Every finding on record at Momentous Health at Vandalia

Based on observations, record review, staff interviews and policy review, the facility failed to the resident had safe, clean, comfortable and homelike environment. This affected seven Residents (#36 ,#60, #45, #46, #90, #91, and #95) out of seven residents reviewed for environment. The facility census was 107.Findings include 1) Review of the medical record for Resident #36 revealed an admission date of 05/01/26. Diagnoses included bipolar disorder, anxiety disorder, and schizoaffective disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was independent with transfers and mobility. Observation of Resident #36's room on 06/03/26 at 12:17 P.M. revealed a very pervasive urine odor. During an interview on 06/03/26 at 12:18 P.M., Resident #36 stated her roommate (Resident #37) smelled of urine and refused to be changed. Resident #36 voiced her concerns related to the constant smell of urine in her room. During an interview on 06/03/26 at 12:19 P.M. Certified Nursing Assistant (CNA) #67 verified Resident #36's room had a strong smell of urine. CNA #37 reported Resident #37 was noncompliant with care and refused to let staff change her after she's soiled. 2) Review of the medical record for Resident #60 revealed an admission date of 02/01/24. Diagnoses included obsessive compulsive disorder (OCD), schizoaffective disorder, bipolar type, and dementia. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #60 had intact cognition as evidenced by a BIMS score of 15. This resident was independent with transfers and mobility. Observation of Resident #60's room on 06/03/26 at 12:22 P.M. revealed a strong pervasive odor or urine. During an interview at the same time, Resident #60 complained of the room smelling of urine because of the roommate (Resident #59). During an interview on 06/03/26 at 12:25 P.M., Licensed Practical Nurse (LPN) #23 verified Resident #59 and Resident #60's room had a strong odor of urine. LPN #23 reported Resident #59 was noncompliant with care. 3) Review of the medical record for Resident #45 revealed an admission date of 11/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), OCD, and type II diabetes mellitus (DM II). Review of the Quarterly MDS assessment dated [DATE] revealed Resident #45 had severely cognitive impairment as evidenced by a BIMS score of zero. This resident was independent with transfers and mobility. Review of the progress note for Resident #45 dated 04/07/26 at 10:20 A.M., revealed Nurse Practitioner (NP) #200 ordered an x-ray to the residents right shoulder due to status post fall and discoloration. The Guardian was notified. Review of the progress note for Resident #45 dated 04/07/26 at 4:21 P.M. revealed the resident was assessed by Registered Nurse (RN) #59 and noted to have swelling to the resident's right shoulder and clavicle area and the area was light pink in color. Resident #45 was observed hitting and pushing her room door open with her right shoulder. New order for x-ray given. The Guardian was made aware. Review of the witness statement dated 04/07/26 by CNA #81, revealed Resident #45 was hitting her right shoulder on the door to open her room door. Review of the witness statement dated 04/07/26 by CNA #55, revealed Resident #45 had to use her right shoulder to push her room door open. Review of the x-ray results dated 04/08/26 at 3:35 A.M., revealed Resident #45 had a comminuted fracture (a type of broken bone where the bone is shattered, splintered, or crushed into three or more pieces) of the distal third of the right clavicle. Review of the progress note for Resident #45's dated 04/09/26 at 2:16 P.M., revealed after an investigation was completed, RN #59 was alerted to the resident's right shoulder and clavicle swelling. NP #200 was notified and ordered an x-ray. Resident #45 injured her right shoulder when she used her right shoulder to hit her room door to get it to open . Review of the work order dated 05/19/26, revealed Resident #45's door was significantly sticking, and Resident #45 had a difficult time getting into her room. During an interview on 06/03/26 at 9:36 A.M., CNA #81 stated Resident #45's door was hard to push open, and the resident had to use her right shoulder to push the door open by ramming her right shoulder into the door. During an interview on 06/03/26 at 10:26 A.M., CNA #55 stated Resident #45 had a cherry red discoloration to the top of her right shoulder on 04/07/26, and by the end of the shift, it was swollen and turning purple. CNA #55 reported Resident #45 would use her right shoulder to hit her room door to open it. During an interview on 06/03/26 at 11:05 A.M., NP #200 stated she was rounding in the building on 04/07/26 and noticed Resident #45's right shoulder was swollen. NP #200 stated she assessed the resident and she had a purple hematoma and tenderness with palpation, so she ordered an x-ray. During an interview on 06/03/26 at 12:15 P.M., RN #59 stated Resident #45's shoulder was red and edematous on 04/07/26. RN #59 stated the resident's door sticks, and she put in a work order on 04/07/26 for maintenance to fix it. Observation of Resident #59's room door on 06/03/26 at 2:00 P.M., revealed the room was very difficult to open. The surveyor had to push hard on the door to get it to open. The door was dragging the ground causing it to stick on the floor. The bottom two doors hinges were loose allowing them to move when the door was opened and closed. Observation of Resident #59 attempting to enter her room on 06/03/26 at 2:03 P.M. with LPN #112, revealed the resident had to use her right shoulder by hitting her shoulder on the door to get it open. Interview with LPN #112 at the same time, verified the findings. 4) Review of the medical record for Resident #95 revealed she was admitted to the facility on [DATE]. Her diagnoses included angina pectoris, diabetes mellitus, anemia, encephalopathy, major depressive disorder, and adult failure to thrive. The resident was assessed to be cognitively intact and independently ambulatory in a wheelchair. Observation of Resident #95's room on 06/03/26 at11:45 A.M., revealed was seated in a wheelchair in the hallway and CNA #76 was standing next to the resident. Resident #95 #95's door handle was broken with a large notch missing out of the wooden door holding the handle in place. Observation at the same time revealed the resident's bathroom door was sticking and it was very hard to open. During an Interview on 06/03/26 at 11:45 A.M., Resident #95 stated she was frustrated that her room door handle and door was broken. Resident #95 stated her room door does not close properly due to the handle being broken. Resident #95 stated she was also frustrated because her bathroom door was sticking and not functioning properly. Resident #95 revealed the facility was aware of the issues; however, nothing wsa being done to fix the issues. During an interview on 06/03/26 at 11:47 A.M., CNA #76 confirmed the conditions of Resident #95's room and bathroom doors. 5) Review of the medical record for Resident #90 revealed she was admitted to the facility on [DATE]. Her diagnoses included paranoid schizophrenia, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), chronic viral hepatitis, and hyperlipidemia. The resident was assessed to be cognitively intact and independently mobile. Medical record review for Resident #91 revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia, anxiety, vascular dementia, osteoarthritis, hyperlipidemia, and hypothyroidism. The resident was assessed to be cognitively intact and independently mobile. Observation of Residents #90 and #91's room door on 06/03/26 at 11:47 A.M., with CNA #76, revealed the room door was not functioning properly and hard to open. Interview with CNA #76 at the same time, verified the condition of Residents #90 and #91's door. During an interview on 06/03/26 at 1:50 P.M. the Administrator stated Residents #90, #91,#94,and #95's room doors were part of the facility's plan of correction from the annual survey in March 2026. The Administrator provided a signed note dated 04/17/26 from the maintenance departments stating they audited and repaired all the resident's doors. The Administrator verified the signed document did not indicated what room doors were fixed or how many doors were repaired. Observation at the same time revealed the Administrator provided an untitled, handwritten document dated 04/17/26 and signed by Maintenance Supervisor (MS) #01 indicating all resident room doors were assessed and all necessary repairs were completed. 6) Review of the medical record for Resident #46 revealed she was admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, bipolar disorder, osteoarthritis, obesity, anxiety disorder, and chronic obstructive pulmonary disease (COPD). Observation of Resident #46's window on 06/01/26 at 11:13 A.M. with the Administrator revealed the window was broken and a large piece of wood covered the window. During an interview on 06/01/26 at 11:14 A.M., the Administrator confirmed the window was broken with a large piece of wood covering Resident #46's window. During an interview on 06/03/36 at 2:40 P.M., Resident #46 stated she moved in approximately six weeks ago and the window was broken and covered with wood when she moved in. Review of the facility policy titled, Homelike Environment, dated 05/01/22, revealed the residents are to be provided with a safe, clean, comfortable environment. The facility shall provide a clean, comfortable, and sanitary environment. This deficiency represents non-compliance investigated under Complaint Number 3009546.

