Every finding on record at Mount Washington Care Center

Based on medical record review, observation, and staff, resident and family interview, the facility failed to ensure call lights were answered timely. This affected three (#02, #04, and #06) of five residents reviewed for care. The facility census was 69.Findings Include:1. Review of the medical record revealed Resident #02 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease (stage four), esophageal obstruction, and hypertensive heart disease.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #02 was cognitively intact, had no behaviors, had not rejected care, and did not wander.During an interview and observation on 01/07/26 at 11:10 A.M., Resident #02 was cold and pushed his call light for assistance. The call light was observed activated at 11:12 A.M. and was not answered until 11:39 A.M. resulting in a 27 minute delay.Interview on 01/07/26 at 11:40 A.M., the Certified Nursing Assistant (CNA) #106 said call lights should ideally be answered within seven to eight minutes.2. Review of the medical record revealed Resident #04 was admitted to the facility on [DATE]. Diagnoses included progressive multiple sclerosis, emphysema, neuromuscular dysfunction of the bladder, and acquired absence of the left leg above the knee.Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #04 was cognitively intact, had no behaviors, had not rejected care, and did not wander.Interview on 01/07/26 at 12:00 P.M., Resident #04 said he has had to wait longer than an hour for his call light to be answered on multiple occasions resulting in a delay in care.3. Review of the medical record revealed Resident #06 was admitted to the facility on [DATE]. Diagnoses included nontraumatic intracerebral hemorrhage, type II diabetes mellitus, atrial fibrillation, and hypertension.Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #06 had moderately impaired cognition, had no behaviors, had not rejected care, and did not wander. Resident #06 was always incontinent of bowel and bladder.Interview on 01/06/26 at 10:29 A.M., Resident #06 and his wife said sometimes we have to wait an hour or more for his call light to be answered.Review of a Care Conference Meeting Summary dated 12/08/25 revealed the family of Resident #06 voiced concerns of nurses not responding to call lights resulting in the resident calling out for help.Interview on 01/07/26 at 9:20 A.M., staff member #105 said she has had complaints from residents about long call light response times. She had been in rooms where call lights had been activated and gone unanswered for as long as 25 to 35 minutes. Interview on 01/07/26 at 12:30 P.M., the Director of Nursing (DON) said the facility does not perform call light audits and does not know the average call light response time.Interview on 01/07/26 at 12:30 P.M., with the [NAME] President of Clinical Services Registered Nurse #107 said the facility does not have a standard for call light response times and stated call lights should ideally be answered in under 20 minutes.This deficiency represents non-compliance investigated under Complaint Number 2670639.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure implementation of physician orders for appropriate respiratory care. This affected one (Resident #71) of three residents reviewed for respiratory care and services. The facility census was 70 residents. Findings include:Review of medical record revealed for Resident #71 revealed an admission date of 07/26/25 with diagnoses including acute respiratory failure, tracheostomy, pneumonia, intracerebral hemorrhage, and functional quadriplegia. Review of the baseline care plan for Resident #71 dated 07/26/25 revealed resident was severely cognitively impaired, was dependent for all care, had a feeding tube for nutrition, and was a full code. Review of a progress note for Resident #71 dated 07/26/25 revealed the note did not include documentation of physician's orders for tracheostomy care or oxygen administration. Review of the admitting physician's orders for Resident #71 dated 07/26/25 revealed they did not include orders for tracheostomy care or oxygen administration. Review of the Treatment Administration Record (TAR) for Resident #71 dated July 2025 revealed it did not include orders for oxygen administration or tracheostomy care. Interview on 08/12/25 at 11:33 A.M. with the Director of Nursing (DON) confirmed there were no orders for tracheostomy care or oxygen administration for Resident #71 upon admission to the facility on [DATE]. The DON further confirmed Resident #71 was sent to the hospital on [DATE] and was admitted with respiratory distress. The DON confirmed the facility staff relied on nursing judgment for the administration of oxygen and tracheostomy care for Resident #71.Interview on 08/12/25 at 1:44 P.M. with Licensed Practical Nurse (LPN) #109 confirmed Resident #71 was admitted to the facility on [DATE] from a subacute care hospital with a tracheostomy in place. The discharge orders from the hospital did not include orders for tracheostomy care or oxygen administration. LPN #109 confirmed when Resident #71 arrived at the facility the resident was receiving oxygen and he continued to administer oxygen at four liters per minute (LPM), but the nurse did not receive or implement orders for tracheostomy care or oxygen administration. LPN #109 confirmed when he came to work on 07/27/25, Resident #71 was experiencing respiratory distress and had an oxygen saturation level of 68 percent (%). LPN #109 called the physician who told the nurse to increase the resident's oxygen flow rate and call 911. LPN #109 confirmed he increased Resident #71's oxygen from four LPM to seven LPM, and the resident's oxygen saturation rate was 76% when the emergency medical technicians arrived to take the resident to the hospital. LPN #109 confirmed he relied on nursing judgment to determine the LPM of oxygen for Resident #71. Review of the facility policy titled Tracheostomy Care dated 2024 revealed tracheostomy care would be provided according to the physician's orders and in accordance with professional standards of practice with a general consideration to provide tracheostomy care at least twice daily. This deficiency represents noncompliance investigated under Complaint Number 2584605.

