the facility's infection preventionist (IP). ADON IP #804 indicated Resident #11 was treated for UTI with an antibiotic (ATB) and was put on contact precautions for the duration of the ATB. ADON IP #804 indicated there was no additional testing to rule out the possibility of ESBL producing organism. ADON IP #804 indicated it was not the facility's policy to rule out possibility of MDROs.Review of the facility policy Multi-Drug Resistant Organisms dated 05/05/17 revealed precautions would be taken to prevent transmission of MDROs including ESBL. The facility policy had not been updated to include EBP.Review of the facility policy Standard and Transmission-based Precautions dated 03/24/24 revealed it was the policy of the facility to take appropriate precautions including isolation to prevent transmission of infectious agents. Enhanced barrier precautions were defined as an infection control intervention to reduce transmission of MDROs.Review of the CDC informational sheet titled ESBL-Producing Enterobacterales dated 06/12/25 revealed ESBLs were resistant to common antibiotics and may require complex treatments. These bacteria can live within a patient without causing infection symptoms known as colonization. Healthcare providers should send a specimen for antimicrobial susceptibility testing to verify presence of ESBL.

Based on record review, resident interview, staff interviews, review of the Self-Reported Incident (SRI) and facility policy review, the facility failed to timely and adequately respond after identification of an incident with injury including assessing on the day of the incident, timely notification of the physician, notification to hospice, completing a skin assessment and logging the incident on the facility's incident log. This affected one resident (#86) of one resident reviewed for incidents. The facility census was 98.Findings include:Review of the medical record for Resident #86 revealed she was admitted to the facility on [DATE] with diagnoses that included senile degeneration of brain, dementia, and chronic obstructive pulmonary disease (COPD).Review of Resident #86's physician orders dated 06/24/25 revealed an order for transfers via a mechanical lift with two people every shift.Review of Resident #86's physician orders dated 10/21/25 revealed an order for the resident to be admitted to hospice care.Review of the list of hospice residents provided by the facility revealed Resident #86 was admitted to hospice care with diagnosis of senile degeneration of brain on 10/21/26.Review of the care plan dated 01/14/26 revealed Resident #86 had an alteration in skin integrity with interventions that included, but not limited to, skin assessments, report changes to hospice and physician, and assistance of two staff members for activities of daily living (ADL).Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #86 was dependent on staff for ADL.Review of Resident #86's physician orders dated 02/08/26 revealed an order for head-to-toe skin check every day shift, every Tuesday and Saturday.Review of the progress note dated 02/15/26 at 10:13 A.M. revealed Licensed Practical Nurse (LPN) #302 noted a small superficial red denuded area to the bridge of the nose with surrounding erythema. Review of the progress note revealed LPN #302 was informed by Registered Nurse (RN) #305 that Resident #86 was observed frequently touching and/or scratching nasal area and noted to hold head and face in her hands throughout the day.Review of the progress note dated 02/15/26 at 11:22 A.M. revealed Resident #86 stated they threw me to the ground and beat me. They broke both of my legs. I heard two snaps. Resident #86 was unable to provide the names or description of staff in question.Review of the progress note dated 02/15/26 at 1:04 P.M. revealed Resident #86 received a new order to apply Bacitracin (antibiotic) ointment to the nose twice a day for seven days.Review of the progress note dated 02/15/26 at 1:30 P.M. revealed Resident #86 stated they threw me to the floor, and they threw me to the bed. Resident #86 was unable to state who they were.Review of SRI #270954 dated 02/15/26 revealed the facility initiated an alleged incident of physical abuse regarding Resident #86. Review of the SRI revealed it was an ongoing investigation. However, review of the facility investigation regarding Resident #86 alleged report of abuse revealed the facility did not initiate abuse protocols until 02/17/26, approximately two days after the initial report of abuse on 02/15/26 and no mention of Resident #86's identified area of the nose.Review of Resident #86's physician orders dated 02/17/26 revealed an order to monitor bruise to left shin area, monitor bruise to area above nose, and apply Skin Prep (forms a protective barrier) to abrasion on nose.Review of the progress note dated 02/17/26 at 2:01 P.M. revealed Certified Nurse Practitioner (CNP) #523 was made aware of the abrasion noted to Resident #86 nose from over the weekend and scattered bruises to the left shin.Review of the assessments dated for the month of February 2026, revealed no documented evidence skin assessments were completed.Observation and interview on 02/17/26 at 10:29 A.M. revealed Resident #86 sitting up in bed with a bright red colored bruise located from the top of her nose to the bottom of the bridge of her nose. Resident #86 stated four days ago an aide slammed my face down onto something.Review of the facility incident log dated 02/16/25 to 02/17/26 revealed no documented incidents regarding Resident #86's nose injury, bruise, and/or abrasion.Interview on 02/18/26 at 9:20 A.M. with Hospice Registered Nurse (HRN) #423 revealed she visited Resident #86 twice a week. RN #423 revealed Resident #86 required assistance with all ADL, was very weak, couldn't ambulate, required