Based on observation, staff interview, resident interview, medical record review, and review of the facility policies the facility failed to implement interventions and provide sufficient supervision to prevent residents from ingesting foreign objects. This affected one (Resident #33) of three (#31, #33, #42) residents reviewed for accident hazards. The facility also failed to ensure a clean and safe smoking area for the residents on the men's and women's secured unit. This had the potential to affect 19 Residents (#29, #30, #31, #32, #33, #35, # 39, #42, #50, #51, #52, #55, #61, #62, #63, #64, #65, #66, and #68) who the facility identified as smokers and utilized the outdoor smoking area. The facility also failed to ensure the secured unit was properly secured. The facility identified 41 Residents (#28, #29, #30,# 31, #32, #33, #34, #35, #36, #37, #38, #39, #40. #41,#42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68) who resided on the secured unit and was independently mobile. The facility census was 107.Findings include: 1) Review of the medical record for Resident #33 revealed an admission date of 11/22/25 with diagnoses including suicidal ideation, obstructive, bipolar disorder, borderline personality, asthma, pica, paroxysmal atrial fibrillation, depression, intellectual disabilities (ID), conversion disorder, and morbid obesity Review of the care plan for Resident #33 dated 02/03/26 revealed the resident had a behavior problem which included swallowing batteries and other foreign objects.Review of the facility incident/accident log from 04/01/26 through 05/31/26, revealed the facility did not record the incidents involving Resident #33 on 04/05/26, 05/14/26, 05/23/26 and 05/26/26. Review of the nurse's progress note for Resident #33 dated 04/05/26 at 2:59 P.M. and authored by Licensed Practical Nurse (LPN) #17, revealed Resident #33 called the police and told them she ate a battery. Resident #33 was observed walking out of her room with a thermometer in her hand. Resident #33 stated she ate the battery from the thermometer the nurse left out on the table. Resident #33 was transferred to the hospital. (incident 1) Review of the nurse's progress note for Resident #33 dated 04/05/26 at 11:48 P.M. and authored by LPN #17, revealed Resident #33 had surgery and two batteries were removed. Review of the nurse's progress note for Resident #33 dated 04/08/26 at 2:43 P.M. and authored by LPN #17, revealed the resident returned to the facility following a hospital stay. Review of the nurse's progress notes for Resident #33 dated 05/14/26 at 12:16 P.M. and authored by LPN #07, revealed the resident reported that she swallowed two small batteries. Resident #33 stated she took them from the pulse oximetry machine and then later stated she got them from the night shift. Resident was monitored. Review of the nurse's progress notes for Resident #33 dated 05/14/26 at 1:34 P.M. and authored by the Unit Mnager (UM) #07, revealed the resident stated she swallowed batteries from the pulse oximetry machine. The resident was sent to the hospital for evaluation.Review of the hospital notes for Resident #33 dated 05/14/26, revealed Resident #33 swallowed a foreign body.Review of Minimum Data Set (MDS) for Resident #33, dated 05/14/26, revealed Resident #33 had impaired cognition. Resident #33 was independently mobile. Review of the nurse's progress notes for Resident #33 dated 05/17/26 at 2:50 P.M. and authored by Registered Nurse (RN) #59, revealed Resident #33 readmitted to the facility from the hospital. Review of the nurse's progress notes for Resident #33 dated 05/23/26 at 11:14 P.M. and authored by LPN #45 revealed Resident #33 approached the nurse's station and stated she swallowed a screw. The resident pointed toward the shower room area when questioned where she got a screw. The resident was sent to the emergency room for evaluation. Review of the hospital paperwork for Resident #33 dated 05/23/26 revealed the resident swallowed a foreign body.Review of the nurse's progress notes for Resident #33 date 05/24/26 at 6:29 A.M. and authored by LPN #45, revealed Resident #33 returned to the facility from the hospital. Resident #33 underwent endoscopic removal of a screw the resident swallowed. Review of a nurse's progress note dated 05/26/26 at 6:54 A.M. and authored by LPN #96, revealed Resident #33 reported that she swallowed a battery. Resident #33 stated it was a flat round battery from the television remote. Resident was sent out to the hospital.Review of the hospital note for Resident #33 dated 05/26/26, revealed the resident was admitted to the hospital related to swallowing a foreign object. The resident had invasive procedures to remove the foreign objects and was discharged back to the facility on [DATE] with instructions to remove all small objects from the Residents room for safety. Review of the nurse's progress note for Resident #33 dated 05/30/26 at 7:06 A.M., authored by LPN #45 revealed Resident #33 returned from the hospital with discharge instructions to remove small object's from Resident #33's room for safety. During an interview won 06/03/26 at 1:42 P.M., the Director of Nursing (DON) stated Resident #33 was quick to grab items from the nurse's desk. The DON stated she thought about placing some type of dividers up around the nurse's station but never did. The DON verified the above incidents involving Resident #33 on 04/05/26, 05/14/36, 05/23/26 and 05/26/26. The DON revealed the guardian had ask the facility to sweep Resident #33's room to ensure Resident #33 was safe to return to her room. The DON confirmed the facility failed to update Resident #33's care plan with any new interventions regarding swallowing foreign objects since February 2026. The DON verified the incidents on 04/05/26, 05/14/26, 05/23/26 and 05/26/26 involving Resident 33 swallowing foreign object were not recorded on the accident /incident log.Review of the facility policy titled Safety and Supervision of Residents dated 05/01/22 revealed the facility would make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents were facility-wide priorities. The care team should implement targeted interventions to reduce individual risks to hazards in the environment, including adequate supervision (such as 15-minute checks or closer observation) and assistive devices. Other interventions could include specific activities for the residents or taking them for a walk outside the facility.Review of the facility policy titled Falls and Incident Investigations dated 07/22/22 confirmed would investigate all resident occurrences whether falls or incidents to ascertain root cause and have a plan developed to prevent recurrence. 2) Observation of the secured unit on 06/01/26 at 10:05 A.M. with LPN #122, revealed the exterior door leading to the unsecured courtyard was unlocked and not alarmed and would freely allow a resident to walk out the door without staff's knowledge. The surveyor was able to open the freely door with no alarm sounding. There were several residents moving throughout the secured unit and no staff were present at the door Directly outside the exterior door was a large broken concrete pad with numerous large chunks of broken cement lying all around the concrete pad and throughout the courtyard. There was a large stack of bricks lying on the ground next to the building. The red metal can that held cigarette butts and ashes was full of cigarette butts. There were hundreds of cigarettes butts strewn all around the cement pad, in the courtyard, in the flower beds with mulch and directly next to the building. There was a large piece of wood covering a broken window to Resident #46's room which was in the same area were residents smoke and numerous cigarette butts were around the boarded-up window. There was no fire blanket and no fire extinguisher near the smoking area. The gate door that exited the secured courtyard was hanging open due to a broken lock assembly and the keypad was broken. The Surveyor was able to exit directly from the courtyard to an open field next. There were no staff present in the courtyard during numerous observations. During an interview on 06/01/26 at 10:10 A.M., LPN #122 confirmed the door to the smoking area for the secured unit was unlocked, unalarmed and unsupervised by staff. LPN #122 stated exterior door had an alarm, but it was not functioning. LPN #122 confirmed the concrete pad was broken and had large chunks of missing concrete. LPN #122 verified the missing chunks of concrete were strewn about the concrete pad and in the courtyard. LPN #122 verified the red metal can was full of cigarette butts and ashes. LPN #122 verified there were hundreds of cigarette butts strewn all around the area. LPN #122 stated the large piece of wood was covering a broken window and verified there were cigarette butts around the piece of wood covering the window to Resident #46's room. LPN #122 confirmed there was no smoking blanket or fire extinguisher in the area. LPN #122 verified the large stack of red bricks piled up directly next to the concrete pad. LPN #122 verified the area was not secured and the gate leaving the secured courtyard was hanging open and the keypad was not working. Observation of the secured unit on 06/01/26 from 10:10 A.M. -10:40 A.M. with LPN #122 revealed the door across the hall from the activity room on the women's section of the secured unit opened directly to the unsecured courtyard and failed to alarm when opened. There was a sign on the door indicting the door had a fifteen second egress when pushed. Continued observation of the door located inside the men's section of the secured unit leading directly outside to an unsecured area did not alarm when opened. There was a sign on the door that indicated the door had a fifteen second egress when pushed. Observation of the door at the end of the three hundred hallway on the men's section of the secured unit revealed it would not open nor alarm when the bar was pushed. Observation of LPN #122 trying several times to open the door without success. LPN #122 was observed pushing on the door very hard several times before it finally opened. When the door opened, there was no audible alarm. There was a sign on the door that indicated the door would alarm after a 15 second egress. During an interview on 06/01/26 at 10:40 A.M. , LPN #122 on 06/01/26 at 10:40 A.M. verified the findings in the secured unit concerning the doors. Observation of the women's section of the secured unit on 06/01/26 at 11:13 A.M., with the Administrator, revealed the exterior door leading to the unsecured courtyard was unlocked, not alarmed and unsupervised. The Administrator stated the red bucket was full of cigarette butts and ashes was full because no on uses that for an ashtray. The Administrator stated the large pile of bricks was likely from some construction at the building. The Administrator verified the courtyard was unsecured due to the gate and alarm at the gate being broken. During an interview on 06/01/26 at 12:07 P.M., Maintenance Supervisor (MS) #01 revealed he was aware of the unsecured door leading the unsecured courtyard. MS #01 stated he made the Administrator aware of the smoking area needing a fire blanket and fire extinguisher over a week ago. Subsequent observations in the secured unit on 06/03/26 at 2:36 P.M. with LPN #112, revealed the large sliding window next to the exterior door was able to be opened all the way and without any restrictive devices attached to the window. During an interview with LPN #112 at the same time, verified the large window was able to be opened all the way without any restrictive devices on the window and led to the unsecured courtyard. Review of the facility policy titled, Smoking, dated 05/01/22, confirmed the facility shall establish and maintain safe resident smoking practices, and Residents will smoke in a safe manner.This deficiency represents non-compliance investigated under Complaint Number 2974781.

Based on observation, staff interview, and facility policy review the facility failed to ensure a safe, functional, sanitary and comfortable environment for the residents, staff and public. The affected all 45 residents housed on the East Unit. The facility census was 107. Findings include:Review of the medical record for Resident #59 revealed an admission date of 02/18/15. Diagnoses included major depressive disorder, bipolar disorder, and anxiety disorder Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had severely cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. Review of the medical record for Resident #60 revealed an admission date of 02/01/24. Diagnoses included obsessive compulsive disorder (OCD), schizoaffective disorder, bipolar type, and dementia. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #60 had intact cognition as evidenced by a BIMS score of 15 Observation of Resident #59 and #60's room on 06/03/26 at 12:22 P.M. with LPN #23, revealed the residents' room had several alive and dead flies throughout their room. During an interview with LPN #23 at the same time verified the flies in the residents' room. Observation the ceiling lights in the secured unit on 06/01/26 at 10:50 A.M. with Licensed Practical Nuse (LPN) #122 revealed nearly all the ceiling lights had copious amounts of visible dead bugs. During an interview with LPN #122 at the same time, verified the light covers had numerous dead bugs in them. Observation of the 200-unit hallway on 06/03/26 at 2:00 P.M. with LPN #05 revealed multiple ceiling lights had numerous dead bugs visible in the lights. During an interview with LPN #05 at the same time, verified multiple ceiling lights had numerous dead bugs visible in the lights. LPN #05 stated the dead bugs were also present during the recent annual survey in March 2026. Review of the facility policy titled, Homelike Environment, dated 05/01/22, revealed the residents are to be provided with a safe, clean, comfortable environment. The facility shall provide a clean, comfortable, and sanitary environment Review of the facility policy titled, Pest Control, dated 05/01/22 revealed the facility shall maintain a pest control program. The facility maintained an on-going pest control program and had pest control.