Based on record review, review of a fall investigation, review of hospital records, staff interviews, and facility policy review, the facility failed to effectively manage one Resident's (#56) pain following an unwitnessed fall on 08/15/24, which subsequently resulted in a left subcapital femoral neck fracture. Actual harm occurred on 08/15/24 around 11:15 P.M. when Resident #56 had an unwitnessed fall in her room and reported left leg and knee pain to Licensed Practical Nurse (LPN) #212 and LPN #213. Resident #56 received one as needed (PRN) Tylenol but no documentation was completed on the medication administration record (MAR). The resident verbally yelled out and had facial grimacing and refused to get out of bed related to continued pain and discomfort in her left leg. The On-call Nurse Practitioner (NP) #214 ordered Resident 56 to receive a left knee x-ray and an ice pack for pain. Resident #56 did not receive any additional pain medications or non-pharmacological pain interventions until the resident arrived at the hospital on 08/16/24 at 6:34 P.M. (approximately 19 hours after the fall occurred) with left leg pain. A computed tomography (CT) scan of Resident #56's left leg pain revealed Resident #56 sustained an acute traumatic mildly impacted subcapital left femoral neck fracture and required a surgical intervention to repair the fracture. This affected one Resident (#56) of the 25 residents assessed for pain. The facility census was 80. Findings include: Review of the medical record for Resident #56 revealed an admitted [DATE]. Diagnoses included major depressive disorder, fracture of left femur, generalized anxiety disorder (GAD), and atrial fibrillation. Review of a physician order for Resident #56 dated 07/08/24, revealed the resident was ordered Tylenol 325 milligrams (mg), give two tablets by mouth every four hours as needed (PRN) for general discomfort. Review of a fall risk assessment for Resident #56 dated 07/08/24, revealed the resident was at risk for falls. Review of the most recent pain assessment for Resident #56 dated 07/22/24, revealed the resident had not been in any pain in the last five days. Review of a Neurological (neuro) checklist dated 08/15/24, revealed Resident #56 expressed pain at a six out of 10 scale (a pain scale where zero is no pain and 10 is severe pain) and the resident also showed nonverbal signs of pain including grimacing and withdraws to the left knee/leg. Review of the fall investigation dated 08/15/24 at 11:15 P.M., revealed Resident #56 was observed sitting on the floor with legs stretched out. Resident #56 attempted to transfer and ambulate self. Resident #56 fell due to weakness, poor safety awareness, and did not use call light. Intervention was to ask Resident #56 before going to bed if she wanted her television on or off and offer the television remote. No statements were collected from the resident or staff. Review of the August 2024 Medication Administration Record (MAR) for Resident #56, revealed no documented evidence that the resident received any pain medications after the fall on 08/15/24. A non-pharmacological intervention (ice pack) was attempted for Resident #56 but refused. Review of the pain levels listed on the MAR on 08/15/24 and 08/16/24 for Resident #56 revealed no pain levels were documented. Review of a progress note for Resident #56 dated 08/16/24 at 6:48 A.M., revealed around 11:15 P.M. (on 08/15/24), the resident was observed on the floor directly on her bottom with legs stretched out in front. Resident #56 reported she was trying to turn off the television. An assessment, vital signs, and neuro checks were initiated. Resident #56 was lifted from the floor by three staff members and placed into bed. NP #214 was notified and gave orders for the resident to have an x-ray of her left knee, and an ice pack applied to the resident's left knee. The guardian and on-call supervisor were notified. PRN Tylenol was given for pain. Review of a progress note for Resident #56 dated 08/16/24 at 12:30 P.M., revealed the Interdisciplinary Team (IDT) met regarding Resident #56's fall. Upon investigation, the resident attempted to self-transfer and ambulate to turn off the television and fell . Resident #56 did not use the remote on the bedside table and did not call for assistance. Resident #56 was confused, had weaknesses, and poor safety awareness. An assessment was completed immediately after the fall and the resident complained of left knee pain. Range of motion was within normal limits for right leg and bilateral arms. Review of a progress note for Resident #56 dated 08/16/24 at 3:19 P.M., revealed the x-ray results for the resident's left knee were negative. Resident #56 continued to complain of pain and discomfort. A new order received for a stat x-ray of the resident's left hip, femur, and tibia/fibula. Review of a progress note for Resident #56 dated 08/16/24 at 3:30 P.M., revealed the x-ray service was unable to get a good x-ray of left hip/femur due to the resident moving and hollering out in pain upon movement. Review of a progress note for Resident #56 dated 08/16/24 at 5:40 P.M., revealed the resident continued to yell out and had facial grimacing. Resident #56 ate very little breakfast and laid in her bed all day, not wanting to get up due to the pain and discomfort she was experiencing in her left leg. Resident #56 refused lunch and dinner. The X-ray Technologist came to get an x-ray of the resident's left hip but was unable to get a good picture even with staff assistance because Resident #56 was not able to hold still due to her pain. Resident #56 was sent out to the emergency room (ER) for evaluation to rule out injury of left leg per Resident #56's daughter's request. Review of the hospital records for Resident #56 dated 08/16/24, revealed Resident #56 arrived at the hospital at 6:34 P.M. complaining of pain after a fall on 08/15/24. Per the Nursing Home report, Resident #56 fell last night when attempting to ambulate to the bathroom. Resident #56 was complaining of left leg pain and the x-rays at the Nursing Home were apparently negative. The Nursing Home reports Resident #56 continued to complain of pain, therefore they sent her to the hospital. The Nursing Home staff was unaware if Resident #56 hit her head, but the resident is on an anticoagulant. Resident #56 was unable to perform left straight leg raise and had tenderness with palpation of the left hip. A Computerized Tomography (CT) scan revealed the resident had an acute traumatic mildly impacted subcapital left femoral neck fracture. The orthopedics were notified, and preoperative laboratory tests (labs) were completed, and Resident #56 had a left hip hemiarthroplasty (a surgical procedure that replaces the ball portion of the hip joint with a metal prosthesis) to repair the femur fracture. Resident #56 was discharged from the hospital on 08/20/24. Review of the care plan for Resident #56 revised on 08/16/24, revealed Resident #56 had a left hip closed bone fracture related to a fall. Interventions included administering pain, anti-inflammatory medications as ordered, handle gently when moving or positioning, monitor, document, and report as needed edema, bruising, loss of sensation distal to fracture, and use ice to affected area as needed. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of five. This resident required set-up assistance with activities of daily living (ADL). Attempted interviews with LPN #212 on 02/26/25 at 10:08 A.M. and 11:17 A.M. during the survey were unsuccessful. The staff member involved in the incident was not employed at the facility at the time of the survey and calls to LPN #212 were never returned. Interview with Certified Nursing Assistant (CNA) #148 on 02/26/25 at 10:09 A.M., who was tasked with caring for Resident #56 on 08/15/24, revealed she was sitting in the hallway across from Resident #56 when she heard a loud commotion. CNA #148 reported Resident #56 was on the floor on her bottom between her bed and the dresser. CNA #148 stated Resident #56 was complaining of pain to her left leg/knee. CNA #148 reported this information to Licensed Practical Nurse (LPN) #212. CNA #148 stated she did not help lift Resident #56 back into bed because she did not feel comfortable moving her with the amount of pain she was in. CNA #148 explained Resident #56 was in pain throughout the rest of the shift and did not want to get out of bed related to pain. CNA #148 reported these findings to LPN #212. Attempted interviews with LPN #213 on 02/26/25 at 10:12 A.M. and 11:15 A.M. during the survey were unsuccessful. The staff member involved in the incident was not employed at the facility at the time of the survey and calls to LPN #213 were never returned. Interview with Director of Nursing (DON) on 02/27/25 at 10:50 A.M., verified Resident #56 had an unwitnessed fall on 08/15/24. The DON stated the nurse charted a PRN Tylenol on 08/16/24 at 6:48 A.M. via the progress note; however, the Tylenol was not documented on the MAR as being administered. The DON verified Resident #56 had expressed multiple signs of pain after the fall and there was no documentation of pain medications given to Resident #56 before the resident was sent out to the hospital on 08/16/24 after 6:00 P.M. The DON verified a stat x-ray was unsuccessful because Resident #56 was unable to sit still related to pain. The DON also stated she could not provide an explanation on why the nurses did not treat Resident #56's pain, but that's part of the reasons why these nurses were no longer employed at the facility. Review of the facility policy titled, Pain Assessment and Management, revised in March 2020, revealed the purposes of this procedure were to help the staff identify pain in the resident, and to develop interventions that were consistent with the resident's goals and needs and that address the underlying causes of pain. Pain Management was defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief was obtained. Ask the resident if he/she was experiencing pain. Be aware the resident may avoid the term pain and use other descriptors such as throbbing, aching, hurting, cramping, numbness or tingling. Review the medication administration record to determine how often the individual requests and receive as needed pain medication, and to what extent the administered medications relieve the resident's pain.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure care conferences were held as required for residents and their representatives. This affected seven Residents (#02, #10, #17, #35, #36, #42 and #56) of the seven residents reviewed for care conferences. The facility census was 80. Findings include: 1) Review of the medical record revealed Resident #02 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis of right knee, diabetes mellitus, Stage IV pressure ulcer (sacrum). Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed Resident #02 had no cognitive impairment. Review of a Care Conference Meeting Summary documents with the Administrator, revealed Resident #02 did not have documented care conferences in the first quarter (January, February and March) and third quarter (July, August and September) of 2024. The only care conference meetings that were documented for 2024 were held on 05/09/24 and 12/12/24. 2) Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis (MS), urinary tract infection, chronic osteomyelitis, severe sepsis with septic shock, bacterial infection and nicotine dependence. Review of the MDS annual assessment dated [DATE], revealed Resident #10 had no cognitive deficits and had a suprapubic catheter and colostomy. Review of Care Conference Meeting Summary documents with the Administrator, revealed Resident #10 did not have documented care conferences in the first quarter (January, February and March) and third quarter (July, August and September) of 2024. The only care conference meetings that were documented for 2024 were held on 06/25/24 and 11/06/24. 3) Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, type two diabetes mellitus, paranoid schizophrenia, and major depressive disorder. Review of the Annual MDS assessment dated [DATE], revealed Resident #17 was unable to complete a Brief Interview for Mental Status (BIMS) because he was rarely/never understood. Review of the medical record for care conferences for the last 12 months revealed Resident #17 received a care conference on 05/28/24, 08/13/24, and 01/09/25. Interview on 02/26/25 at 3:20 P.M. with Social Services Director (SSD) #106 revealed care conferences should be held quarterly. SSD #106 verified Resident #17 had not received care conferences quarterly as required. 4) Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses include cerebral infarction with right (dominant) side hemiplegia and hemiparesis, unspecified dementia and methicillin-resistant staphylococcus aureus (MRSA). Review of the MDS quarterly assessment dated [DATE], revealed Resident #35 had moderate cognitive impairment. Review of Care Conference Meeting Summary documents with Administrator, revealed Resident #35 did not have documented care conferences in the first quarter (January, February and March), second quarter (April, May and June) and third quarter (July, August and September) of 2024. The only care conference meeting that was documented for 2024 was held on 11/18/24. Interview on 02/26/25 at 3:31 P.M. with the SSD #106, verified Resident #35 had one care conference in 2024 (11/18/24); verified Resident #02 had two care conferences in 2024 (05/09/24 and 12/12/24); and verified Resident #10 had two care conferences in 2024 (06/25/24 and 11/06/24). 44412 5).Review of the medical record for Resident #36 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, depression, and chronic respiratory failure with hypoxia. Review of the MDS assessment dated [DATE], revealed Resident #36 had intact cognition as evidenced by a BIMS score of 14. Review of the medical record for care conferences for the last 12 months revealed Resident #36 had a care conference on 04/15/24 and 10/09/24. 6) Review of the medical record for Resident #42 revealed an admitted [DATE]. Diagnoses included pneumonia, type two diabetes mellitus, acute respiratory failure with hypoxia, and major depressive disorder. Review of the MDS assessment dated [DATE], revealed Resident #42 had moderate cognitive impairment as evidenced by a BIMS score of nine. Review of the medical record for care conferences for the last 12 months revealed Resident #42 had a care conference on 08/23/24 and 10/01/24. 7) Review of the medical record for Resident #56 revealed an admitted [DATE]. Diagnoses included major depressive disorder, fracture of left femur, generalized anxiety disorder (GAD), and atrial fibrillation. Review of the MDS assessment dated [DATE], revealed Resident #56 had severe cognitive impairment as evidenced by a BIMS score of five. Review of the medical record for care conferences for the last 12 months revealed Resident #56 had a care conference on 07/11/24 and 01/31/25. Interview on 02/26/25 at 3:20 P.M. with SSD #106, revealed care conferences should be quarterly. SSD #106 verified Residents #36, #42 and #56 had not received care conferences quarterly as required. Review of the policy titled, Care Planning-Resident Participation, dated 08/24, revealed the facility supports the resident's right to be informed of, and participate in, his or her planning and treatment (implementation of care). The facility will discuss the plan of care with the resident and/or resident representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, and at routine intervals, and after significant changes.