a mechanical lift of two staff members for all transfers, and required assistance with bed mobility. HRN #423 revealed she was not aware of Resident #86 bruise to her nose, and facility staff did not inform her. HRN #423 revealed this was her first time seeing Resident #86 face, and she would need to be updated by staff.Interview on 02/18/25 at 9:25 A.M. with Certified Nurse Assistant (CNA) #612 revealed she was aware of Resident #86 bruise to the nose and stated, I plead the fifth when asked what happened. CNA #612 revealed Resident #86 required assistance of two people for all care and could have hit her face on something. CNA #612 revealed she had not observed Resident #86 picking or scratching her face.Interview on 02/18/26 at 9:35 A.M. with RN #706 revealed she was informed Resident #86 hit her face on the mechanical lift during a transfer. RN #706 revealed she could not provide any further information.Interview on 02/18/26 at 10:42 A.M. with the Director of Nursing (DON) revealed she was not present at the time of the incident but was informed by LPN #302 that Resident #86 was rubbing and scratching her face over the weekend, Sunday 02/15/26. The DON revealed LPN #302 was on-call and received a call regarding Resident #86 bruise on the nose. The DON revealed she could not provide further details of the incident.Interview on 02/18/26 at 1:06 P.M. with RN #305 revealed CNA #716 was providing care to Resident #86 and exited the room and informed her there was a bruise on Resident #86 nose. RN #305 revealed she asked Resident #86 what happened, and Resident #86 stated Someone hit me. It was two people. RN #305 revealed Resident #86 required assistance from two people and probably was handled wrongly in bed or maybe got hit with the Hoyer lift. RN #305 revealed she did not observe Resident #86 scratching or picking at her nose or face prior to observing the bruise. RN #305 revealed Resident #86 did not have a bruise on the nose prior to 02/15/26. RN #305 revealed Resident #86 bruise to the nose and reports of physical abuse were new and she did not know exactly what happened, therefore she reported it to the Administrator.Interview on 02/19/26 at 10:45 A.M. with LPN #302 revealed she only worked Monday through Fridays, no weekends, and she was assigned to rooms 123 through 147. LPN #302 revealed she did not work the unit Resident #86 resided on. LPN #302 noted that Resident #86 resided in room [ROOM NUMBER] and was covered by another staff nurse.Follow-up interview on 02/19/26 at 11:23 A.M. with LPN #302 regarding a progress note dated 02/15/26 at 10:13 A.M. that was documented by her, on a day she stated she did not work, revealed she annotated the note but did not observe Resident #86 as stated in the progress note. LPN #302 recanted her initial interview and stated she worked on 02/15/26, a weekend, from 11:00 A.M. to approximately 1:30 P.M. However, changed the time she entered the facility to an earlier time frame after informed that her progress note was entered at 10:13 A.M. on 02/15/26, approximately 45 minutes prior to her arrival. LPN #302 revealed she received a call from RN #305 but did not come into the facility for that reason and did not complete any documentation although she was the manager on call. LPN #302 revealed she could not confirm her time of arrival and exit or verify the state of Resident #86 condition.Interview on 02/19/26 at 1:57 P.M. with CNA #716 revealed on 02/15/26 she entered Resident #86 room and noticed she had a red bruise on her nose and Resident #86 stated someone hit her in the face but did not identify the person. CNA #716 revealed she reported it to RN #305. CNA #716 revealed she did not see Resident #86 scratching or picking at her face and it was not present the day before. CNA #716 revealed Resident #86 was dependent on two staff for all care and required a mechanical lift for transfers.Interview on 02/19/26 at 2:00 P.M. with Human Resources (HR) #400 revealed there were no current staff suspended pending investigation related to allegations of abuse and no staff had received any disciplinary actions other than for attendance concerns.Interview on 02/19/26 at 3:07 P.M. with the administrative staff, including the Administrator, DON, Regional Administrator (RA) #323, and Regional Clinical Representative (RCR) #333 verified and confirmed the facility initiated an SRI for physical abuse for Resident #86's alleged abuse. Administrative staff revealed Resident #86 bruise to the nose was not present prior to the alleged abuse and was discovered at the time Resident #86 informed staff. However, the administrative staff revealed the alleged abuse and bruise to the nose were separate incidents but acknowledged that the first report of the bruise was documented at the same time as the alleged abuse on 02/15/26. The administrative staff was unable to confirm what happened to Resident #86 nose and assumed that it was caused by Resident #86 scratching her nose despite her alleged report of abuse and no staff member observing her scratching at her nose.Review of Resident #86 medical record revealed no documented incidents of Resident #86 scratching her nose, no prior skin assessments identifying any previous areas of concerns, and no notifications to hospice regarding alleged reports of abuse or new bruising to the skin and/or nose.Review of the facility document titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property dated 11/21/16, revealed the facility had a policy in place to investigate all alleged violations, perform an initial assessment, report to the physician, and document in the resident's medical record. If a staff member is accused of abuse of a resident, the facility should remove that staff member from the facility pending the outcome of the investigation.