Based on observation, staff interview, and record review, the facility failed to ensure residents who had bed rails affixed to their beds were properly assessed and monitored for safety. This affected one (#42) out of three Residents (#31,#40, and #42) reviewed for bedrails. The facility identified a total of eleven Residents (#29, #30, #31, #34, #35, #38, #40, #41, #42, #46, and #48) who required assist bars on the secure unit. The facility census was 107.Findings include: Medical record review for Resident #42 revealed she was admitted to the facility on [DATE]. Diagnoses included conversion disorder with seizures, bipolar disorder, adult failure to thrive, major depressive disorder, hyperlipidemia, hypoglycemia, autistic disorder, cerebral aneurysm, aphasia, joint derangement. The Resident required hospice services. Review of the active care plan for Activity of Daily Living (ADL) assistance and falls for Resident #42 revealed intervention for bilateral assist bars to Resident #42 's to bed to assist and enhance with bed mobility. There was an active care plan in place related to wound care and interventions including padding and protecting the foot board of Resident #42's bed. There were no interventions related to padding the half side rails on Resident #42's bedReview of the most recent side rail assessment for Resident #42 dated 08/11/22, revealed the resident was marked as not having side rails.Review of the Enabler Evaluation/Assessment for Resident #42 dated 01/06/26, revealed the secured unit was listed as the device assessed and there was no other information related to the resident having side rails on the assessment. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 was cognitively impaired. Resident #42 was dependent on staff for all ADL. The assessment indicated there were no bed rails utilized. Review of a progress note for Resident #42 dated 05/25/26 at 7:47 P.M. and authored by Licensed Practical Nurse (LPN) #112, revealed the resident was noted to have a bruise to the right side of her forehead. The resident moved around in her bed. Review of a progress note for Resident #42 dated 05/26/26 at 3:35 P.M. and authored by the Director of Nursing (DON), revealed an interdisciplinary team (IDT) investigated Resident #42 having bruising to her forehead. Resident #42 was assessed and the area appeared to be consistent with Resident #42 hitting her forehead on her side rails. The new intervention was for the siderails to be padded and protected.Review of the Skin Assessment for Resident #42 dated 05/25/26 at 7:31 P.M., revealed a bruise located on the top of her scalp that measured 10 centimeters (cm) by 7 cm. The report revealed old bruising noted to the right side of Resident #42's forehead.Review of the incident report dated 05/25/26 at 3:00 P.M., and authored by LPN #112, revealed Resident #42 had old bruising noted to her forehead and had a bruise of unknown origin. LPN #112 noted Resident #42 flails around in her bed. The physician and family were notified. Review of a staff statement dated 05/25/26 and authored by Certified Nursing Assistant (CNA) #06 revealed when care was being provided to Resident #42, she would flail around and hit her head on the side rails. Review of a staff statement dated 05/25/26 and authored by CNA #67 revealed Resident#42 would flail around in the bed when care was being provided and Resident #42 would hit her head on the side rails.Observation of Resident #42 on 06/03/26 at 11:58 A.M. with LPN #112, revealed the resident was in her bed with head facing the footboard with half bed rail on each side the upper part of the bed. There was kerlix wound dressing partially and a thin layer wrapped on the side rails. During an interview at the same time with LPN #112, verified Resident #42 was in bed with half bed rails on each side of her bed with kerlix wrapped on the bed rails. LPN #112 stated Resident #42 was unable to assist with bed mobility, and the bed rails were because Resident #42 moved around in her bed.Subsequent observation of Resident #42 on 06/03/26 at 2:35 P.M. with LPN #112, revealed the resident was lying with her head towards the footboard and there were two half bed side rails in the up position. The half size bed rails were wrapped with a thin layer of discolored Kerlix wound dressings. Resident #42 was observed with bruising on her forehead over her right eye and forehead.During an interview on 06/03/26 at 2:36 P.M., LPN #112 confirmed Resident #42 was lying in bed upside down with the half size bed rails up and covered with a thin layer of discolored Kerlix wound dressing. LPN #112 stated Resident # 42 moved around in her bed which resulted in a bruising to her forehead. LPN #112 stated the bed rails on Resident #42's bed were half rails. LPN #112 stated the hospice company was supposed to supply something for Resident #42's bed rails to protect the resident and the Kerlix was a temporary fix until the hospice company provided a new bed.During an interview on 06/04/26 at 2:26 P.M., Patient Care Coordinator (PCC) #300, stated she was with the current hospice company. PCC #300 stated Resident #42 has half bed rails on her bed and had unknown bruising identified to her forehead. PCC #300 stated the half bed rails were supposed to have seizure pads applied to them to protect Resident #42 while in bed. During an email correspondence on 06/04/26 at 12:49 P.M., Chief Operating Officer (COO) #202 reported residents only used grab or assistance bars. COO #202 stated the facility did not have a separate policy related to rails, grab or assistance bars. COO #202 stated the facility utilized Restraint/Enabler Assessment tool for rails. Review of the June 2026 physician order summary report for Resident #42, revealed there were no orders for resident to have half side rails affixed to her bed and no physician orders to assess and monitor the resident for having side rails.Review of the facility policy titled, Healthcare Management Group, undated, confirmed the purpose of the policy was to identify acceptable reasons for the use of grab bars. The approved reasons included mobility assistance, transfer assistance, and safety during uncontrolled movement disorders. Further review of the policy confirmed side rails may not be used solely to prevent a resident from getting out of bed or restrict freedom of movement.

Based on review of the medical record and staff interviews, the facility failed to ensure medical providers completed and signed their notes at the time of visit. This affected one (#45) of the three residents reviewed for provider visits. The facility census was 107.Findings include:Review of the medical record for Resident #45 revealed an admission date of 11/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), obsessive compulsive disorder (OCD), and type II diabetes mellitus (DM II).Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had severely cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. Review of a physician progress note dated 04/07/26 for Resident #45 revealed the progress note was completed and signed on 06/03/26 at 11:42 A.M.During an interview on 06/03/26 at 10:29 A.M., Nurse Practitioner (NP) #200 verified she saw Resident #45 on 04/07/26 related to a hematoma to right shoulder but had not completed the progress note yet.

Based on observations, interviews, and policy review, the facility failed to ensure appropriate infection control measures were followed during incontinence care. This affected one (#45) of three residents reviewed for urinary incontinence. The facility census was 107.Findings include:Review of the medical record for Resident #45 revealed an admission date of 11/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), obsessive compulsive disorder (OCD), and type II diabetes mellitus (DM II).Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #45 had severely cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This resident was assessed to require partial assistance with eating, substantial assistance with toileting, bathing, and dressing, and setup with transfers. Review of section H for bowel and bladder of the Quarterly MDS assessment dated [DATE] revealed Resident #45 was frequently incontinent of bowel and bladder.Observation on 06/03/26 at 1:17 P.M. revealed Certified Nursing Assistant (CNA) #67 and CNA #81 completed incontinence care to Resident #45. During incontinence care, CNA #67 did not change gloves during care. CNA #67 proceeded to touch the resident, clean depends, and sheets with soiled gloves.During an interview on 06/03/26 at 1:32 P.M. with CNA #67 verified she did not change her gloves during incontinence care and touched Resident #45, clean depends, and sheets with soiled gloves.Review of the facility policy titled, Peri Care, dated 05/01/22 revealed to provide cleanliness and comfort to the resident, prevent infections and skin irritations, and observe the resident's skin condition. For cleansing the resident, use a clean area of cloth for each area cleansed. Remove gloves and perform hand hygiene. Apply clean gloves and apply clean brief and reapply clothing. Remove gloves and perform hand hygiene. Reposition resident into a safe and comfortable position and return bed to the lowest position.

Based on record review, staff interview, and review of the facility policy review, the facility failed to ensure there was a Registered Nurse (RN) scheduled at least eight consecutive hours per day, seven days per week. This had the potential to affect all of the residents residing in the facility. The facility census was 108 residents. Findings include: Findings Include: Review of policy titled Staffing and dated 05/01/22 reveals that the facility should maintain adequate staffing on each shift to ensure resident's needs and services are met. Interview on 03/13/26 at 1:52 P.M. with Chief Operating Officer (COO) #400 confirmed the facility di not have a Registered Nurse(RN) on duty in the facility on 02/28/26. Review of the Minimum Direct Care Daily Average of 2.50 - Survey Tool dated from 02/27/26 through 03/05/26 revealed there was no RN coverage on 02/28/26.