Based on observation, staff interview and record review, the facility failed to utilize the correct transfer lifting sling for the mechanical lift, as listed in the manufacture directions. This affected one Resident (#22) but had the potential to affect 13 additional Residents (#17, #10, #15, #1, #66, #76, #233, #25, #40, #58, #23, #231 and #63) who the facility identified as being dependent on staff for transfer via mechanical lift. The facility also failed to properly assess/evaluate residents for safe smoking practices. This affected two Residents (#10 and #33) of the two residents identified as being smokers. The facility census was 80. Findings Include: 1) Review of the medical record for Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #22 include multiple sclerosis, left above knee amputation, muscle weakness, peripheral vascular disease, gout, and neuromuscular dysfunction of bladder. Review of a physician order dated 12/19/23 for Resident #22, revealed the resident was ordered to be transferred via a mechanical lift for all transfers. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed the resident had intact cognition and was dependent on staff for transfers via mechanical lift. Observation of a mechanical lift/Hoyer transfer for Resident #22 on 02/25/25 at 3:40 P.M., revealed Certified Nursing Assistants (CNAs) #103 and #127 placed all four loops of a Proactive mechanical lift transfer sling into two attachment points on the bar of a Handicare mechanical lift. CNAs #103 and #127 transferred Resident #22 from a wheelchair to the bed using the Handicare mechanical lift. Interview with CNAs #103 and #127 immediately afterwards, revealed they were unsure which transfer sling was supposed to be used with a Handicare mechanical lift. CNAs #103 and #127 verified they used a transfer sling labeled for a Proactive mechanical lift and there were no Handicare mechanical lift transfer slings in the facility. Observation of the storage area for the mechanical lift transfer slings on 02/25/25 at 3:50 P.M. with CNA #143, revealed only Proactive mechanical lift transfer slings were on hand to be used. Observation revealed no there were no Handicare mechanical lift transfer slings on hand and there were four transfer slings with no manufacture labels or instruction for use. Interview at the same time with CNA #143, verified there were no Handicare mechanical lift transfer slings on hand in the facility. CNA #143 stated Proactive mechanical lift transfer slings were used for showers and they were also used with the Handicare mechanical lifts. CNA #143 indicated he was unable to identify the four unlabeled transfer slings brand and stated the staff used all the slings from the storage area. Interview with CNA #142 on 02/27/25 from 9:25 A.M. through 9:35 A.M., verified there were no Handicare mechanical lift transfer slings on hand in the facility. CNA #142 indicated she had no knowledge of a specific transfer sling having to be used with the mechanical lifts and she just grabbed any sling that was available. Interview on 02/27/25 at 3:13 P.M. with the Director of Nursing (DON), revealed the Proactive mechanical lift transfer slings were universal and could be used on the Handicare mechanical lifts. The DON verified there was no documentation provided in Handicare mechanical lift manufacture instructions of allowance of any universal transfer slings. Interview with Proactive Representative #600 on 03/03/25 9:35 A.M., revealed the Proactive mechanical lift transfer slings were not universal and they were only to be used with their mechanical lifts. Proactive Representative #600 stated he would not advise using their slings on the Handicare mechanical lifts because their mechanical lifts utilized a different attachment set-up for the patient. Review of the Handicare mechanical lift/Hoyer manufacture instructions (related to Model EVA400EE being utilized in the facility), revealed their transfer slings were to be used with their brand. Handicare mechanical lifts had one bar with two attachment points and contained no chains or S type hooks for attaching the transfer slings to the mechanical lifts. The instructions indicated there was no allowance for the use of any universal transfer slings. Review of the Proactive mechanical lift transfer sling instructions provided by the facility, revealed the Proactive mechanical lift transfer sling instructions were to be used for their lifts which included two attachment points bar and utilized chains and S type hooks to allow positioning adjustments to be made by selecting different links. Instructions for use included a chain-link with the red markings connected to the cradle, and attachment at the shoulder level of the patient and there was an attachment of chains at the patient's legs. There was an S type hook to be inserted through the metal sleeve from the patient side of the sling out, to avoid injuring the patient. Review of facility policy titled, Using a Mechanical Lifting Machine, dated 2017, revealed the general principles of the policy is not a substitute for manufacturer's instructions. Lift and design and operation vary across manufacturers. Staff must be trained and demonstrate competencies using specific machines utilized in the facility. 49771 2) Review of the medical record for Resident #10, revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis (MS), urinary tract infection, chronic osteomyelitis, severe sepsis with septic shock, bacterial infection and nicotine dependence. Review of the MDS annual assessment dated [DATE], revealed Resident #10 had no cognitive deficits. Review of the medical record revealed Resident #10 did not have any documented evidence a Safe Smoking Evaluation was ever completed. Interview with Resident #10 on 02/25/25 at 8:40 A.M., revealed he smokes on a regular basis, usually in the late afternoon, and he was observed to have his smoking materials in his possession. 3) Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included lumbar disc degeneration, morbid obesity, psychotic disorder with delusions, unspecified dementia and diabetes mellitus. Review of the MDS quarterly assessment 12/30/24, revealed Resident #33 no cognitive impairment. Review of the medical record for Resident #33, revealed the most recent Safe Smoking Evaluation was completed on 04/02/24. Interview with Licensed Practical Nurse (LPN) #117 on 02/26/25 at 7:49 A.M., verified Residents #10 and #33 are smokers. Interview with the Director of Nursing (DON) on 02/27/25 at 10:59 A.M., verified Resident #10 had never been evaluated for safe smoking, and the last time Resident #33 was assessed for safe smoking was 04/02/24. The DON verified residents identified to smoke were to be assessed/evaluated on a quarterly basis. Review of documentation provided by the facility, identified Residents #10 and #33 as being the only residents in the facility who smoked. Review of the policy titled, Smoking Policy-Residents, dated 2001, revealed the resident will be evaluated on admission to determine if she is she is a smoker or non-smoker and the evaluation will include the current level of tobacco consumption, method of tobacco consumption (traditional cigarettes, electronic cigarettes, pipe, etc.), desire to quit smoking, and the ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff.