Based on observation, interview, record review, and facility policy review the facility failed to obtain a physician order for medication at the bedside, assess and document self-medication administration for Resident #45. This affected one resident (#45) out of seven residents reviewed for medication administration. The facility census was 97. Findings Include: Review of the medical record for Resident #45 revealed an admitted [DATE]. Diagnoses included psoriasis, other pruritus, intrinsic allergic eczema, and chronic kidney disease stage 3. Review of the physician order dated 11/14/23 indicated Triamcinolone Acetonide External Cream 0.5 % (Triamcinolone Acetonide (Topical)), apply to arms, chest, trunk, legs topically every shift on Monday, Tuesday, Wednesday and Thursday for eczema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed no cognitive impairment, and application of ointments/medications were applied other than to the feet during the assessment period. There was no medication self-administration skills assessment. Review of the Treatment Administration Records (TARs) from December 2023 through February 2024 indicated Triamcinolone was signed as administered by the nurses twice daily with no indication Resident #45 was self-administering the medication. Observation on 02/20/24 at 1:44 P.M. revealed one jar of Triamcinolone cream (used to treat eczema) on Resident #45's bedside tray table. Interview at the time of the observation with Resident #45 indicated he applied it for itchy skin when needed. Observation on 02/21/24 at 11:03 A.M. revealed one jar of Triamcinolone cream on Resident #45's bedside tray table. The prescription directions stated to apply to affected areas Monday through Thursday and to take a break on the weekends. Interview at the time of the observation with Resident #45 reported the prescription was from a non-facility pharmacy which he ordered independently and applied it when his skin itched but followed the prescription instructions. Resident #45 stated the dermatologist educated him on how and when to apply the medication but denied facility staff provided any instruction or oversight. Interview on 02/21/24 at 11:05 A.M. with Registered Nurse (RN) #380 verified Resident #45 had a current order for Triamcinolone cream and indicated it was kept at the bedside because Resident #45 applied it himself. RN #380 explained the medication was kept at the bedside and Resident #45 was asked whether the cream was applied, and if so, was documented as given. Sometimes Resident #45 would allow the nurses to apply it. RN #380 indicated only seeing it applied a few times, but reported it was applied correctly when observed. RN #380 confirmed there was no physician order for the medication to be kept at bedside or for self-administration of the medication, and no documentation of the medication being self-administered by Resident #45. RN #380 stated an order should have been obtained and denied assessing Resident #45 for self-administration. RN #380 also stated being unaware of whether the physician knew of the medication at the beside or being self-administered. Interview on 02/21/24 at 11:11 A.M. with Assistant Director of Nursing (ADON) #386 denied knowledge of the Triamcinolone medication at Resident #45's bedside for self-administration. ADON #386 indicated for self-administration or medication at the bedside, a physician order was obtained, and a self-administration skills assessment was completed. ADON #386 confirmed Resident #45 had no self-administration skills assessment completed, and no physician order to keep the medication at the bedside for self-administration. Additional medical record review of Resident #45 revealed a new physician order was initiated on 02/21/24 at 11:43 A.M. for Triamcinolone Acetonide External Cream 0.5 % (Triamcinolone Acetonide (Topical)), apply to arms, chest, trunk, legs topically every shift on Monday, Tuesday, Wednesday, and Thursday. May keep at bedside and self-administer. A progress note dated 02/21/24 at 11:43 A.M. revealed the physician was notified of Resident #45's wishes to self-administer topical Triamcinolone cream and store the medication in the room at bedside. A self-medication administration assessment was completed which determined Resident #45 was able to apply the medication, state its proper use and instructions. The physician agreed to allow Resident #45 to self-administer and maintain the medication at bedside. A self-administration skills assessment was initiated for Resident #45 on 02/21/24 at 11:35 A.M. Review of the facility policy, Self-Administration of Medications, dated 10/30/17, revealed a resident may be offered opportunity to self-administer medications once the physician and the interdisciplinary team concurs the practice is safe and/or is part of discharge planning; self-administration of medications is documented by the licensed nurse on the Medication Administration Record (MAR); and residents who self-administer medications are re-assessed as needed and pursuant to a significant change in condition of the resident to assure that safe self-administration of medications is still feasible.

Based on record review, interview, and facility policy review the facility failed to monitor medication parameters per the physician orders for Resident #40. This affected one resident (#40) of five residents reviewed for unnecessary medications. The facility census was 97. Findings include: Review of the medical record for Resident #40 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, hypertension, morbid obesity, unspecified psychosis, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had severe cognitive impairment. Resident #40 was noted to require moderate assistance for upper body dressing, personal hygiene, mobility, maximum assistance for bathing, and was dependent on staff for toileting and lower body dressing. Review of the physician orders for Resident #40 revealed an order dated 12/13/23 for Metoprolol Tartrate oral tablet 25 milligrams (mg). Give 12.5 mg by mouth two times a day related to essential (primary) hypertension. Hold for heart rate less than 60 or systolic blood pressure (SBP) less than 110. Review of the Medication Administration Record (MAR) for February 2024 for Resident #40 revealed heart rate and blood pressure monitoring were not completed twice daily per the physician's orders when Metoprolol Tartrate was administered. Interview on 02/22/24 at 12:00 P.M. with the Director of Nursing (DON) confirmed the parameters for Metoprolol Tartrate were not being monitored per physician order for Resident #40. Review of the facility policy titled Medication Administration, dated 06/21/2017, revealed under procedure number one revealed to check medication administration record for order. Read label three times before administering, comparing with the MAR.