Based on medical record review, staff interview, and review of the facility policies the facility failed to implement interventions and provide sufficient supervision to prevent residents from ingesting foreign objects. This affected one (Resident #8) of three residents reviewed for supervision. The facility also failed to ensure fall prevention interventions were in place. This affected one (Resident #7) of three residents reviewed for supervision. The facility also failed to ensure hazardous chemicals were secured. This had the potential to affect the following facility-identified cognitively impaired and independently mobile (Residents (#27, #44, #55, #59, and #80) on the 100 hall. The facility census was 108 residents. Findings include:1.Review of the medical record for Resident #8 revealed an admission date of 11/22/25 with diagnoses including pica, borderline personality disorder, bipolar, morbid obesity, and conversion disorder. Review of a nurse progress note for Resident #8 dated 12/17/25 at 7:04 A.M. revealed while nurse was on the phone the resident put a thumb tack in her mouth. Another nurse tried to get Resident #8 to spit the thumb tack out, but the resident swallowed it. Staff called emergency medical services (EMS) and transported the resident to the hospital. Review of the hospital note for Resident #8 dated 12/17/25 revealed the resident presented to emergency department after swallowing a thumb tack. Resident #8 passed the thumb tack through her digestive tract spontaneously and sustained no injuries. Review of the nurse progress note for Resident #8 dated 01/10/26 revealed the resident told staff she had gotten a battery from a blood pressure cuff at the nurses' station and swallowed it and then called 911. Resident #8 said she had gotten into an argument with her mom, and she swallowed the batter because she was mad. EMS transported Resident #8 to the hospital. Review of the hospital note for Resident #8 dated 01/10/26 revealed the resident was admitted to the hospital for ingestion of two triple A sized batteries. Resident #8 passed the batteries through her digestive tract spontaneously and sustained no injuries. Review of a nurse progress note for Resident #8 dated 01/31/26 revealed the resident told the nurse she ate the battery out of the thermostat. Th nurse called EMS and the resident was transported to the hospital. Review of the hospital note for Resident #8 dated 01/31/26 revealed the resident was admitted to the hospital following ingestion of two double A batteries. The hospital staff successfully removed the batteries from Resident's stomach using a Roth net (a device used to retrieve items from the digestive tract), and the resident sustained no injuries. Review of the care plan for Resident #8 dated 02/03/26 revealed the resident had a behavior problem which included swallowing batteries and other foreign objects. Interview on 03/11/26 at 11:24 A.M. with Licensed Practical Nurse (LPN) #331 confirmed Resident #8 had a behavior of swallowing batteries and/or other foreign objects after she had an argument with her parents or she was told that she couldn't have or do something she wanted to do. Interview on 03/12/26 1:30 P.M. with the Chief Operating Officer (COO) confirmed Resident #8 was admitted to the facility from a sister facility and had exhibited the behavior of swallowing foreign objects in the sister facility. The COO confirmed they transferred Resident #8 to the facility because she would be able to be in a smaller secured unit where they could provide a higher level of supervision. The COO stated the facility knew upon admission that Resident #8 had the behavior problem of ingesting foreign objects, but the facility did not put a care plan in place regarding the behavior until 02/03/26. The COO confirmed Resident #8 had three incidents of ingesting foreign objects followed by transport to the hospital on [DATE], 01/10/26, and 01/31/26. Interview on 03/19/26 at 2:00 P.M. with the Administrator and the Director of Nursing (DON) confirmed the facility had not completed follow-up investigations to determine root cause and interventions to prevent recurrence for the incidents for Resident #8 on 12/17/25, 01/10/26, and 01/31/26 Review of the facility policy titled Safety and Supervision of Residents dated 05/01/22 revealed the facility tried to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents were facility-wide priorities. The care team should implement targeted interventions to reduce individual risks to hazards in the environment, including adequate supervision (such as 15-minute checks or closer observation) and assistive devices. Other interventions could include specific activities for the residents or taking them for a walk outside the facility. Review of the facility policy titled Falls and Incident Investigations dated 07/22/22 confirmed would investigate all resident occurrences whether falls or incidents to ascertain root cause and have a plan developed to prevent reccurrence. 2. Review of the medical record for Resident #7 revealed an admission date of 01/05/21 with diagnoses including alcohol abuse, anxiety disorder, and major depressive disorder. Review of the physician's orders for Resident #7 revealed an order dated 04/28/25 for Dycem (a rubberized mat to prevent slipping) to wheelchair every shift. Review of the MDS assessment for Resident #7 dated 12/19/25 revealed the resident had impaired cognition and required staff assistance with activities of daily living (ADLs.) Review of the fall care plan for Resident #7 dated 01/13/26 revealed the resident was at risk for falls related to impaired cognition, impaired mobility, resistance to care, and use of psychotropic drugs. Interventions included the following: bed against wall for environmental enhancement, bed in lowest position at all times unless providing care, bring resident to the common area when restless, Dycem above and below wheelchair cushion, Dycem to wheelchair seat, encourage to remind to ask for assistance, floor mat next to the bed when the resident was in bed. Observation on 03/11/26 at 1:45 P.M. of Resident #7 revealed the resident was lying in bed with no fall mats beside the bed. Next to the bed was Resident #7's wheelchair with no Dycem above or below the wheelchair cushion. Interview on 03/11/26 at 1:45 P.M. with Certified Nurse Aide (CNA) #240 confirmed Resident #7 was lying in bed and did not have a fall mat beside the bed. CNA #240 confirmed the wheelchair parked next to Resident #7 belonged to the resident and did not have Dycem above or below the wheelchair cushion. Interview on 03/11/26 at 1:50 P.M. with Registered Nurse (RN) #327 confirmed Resident #7's care plan indicated the resident was supposed to have fall mats beside the bed when the resident was in bed and was supposed to have Dycem to his wheelchair above and below the wheelchair cushion. Observation on 03/16/26 at 8:25 A.M. of Resident #7 revealed the resident did not have Dycem to his wheelchair above or below the cushion. Interview on 03/26/26 at 8:25 A.M. with the DON confirmed Resident #7 did not have dycem to his wheelchair above or below his wheelchair cushion. Review of the facility policy titled Falls and Incident Investigations dated 07/22/22 confirmed the facility would implement fall prevention interventions to prevent resident falls. 3. Observation on 03/09/26 at 10:53 A.M. on the 100 hall revealed there janitor's closet was unlocked and contained three containers of sanitizing chemicals labeled as Concentrated Sanitizing Fabric Refresher. The containers had warning labels indicating they should be kept of reach of children, and they could be hazardous to humans and domestic animals. The substance in the containers was corrosive and could cause irreversible eye damage and could be harmful if absorbed through skin. Interview on 3/9/26 at 10:53 A.M. with CNA #274 confirmed the janitor closet on the100 hall was not locked and contained three containers of sanitizing chemicals with warning labels. Interview on 3/9/26 at 11:00 A.M. with LPN #248 confirmed janitor closet on the 100 hall should be locked when unattended. Observation on 3/11/26 at 12:02 P.M. revealed the janitor closet on the 100 was unlocked and there were three containers of sanitizing chemicals inside. Interview on 3/11/26 at 12:02 P.M. with Registered Nurse (RN #228) confirmed the janitor closet was unlocked and there were three containers of sanitizing chemicals inside. Interview on 3/11/26 at 3:57 P.M. with Administrator confirmed the janitor closet as unlocked and there were three containers of sanitizing chemicals. Administrator confirmed the janitor closet should be locked and this was of particular concern for the following facility-identified residents who were cognitively impaired and independently mobile: Residents #27, #44, #55, #59, and #80. This deficiency represents noncompliance investigated under Complaint Number 2703709.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure current and accurate documentation of resident advanced directives were included in the medical record. This affected four (Residents #6, #24, # 27, # 65) of 32 residents reviewed for advanced directives. The facility census was 108 residents. Findings include:1.Review of the medical record for Resident #24 revealed an admission date of 08/29/24 with diagnoses including chronic pain syndrome, major depressive disorder, and bipolar disorder. Review of the physician's orders for Resident #24 revealed an order dated 03/12/25 for a code status of Do Not Resuscitate Comfort Care (DNRCC.) Review of the care plan for Resident dated 12/05/25 revealed the resident had a code status of DNRCC. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 12/09/25 revealed the resident was cognitively intact. Review of the hard (physical) chart for Resident #24 revealed there was a sticker undated on the outside of the chart indicating the resident was a full code status. Interview on 03/10/26 at 10:47 A.M. with Registered Nurse (RN) #223 confirmed the code status sticker on the outside of Resident #24's chart did not match the order in the resident's record. 2. Review of the medical record for Resident #65 revealed an admission date of 03/01/18 with diagnoses including cerebral infarction, fracture of left femur, and vascular dementia. Review of the physician's orders for Resident #65 revealed an order dated 05/19/25 for the resident to be a full code status. Review of the care plan for Resident #65 dated 11/24/25 revealed the resident's code status was DNRCC. Review of the Resident #65's hard (physical) chart revealed it contained a signed and completed state of Ohio DNRCC form. Interview on 03/10/26 at 10:48 A.M. with RN #223 confirmed orders in hard chart did not match orders in the EHR. 3. Review of medical record for Resident #6 revealed an admission date of 03/14/24 with diagnoses including generalized muscle weakness, chronic obstructive pulmonary disease, and chronic pain syndrome. Review of the care plan for Resident #6 dated 11/25/25 revealed the resident's code status was full code. Review of the physician's orders for Resident #6 revealed an order dated 01/14/26 for the resident to have a code status of DNRCC. Review of the MDS assessment for Resident #6 dated 02/25/26 revealed the resident was cognitively intact. Review of the care plan for Resident #6 dated 11/25/25 revealed the resident's code status was full code. Review of the face sheet for Resident #6 undated revealed the resident's code status was full code. Interview on 3/10/26 at 10:46 A.M. with Licensed Practical Nurse (LPN #320) confirmed the face sheet and the care plan indicated Resident #6's was a full code, but the resident's order was for DNRCC. 4. Review of medical record for Resident #27 revealed an admission date of 3/05/20 with diagnoses including traumatic brain injury, dementia, and bipolar disorder. Review of the MDS assessment for Resident #27 completed on 12/10/25 revealed the resident had severe cognitive impairment. Review of the physician's orders for Resident #27 undated revealed an order dated 02/05/24 for the resident to have a code status of DNRCC. Review of the face sheet for Resident #27 undated revealed the resident's code status was full code. Interview on 3/10/26 at 10:47 A.M. with RN #216 confirmed Resident #27's face sheet indicated the resident's code status was full Code which did not match the physician's order in the resident's chart. Review of facility policy titled Advance Directives dated 05/01/22 revealed the resident's advanced directives would be reviewed upon admission, readmission from the hospital, quarterly, and annually by the social worker. Documentation of the review should be noted on the advance directive care plan, quarterly social work assessment, and/or admission/annual advance directive information form.

Based on review of the medical record, observation, resident interview, staff interview, and review of the facility policy, the facility failed to maintain resident rooms in good repair. This affected two (Residents #69 and #80) of 32 residents reviewed The facility census was 108 residents.Findings include: 1.Review of the medical record for Resident #80 revealed an admission date on 12/11/25 with diagnoses including paranoid schizophrenia, presbyopia, and diabetes mellitus two. Review of the Minimum Data Set (MDS) assessment for Resident #80 dated 12/26/25 revealed resident had moderate cognitive impairment. Observation on 03/09/26/26 at 5:02 P.M. of Resident #80's room revealed there were multiple small holes on the bedroom wall and the outside of the bathroom door had scratches and chipped paint. Interview on 03/09/26 at 5:02 P.M. with Resident #80 confirmed she did not like the holes on the bedroom wall and she felt the bathroom door with the scratches and chipped paint should be repaired. Interview on 03/16/26/26 at 9:18 A.M. with Maintenance Assistant (MA) #313 confirmed there were multiple small holes in Resident #80's wall made by screws which should have been filled in with plaster and repaired. MA #313 confirmed Resident #80's bathroom door was scratched and needed to be repainted. 2. Review of the medical record for Resident #69 revealed an admission date of 03/04/26 with diagnoses including, cerebral infarction, major depressive disorder, and diabetes mellitus. Review of the MDS assessment for Resident #69 dated 02/26/26 revealed resident was cognitively intact. Observation on 3/09/26 at 9:14 A.M. of Resident #69's room revealed the bedroom door was difficult to shut as the door was cracked and got caught on the door frame. Interview on 03/09/26 at 10:13 A.M. with Resident #69 confirmed she was concerned about her bedroom door being in poor repair and that the door was unable to be fully closed. Interview on 3/16/26 at 9:14 A.M. with MA #313 confirmed Resident #69's bedroom door needed the hinges adjusted so it would not catch on the door frame and there were cracks on the side of the door. Review of facility policy titled Homelike Environment dated 05/01/22 revealed that facility would provide a homelike and orderly environment for the residents.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to develop comprehensive care plans to address residents' identified needs. This affected three (Residents (#42, #9, and #8) of four residents reviewed for care plans. The facility census was 108 residents.Findings include: 1.Review of the medical record for Resident #42 revealed an admission date of 12/03/25 with diagnoses including osteoarthritis, obstructive sleep apnea, and congestive heart failure. Review of the care plan for Resident #42 initiated 12/03/25 revised 12/31/25 revealed the resident was at risk for potential pain or discomfort. Further review of the care plan revealed it did not include interventions related to pain management. Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 01/07/26 revealed the resident was cognitively intact. Review of the physician's orders for Resident #42 revealed an order dated 01/19/26 for Voltaren gel to be applied to the right shoulder topically every six hours as needed for pain. Interview on 03/09/26 at 1:12 P.M. with Resident #42 confirmed he frequently requested his as needed Voltaren gel for his right shoulder pain. Interview on 03/11/26 at 11:59 A.M. with Licensed Practical Nurse (LPN) #231 verified Resident #42 had a pain care plan which did not include pain management interventions. 2. Review of the medical record for Resident #9 revealed an admission date of 03/11/24 with diagnoses including anxiety disorder, hypertension, Alzheimer's disease, and schizoaffective disorder. Review of the MDS assessment for Resident #9 dated 01/01/26 revealed the resident had mild cognitive impairment. Review of the care plan for Resident #9 dated 03/11/24 revealed there was no activities care plan for the resident. Interview on 03/09/26 at 3:19 P.M. with Resident #9 confirmed she did not like to go to the facility activities because they were infantile. Interview on 03/11/26 at 1:25 P.M. with the Chief Operating Officer (COO) confirmed the facility had not developed an activities care plan for Resident #9. 3. Review of the medical record for Resident #8 revealed an admission date of 11/22/25 with diagnoses including pica, borderline personality disorder, bipolar, morbid obesity, and conversion disorder. Review of the nurse progress notes for Resident #8 dated 12/17/25, 01/10/26, and 01/31/26 revealed the resident had ingested foreign objects including a thumb tack on one occasion and batteries on two other occasions. Review of the care plan for Resident #8 dated 02/03/26 revealed the resident had a diagnosis of pica and had a behavior of ingesting foreign objects. Review of the MDS assessment for Resident #8 dated 02/08/26 revealed the resident was cognitively impaired. Interview on 03/11/26 at approximately 1:25 P.M. with the COO#400 confirmed the facility did not develop and implement a behavioral care plan for Resident #8 until 02/03/26 which was after the resident had ingested foreign objects on three occasions. Review of the facility policy titled Resident Care Plans dated 05/01/22 revealed the facility would develop a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the residents' physical, psychosocial, and functional needs and would implement the care plan for each resident.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure resident care plans were revised to reflect changes in toileting needs. This affected one (Resident #4) of four residents reviewed for care plans. The facility census was 108 residents. Findings include: Review of the medical record for Resident #4 revealed an admission date of 11/02/24 with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus type two, and acquired absence of right and left leg below knee. Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 12/16/25 revealed the resident did not have an indwelling catheter and was occasionally incontinent of urine. Review of care plan for Resident #4 dated 1/09/26 revealed the resident had indwelling foley catheter and requires catheter care per facility policy. Observation on 03/09/26 at 10:35 A.M. revealed Resident #4 was in bed and did not have a foley catheter. Interview on 3/16/26 at 10:59 A.M. with Registered Nurse (RN) #307 confirmed the resident no longer had a foley catheter, and the facility had not updated the resident's care plan. Review of facility policy titled Resident Care Plans dated 5/1/22 revealed resident care plans should be revised and updated with changes in resident condition and status.