Based on observation, staff interviews and record review, the facility failed to maintain a sanitary kitchen to prevent cross contamination of food. This affected 78 Residents who received food from the kitchen. The faciity identified two residents who did not receive any food from the kitchen. The facility total census was 80. Findings Include: Observation on 02/24/25 at 8:50 A.M., revealed there was a gray material blowing off of the grill of the wall fan blowing towards a table where foods were being prepared by [NAME] #180. In the dry food storage area, there were three bags of open, undated and unlabeled foods. There was an outputting air vent, three feet from foods being cooked on the stove, with a heavy buildup of grayish debris. Above the stove, the exhaust vents were noted with gray debris hanging over foods cooking on the stove. There were approximately 30 large unopened food cans in a storage rack with no date of delivery. In the walk-in refrigerator, there was an opened cottage cheese container with an expiration date of 02/17/25. Interview on 02/24/25 at 8:55 A.M., the Registered Dietitian, (RD) #695 verified the kitchen storage area did not have labeling to ensure foods were sealed, dated and rotated to ensure safe food practices. The RD #695 verified the fans, and inputting and exhaust vents needed to be cleaned. Observation on 02/25/25 at 8:15 A.M., revealed [NAME] #180 picked up a food plate, then a utensil, then touched the counter, with gloved hands. With the same gloved hands, the [NAME] #180 picked up bacon and toast put on residents' breakfast plate. [NAME] #180 then touched the counter, the oven door, and dish rack, and then returned to pick up bacon and serve onto residents' meal plate. [NAME] #180 did not change gloves, use food utensils for the toast or bacon or perform hand hygiene during the meal service. Interview on 02/26/25 8:18 AM [NAME] #180 verified she did not change her gloves or perform hand hygiene between touching non-food items and food items. [NAME] #180 verified she should have used utensils to serve the bacon and toast. Observation on 02/25/25 at 11:43 A.M., revealed [NAME] # 150 and Diet Aid #135 did not have beard coverings to cover facial hair. [NAME] #150 had 10 to 20 one half inch wide by six-inch-long hair strands surrounding the head and extending beyond the hairnet on the top of [NAME] #150's head. [NAME] #150 was preparing food for the lunch meal and Diet Aid #135 was storing clean dishes. Interview on 02/25/25 at 11:43 A.M. [NAME] #150 and Diet Aid #135 verified they should have beard coverings, and the hair net should cover the entire head of hair. Observation on 02/26/25 at 11:14 A.M., revealed [NAME] #180 was preparing puree foods using a rotary blender. [NAME] #180 disassembled the blender blade from the blender bowl into the dishwasher with gloved hands. [NAME] #180 touched the dishwasher area while awaiting the dishwashing completion. [NAME] #180 reassembled the clean food blade into the clean blender bowl with the same gloved hands. Interview on 02/26/25 at 11:53 A.M., [NAME] #180 verified she did not change gloves or perform hand sanitation between disassembling the puree blender blade from the blender bowl and then reassembling the clean blade into the clean blender bowl. Interview on 02/26/25 at 11:53 A.M., RD #300 verified the staff must have hair and beards covered and gloves must be changed from the dirty side of dishwashing to the clean side of dishwashing. Review of facility policies entitled, Food Safety, Food Storage, Personal Hygiene, and Dish Machine, dated 2021, revealed food passed expiration date should be discarded. Foods in unmarked containers should be marked with the current date the food was stored. Foods will be stored to keep foods safe and to prevent contamination. Employees will wear hair restraints and beards must be retrained using beard covers. The person loading dirty dishes will not handle clean dishes unless the hands are washed thoroughly before moving from dirty to clean.

Based on observation, staff interviews and record review, the facility failed to serve meals to all residents in the dining room in a timely manner. This affected two Residents (#65 and #71) of the three residents dependent on staff in the 200-unit dining room. The facility census was 80. Findings Include: 1) Review of medical record for Resident #65, revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #65 include dementia, cerebral infarction, hemiplegia, dysphagia, anxiety disorder, restlessness and agitation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE], revealed the resident had severely impaired cognition and was dependent on staff for meal assistance. The resident received a regular puree diet. 2) Review of the medical record for Resident #71 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident # 71 include hemiplegia, dysphagia, restlessness and agitation. Review of the MDS comprehensive assessment dated [DATE], revealed the resident had severely impaired cognition and the resident required set up meal assistance. The resident received a regular mechanically altered diet. Observation on 02/26/25 at 12:33 P.M., revealed in the 200-unit Main Dining Room, Resident #65 in a tilting wheelchair in a corner area of the dining room within 10 feet of approximately 15 residents seated at dining room tables. The 15 residents had been served and were consuming their lunch meals. Resident #65's lunch meal was at her table at 12:33 P.M. and the resident appeared anxious with body movements in the tilting wheelchair. Resident #65 was not assisted by Certified Nursing Assistant, (CNA) #195 until 12:54 P.M. Observation on 02/26/25 at 12:33 P.M., revealed Resident#71 was seated at the dining room table with approximately 15 residents who were served and were consuming their lunch meal at 12:33 P.M. Resident #71 did not receive his lunch meal tray until 12:51 P.M. Interview on 02/26/25 at 12:51 P.M. with CNA #178 revealed Resident #71's meal tray was sent to the 100 unit instead of the 200 unit and meal tray had been misrouted daily for nearly two weeks. STNA #178 verified Resident #71 waited for nearly 20 minutes while other residents consumed their meal in front of him. CNA #178 verified that all residents should be served meals at the same time. Interview on 02/26/25 at 12:51 P.M. with Registered Dietitian, (RD) #300 verified Resident #65 and #71 should have received their meal tray and provided assistance with the lunch meal tray when the other 15 residents received their meal tray. Interview on 02/26/25 at 12:54 P.M. with CNA #195, verified Resident #65's meal was delivered and was on the table in front of her for over twenty minutes. CNA # 195 stated there were two CNAs available to feed the three residents who required meal assistance. CNA #195 stated Resident #65 becomes anxious when waiting for assistance.

2) Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction with hemiplegia, dysphagia, chronic obstructive pulmonary disease (COPD), diabetes mellitus and malnutrition. The resident was discharged to the hospital on the date of 08/19/24. Review of records provided by the facility, revealed no documented evidence the Ombudsman was notified of Resident #58's discharge to the hospital on the date of 08/19/24. Interview on 02/26/25 03:26 P.M. with SSD #106, verified the Ombudsmen had not been notified of resident discharges and admissions to the hospitals since April 2024. SSD #106 verified there should have been notification to the Ombudsmen when Residents #42 and #58 were discharged to the hospital from the facility. Review of the facility policy titled, Transfer or Discharge Notice, revised March 2021 revealed residents and/or representatives were notified in writing, and in a language and format they understand, at least 30 days prior to a transfer or discharge. A copy of the notice was sent to the Office of the State Long-Term Care Ombudsman at the same time as the notice of transfer or discharge was provided to the resident and representative. Based on interview and record review, the facility failed to notify the Ombudsman when residents were transferred or discharged from the facility. This affected two Residents (#42 and #58) of the two residents reviewed for Ombudsman notification. The facility total census was 80. Findings Include: 1) Review of the medical record for Resident #42 revealed an admission date of 08/18/21. Diagnoses included pneumonia, type two diabetes mellitus (DM II), acute respiratory failure with hypoxia, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of nine. This resident was assessed to require setup with eating, partial assistance with toileting and transfers, and supervision with bathing and dressing. Review of the medical record revealed Resident #42 was sent to the hospital and admitted on the following dates: 08/10/24, 08/24/24, and 09/16/24 with no documentation of notification to the Ombudsman. Review of records provided by the facility, revealed no evidence the Ombudsman was notified of Resident #42's discharges to the hospital on the dates of 08/10/24, 08/18/21, and 09/16/24. Interview on 02/26/25 at 3:26 P.M. with Social Services Director (SSD) #106, verified the Ombudsman had not been notified of hospitalizations and/or discharges since April 2024.