Based on interview, record review, and facility policy review, the facility failed to ensure timely interventions were implemented to appropriately treat a deteriorating [CONDITION(S)] for Resident #64. Actual Harm occurred on 09/18/21 when Resident #64 had an MRI (Magnetic Resonance Imaging) exam of the right foot on 09/07/21, which revealed findings for [CONDITION(S)] (infection of bone or bone marrow). This was not reported to the resident's primary care physician (PCP) until 09/08/21 and was not addressed by a physician until 09/16/21. Resident #64 was subsequently admitted to the hospital with [CONDITION(S)] (infection in the blood). This affected one (Resident #64) of three (Resident's #1, #45 and #64) reviewed for wound care. The facility census was 86. Findings include: Review of the medical record for Resident #64 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/06/21, revealed Resident #64 had intact cognition. The resident required extensive one staff assistance for bed mobility, transfers, and toileting, was independent for dressing, required staff supervision for personal hygiene, and physical help for bathing was limited to transfers only one staff assistance. The assessment indicated the resident was frequently incontinent of urine and always continent of bowel, and had no unhealed pressure ulcers/injuries, no infection of the foot, no diabetic foot ulcers, and no open [CONDITION(S)] on the foot. Review of the plan of care dated 09/08/21 revealed the resident had alteration in elimination and required assistance with toileting; was at risk for alteration in skin integrity; and was at risk of hypo/[CONDITION(S)] episode related to diabetes mellitus. Interventions included to provide incontinence care as needed; to provide medications as ordered; monitor lab values as ordered and report to the physician; to encourage and assist resident to turn and reposition as needed; to notify the physician and family of changes as needed; to provide assistance with activities of daily living and positioning as needed; and provide skin care as needed. Review of Resident #64's profile sheet in the medical record revealed Resident #64 was listed as self-responsible, and there was one daughter listed as first emergency contact who was power of attorney for health care. Review of the physician orders effective August 2021 revealed [MEDICATION(S)] 100 milligrams (mg) twice daily for pain; [MEDICATION(S)] 5 mg twice daily (diabetes); [MEDICATION(S)] 100 units/milliliter (ml) 28 units subcutaneously at bedtime (diabetes); and [MEDICATION(S)] (insulin) solution 100 units/ml per sliding scale subcutaneously before meals for diabetes. Review of the Skin Assessment Admission/Re-admission, dated 03/08/21, revealed no pressure ulcers/injuries and no non-pressure areas were present. Review of the pressure ulcer risk assessments dated 06/08/21 and 09/06/21 revealed the resident was at risk for development of pressure ulcers. Review of the nursing progress note dated 08/06/21 revealed the resident's primary care physician (PCP) was contacted regarding deep pitting [CONDITION(S)] to both extremities and swelling and redness to the right foot middle toe. The physician ordered [MEDICATION(S)] (diuretic) 20 milligrams (mg) daily and the resident was informed. Review of the PCP progress note, dated 08/09/21, revealed the resident was examined, and the resident's extremities had no [CONDITION(S)] with pulses present. There was no documentation regarding the resident's right foot. Review of the podiatrist progress note, dated 08/10/21, revealed hammertoe third toe right foot with infection; possible [CONDITION(S)] third toe right foot; [MEDICATION(S)] (antibiotic) 500 mg every 12 hours for seven days and stat x-rays three views of right third toe. Review of the nursing progress note dated 08/10/21 revealed the resident's family was notified of the podiatrist examination and new orders. Review of x-ray exam of the resident's right toes, performed on 08/10/21, revealed no definite evidence of [CONDITION(S)], consider a three-phase bone scan or an outpatient, contrast-enhanced MRI. Review of the podiatrist progress note, dated 08/16/21, revealed hammertoe third toe right feet with infection; possible [CONDITION(S)] third toe right foot; x-rays three views right third toe was uncertain; ordered MRI third toe right foot. Review of the nursing progress note, dated 08/16/21, revealed the resident was examined by podiatrist, and x-rays were reviewed with a new order for an MRI. The family was contacted to participate in scheduling of MRI exam. Review of the physician orders, dated 08/18/21, revealed MRI of right foot third toe for pain, discoloration, swelling, non-healing wound, which was ordered by the resident's PCP and completed on 09/08/21. Review of the nursing progress note, dated 08/30/21, revealed the resident's PCP examined the resident who complained of increased leg pain. The physician ordered to increase [MEDICATION(S)] to 200 mg three times daily, and the resident was informed. Review of the Skin Grid Non-Pressure, dated 09/02/21, revealed a right foot [CONDITION(S)], acquired on 09/02/21, which measured 1.3 centimeters (cm) length, 1.5 cm width, and undetermined depth. The wound was described as a black area to tip of toe, and dark colored area to top of same toe, thick dry callous like skin surrounding the