Based on review of the medical record, observation, and staff interview, the facility failed to ensure oxygen therapy was administered as ordered by the physician. This affected one (Resident #2) of three residents reviewed for oxygen therapy. The facility census was 108 residents. Findings include:Review of the medical record for Resident #2 revealed an admission date of 08/11/25 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease (COPD) and respiratory failure. Review of the care plan for Resident #2 dated 08/11/25 revealed the resident was at risk for altered respiratory status, difficulty breathing, or potential for an alteration in respiratory status related to COPD. Interventions included provide oxygen per physician's order. Review of the physician's orders for Resident #2 dated March 2026 revealed there was no order for oxygen therapy. Observation on 03/10/26 at 1:48 PM revealed Resident #2 was receiving continuous oxygen therapy via nasal cannula per concentrator set at three liters per minute (LPM). Interview on 03/11/26 at 12:02 PM with Licensed Practical Nurse (LPN) #231 confirmed Resident #2 utilized continuous oxygen therapy. LPN #231 stated she did not know what level of oxygen had been ordered by Resident #2's physician. LPN #231 confirmed they typically set all the residents' oxygen at three LPM unless otherwise ordered.

Based on medical record review, resident interview, and staff interview, the facility staff failed to provide pain management interventions as ordered by the physician and per resident request. This affected one (Resident #42) of six residents reviewed for pain management. The facility census was 108 residents. Findings include: Review of the medical record for Resident #42 revealed an admission date of 12/03/25 with diagnoses including osteoarthritis, obstructive sleep apnea, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 01/07/26 revealed the resident was cognitively intact. Review of the physician's orders for Resident #42 revealed an order dated 01/19/26 for Voltaren gel to be applied to the resident's right shoulder topically every six hours as needed for pain. Review of the Medication Administration Record (MAR) for Resident #42 dated March 2026 revealed there was no record of administration of Voltaren gel on 03/07/26, 03/08/26, 03/09/26, and 03/10/26. Interview on 03/09/26 at 1:12 P.M. with Resident #42 confirmed he requested his as needed Voltaren gel on 03/07/26 and 03/08/26, but the nurses told him it was not available. Interview on 03/11/26 at 11:09 A.M. with Resident #42 confirmed he requested his as needed Voltaren gel on 03/09/26 and 03/10/26, but the nurses told him it was not available. Interview on 03/11/26 at 11:59 A.M. with Licensed Practical Nurse (LPN) #231 confirmed Resident #42 had a physician's order for Voltaren gel and had asked for the medication to be applied to his right shoulder, but the medication was out of stock. This deficiency represents noncompliance investigated under Complaint Number 1360651.

Based on observation, staff interview, and review of a facility emergency management plan, the facility failed to ensure there was an adequate amount of food available in the facility to account for scheduled meals and emergency situations. This had the potential to affect all 99 residents in the facility who the facility identified as receiving food from the kitchen. The census was 99. Findings include: Observation of the kitchen with [NAME] #59, on 12/03/24 at 8:31 A.M. through 8:44 A.M., revealed the facility's dry food storage consisted of dry pancake mix, dry cake mix, instant potatoes, noodles, onions, brown sugar, two canisters of oats, frosting, 11 cans of fruit, six cans of vegetables, and 25 pounds of rice. The refrigerated food storage consisted of one opened gallon of milk, two five-pound logs of cheese, one bag of broccoli, one bag of carrots, and an opened bottle of salad dressing. Observation of frozen food items in the kitchen consisted of two bags of peas and carrot mix and approximately 60 breakfast sausage links. Interview at time of the kitchen tour with [NAME] #59 confirmed the facility did not have an emergency supply of food at that time. [NAME] #59 further confirmed the facility served meals as scheduled and had enough food at each meal, but hardly had any leftovers if any resident wanted a second serving. Interview on 12/03/24 at 8:49 A.M. with [NAME] #173 revealed the facility was able to serve the meals as scheduled on a daily basis, but had no extra food or an emergency food supply for a long time. Interview on 12/03/24 at 10:17 A.M. with Dietician #96 revealed the Administrator was aware of the facility did not have an emergency supply of food. Interview on 12/03/24 at 12:01 P.M. with [NAME] #4 revealed he did not have any lunch meat to use to start preparing for the evening meal of submarine (sub) sandwiches. Observation on 12/03/24 at 1:10 P.M. revealed Dietician #96 purchased and brought supplies into the kitchen consisting of 36 small cans of tuna, five one-gallon containers of milk, two roasted turkey breasts, 36 cans of ravioli, and 36 cans of fruit. Interview on 12/03/24 at 1:10 P.M. with [NAME] #4 confirmed the facility sent a kitchen staff member to the store after the observation of the lack of food supply in the kitchen earlier that morning. Interview on 12/03/24 at 3:01 P.M. with the Administrator revealed the facility food vendor had not been supplying the facility with all food ordered on a weekly basis and the facility and was working with them to get those items delivered. The Administrator confirmed she has been the administrator since 10/01/24 and she was not aware of the facility not having an emergency food supply until recently. Interview on 12/04/24 at 7:27 A.M. with Dietary Supervisor #90 confirmed he has worked for the facility for approximately 90 days and the facility has not had an emergency food supply since he was hired. Dietary Supervisor #90 reported the food he ordered weekly just barely gets the kitchen through the week. Review of the undated document for the facility comprehensive emergency management plan (CEMP) revealed the facility will ensure there was an emergency food and drink service, and will procure and maintain a seven-day supply of food and meal service products on hand at all times. This deficiency represents non-compliance investigated under Master Complaint Number OH00160283.

Based on observations and staff interviews, the facility failed to maintain the building in a safe homelike manner. This had the potential to affect the 21 residents (#48, #49, #50, #51, #52, #53, #54, #55, #56, #56, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67 and #68) residing in the Northeast Unit of the facility. The facility census was 103. Findings include: Observation on 10/07/24 at 1:55 P.M. of the facility roof revealed areas over the Northeast unit, facing the south had an area of splintered/missing wood with rain gutters not attached to the roof exposing the soffit and sagging. Further observation of the roof in the same area revealed multiple rows of shingles sagging between the roof rafters. Observation on 10/07/24 at 1:59 P.M. of the facility roof revealed two areas over the Northeast Unit, facing north had areas of splintered/missing wood with rain gutters not attached and sagging exposing the soffit and roofing shingles sagging between the rafters. Additionally, there was a large blue tarp present over the shingles in the same area. Observation on 10/08/24 at 9:05 A.M. of the dining area in the Northeast Unit revealed two outlets that did not have covers on them. Additional observation revealed a ceiling light that did not have a cover on it, exposing the electrical outlet boxes on all three items. Observation on 10/08/24 at 9:07 A.M. of the corridor located just outside of the nursing station revealed an entire section of the wall from the ceiling to the floor was covered with heavy black plastic and stapled in place. Additionally, observations noted a section on plaster cut from the wall approximately two inches vertically and twelve inches horizontally exposing the inside of the space between the walls. Additionally, directly below the cut plaster was an electrical outlet with undetermined type of beige tape covering the entire perimeter of the outlet cover. Interview on 10/08/24 at 9:11 A.M. with the Maintenance Director verified the observations and stated prior to his employment in July 2024 the facility had had a water heater leak and the water damaged the areas in the dining area, the hot water storage area, the corridor outside of the storage area and the resident room next to the storage area. Additionally, stated the facility has called multiple repair companies and have not had any return calls to address the repairs so he has been fixing them himself as time will allow. The facility confirmed there were 21 residents (#48, #49, #50, #51, #52, #53, #54, #55, #56, #56, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68) residing in the Northeast Unit of the facility that could potentially be affected by the identified concerns/observations. This deficiency represents non-compliance investigated under Complaint Number OH00158425 and OH00158273.