Based on observations, medical record review and staff interviews, the facility failed to ensure residents who were at risk for skin breakdown, had interventions implemented to prevent skin breakdown. This affected one Resident (#23) of the three residents reviewed for pressure ulcers. The facility census was 80. Findings include: Record review of Resident #23 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #23 include hemiplegia, aphasia, dementia, dysphagia, and malnutrition. Review of a physician order for Resident #23 dated 12/04/24, revealed the resident was ordered to wear heel lift boots to bilateral extremities when in bed for prevention of skin breakdown. Review of the Minimum Data Set, (MDS) comprehensive assessment for Resident #23 dated 12/31/24, revealed the resident had severely impaired cognition and was dependent on staff for activities of daily living (ADS). Review of a therapy note for Resident #23 dated 12/31/24, revealed the resident should have a pillow under the right flexed knee and should have heel lift boots on the feet for prevention of skin breakdown. Resident #23 tolerated the positioning pillow and the heel lift boots. Review of the February 2025 Medication Administration Record (MAR) for Resident #23, revealed no documented refusals of heel lift boots or positioning pillows. Observations on 02/24/25 at 9:22 A.M., revealed Resident #23 had no positioning pillows or heel protection boots in place. Interview with Licensed Practical Nurse (LPN) #177 on 02/24/25 at 9:22 A.M. verified Resident #23's right knee was contracted and lying on top of the left leg. LPN #177 verified there were no positioning pillows between right knee and no heel lift boots in place. Observations on 02/25/25 at 3:47 P.M., revealed Resident #23 had no positioning pillows or heel protection boots in place. Observations on 02/27/25 at 9:01 A.M.,, revealed Resident #23 had no positioning pillows or heel protection boots in place. Interview with LPN #126 on 02/27/25 at 9:32 A.M., verified Resident #23 did not have any positioning pillows or heel lift boots in place. LPN #126 verified the resident should have the pillow between the right knee to the left leg and heel lift boots to prevent skin breakdown. Interview with the Director of Nursing (DON) on 02/27/25 at P.M., revealed Resident #23 should have had the heel lift boots as orders and position pillows to prevent skin breakdown.

Based on record review, observations, staff interviews, review of hospital records, and policy review, the facility failed to provide adequate hydration for a dependent resident. This affected one Resident (#17) of the residents reviewed for hydration. The facility also failed to adequately monitor residents weight loss/gain, notify the physician and implement interventions. This affected two Residents (#10 and #73) of the four residents reviewed for nutrition. The facility census was 80. Findings include: 1) Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, type two diabetes mellitus, paranoid schizophrenia, and major depressive disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 was unable to complete a Brief Interview for Mental Status (BIMS) because he was rarely/never understood. Resident #17 was dependent on staff with eating, toileting, bathing, dressing, and transfers. Review of the hospital records dated 02/23/25, revealed Resident #17 was admitted related to urinary tract infection (UTI), acute encephalopathy, and acute kidney injury on chronic kidney disease stage three, likely due to poor oral intake. Observation on 02/24/25 at 2:05 P.M., revealed Resident #17's water pitcher was sitting on end table of the adjacent wall and not within his reach. Interview on 02/24/25 at 2:06 P.M. with Resident #17's wife, revealed she filled his water pitcher up every day before she left the facility and reported it was in the same spot and completely full when she returned the next day. Observation on 02/25/25 at 3:36 P.M., revealed Resident #17's water pitcher was sitting on end table of the adjacent wall and not within his reach. Observation on 02/26/25 at 1:59 P.M., revealed Resident #17's water pitcher was sitting on end table of the adjacent wall and not within his reach. Interview on 02/26/25 at 3:54 P.M. with Certified Nursing Assistant (CNA) #166, verified Resident #17's water pitcher was out of reach, and fluids had not been offered during the interaction. Observation on 02/27/25 at 10:03 A.M., revealed Resident #17's water pitcher was sitting on end table of the adjacent wall and not within his reach. Review of the facility titled, Hydration - Clinical Protocol, revised in September 2017 revealed the physician and staff would help define the individual's current hydration status. The staff, with the physician's input, would identify and report to the physician individuals with signs and symptoms or lab test results that might reflect existing fluid and electrolyte imbalance. 49771 2) Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis (MS), urinary tract infection, chronic osteomyelitis, severe sepsis with septic shock, bacterial infection and nicotine dependence. Review of comparative graph of Resident #10's weights over a period from 03/14/24 to 02/23/25, revealed an unplanned weight gain of 36.81 percent from 184.2 pounds (lbs.) on 03/14/24 (admission) to 252 lbs on 02/23/25. Review of the plan of care dated 03/16/24, revealed Resident #10 had a focus area for being at a moderate to severe nutritional risk, with a goal to have no significant weight changes. The interventions included Boost (nutritional supplement) 237 milliliters (ml) three times a day (resident is refusing) initiated on 03/16/24 and revised on 09/02/24; Juven (nutritional supplement) one packet initiated on 12/05/24 and discontinued on 01/07/25; large portions of protein for all meals initiated on 11/18/24 and discontinued on 01/07/25; and Prostat (protein supplement) advanced wound care (AWC) 30 ml two times a day initiated 03/16/24. Review of a nutrition progress note for Resident #10 dated 03/16/24 and authored by Registered Dietitian (RD) #695, revealed Resident #10 was admitted for rehabilitation after hospitalization due to osteomyelitis (bone infection) in the left fibula. The resident stated his usual body weight was 180 lbs. The resident's weight was 184.2 lbs and a body mass index (BMI) of 25.0, which indicated a normal status for his height per the BMI parameters. The resident was on a regular diet with thin liquids, Boost plus supplement 237 milliliters (ml) three times a day and Prostat AWC supplement 30 ml two times a day. The resident's skin was impaired with multiple wounds and laboratory findings were altered. The resident appeared hydrated per a visual assessment. The resident was at moderate nutritional risk and will be monitored for change in status and reentry into nutrition care. The ideal body weight for the resident was 166 lbs. plus or minus 10 percent. The resident feeds himself with set up assistance. The current diet offerings per day (with supplements): 2200 -2400 kilocalorie (kcal)/95 -105 grams (gms) of protein. His estimated needs per day are: 2479 kcal/100 gms protein. Review of a nutrition progress note dated 04/10/24 and authored by RD #695, revealed Resident #10 had been requesting seconds for breakfast & lunch and would serve him large portions for breakfast and lunch. Review of a nutrition progress note dated 11/11/24 and authored by RD #695, revealed Resident #10 recently returned from the hospital following treatment for a urinary tract infection. The resident's weight on 11/09/24 was 248.1 lbs. This was a significant weight gain of 69 lbs. The accuracy of the weight was questioned and alerted nursing to his weight gain. Review of a nutrition progress note dated 11/25/24 and authored RD #695, revealed Resident #10 weighed 235.6 lbs. on 11/18/24. This would represent a significant weight loss in 30 days. The resident ate 75 to 100 percent of most meals. The resident stated he was getting plenty to eat and wanted no additional food/supplements at this time. Nursing was alerted to his weight fluctuations. Review of the progress notes for Resident #10 from 12/16/24 to 02/12/25, revealed no documentation the physician was notified of the resident's 20.63 percent weight loss between 12/16/24 and 02/12/25. Review of the MDS annual assessment dated [DATE], revealed Resident #10 had no cognitive deficits and had a suprapubic catheter and colostomy. The resident required set-up assistance for eating. Section K (Swallowing/Nutritional Status), dated 03/20/24 revealed Resident #10 was six feet tall and weighed 184 lbs. On 06/18/24, assessments revealed Resident #10 weighed 181 lbs. On 09/18/24, assessments revealed Resident #10 weighed 178 lbs. On 10/25/24, assessments revealed Resident #10 weighed 179 lbs. On 11/08/24, assessments revealed Resident #10 weighed 248 lbs. and on 02/17/25, Resident #10 weighed 252 lbs. Review of a nutrition progress note dated 01/07/25 and authored by RD #695, revealed Resident #10 weighed 239.1 lbs. on 01/05/25, which represented a significant weight gain for 180 days. The resident's BMI was now 32.4 which indicated an obese status for his height per BMI parameters. The resident is on a regular diet with regular texture and thin liquids, and receives Prostat AWC 30 ml two times a day, Juven one packet every day and double portions of protein for all meals. The resident's skin impairments were healed. The resident appeared hydrated at visual assessment. Juven was discontinued and double portions of protein for all meals. The mini nutritional assessment (MNA) was at 13, which indicated normal nutritional status. The resident is at a moderate nutritional risk and will continue with the current plan of care/clinical course. Review of Resident #10's weights, revealed on 01/01/25 the resident weighed 186.6 lbs. and on 02/27/25 the resident weighed 175 lbs. This represented a 6.22 percent weight loss. Review of a nutrition progress note dated 02/23/25 and authored by RD #695, revealed Resident #10 weighed 252 lbs. on 02/20/25 which represented a significant weight gain for 180 days. The resident was currently being treated for a urinary tract infection. The resident remains on a regular diet with thin liquids and Prostat AWC 30 ml two times a day. The resident appeared hydrated per a visual assessment. The MNA was at 12, which indicated normal nutritional status. Nursing was alerted to the resident's weight gain and will continue with the current plan of care/clinical course. Interview with RD #695 via Phone on 02/27/25 at 1:48 P.M., revealed she was only a consultant, and she had asked for a reweight and alerted nursing to the resident's weight gain. RD #695 thought the weight gain was due to the weight of the resident's wheelchair being added to the resident's body weight. When surveyor mentioned the resident's weight on 02/20/25 was also 252 pounds and was obtained using the Hoyer lift scale, she responded by saying this was a nursing problem. Review of Resident #10's weights, revealed on 02/27/25 the resident weighed 175 lbs. The weights recorded on 02/12/25 and 02/15/25 were documented on 02/27/25 as being incorrect by RD #695 and Registered Nurse (RN) #181. Interview with the Director of Nursing (DON) on 02/27/25 at 2:34 P.M., verified Resident #10's significant weight gain between 10/04/24 and 11/04/24 but could offer any insight as to how and why the resident had a 40.63 percent weight gain in a 30-day period or of specifics as to how the facility responded to the resident's weight gain. The DON also verified the physician had not been made aware of the resident's significant weight gain. 3) Review of the medical record revealed Resident #73 was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, abdominal aortic aneurysm, malignant neoplasm of right renal pelvis, chronic kidney disease stage III and diabetes mellitus type II. Review of the plan of care dated 12/16/24, revealed Resident #73 was at a moderate nutritional risk secondary to diagnoses of diabetes mellitus, peripheral vascular disease, hypertension, hyperlipidemia and chronic kidney disease stage III. Interventions included Boost 237 ml two times a day, monitor laboratory finds (labs), intakes, weights, skin assessments, ordered a no added salt, no concentrated sugars, regular texture, thin liquid diet, observe for signs and symptoms of dehydration and difficulties with chewing/swallowing and Prostat 30 ml daily. Review of the documented weights for Resident #73, revealed the resident weighed 189 lbs. on 12/16/24 and 150 lbs. on 02/12/25. This represented a 20.63 percent weight loss in 60 days. The weight on 02/15/25 was documented as obtained using a standing scale. A re-weight on 02/15/25 confirmed the weight of 150 lbs. and was documented as obtained using a mechanical lift scale. Review of a nutrition progress note dated 12/19/24 and authored by RD #695, revealed Resident #73 was admitted for rehabilitation after hospitalization due to left lower extremity graft thrombectomy. The resident's BMI was 26.4 which indicated the resident was overweight. It was recommended the resident receive Prostat 30 ml and Boost 237 ml daily. The MNA indicated the resident was at risk for malnutrition. Review of the MDS five-day assessment dated [DATE], revealed Resident #73 had moderate cognitive impairment and was occasionally incontinent of bowel and bladder. The resident required set-up assistance for eating. Review of a nutrition progress note dated 12/23/24 and authored by RD #695, revealed Resident #73 weighed 180 lbs. on 12/22/24. RD #696 questioned the accuracy of the admission weight. The resident's Boost will be increased to 237 ml two times a day. This dietary progress note was the most recent dietary note for Resident #73. Interview via phone with RD #696 on 02/27/25 at 1:48 P.M., verified Resident #73 was not assessed and there were no dietary progress notes for the resident between 12/23/24 and 02/27/25. Interview with DON on 02/27/25 at 2:04 P.M., revealed there is a weekly meeting with RD #695 where residents with weight loss/gain are discussed. There was a risk meeting on 02/19/25 and Resident #73 was not discussed. Review of the policy titled, Nutrition (Impaired)/Unplanned Weight Loss, revised 09/17, revealed the nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparison over time. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. The physician will review medical causes of weight gain, anorexia and weight loss before ordering interventions.