areas. The physician and family were notified. Review of the physician orders, dated 09/03/21, revealed to cleanse right foot third toe with normal saline, pat dry, apply [MEDICATION(S)] (antiseptic) to top and bottom of toe, wrap toe with nonstick gauze daily. Review of the nursing progress note, dated 09/05/21, revealed the resident vomited and had diarrhea. The family and physician were notified. [MEDICATION(S)] (antidiarrheal) was administered and was effective. Review of the PCP progress note, dated 09/07/21, revealed the resident was examined, and the resident's extremities had no [CONDITION(S)] with pulses present. There was no documentation regarding the resident's right foot [CONDITION(S)]. Review of the nursing progress notes, dated 09/07/21, revealed the resident had elevated blood sugars and increased [CONDITION(S)] to bilateral lower extremities. The physician was notified and increased [MEDICATION(S)] (insulin) to 35 units, added 5 units of insulin to the standing order, discontinued [MEDICATION(S)], increased [MEDICATION(S)] to 40 mg, and indicated would examine resident on 09/08/21 in the facility. The resident and family were informed of the changes. There was no PCP progress note in the medical record dated after 09/07/21. Review of the MRI exam of the resident's right foot, performed on 09/07/21, revealed findings concerning for [CONDITION(S)] involving the third middle phalanx, and possible destructive changes of the third distal phalanx likely due to [CONDITION(S)]. The MRI findings were discussed with the resident's primary care physician on 09/08/21 at 12:17 P.M. Further review of the MRI report revealed a date of 09/16/21 printed in the right lower corner. Review of Skin Grid Non-Pressure, dated 09/09/21, revealed right foot [CONDITION(S)], acquired on 09/02/21, which measured 1.2 cm length, 1.2 cm width, and undetermined depth. The wound was described as tip of toe with open area with small yellow center, no bone exposed, and no signs or symptoms of infection. The resident was examined by the wound physician. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note, dated 09/14/21, revealed the resident had elevated blood sugars despite increased insulin from the previous week. The physician was notified and increased [MEDICATION(S)] to 30 units twice daily. The family was notified. Review of the nursing progress note, dated 09/16/21, revealed the facility contacted the hospital radiology department to retrieve the resident's MRI results. The podiatrist reviewed and requested an infectious disease physician consult. The facility contacted the PCP and was waiting for a response. The family was notified of the MRI results, and the resident's toe was cultured by the wound physician. Review of the Skin Grid Non-Pressure, dated 09/16/21, revealed right foot [CONDITION(S)], acquired 09/02/21, which measured 1.5 cm length, 1.5 cm width, and undetermined depth. The wound was described to have purulent (discharging pus) drainage, slight odor, and the toenail fell off. The resident was examined by the wound physician, the wound was cultured, an MRI test indicated [CONDITION(S)], and the treatment was changed to Dakin's (antiseptic) one quarter strength moistened gauze and cover with a bandage. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Debridement was performed of skin, fat, tendon, and bone down to healthy bleeding tissue. A soft tissue and bone culture swab was obtained, and bone sample was sent for pathology. Review of the wound culture results, collected on 09/16/21, and reported on 09/21/21 revealed heavy growth of three types of bacteria. Review of the nursing progress note, dated 09/17/21, revealed at 6:44 P.M., the resident's family visited and requested the resident be sent to the hospital due to the infection in the right foot third toe and indicated the resident was not acting normal and was fearful the resident was going septic. The PCP was notified of the family's request and the physician approved of the transfer. At 9:01 P.M., the resident was sent to the hospital with a copy of the recent MRI. Review of the the nursing progress note, dated 09/18/21, revealed the resident was admitted to the hospital with [CONDITION(S)]. Interview on 09/28/21 at 2:48 P.M. with Licensed Practical Nurse (LPN) #200 revealed Resident #64 obtained MRI exam at hospital on 09/07/21, the family was involved in the set-up and transport, and there was a two week delay due to a pre-authorization requirement with the resident's insurance. LPN #200 confirmed the resident's podiatrist requested the MRI, but the order was not signed upon the resident's arrival, so the PCP signed the order which was why the hospital released the MRI results to the PCP and not to the podiatrist. LPN #200 verified Resident #64's right foot was swollen but indicated it was not alarming and denied contact with the PCP. Interview on 09/28/21 at 4:20 P.M. with Registered Nurse (RN) #201 indicated the facility's podiatrist typically consults infectious disease, and verified the facility tried to contact Resident #64's PCP. RN #201 verified the facility obtained the MRI results on 09/16/21 from the hospital radiology department by request of Resident #64's podiatrist, and stated it was the original physician who ordered the test. RN #201 verified the facility was working on getting approval for the infectious disease