Based on medical record review, staff and resident interviews, observations and policy review the facility failed to ensure prescription medications were appropriately stored in a secured manner. This had the potential to affect 17 residents (#69, #70, #73, #75, #78, #79, #80, #83, #85, #86, #88, #89, #91, #94, #95, #97 and #101) residing on the [NAME] Hall and eight resident (#6, #7, #11, #17, #21, #22, #23 and #29) residing on the East Hall who were cognitively impaired and independently mobile who could potentially access unsupervised and unsecured medications. Additionally, the facility failed to ensure refrigerated medications were appropriately stored. This had the potential to affect 21 residents (#48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67 and #68) residing in the Northeast unit. The facility census was 103. Findings include: 1. Medical record review for Resident #82 revealed an admission on 04/13/23 with diagnoses including but not limited to respiratory failure with hypoxia, chronic obstructive pulmonary disease, type two diabetes, hypothyroidism, schizoaffective affective disorder, anxiety, open angle glaucoma severe and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #82 dated 07/30/24 revealed an intact cognition. Resident required set up for meals and supervision for toileting, bed mobility and transfers. Review of the plan of care for Resident #83 revealed cognitive function altered related to diagnoses of depression, psychosis, schizoaffective disorder, cognitively compromised, unable to make safe decisions, mental function varies over the course of the day. Resident #83 has a history of auditory and visual hallucinations, short term/long term memory impairment, impulse control impairment, resident can become verbally and physically aggressive with staff and other residents, has a rigid medication regimen. Interventions include allow resident time to remember and respond, assist with decision making problems and provide cues or reminders. Review of the active physician orders for Resident #82 revealed an order dated 10/02/24 stating resident able to self-administer drops and inhaler, an order dated 03/28/24 for Brimonidine Tartrate Opthalmic solution 0.2 percent instill one drop in both eyes three times a day for glaucoma, an order dated 03/22/24 for carboxymethycellulose sodium ophthalmic solution one percent instill one drop in left eye four times a day for dry eye, an order dated 03/23/24 for Dulera inhalation aerosol 200-5 microgram(mcg) one puff two times a day for shortness of breath, rinse mouth with water and spit after each use, an order dated fluticasone propionate nasal suspension 50 mcg instill one spray in both nostrils one time a day for rhinosinusitis, an order dated 03/22/24 for Luteomas ophthalmic gel instill one drop in left eye one time a day for dry eyes, an order dated 03/21/24 for tiotropium Bromide Monohydrate inhaler aerosol solution 1.25 mcg inhale orally one time a day for shortness of breath. Review of the self-administration assessment dated [DATE] at 7:23 A.M. revealed Resident #82 was able to self-administer medications. Observation on 10/02/24 at 10:05 A.M. of the top of the medication cart on the [NAME] Hall revealed multiple clear medication bags with a pharmacy label for Resident #82 which were unsupervised and unsecured. The bags contained Luteomas eye gel, Tiotropium Bromide Monohydrate inhaler, fluticasone nasal spray, and bromide monohydrate inhaler aerosol solution. Interview on 10/02/24 at 10:10 A.M. with Licensed Practical Nurse (LPN) #18 verified she had left the medication in Resident #82's room for her to administer. LPN #18 stated she must have brought them out to the cart after she was finished. LPN #18 stated she thought she had an order for her to self-administer. Interview on 10/02/24 at 11:15 A.M. with Unit Manager LPN #121 verified the order to administer eye drops and inhalers was added after the observation of medication unsecured and unsupervised on the medication cart. Interview on 10/02/24 at 11:19 A.M. with the Nurse Practitioner (NP) #501 verified the facility notified him with a request to allow Resident #82 to self-administer medications, was unable to recall the exact but stated it was after 10:30 A.M. Review of the physician's order dated 10/02/24 at 11:23 A.M. revealed the resident was able to self-administer gtt (drops) and inhalers. The order was signed by LPN #18 and ordered by NP #502. Interview on 10/02/24 at 11:37 A.M. with Resident #82 stated the nurses leave her medication in her room and she takes it by herself and has been for a long time. 2. Observation of the facility treatment cart in the [NAME] Hall was unlocked and unsupervised. Observation of the top drawer revealed multiple tubes of barrier creams and a bottle of betadine with a warning label indicating to seek medical assistance if ingested. Interview on 10/02/24 at 10:07 A.M. with LPN #121 verified the treatment cart was unlocked and should not have been. 3. Observation on 10/08/24 at 8:40 A.M. of treatment cart on East Hall unlocked and supervised. Observation of treatment cart contents in the top drawer revealed hydrocortisone cream, nystatin powder and betamethasone dipropionate cream. Hydrocortisone cream was labeled with warning label to seek medical treatment if cream was ingested. Interview on 10/08/24 at 8:42 A.M. with LPN #26 verified the treatment cart was unlocked and unsupervised and should not have been. The facility confirmed there are 17 residents (#69, #70, #73, #75, #78, #79, #80, #83, #85, #86, #88, #89, #91, #94, #95, #97 and #101) residing on the [NAME] Hall and eight resident (#6, #7, #11, #17, #21, #22, #23 and #29) residing on the East Hall who were cognitively impaired and independently mobile and that could potentially access unsupervised and unsecured medications. 4. Observation on 10/08/24 at 8:59 A.M. of the nurses' station refrigerator on the Northeast unit revealed no log for monitoring the temperatures on a daily basis. Additionally, observation of the inside of the refrigerator revealed a thermometer with a reading of forty-eight degrees and a large buildup of ice around the small freezer. Medication stored in the refrigerator at the time of the observation included one Retacrit injection, tuberculin purified multidose vial, one Basaglar kwikpen insulin, two Mounjaro pen 2.5 milligrams/0.5 milliliters, and a bottle of Ativan liquid all with labels indicating it should be stored between thirty-six- and forty-six-degrees F. Interview on 10/08/24 at 9:03 A.M. with LPN #44 verified the observation and stated the refrigerator temperatures supposed to be monitored daily on night shift and the medication will have to be replaced. Interview on 10/08/24 at 4:50 P.M. with the Administrator verified the pharmacy would be notified and the medications replaced due to the elevated temperatures. The Administrator further verified each refrigerator should have a log on the front for staff to monitor the temperature daily. Observation on 10/08/24 at 8:59 A.M. of the nurses' station refrigerator revealed no log for monitoring the temperatures on a daily basis. Additionally observation of the inside of the refrigerator revealed a thermometer with a reading of forty eight degrees and a large build up of ice around the small freezer. Medication stored in the refrigerator at the time of the observation included Retacrit. The facility confirmed there are 21 residents (#48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67 and #68) residing in the Northeast unit who potentially be affected by the identified concern with the medication refrigerator. Review of the facility policy titled Medication Storage, dated 05/01/22 stated the facility shall store all drugs and biologicals in a safe, secure and orderly manner. This deficiency represents non-compliance investigated under Complaint Number OH00158425.

Based on medical record review, observations and resident and staff interviews and policy review, the facility failed to ensure an adequate supply of paper towels and toilet paper for a resident's bathroom. This affected one (#84) out of three residents reviewed for the physical environment. The facility census was 103. Findings include: Medical record review for Resident #84 revealed an admission on 09/04/23 with diagnoses including but not limited to synovitis, hypertension, diabetes mellitus, depression and schizophrenia. Review of the Minimum Data Set (MDS) assessment for Resident #84 dated 07/24/24 revealed an intact cognition. Resident #84 required supervision for eating, bed mobility and transfers. Resident #84 required moderate assistance with toileting. Interview on 10/08/24 at 8:10 A.M. with Housekeeper #21 stated the facility was out of toilet paper and paper towels today. Additionally, Housekeeper #21 stated that it happens often and they are just not ordering enough until the next order comes in. Interview on 10/08/24 at 8:12 A.M. with Housekeeper # 56 stated the facility was out of toilet paper and paper towels today and they didn't have enough to stock Resident #84's bathroom room. Interview on 10/08/24 at 8:16 A.M. with Resident #84 stated they have run out of paper towels and toilet paper before. Interview on 10/08/24 at 11:15 with Housekeeping and Laundry Director #503 verified that the facility did not have toilet paper or paper towel. Request for a policy related to stock supplies was requested and advised the facility did not have a policy by management. This deficiency represents non-compliance investigated under Complaint Number OH00158425 and OH00158273.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the online license verification system of the Bureau of Executives of Long-Term Services and Supports (BELTSS), review of the Administrator job description, and staff interview, the facility failed to ensure there was a licensed nursing home administrator (LNHA) with a valid license providing supervision and leadership to the facility. This had the potential to affect all of the residents residing in the facility. The facility census was 106 residents. Findings include: Review of the online license verification system for BELTSS at https://beltss.ohio.gov/licensing/license-lookup revealed Administrator #1 was issued an Ohio LNHA license on [DATE] with an expiration date of [DATE]. Review of the online license verification system for BELTSS at https://beltss.ohio.gov/licensing/license-lookup revealed Administrator #2 was issued an Ohio LNHA license on [DATE] with an expiration date of [DATE]. Review of the facility job description titled Administrator dated [DATE] revealed the Administrator must possess a valid license to practice as a nursing home administrator in the state of Ohio and provided overall direction for all activities related to administration, personnel, physical structure, information systems, office management, and marketing of the entire facility. The Administrator should work closely with all members of the management team and others to ensure their responsibilities were effectively and consistently discharged . Interview on [DATE] at 11:35 A.M. with Administrator #1 confirmed she had served as the facility LNHA of record since [DATE]. Administrator #1 confirmed a representative from BELTSS notified her on [DATE] that her license to practice as an LNHA had expired on [DATE]. Further interview with Administrator #1 confirmed she asked Administrator #2, who was employed with a sister facility, to serve as the LNHA for the facility until she could get her license renewed. Administrator #1 confirmed Administrator #2 served as the LNHA of record from [DATE] until [DATE]. Administrator #1 confirmed her license was renewed and valid on [DATE], and she had been serving as LNHA of record since then. Administrator #1 confirmed the facility did not have an LNHA with a valid license serving from [DATE] to [DATE]. Interview on [DATE] at 5:42 P.M. with Administrator #2 confirmed she served as the LNHA of record for the facility from [DATE] through [DATE]. Administrator #2 confirmed she had a valid Ohio license to practice as an LNHA during the time frame she worked in the facility. The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: -On [DATE] Administrator #2 became the LNHA of record for the facility. -On [DATE] Administrator #1 updated her email address with BELTSS to ensure she received communications from them. -On [DATE] Administrator #1 educated the Human Resources Director (HRD) to perform an annual audit of the renewal date for the LNHA of record for the facility to ensure the license was valid and current. -On [DATE] Administrator #1's Ohio license to practice as an Ohio LNHA was renewed through [DATE]. This deficiency represents noncompliance investigated under Complaint Number OH00156149 and Complaint Number OH00156286.