Based on observatoin, medical record review, staff interviews, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected four Residents (#09, #30, #41 and #49) of the 17 residents with medications stored in the two-center medication cart. The facility census was 80. Findings include: 1) Review of the medical record revealed Resident #09 was admitted to the facility on [DATE]. Diagnoses of diabetes mellitus type 1 with diabetic polyneuropathy, hypertension, chronic kidney disease state III and moderate protein-calorie malnutrition. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #09 had severe cognitive impairment and was dependent on staff for medications. Review of a physician order for Resident #09 dated 04/05/25 revealed the resident was ordered to receive Novolog (Aspart fast acting insulin) 100 Unit/milliliter (mL) dated 04/05/24 per sliding scale according to the resident's blood sugar readings. Review of the February 2025 Medication Administration Record (MAR) revealed Resident #09 received Novolog insulin one to three times daily from 02/01/25 through 02/25/25. 2) Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. Diagnoses of diabetes mellitus type 2 with ketoacidosis, encephalopathy, adult failure to thrive and sepsis. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #30 had moderate cognitive impairment and was dependent on staff for medications. Review of physician orders for Resident #30 dated 09/14/24 revealed the resident was ordered to receive Humalog (Lispro fast acting insulin) 100 Unit/mL per sliding scale according to the resident's blood sugar readings. A physician order dated 09/24/24 revealed the resident was ordered eight units of Lantus glargine at bedtime for diabetes mellitus. Review of the February MAR revealed Resident #30 received Humalog insulin one to two times daily from 02/01/25 through 02/25/25 and Lantus daily from 02/01/25 through 02/25/25. 3) Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] Diagnoses included diabetes mellitus type 2 with circulatory complications, necrotizing fasciitis, morbid obesity and chronic kidney disease. Review of the MDS quarterly assessment dated [DATE], revealed Resident #41 had no cognitive impairment and was dependent on staff for medications. Review of a physician order dated 08/30/24 for Resident #41 revealed the resident was ordered Lantus glargine 15 units at bedtime for diabetes mellitus. A physician order dated 08/30/24 revealed the resident was ordered Novolog 100 Unit/mL per sliding scale according to the resident's blood sugar readings. Review of the February 2025 MAR revealed Resident #41 received Lantus insulin daily from 02/01/25 through 02/25/25; and sporadic doses of Novolog in December 2024, sporadic doses in January 2025 and no documented doses in February. 4) Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus type 2 with polyneuropathy, cerebral infarction, sepsis and moderate protein-calorie malnutrition. Review of the MDS quarterly assessment dated [DATE] revealed Resident #49 had severe cognitive impairment and was dependent on staff for medications. Review of a physician order dated 12/02/24 revealed the resident was ordered d 12/02/24 for Humalog 100 Unit/mL per sliding scale according to the resident's blood sugar readings. Review of the February 2025 MAR for Resident #49 revealed the resident Humalog insulin one to three doses daily from 02/01/25 through 02/15/24. Observation of the two-center medication cart on 02/26/25 at 9:10 A.M. with LPN #55 revealed Resident #09's Novolog insulin vial was opened on 01/22/25. Resident #30's Lantus glargine insulin vial was opened 01/03/25 and Resident #30's Humalog insulin was opened 11/13/24. Resident #41's Lantus insulin was opened without an open date and Resident #41's Novolog insulin was opened on 11/13/24. Resident #49's Humalog insulin was opened 01/14/25. Interview with LPN #155 on 02/26/25 at 9:20 A.M. verified insulin vials should be dated when opened and that Resident #30 had Lantus insulin with an opened date of 01/03/25 and a Lispro insulin opened date of 11/13/24; Resident #41 had Lantus insulin that was in the medication cart and was not dated and a Novolog insulin opened date of 11/13/24; Resident #09 had Novolog insulin opened date of 01/22/25; and Resident #49 had Humalog insulin dated 01/14/25. Interview with Consulting Pharmacist #199 on 02/26/15 at 12:46 P.M. revealed Lispro insulin, Humalog insulin, Novolog insulin and Lantus insulin had 28-day expirations after being opened or removed from refrigeration. Review of document titled, Expiration Guidelines for Insulin Products, written by the facility's pharmacy provider, revealed insulin products are to be labeled with the date opened when taken from the refrigerator or put in the medication cart; and to discard and reorder insulin at least three (3) days before expiration or patient runs out. The expiration for Lispro (Humalog) insulin was 28 days; Aspart (Novolog) insulin 28 days; and Glargine (Lantus) 28 days after opened. Review of the policy titled, Storage of Medications, revised 11/20, revealed that drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, staff interview and record review, the facility failed to provide timely dental care services. This affected one Resident (#58) of one resident reviewed for dental services. The facility total census was 80. Findings Include: Record review of Resident #58 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on 08/19/24. Diagnoses included hemiplegia, cerebral infarction, dysphagia, chronic obstruction pulmonary disease, diabetes, and malnutrition. Review of a physician order dated 09/01/23, revealed the resident may see dental services as needed. Review of a care conference dated 12/04/24, revealed Resident #58 requested a dental appointment to have dentures repaired. There was no documented evidence that the resident had a dental appointment since admission of 09/01/23. Review of Dental Service Contract dated 12/16/24, revealed Resident #58's Power of Attorney, (POA) signed an authorization for the resident to have dental services. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed Resident #58 had intact cognition and was dependent on staff for Activities of Daily Living (ADLS). Observation on 02/24/25 at 9:30 A.M., revealed Resident #58 had no natural teeth and no dentures in place. Interview with Resident #58 on 02/24/25 at 9:30 A.M., revealed the resident had all of his teeth extracted several years ago. The resident stated he had dentures, but they needed repaired. The resident stated he would like to eat the pleasure foods, as ordered, but does not like the puree consistency required for not having dentures. The resident stated if he had dentures he would enjoy the food. He also stated the thought he would look better if he had his dentures. The resident stated he had not seen a dentist since his admission on 09/01/23. Interview with Licensed Practical Nurse, (LPN) #104 on 02/27/25 at 10:52 A.M., verified there was no documentation Resident #58 had been seen by a dentist since admission on 09/01/23. LPN #104 was unaware of any dental appointment currently set up or knowledge of previous dental appointments being made for Resident #58. Interview with Social Services Designee #106 on 02/27/25 at 2:04 P.M., revealed the facility had delayed dental services due to appointment complications since the resident's admission on 09/01/23. SSD #106 stated during the care conference on 12/04/24, Resident #58 repeated his request for dental services. SSD #106 verified paperwork for the contract dental services had been signed by the POA, and the resident had a physician order for dental services. SSD #106 verified there was no documentation Resident #58 had dental services provided since admission and there had been no contracted dental services set up since.