consult with the PCP, but the resident's condition worsened. RN #201 denied contact with the PCP. Interview on 09/28/21 at 4:37 P.M. with Director of Nursing (DON) and Executive Director (ED) confirmed the facility did not obtain Resident #64's MRI results until 09/16/21 and verified the resident's PCP had received the results on 09/08/21. DON and ED indicated there was a delay in response to the MRI results by the podiatrist due to a personal emergency but denied contact with the PCP. DON and ED stated both nurse managers who were assigned to Resident #64's unit and involved with the resident's changes in condition no longer worked at the facility, were not available for interview, and left no documentation related to the events. Interview on 09/28/21 at 6:11 P.M. with DON confirmed Resident #64's PCP did not respond to the resident's MRI results because it was assumed the podiatrist was taking care of it, but it was not known that the podiatrist had a personal emergency so there was a delay. Interview on 09/29/21 at 11:00 A.M. with DON and ED verified Resident #64's PCP was aware of the MRI results but indicated since the podiatrist was the physician who originally ordered the test, the test was left for the podiatrist to handle. Review of the facility policy, Staff Physician Privileges/Job Responsibilities, revised October 2011, revealed each physician desiring to participate in staff privileges must provide medical information necessary to maintain continuous medical care and treatment; and promote participation in the resident assessment and care planning, monitoring changes in the resident's medical status and provide consultation or treatment when called by the facility. Review of the facility policy, Change of Condition, revised April 2013, revealed significant changes in resident's clinical condition or status include improvement or decline in change in condition of a wound or pressure sore and improvement or deterioration in overall condition. The Unit Supervisor or Charge Nurse will notify the resident, physician and guardian/interested family member of all changes as stated above and of any other situations requiring notification. Review of the facility policy, Resident's Bill of Rights, undated, revealed Nursing home residents have the right to participate in decisions that affect the residents' life including the right to communicate with physician and employees of the home, obtain current information on status and participate in planning of care. This deficiency substantiates Complaint Number OH 965.

Based on record review, observation and interview, the facility failed to ensure proper infection control practices during a dressing change. This affected one resident (Resident #83) of two residents reviewed for dressing changes. The facility census was 98. Findings include: Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission assessment dated [DATE] revealed the resident was cognitively intact. She required extensive assistance of two staff for bed mobility, dressing, and personal hygiene. She was dependent on staff for toilet use. This admission assessment also revealed the resident was admitted with wounds. Review of the Braden Scale assessment for predicting pressure ulcer risk dated 03/25/21 revealed the resident was at risk for the development of pressure ulcers. Observation 03/26/21 at 6:00 A.M. revealed Licensed Practical Nurse (LPN) #200 and State tested Nurse Aide (STNA) #208 were preparing to change the resident's left leg dressing. At the time of this observation, the resident had been incontinent of a large amount of loose brown stool. Her gown was stained with stool as well as her lower thighs. It was also noted the lower part of the sheet was wet from drainage from the resident's calf wound. LPN #200 and STNA #208 proceeded to remove the old dressing without cleaning up and changing the resident's linens. After removal of the dressing, the resident asked STNA #208 to lower her leg because it hurt from being lifted. STNA #208 lowered the resident's leg back onto the wet bed sheet. Observation revealed the wound measured approximately 15 centimeters (cm) in length by 15 cm in width with a depth of 0.3 cm. The wound bed appeared pink in color with areas of slough (yellow, tan, green or brown in color and may be moist, loose, and stringy in appearance). There was a large amount of serous (thin, clear) drainage. It was staged as a Deep Tissue Injury (persistent non-blanchable deep red, maroon, or purple discoloration). STNA #208 then lifted the resident's leg again for LPN #200 to cleanse the wound. LPN #200 cleansed the wound with Dakin's (antiseptic) solution. After the wound was cleansed, STNA #208 lowered the resident's leg wound onto the wet bed sheet. The resident's leg was lifted again and [MEDICATION(S)] (non-adhering dressing) was applied to the wound. The resident's leg (with the [MEDICATION(S)] on the wound) was again lowered onto the wet bedding. Her leg was raised a one last time and was wrapped with Kerlix gauze. Interview with LPN #200 on 03/26/21 at 6:30 A.M. verified after the old dressing was removed, she did not have a clean field to rest the resident's leg on. She also verified after she cleansed the wound, it was contaminated by being placed on the wet soiled bedding. This is an example of continued noncompliance from the survey completed on 03/08/21.