Based on observations and resident and staff interviews, the facility failed to ensure shower rooms were clean and ceilings were maintained. This had the potential to affect 60 (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, #101, #102 and #103) residents who receive showers in the [NAME] and Northeast shower rooms. The facility census was 101. Findings include: Interview with Resident #96 on 05/20/25 at 8:30 A.M. revealed the [NAME] shower room smelled like mold. Observation of facility on 05/20/24 at 8:35 A.M. revealed there was a black substance on the floor of the [NAME] shower room where the floor of the shower met the wall of the shower. There was also a black substance on the floor and caulk where the floor of the shower met the wall of the shower and a large round black spot on the ceiling of the shower in the Northeast shower room. Interview with Licensed Practical Nurse (LPN) Unit Manager #800 on 05/20/24 at 8:35 A.M. verified there was black substance on the floor of the [NAME] shower room where the floor of the shower met the wall of the shower. LPN Unit Manager #800 also verified there was also a black substance on the floor and caulk where the floor of the shower met the wall of the shower and a large round black spot on the ceiling of the shower in the Northeast shower room. Interview with Registered Nurse (RN) #148 on 05/20/25 at 9:14 A.M. revealed the State tested Nurse Aides (STNA's) had informed her that there was mold in the shower room on the Northeast unit, but she did not go in the shower room. Interview with LPN #124 on 05/20/24 at 9:19 A.M. revealed there was mildew in the shower room on the Northeast unit. Interview with STNA #114 on 05/20/24 at 9:20 A.M. revealed there was mold in the shower room on the Northeast unit. Interview with Housekeeper #88 on 05/20/24 at 9:22 A.M. revealed there was mold in the shower room on the Northeast unit. The facility confirmed 60 (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, #101, #102 and #103) residents who receive showers in the [NAME] and Northeast shower rooms. This deficiency represents non-compliance investigated under Complaint Number OH00153585.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a closed medical record, review of hospital records, review of the Emergency Medical Services (EMS) report, interviews with staff, review of the facility investigation, and review of the facility policy, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) timely for one resident (Resident #120) when the resident was found unresponsive, without a pulse or respirations, and who was identified as a full code status. This resulted in Immediate Jeopardy and life-threatening harm when Resident #120 did not immediately receive CPR and expired at the hospital. This affected one (Resident #120) of three residents reviewed for full code status and death. The facility identified a total of 67 current residents who were designated as having a full code status. The facility census was 111. On [DATE] at 2:13 P.M., Administrator #200 and Clinical Service Manager (CSM) #201 were notified Immediate Jeopardy began on [DATE] at 5:10 P.M. when Resident #120 was found unresponsive by State tested Nursing Assistant (STNA) #32, who then notified Licensed Practical Nurse (LPN) #220 the resident did not look right. LPN #220 and LPN #88 assessed the resident and found no pulse or respirations. At 5:24 P.M., LPN #220 notified the hospice agency, then notified the physician. The physician gave a verbal order to release the body to the funeral home. At 5:30 P.M., LPN #88 received notification from LPN #300, the resident's hospice nurse, that Resident #120 was a full code. LPN #88 announced code blue. The crash cart was obtained and at 5:30 P.M., twenty minutes after Resident #120 was first found unresponsive, LPN #52 and LPN #88 initiated CPR until EMS arrived at 5:40 P.M. Resident #120 was transported to the hospital by EMS, where she expired at 6:39 P.M. The Immediate Jeopardy was removed, and the deficient practice corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE], an investigation was initiated regarding Resident #120's resuscitative efforts by CSM #201. · On [DATE], chart reviews had been completed for advanced directives and care plans. There were no concerns identified with the chart reviews. · On [DATE] and [DATE], the Assistant Director of Nursing (ADON) began educating all nursing staff regarding emergency procedures with emphasis on implementation of CPR, assessment, Hospice residents without DNR, and documentation. · On [DATE] at 2:30 P.M., LPN #220 was suspended pending an investigation into the incident involving Resident #120. · On [DATE], an ad hoc Quality Assessment and Assurance (QAA) committee meeting was held with the Medical Director to review the case, internal action plan and audits. Mortality review audits were added to the routine Quality Assessment and Performance Improvement (QAPI) meeting scheduled for ongoing evaluation of quality standards. · On [DATE], all elements of the Quality Assurance (QA) plan were fully implemented. · On [DATE], mock code drills were completed with the nurses by the Supervisor/Unit Manager. There were no concerns identified with the audits. · On [DATE], LPN #210 was terminated for failure to comply with standard nursing practices and facility policies and procedures. · On [DATE], CSM #201 and the unit manager conducted staff interviews to ascertain comprehension of CPR protocols and in-service education. · Two additional residents with a full code status who expired in the facility, and two additional current residents were reviewed for code status and no further concerns were identified. · On [DATE], interviews with four (LPNs #53, #91, #92 and #108) nurses revealed they were in-serviced on the emergency and all participated in the mock code drills and could locate the facility crash cart. Findings include: Review of the closed medical record for Resident #120 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #120's physician orders dated [DATE] revealed a full code status order. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. The resident was admitted to hospice care on [DATE] and remained a full code status. Review of the facility's general investigation of incident, dated [DATE] revealed at 5:10 P.M., the resident was seen by staff. She had pulled her tray off the over bed table. AT 5:10 P.M., an STNA alerted the nurse the resident did not look right. The resident was assessed by LPN #220 and #88. The resident had no vital signs. At 5:18 P.M., LPN #220 called the hospice nurse, LPN #300, and notified her of the resident's death. At 5:22 P.M., LPN #220 notified the physician, who gave orders to release the resident's body to the funeral home. Between 5:30 and 5:45 P.M., LPN #300 called the facility back and notified the staff Resident #120 was a full code. CPR was started at that time. Nine-one-one was called by another staff member. CPR continued until the squad took over, and they continued CPR until they received a pulse. The hospice agency was attempting to reach the family but was unable to reach anyone. The physician was notified of CPR being done. The resident was taken to hospital. During an interview on [DATE] at 1:30 P.M., LPN #88 verified CPR was not started until after LPN #300 informed her via telephone that Resident #120 was a full code, twenty minutes after finding the resident unresponsive with no heartbeat. LPN #88 stated she was not Resident #120's assigned nurse but was aware Resident #120 was receiving hospice services and assumed she was a Do Not Resuscitate (DNR). During an interview on [DATE] at 11:01 [NAME]M., STNA #32 stated the day of the incident at approximately 5:00 P.M., she assisted LPN #220 to clean the resident after Resident #120 knocked her food tray off the bedside table. The resident was awake at that time and no concerns were noted. STNA #32 stated approximately fifteen minutes later, she was passing Resident #120's room when she was coming from the dining room and noticed the resident didn't look right and didn't appear to be breathing. She alerted LPN #220. LPN #88 and LPN #220 proceeded to the resident's room and STNA #32 stated she knew the resident was a hospice resident and did not realize she was a full code. STNA #32 stated she saw LPN #220 go to the nurse's station and was making phone calls and she assisted LPN #88 with changing the resident's gown because food was on it from spilling her tray earlier. STNA #32 stated LPN #88 answered the phone and then stated the resident was a full code. STNA #32 stated she immediately got the crash cart and then called 911 as instructed by LPN #88. On [DATE] at 10:43 [NAME]M., an attempt was made to contact LPN #220 for an interview but was unsuccessful. During a telephone interview on [DATE] at 12:30 P.M., LPN #300 stated on [DATE] at approximately 5:30 P.M. she was notified by her office the facility called and reported Resident #120 had expired. LPN #300 stated she was in route to the facility and called the facility to inform them the resident was a full code. LPN #300 stated when she arrived at the facility at approximately 5:45 P.M., EMS was with the resident and regained a heartbeat and EMS transported the resident to the hospital at approximately 6:00 P.M. Review of the EMS report dated [DATE] revealed EMS arrived at the facility at 5:40 P.M. Resident #120 was found unconscious with the facility staff completing CPR. EMS took over CPR and after approximately 25 minutes, the resident regained a pulse and was transported to the hospital at 6:19 P.M. Review of hospital records dated [DATE] revealed Resident #120 expired on [DATE] at 6:39 P.M. Review of the facility policy titled Cardio-Pulmonary Resuscitation, dated revised (MONTH) 2013, revealed Procedure: When resident becomes unresponsive: 1.) check clinical record for therapeutic interventions. 2.) Check resident's code status. 3.) If resident is a full code: [NAME] Call 911. B. palpate carotid pulse and check for signs of life for ten seconds. Establish absence of pulse. C. Begin CPR per American Heart Association/Red Cross Guidelines. This deficiency substantiated Complaint Number OH 862.

Based on record review, staff and physician interview, and policy review, the facility failed to provide adequate care and services by obtaining an ordered urinalysis (analysis of urine by physical, chemical, and microscopical means to test for the presence of disease, drugs, etc.) and failing to notify the provider of the inability to obtain the ordered test for Resident #2 and #1. This resulted in actual harm when Resident #2's urinalysis was not obtained and the resident was subsequently admitted to the hospital for treatment of [REDACTED]. This affected two (#2 and #1) of three residents reviewed. The census was 113. Findings include: 1. Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's physician order [REDACTED].#350. Review of the nurse's progress notes dated 03/29/18 and 03/30/18 revealed no documentation of facility staff attempting to obtain Resident #2's urine for urinalysis. Review of a medication administration note dated 03/31/18 at 5:46 A.M. revealed Resident #2 refused the urinalysis. The medical record contained no documentation of physician or nurse practitioner notification of the refusal. Continued review of the nurse progress notes revealed the next attempt to obtain Resident #2's urine for urinalysis was documented on 04/06/18 at 6:01 A.M. Documentation revealed an attempt was made to obtain urine. The documented the resident did not void enough in the collection container and the urinalysis not obtained. Review of the nurse progress noted from 03/31/18 to 04/07/18 revealed no documentation of the physician or nurse practitioner being made aware of the facility not obtaining the urinalysis for Resident #2. Further review of the nurse progress note dated 04/08/18 at 4:00 P.M. revealed Resident #2 was sitting on a seated walker with head down, drooling, and difficult to arouse. Vital signs were documented as manual blood pressure 77/ 49 millimeters of mercury (mmHg), pulse 69 beats per minute, respirations 15 per minute, temperature 97.4 degrees Fahrenheit (F). The resident's oxygen saturation was 95 percent (%) on room air and blood sugar was 341. The resident nurse practitioner was made aware of Resident #2's status change. A new order was received for intravenous (IV) therapy of normal saline 0.9 percent at 500 cubic centimeters (cc) per hour. Review of the progress note dated 04/08/18 at 4:26 P.M., revealed staff were unable to place the IV. The nurse practitioner was made aware of the IV not in place and the resident continuing to be difficult to arouse. A new order was received to send Resident #2 to the emergency room for evaluation. Review of the nurse progress note dated 04/09/18 at 5:43 P.M., revealed Resident #2 was admitted to the intensive care unit at a local hospital. Review of hospital documentation dated 04/08/18, revealed Resident was admitted to the hospital for treatment of [REDACTED]. Resident #2's hospital coarse and treatment IV antibiotic therapy for a urinary tract infection and treatment for [REDACTED]. Review of the urinalysis results completed at the hospital on [DATE], revealed urine color was yellow, appearance clear, pH and specific gravity were within normal limits. Resident #2's urine protein, glucose, [MEDICATION NAME], bilirubin, and [MEDICATION NAME] were negative. Documentation revealed the resident's urine contained a moderate amount of blood and leukocytes (reference range negative). Continued review of hospital documentation revealed the urinary tract infection was secondary to Escherichia coli (E. coli). Interview on 04/25/18 at 8:00 A.M. with the Administrator revealed the facility does not have a policy regarding obtaining ordered labs. Interview on 04/25/18 at 9:11 A.M. with licensed practical nurse (LPN) #300 revealed Resident #2 was exhibiting abnormal behaviors around the time the urinalysis was ordered. LPN #300 revealed an attempt should be made to obtain a urine sample the day the urinalysis was ordered. If a resident would refuse or was unable to provide the urine sample further attempts should be made to obtain the urine sample. LPN #300 verified the physician or nurse practitioner should be timely notified if a resident refused a urinalysis or if the facility was not able to obtain urine for urinalysis. Interview on 04/25/18 at 9:30 A.M. with the assistant director of nursing (ADON) verified the medical record for Resident #2 contained no documentation of the physician or nurse practitioner being notified regarding the facility staff inability to obtain the urinalysis for Resident #2. Continued interview with ADON verified Resident #2 was admitted to the hospital on [DATE] for the treatment of [REDACTED]. On 04/25/18 at 11:15 A.M., NP #350 was called by phone; however, the NP was unavailable to be interviewed. Telephone interview on 04/25/18 at 1:33 P.M. with Resident #2's primary care physician (PCP) revealed the PCP did not know the reason the NP ordered the urinalysis for Resident #2. Interview with the PCP revealed if a resident refused ordered labs or if facility staff was not able to obtain a lab it was the PCP's expectation that facility staff would notify the person who ordered the lab of the inability to complete the order. Review of the policy titled, Change of Condition revision date 04/03, revealed a change of condition is defined as deterioration in health, mental health, or psychosocial status of a resident related to a life-threatening condition, a significant alteration in treatment, or a significant change in the resident's clinical condition or status. The unit supervisor or charge nurse will notify the resident, physician, and guardian/family member of all changes. The person doing the notification will document all notification in the medical record. 2. Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the nurse progress note dated 04/06/18 at 1:01 P.M. revealed a nurse called the Nurse Practitioner (NP) to notify of a change in condition. The documented change of condition for Resident #1's was the clysis site leaking a red discharge and the resident abdomen was slightly swollen. New orders were received to insert an intravenous (IV) catheter and obtain a urinalysis related to elevated white blood cell count. Review of Resident #1's medical record revealed no documentation of urine being obtained for urinalysis on 04/06/18, 04/07/18, 04/08/18, 04/09/18, or 04/10/18. Review of Resident #1's nurse's progress notes dated 04/06/18 to 04/11/18 revealed no documentation of the resident refusing the urinalysis. Review of the nurse progress note dated 04/11/18 at 7:32 P.M. revealed a urinalysis was obtained. The urinalysis revealed abnormal results. The nurse practitioner was notified of the abnormal results. A new order was received to administer the antibiotic [MEDICATION NAME] milligrams (mg) one time a day for five days. Interview on 04/25/18 at 9:30 A.M. with the assistant director of nursing (ADON) verified the urinalysis ordered for Resident #1 on 04/06/18 was not obtained timely. This deficiency substantiates Complaint Number OH 319.