Based on review of the medical record, observations, staff interviews, review of online resources from the Centers for Disease Control (CDC), and policy review, the facility failed to provide appropriate infection control measures while performing incontinence care and failed to ensure enhanced barrier precautions (EBPs) were implemented and followed according to guidelines. This affected one Resident (#17) of the 17 residents reviewed for incontinence care and being on EBPs. The facility census was 80. Findings include: Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, type two diabetes mellitus, paranoid schizophrenia, and major depressive disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 was unable to complete a Brief Interview for Mental Status (BIMS) because he was rarely/never understood. This resident was dependent on staff for activities of daily living (ADLs). Review of the hospital records dated 02/22/25, revealed Resident #17 was admitted to the hospital for a urinary tract infection (UTI). Resident #17 had a history of frequent UTI's with extended spectrum beta-lactamase (ESBL). Observation on 02/27/25 at 10:01 A.M., revealed incontinence care was provided to Resident #17 by Certified Nursing Assistant (CNA) #103. Hand hygiene was not performed prior applying gloves. After gathering supplies, CNA #103 placed clean linens on bedside table without cleaning the bedside table. CNA #103 performed incontinence care on Resident #17 with those linens. Observation revealed CNA #103 only wore gloves during the incontinence care. Observation revealed no signage on the door or within the resident's room, indicating Resident #17 was to be in EBPs. Interview on 02/27/25 at 10:07 A.M. with CNA #103, verified she did not perform hand hygiene prior to applying gloves. CNA #103 also verified she put clean linens on the bedside table without cleaning it and then used those linens while providing incontinence care. CNA #103 verified she only used gloves to provide incontinence care to Resident #17 and wasn't aware she needed to wear any additional personal protective equipment (PPE). Interview on 02/27/25 at 10:43 A.M. with the Director of Nursing (DON), verified Resident #17 was not in EBPs and there were no active orders for the resident to be in EBPs Interview on 02/27/25 at 11:27 A.M. with Registered Nurse (RN) #181, verified Resident #17 had ESBL which was considered a Multi Drug Resistant Organism (MDRO), and Resident #17 should be in EBPs. Review of the February 2025 active physician orders for Resident #17, revealed he was not ordered to be in EBPs. Review of the facility policy titled, Hand Hygiene, dated 2023, revealed all staff were to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately removing gloves. Review of CDC website at (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html) dated 06/28/24, revealed infection control management of MDROs in healthcare settings revealed MDRO's were defined as microorganisms, predominantly bacteria, that were resistant to one or more classes of antimicrobial agents. ESBL was considered a MDRO and was resistant to multiple classes of antimicrobial agents. EBPs are an infection control intervention designed to reduce transmission of MDROs in nursing homes. EBPs precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Review of the facility policy titled, Enhanced Barrier Precautions, undated, revealed it was the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms. Enhanced barrier precautions referred to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employed targeted gown and glove use during high contact resident care activities.

Based on medical record review, interview with the physician, and review of the facility policy, the facility failed to timely notify the physician when Resident #78 had abnormal vital signs during the time Resident #78 was exhibiting a change in condition and being treated for an infection. This affected one (Resident #78) of three residents reviewed for change in condition. Findings include: Review of the medical record revealed Resident #78 was readmitted to the facility on [DATE]. Diagnoses included cholecystitis, severe protein-calorie malnutrition, vascular dementia, and urine retention. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was severely cognitively impaired. Review of the plan of care dated 11/21/23 revealed Resident #78 was at risk for activity of daily living and self-care performance deficit related to intolerance, dementia, and fatigue. Interventions included to obtain and record all vital signs per orders and as needed, and report changes from usual to physician. Review of the progress note dated 11/29/23 documented by Unit Manager (UM) #225 revealed at 4:00 P.M., the resident's temperature was 101.3 Fahrenheit (F). The physician was notified to have new order to obtain STAT complete blood count (CBC), basic metabolic panel (BMP), UA and culture and sensitivity if indicated. Rocephin one gram intramuscular (IM) every day for seven days for fever/urinary tract infection. The progress note dated 11/29/23 documented by UM #225 revealed a new order to obtain for vital signs every shift while on antibiotic therapy. Review of the vital signs for Resident #78 revealed the following the resident's oxygen saturation on 11/29/23 at 9:40 A.M. was 92% on room air; on 11/30/23 at 7:15 A.M. was 91% on room air; on 11/30/23 at 5:51 P.M. was 90% on room air; and on 12/01/23 at 6:53 A.M. was 91% on room air. Further review of the medical record revealed the physician was not made aware of Resident #78's oxygen saturations being 90 and 91 on 11/30/23. There was no physician orders for supplement oxygen and no notes that supplemental oxygen was administered to Resident #78. Review of the progress note dated 12/01/23 at 10:30 A.M. revealed Resident #78 was not responding to sternum rub, calling resident by name, increase respirations 48, blood pressure 93/64, oxygen saturation was 86% room air, temperature was 99.5, and Resident #78 slightly opening his eyes. LPN #227 sent a message to physician with new orders to send to emergency room . The progress note dated 12/01/23 revealed the hospital notified the facility that Resident #78 was admitted to the hospital with septic shock. Interview on 01/04/24 at 12:52 P.M. with Medical Director #440 stated UM #225 had called her and gave her information about Resident #78 and was not eating, or drinking, and had lethargy on 11/29/23. MD #440 stated she wanted the facility to push fluids. MD #440 stated she did not get notified on 11/30/23 when Resident #78's oxygen saturation was 90-91% room air. MD #440 said oxygen supplementation would have been ordered for Resident #78. MD #440 stated she expected the facility staff to notify her of abnormal vital signs. Review of the facility policy titled Notification of Changes, dated 2023, revealed the purpose of the policy was to ensure the facility promptly informs the resident, consults the resident's physician, and notified, consistent with his or her authority, the resident's representative when there was a change requiring notification. This deficiency represents non-compliance investigated under Complaint Number OH00148872.