Based on observations, staff interview, review of the facility's Coronavirus (COVID-19) policy, review of the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH (revised 3/13/20), review of the World Health Organization (WHO) hand hygiene brochure, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure proper hand hygiene was implemented after care for Resident #3, who was on droplet precautions, to potentially prevent the spread of COVID-19 infections. This had the potential to affect all 46 residents residing on the West Unit. The facility census was 91. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that the resident required extensive assist with one staff for most activities of daily living (ADL). Extensive assistance with two staff was required for transfers and toileting. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff was to wear PPE upon entering the room, and the resident was to remain in the room during this time. Observation on 03/05/21 at 8:48 A.M. revealed State tested Nursing Assistant (STNA) #168 did not wash her hands when she left the room. The room was clearly marked See Nurse, PPE was well stocked in a bin outside the room, and a sign was posted to demonstrate donning and doffing of PPE for droplet precautions. STNA #168 verified that she should have disinfected her hands prior to leaving the room. Review of the facility's policy titled Infection Control Policy and Procedure, dated 11/28/17, revealed staff will perform hand hygiene before and after contact with a resident. Review of the CMS policy memo QSO-20-14-NH, revised 3/13/20 titled Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes, revealed facilities were to Increase the availability and accessibility of alcohol-based hand rubs, and to reinforce strong hand-hygiene practices. Review of the CDC training titled, Hand Hygiene in Nursing Homes, dated 02/25/19, revealed hand hygiene was an element of standard precautions. It was an important Infection Prevention Control (IPC) practice for breaking the chain of infection. Hand hygiene protects both residents and staff. Hand hygiene was a simple and effective method for preventing the spread of pathogens by direct and indirect contact. The hands of staff members may become transiently contaminated with pathogens after touching a resident or surfaces in their environment. Staff members can transfer those pathogens to themselves and they can also transfer those pathogens to other residents or surfaces. Performing hand hygiene removes pathogens and protects both staff and residents. Since staff cannot tell whether their hands have been contaminated with a pathogen, hand hygiene should be consistently performed. Review of the WHO Hand Hygiene brochure titled Hand Hygiene: Why, How, and When?, revised August 2009, revealed hands are the main pathways of germ transmission during health care and hand hygiene is therefore the most important measure to avoid the transmission of harmful germs and prevent health care-associated infections. The brochure further revealed hand hygiene is indicated after touching any object or furniture when leaving the patient surroundings to protect the health-care environment against germ spread.

Based on interview, record review, self-reported incident (SRI) review, personnel record review and policy review, the facility failed to ensure an allegation of physical abuse involving Resident #70 was reported timely to administration as required. This affected one resident (Resident #70) of three residents reviewed for abuse. The facility census was 90. Findings include: Review of Resident #70's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #70 had a memory problem, no behaviors and required extensive assistance of two staff for hygiene and bathing. Care plans were in place for the resident's alterations in mood and behavior which included unwillingness to participate, non-compliance with personal care at times and self-care deficit which included needing assistance for bathing and dressing. Review of a self-reported incident dated 04/16/19 revealed State tested Nursing Assistant (STNA) #102 reported to the facility that STNA #105 allegedly threw a towel at Resident #70 following a shower completed by both staff members. Both staff members were suspended immediately and interviewed. Skin assessments were completed and notifications were made as required. Review of the facility's investigation for the allegation of physical abuse revealed undated interviews with Resident #2, Resident #22, Resident #31, Resident #32, Resident #68 and Resident #70 as well as an undated sheet of staff interviews regarding STNA #105's character. The facility found the allegation of abuse to be unsubstantiated. A statement dated 04/17/19 written by STNA #105 revealed on 04/21/19 (incorrect date) while she was dressing Resident #70 he stated, keep this [***] away from me. She politely removed his hand out of her face to finish dressing him and denied ever throwing anything at Resident #70. A statement dated 04/17/19 written by STNA #102 revealed on Sunday afternoon (04/14/19) he witnessed an interaction with Resident #70 and an unidentified staff member where a wash cloth was thrown on Resident #70's face and then the staff member proceeded to poke him in the face on his left cheek with her finger. An undated statement written by Licensed Practical Nurse (LPN) #108 who also served as the facility's medical records personnel revealed on 04/16/19 at 3:30 P.M. STNA #102 came into her office and asked her opinion about an instance of abuse he had witnessed at the facility. STNA #102 told her the incident occurred on 04/14/19 and he was worried about backlash from staff if he reported it. LPN #108 told STNA #102 he was required to report abuse immediately and offered to take STNA #102 to the Administrator. LPN #108 then called the Administrator to speak with STNA #102 regarding reporting the allegation of abuse. Review of STNA #102's personnel file revealed a hire date of 10/03/18 and a termination date of 04/19/19. STNA #102 had completed abuse training on 10/03/18, 10/27/18, 03/15/19 and 04/17/19. Review of a disciplinary action form dated 04/19/19 revealed on 04/16/19, STNA #102 reported an allegation of abuse that allegedly occurred on 04/14/19 and was terminated for failure to timely report an allegation of suspected or witnessed abuse, neglect or mistreatment of [REDACTED]. In a phone interview on 05/17/19 at 11:35 A.M., STNA #102 verified the alleged abuse occurred on 04/14/19 but he did not report the allegation to the facility until 04/16/19. STNA #102 verified he had been educated on abuse while employed at the facility and stated his termination was due to his failure to report abuse timely to administration. On 05/17/19 at 12:22 P.M. LPN #108 verified her written statement and stated STNA #102 had come to her on Tuesday (04/16/19) asking about something he had witnessed Sunday (04/14/19) and she immediately took him to the Administrator to report an allegation of abuse. On 05/17/19 at 12:41 P.M. STNA #105 verified she had written an incorrect date (04/21/19) on her written statement. On 05/17/19 at 1:22 P.M. an interview was conducted with the Administrator and the Director of Nursing (DON). The Administrator verified the abuse allegedly occurred on 04/14/19, but he was made aware of the allegation of abuse on 04/16/19. The Administrator stated the facility expectation was that abuse was to be reported immediately, not two days later. The Administrator verified STNA #102 had failed to report an allegation of abuse timely and his employment with the facility was thus terminated. Review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/21/16 revealed protocols in place for abuse screening, training, prevention and identification. Staff were to protect the resident and report all incidents and allegations immediately to the Administrator. If a staff member was accused or suspected of abuse, the facility should remove that staff member from the facility and schedule pending the outcome of the investigation. All allegations of abuse were to be reported immediately to the Administrator and the State Agency, all allegations were to be thoroughly investigated, further abuse was to be prevented and investigations were to be completed within five working days of the incident. This deficiency substantiates Complaint Number OH 161.