Based on observation, record review, staff interview, resident interview, durable medical equipment information review and equipment representative interview, the facility failed to ensure adequate pressure relief to prevent pressure ulcer development and failed to ensure services were provided timely to promote healing of the pressure ulcer. Resident #136 developed an avoidable Stage IV pressure ulcer, had avoidable contamination of the ulcer and was seated on the ulcer without adequate pressure relief. This affected one (Resident #136) of three sampled residents with pressure ulcers. The facility identified seven residents with pressure ulcers. Findings include: Resident #136's admission skin assessment dated [DATE] identified the resident was at risk for development of pressure ulcers due to [MEDICAL CONDITION], hypertension, [MEDICAL CONDITIONS] bladder, [MEDICAL CONDITIONS] and arthritis. Interventions listed on the care plan dated 10/01/09 included: turn and reposition every two hours and pressure reduction pad in chair. The record did not include an assessment of the resident's wheelchair cushion to ensure pressure relief capabilities met the resident's requirements. Review of the 10/09/09 Minimum Data Set (MDS) revealed the resident was independent in decision making with no mood or behaviors patterns and was dependent on staff for activities of daily living, including one person physical assistance for bed mobility and at least two persons assistance for transfer and toilet use. The MDS further documented Resident #136 had full loss of voluntary movement in her arms, hands, legs, and feet and had bowel and bladder incontinence. The 10/12/09 Resident Assessment Protocol Review revealed Resident #136's primary mode of locomotion was a motorized wheelchair propelled by head movement. Bath/shower report forms completed by State tested Nurse Aides (STNA) dated 11/14/09, 11/17/09, 11/24/09 and 12/08/09 indicated the resident's skin was intact. The weekly skin condition/assessment and progress report dated 12/09/09 by Registered Nurse (RN) #5 (treatment nurse) documented on 12/09/09 the resident was discovered with a Stage III pressure ulcer on the coccyx, which measured 5.8 centimeters (cm) wide, 8.0 cm long and 1.5 deep with yellow slough, moist wound bed with 75% necrosis, moderate serous exudate with redness, discolored surrounding tissue and the wound was painful ("6" on a scale of 1 - 10). RN #5 documented the "wound could have underlying Stage IV, very discolored surrounding skin". Ancillary notes dated 12/09/10 by RN #5 further stated the resident "stays up in her chair most of the day, insists on lying on her back in bed". The note further stated a wound treatment order was written and to place small pillow on the resident's right and left lower sides of the ischium, alternate every hour while in wheelchair; right and left turns while in bed, not to be on back; reposition every two hours. The record did not include an assessment or provision of a wheelchair cushion to ensure pressure relief capabilities met the resident's requirements. According to The U.S. Department of Health and Human Services Quick Reference Guide for Clinicians, Number 3, Pressure Ulcers in Adults: Prediction and Prevention, page 7 - 10: All individuals at risk should have a systematic skin inspection at least once a day, paying particular attention to the bony prominences. Results of skin inspection should be documented. For chairbound individuals, the use of a pressure reducing device such as those made of foam, gel, air, or a combination in indicated. Do not use donut type devices. Positioning of chairbound individuals should include consideration of postural alignment, distribution of weight, balance and stability, and pressure relief. A written plan for the use of positioning deices and schedules may be helpful for chair bound individuals. According to The U.S. Department of Health and Human Services Clinical Practice Guideline Number 15, page 41: A patient who has a pressure ulcer on a sitting surface should avoid sitting. If pressure on the ulcer can be relieved, limited sitting may be allowed. Those whose mobility is impaired are unable to reposition themselves independently and depend on outside resources to relieve the pressure for them. The MDS dated [DATE] documented the resident continued with no mood or behavior patterns, including resistance to care. The MDS also documented the resident had a Stage IV pressure ulcer. During interview on 02/16/10 at 2:40 P.M., Resident #136 stated she had a Stage IV pressure ulcer on her coccyx. The resident stated she was unable to reposition herself due to [MEDICAL CONDITION] and never before had a pressure ulcer. Resident #136 stated the ulcer was very close to her rectum and when she was incontinent of urine, the urine ran into the pressure ulcer and it "burned very bad." Resident #136 described that, during a visit with the Ombudsman on 01/20/10, she requested the Ombudsman speak with staff and ask them to put a Foley catheter (indwelling urinary drainage catheter), which the facility did. The resident stated she had been in bed for some time now due to the pressure ulcer. She further stated staff told her she was at fault for the pressure ulcer because she stayed up in her electric wheelchair too long. Resident #136 stated she had a routine of getting up each morning around 10:00 A.M. and staying up until 2:00 P.M. She then stayed in bed until supper. She further stated, she then stayed up until 9:00 P.M. or 10:00 P.M. Resident #170 confirmed the facility did not place a pressure relief cushion in her wheelchair and stated she sat on the cushion which came with her specialty wheelchair. On 02/17/09 at 9:10 A.M., treatment to the pressure ulcer was observed. RN #5 removed the [DEVICE] and measured the pressure ulcer over the coccyx as 2.2 centimeters (cm) long, 1.9 cm wide, 2.9 cm deep at 1:00 o'clock, 3.0 cm deep at 2:00 o'clock and 3.0 cm deep at 3:00 o'clock. During interview at that time, RN #5 stated she did not know the pressure relief properties of the wheelchair cushion and would call the company to determine the type of cushion in Resident #136's wheelchair. During observation on 02/17/09 at 1:05 P.M., Resident #136 was seated in her electric wheelchair in the dining room. The electric wheelchair did not have a pressure relief cushion. On 02/18/10 at 12:40 P.M., interview was conducted with RN #5, the Wound Care Director (WCD) and Clinical Support Nurse (CSN). The WCD affirmed bath/shower reports through 12/08/09 were silent for skin problems and the treatment nurse documentation started on 12/09/09 when the pressure ulcer was identified as Stage III or IV. During this interview, RN #5 presented a fax from the manufacturer of the resident's seat cushion, which documented the wheelchair was requested on 10/16/06. The manufacturer's information described the cushion provided with the wheelchair was an "antithrust seat foam" which "helps maintain ischial placement and pelvic positioning". On 02/18/10 at 12:50 P.M., a telephone interview was conducted with the manufacturer representative of the cushion on the resident's wheelchair. The representative stated the cushion was made of a "sturdy" foam for positioning, was not for pressure relief or pressure reduction and had 1.5 inches of high density foam over the firm seat. The representative clarified that this layer of foam did not have pressure reduction of relief properties. The representative stated a second cushion must be applied over the positioning cushion to provide pressure relief. The representative stated the cushion currently on the wheelchair was not made to be used by anyone with a Stage IV pressure ulcer. During interview on 02/18/10 at 12:40 P.M., RN #5 also stated she was unaware until informed by her supervisor that a Foley catheter should be inserted to protect the Stage IV pressure ulcer from contamination by urine or feces. According to the U.S. Department of Health and Human Services Clinical Practice Guideline Number 15, treatment of [REDACTED]. RN #5 affirmed the Foley catheter was inserted on 01/20/09 when the resident had a Stage III or IV pressure ulcer on the coccyx on 12/09/09. The treatment nurse also confirmed the resident had an infection of the wound identified on 01/21/09 and on 01/27/10 a wound vac was ordered for treatment of [REDACTED].

Based on record review, staff interview and resident interview, the facility failed to ensure a resident received pain medication when needed in accordance with physician orders [REDACTED]. This affected one (Resident #70) of three sampled residents with pain. Resident #70 had unrelieved pain in his knees for over two days and was unable to sleep due to the pain. Findings include: The medical record documented Resident #70 had [DIAGNOSES REDACTED]. The current physician order [REDACTED]. The care plan for pain management included administration of medication as ordered by the physician. Review of the resident's treatment documentation revealed he had diabetic ulcers on his lower legs with orders to treat the legs daily. Review of the narcotic documentation form dated 02/01/10 through 02/14/10 revealed Resident #70 was medicated for pain with [MEDICATION NAME] on 02/01/10, 02/02/10, 02/03/10, 02/05/10, 02/06/10, 02/08/10, 02/10/10, 02/11/10, 02/12/10, 02/13/10 and 02/14/10. The resident's lower leg pain was documented by nurses on those dates as "severe". There was no documentation of [MEDICATION NAME] administration on 02/15/10 and 02/16/10. During observation on 02/16/10 at 4:00 P.M., Resident #70 was seated in a wheelchair in his room and his legs were swollen. The lower legs were wrapped with bandages and the skin above the bandages had multiple scratch marks on them. During interview at that time, Resident #70 stated the swollen legs caused his skin to itch and his "knees were killing him." He stated he needed his pain medication. Resident #70 further stated he had not had the pain medication for the last two days because the facility was out of his pain medication. Resident #70 stated he told the nurses, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) that he was in pain and needed his pain medication. During interview on 02/16/10 at 4:10 P.M., Licensed Practical Nurse (LPN) #43 confirmed the facility ran out of Resident #70's [MEDICATION NAME] on 02/14/10. LPN #43 further stated the pharmacy re-order label was faxed to the pharmacy on 02/13/10, but the medication had not yet been delivered. LPN #43 also stated she was unaware if the pharmacy or physician had been contacted concerning the delayed pain medication refill. On 02/17/10 at 8:30 A.M., Resident #70 was interviewed concerning his pain. The resident stated his knees were "still killing him" and he was unable to sleep due to the pain. During interview on 02/17/10 at 10:00 A.M., the DON reviewed and confirmed the fax that was sent to the pharmacy on 02/13/09 for renewal of Resident #70's [MEDICATION NAME]. The DON presented the narcotic count which showed at the time the fax was sent to the pharmacy to reorder, the resident had 10 [MEDICATION NAME] left. The narcotic count sheet also confirmed on 02/14/10 at 4:30 P.M. the resident was administered his last dose of the [MEDICATION NAME]. The DON stated the pharmacy informed the facility they could not refill the medication without a new written prescription from the physician. Review of nursing documentation dated 02/16/10 at 4:40 P.M. revealed the facility paged the physician on call to request Resident #70's [MEDICATION NAME] medication be refilled. The physician on call instructed the nurse to call his office the next morning. During interview on 02/17/10 at 10:15 A.M., Registered Nurse (RN) #22 presented a fax the facility sent to the pharmacy dated 02/17/10 at 7:40 A.M. requesting to remove one [MEDICATION NAME] from the facility pharmacy emergency box. At 9:46 A.M., the pharmacy returned the fax giving approval for the removal of one [MEDICATION NAME] from the emergency box. At 10:20 A.M., the facility administered one [MEDICATION NAME] from the emergency box to Resident #70. RN #22 confirmed that this was a "one time" order and that the facility had not obtained the resident's [MEDICATION NAME] to control his pain. On 02/17/10 at 1:10 P.M., Resident #70 was observed resting in bed. His legs were elevated and eyes closed. His roommate stated that was the first he slept like that for days.