Based on interview, record review, self-reported incident (SRI) review, personnel record review and policy review, the facility failed to ensure implementation of their abuse policy and procedure related to immediate reporting. This affected one resident (Resident #70) of three residents reviewed for abuse. The facility census was 90. Findings include: Review of Resident #70's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #70 had a memory problem, no behaviors and required extensive assistance of two staff for hygiene and bathing. Care plans were in place for the resident's alterations in mood and behavior which included unwillingness to participate, non-compliance with personal care at times and self-care deficit which included needing assistance for bathing and dressing. Review of a self-reported incident dated 04/16/19 revealed State tested Nursing Assistant (STNA) #102 reported to the facility that STNA #105 allegedly threw a towel at Resident #70 following a shower completed by both staff members. Both staff members were suspended immediately and interviewed. Skin assessments were completed and notifications were made as required. Review of the facility's investigation for the allegation of physical abuse revealed undated interviews with Resident #2, Resident #22, Resident #31, Resident #32, Resident #68 and Resident #70 as well as an undated sheet of staff interviews regarding STNA #105's character. The facility found the allegation of abuse to be unsubstantiated. A statement dated 04/17/19 written by STNA #105 revealed on 04/21/19 (incorrect date) while she was dressing Resident #70 he stated, keep this [***] away from me. She politely removed his hand out of her face to finish dressing him and denied ever throwing anything at Resident #70. A statement dated 04/17/19 written by STNA #102 revealed on Sunday afternoon (04/14/19) he witnessed an interaction with Resident #70 and an unidentified staff member where a wash cloth was thrown on Resident #70's face and then the staff member proceeded to poke him in the face on his left cheek with her finger. An undated statement written by Licensed Practical Nurse (LPN) #108 who also served as the facility's medical records personnel revealed on 04/16/19 at 3:30 P.M. STNA #102 came into her office and asked her opinion about an instance of abuse he had witnessed at the facility. STNA #102 told her the incident occurred on 04/14/19 and he was worried about backlash from staff if he reported it. LPN #108 told STNA #102 he was required to report abuse immediately and offered to take STNA #102 to the Administrator. LPN #108 then called the Administrator to speak with STNA #102 regarding reporting the allegation of abuse. Review of STNA #102's personnel file revealed a hire date of 10/03/18 and a termination date of 04/19/19. STNA #102 had completed abuse training on 10/03/18, 10/27/18, 03/15/19 and 04/17/19. Review of a disciplinary action form dated 04/19/19 revealed on 04/16/19, STNA #102 reported an allegation of abuse that allegedly occurred on 04/14/19 and was terminated for failure to timely report an allegation of suspected or witnessed abuse, neglect or mistreatment of [REDACTED]. In a phone interview on 05/17/19 at 11:35 A.M., STNA #102 verified the alleged abuse occurred on 04/14/19 but he did not report the allegation to the facility until 04/16/19. STNA #102 verified he had been educated on abuse while employed at the facility and stated his termination was due to his failure to report abuse timely to administration. On 05/17/19 at 12:22 P.M. LPN #108 verified her written statement and stated STNA #102 had come to her on Tuesday (04/16/19) asking about something he had witnessed Sunday (04/14/19) and she immediately took him to the Administrator to report an allegation of abuse. On 05/17/19 at 12:41 P.M. STNA #105 verified she had written an incorrect date (04/21/19) on her written statement. On 05/17/19 at 1:22 P.M. an interview was conducted with the Administrator and the Director of Nursing (DON). The Administrator verified the abuse allegedly occurred on 04/14/19, but he was made aware of the allegation of abuse on 04/16/19. The Administrator stated the facility expectation was that abuse was to be reported immediately, not two days later. The Administrator verified STNA #102 had failed to report an allegation of abuse timely and his employment with the facility was thus terminated. The DON stated STNA #105's statement contained an incorrect date of 04/21/19. The Administrator stated the lack of dates on the resident and staff interviews was an oversight and everything in the SRI investigation had been completed sometime between 04/16/19 and 04/19/19. Review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/21/16 revealed protocols in place for abuse screening, training, prevention and identification. Staff were to protect the resident and report all incidents and allegations immediately to the Administrator. If a staff member was accused or suspected of abuse, the facility should remove that staff member from the facility and schedule pending the outcome of the investigation. All allegations of abuse were to be reported immediately to the Administrator and the State Agency, all allegations were to be thoroughly investigated, further abuse was to be prevented and investigations were to be completed within five working days of the incident. This deficiency substantiates Complaint Number OH 161.