Based on staff interview, record review, and review of the facility's policy, the facility failed to investigate resident falls and determine the root cause of the resident's falls. This affected three (#25, #82, and #86) of three residents reviewed for falls. The facility census was 82. Findings include: 1. Review of the closed medical record revealed Resident #86 had an admitted on [DATE]. Resident #86 discharged from the facility on [DATE]. Diagnoses included hypertension and systolic congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was moderately cognitively impaired. Review of the plan of care dated [DATE] revealed Resident #86 was at risk for falls related to confusion, gait and balance problems, hypotension, poor communication, and comprehension and unawareness of safety needs. Interventions included non-skid socks as tolerated and ensure the resident was wearing appropriate non-skids in bed. Review of the fall risk tool dated [DATE] revealed Resident #86 was at a high fall risk with the score of 16.0. Resident #86 had daily incontinence and needed assistance, had a wheelchair with balance issues, and needed transfer assistance. Review of the facility's fall and incident log dated from [DATE] through [DATE] revealed Resident #86 fell on [DATE] and [DATE]. Interview on [DATE] at 4:40 P.M. with the Director of Nursing (DON) verified there was no fall investigation or root cause analysis for Resident #86's falls on [DATE] and [DATE]. 2. Review of the closed medical record for Resident #82 revealed an admitted [DATE]. Resident #82 expired in the facility on [DATE]. Diagnoses included severe protein calorie malnutrition, vascular dementia with severe agitation, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 was severely cognitively impaired. Review of the plan of care dated [DATE] revealed Resident #82 was at risk for falls related to confusion and gait and balance problems. Interventions included personal items within reach, call light in reach, encourage activities, follow fall protocol, continue interventions on the at-risk plan, declutter room, encourager resident to be out of bed, collaborate with hospice, and medication review as needed. Review of the fall risk tool dated [DATE] revealed Resident #82 had a score of 14 which indicated the resident was at a high risk for falling. Resident #82 had moderate vision impairment, cognitive level was severely impaired, and had a wheelchair with balances issues and needing transfer assistance. Review of the fall and incident log dated from [DATE] through [DATE] revealed Resident #82 fell on [DATE], [DATE], [DATE], and [DATE]. Interview on [DATE] at 4:40 P.M. with the Director of Nursing (DON) verified there was no fall investigation or root cause analysis for Resident #82's falls on [DATE], [DATE], [DATE], and [DATE]. 3. Review of the medical record for Resident #25 revealed an admitted [DATE]. Diagnoses included adult failure to thrive, disorder of bladder, type two diabetes mellitus, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was severely cognitively impaired. Review of the plan of care dated [DATE] revealed Resident #25 was at risk for falling related to decreased mobility, decreased cognition, decreased communication and resident fell out of wheelchair related to having pillow in seat on [DATE]. Interventions included dycem in wheelchair, offer to assist with toileting, bed to be in lowest position, keep resident in common area while up in wheelchair, monitor wheelchair for pillows, offer to assist with toileting after meals, visual signs in room to call for help with transfers, anticipate resident's needs, ensure the resident was wearing non-skid footwear, and call light in reach. Review of the fall risk tool dated [DATE] revealed Resident #25 had a fall score of 21 which indicated the resident was at a high risk for falling. Resident #25 had moderate vision impairment, cognitively moderately impaired and not following safety needs, and daily incontinence. Review of the fall and incident log dated from [DATE] through [DATE] revealed Resident #25 fell on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview on [DATE] at 4:40 P.M. with the Director of Nursing (DON) verified there was no fall investigation or root cause analysis for Resident #25's falls on [DATE], [DATE], and [DATE]. Review of the facility policy titled Falls-Clinical Protocol, dated ,d+[DATE], revealed the physician will help identify individuals with history of falls and risk factors for falling. Nurse shall assess, perform vitals, document, and report injury, observe for change in condition or level of consciousness, neurological status, pain, frequency, and number of falls since last physician visit, precipitating factors on details how fall occurred, all current medications and active diagnosis. This deficiency represents non-compliance investigated under Complaint Number OH00149067 and Complaint Number OH00149419.

Based on staff interviews, observation, record review, and review of the facility policy, the facility failed to provide timely incontinence care for a resident. This affected one (Resident #80) of three residents reviewed for incontinence care. The facility census was 82. Findings include: Review of Resident #80's medical record revealed an admitted [DATE]. Diagnoses included dementia severity, anxiety disorder, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was severely cognitively impaired. Resident #80 required substantial maximum assistance from staff for toileting. Review of the plan of care dated 12/01/23 revealed Resident #80 was at risk for incontinence and wearing disposable briefs, required and received assistance with toileting and incontinence care, and was at increased risk for skin breakdown and urinary tract infections. Interventions included to monitor and document signs and symptoms of urinary tract infection and to notify the physician of symptoms burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urine odor, change in behaviors, and change in eating problems. Staff to check four times for incontinence per shift and as required for incontinence, wash and rinse perineum. Apply barrier cream. Change clothing as needed after incontinence episodes. Observation on 01/02/24 at 3:35 P.M. revealed Nurse Aide (NA) #802 and NA #444 laid Resident #80 down in her bed and began to provide incontinence care to Resident #80. Resident #80 had a large wet stain on her bottom through her pants. Resident #80 had a incontinent brief on that had an odor, severely saturated in urine with bowel movement up the front in peri area. Resident #80 had redness all on peri area, leg creases, and bottom. Interview on 01/02/24 at 3:45 P.M. with NA #444 confirmed the large wet spot-on Residents #80 pants, odor, severe urine saturation, and bowel movement that was encrusted in the peri area. NA #444 and NA #802 confirmed Resident #80 was not their assignment for that day (01/02/24) and they did not provide incontinence care during their shift until 3:35 P.M. NA #444 stated they were told to help NA #399 because she was trying to give care to other residents on her floor. Interview on 01/02/24 at 3:48 P.M. with Licensed Practical Nurse (LPN) #227 verified Resident #80's skin on her bottom, peri area, and leg creases were red. Interview on 01/02/24 at 3:50 P.M. with NA #602 stated she did not check and change Resident #80 because the resident was not on her assignment for that day (01/02/24). Interview on 01/02/24 at 4:00 P.M. with NA #399 stated her original assignment was to be the shower aide but got pulled to the floor to work as a nurse aide. NA #399 verified she did not provide incontinence care to Resident #80 that day (01/02/24). NA #399 stated Resident #80 was already up and dressed for the day when she began her shift at 8:00 A.M. Interviews on 01/02/24 at 4:05 P.M. with NA #204, at 4:10 P.M. with NA #44, at 4:15 P.M. with NA #815, and at 4:43 P.M. with NA #305 stated they did not change or provide incontinence care to Resident #80. Interview on 01/02/24 at 4:35 P.M. with NA #300 stated she had dressed and provided care to Resident #80 at 6:20 A.M. this morning (01/02/24) before she left at 7:00 A.M. Subsequent review of the wound physician progress note and physician orders dated 01/02/24 revealed Wound Nurse Practitioner (WNP) #311 stated Resident #80 was assessed today due to skin issue. Resident #80 seen as nurse request of report of redness to buttocks area. WNP #311 stated incontinence associated dermatitis. WNP #311 stated to start Calmoseptine cream to be applied after periods of incontinence every shift and as needed every shift for blanchable redness. The physician order dated 01/02/24 revealed Resident #80 had an order for Calmoseptine cream applied after periods of incontinence every shift and as needed. Review of the facility policy titled Activities of Daily Living, Supporting, dated 03/2018, revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Appropriate care and services will be provided for residents who are unable to carry out the activity of daily living independently. This deficiency represents non-compliance investigated under Complaint Number OH00148872 and Complaint Number OH00149419.

Based on staff interview and record review, the facility failed to have a full time qualified social worker for a facility with more than 120 beds. This had the potential to affect all 82 residents residing in the facility. Findings include: Review of the facility's demographics revealed the facility was certified for 129 beds. Review of the former social worker's employee file revealed the Director of Social Services #575 last day worked was 11/21/23. Interview on 01/02/24 at 10:56 A.M. with the Director of Nursing (DON) verified the facility did not have a full time qualified social worker. The DON stated the current Administrator was off on personal leave and unable to be reached. This deficiency represents non-compliance investigated under Complaint Number OH00149067.

Based on medical record review and staff interview, the facility failed to coordinate care with the home health agency to ensure a smooth and safe resident discharge. This affected one (#90) of three residents reviewed for discharge planning. The facility census was 89. Findings include: Review of the medical record for Resident #90 revealed an admitted [DATE], with diagnoses including chronic osteomyelitis, atherosclerotic heart disease, presence of cardiac pacemaker, atrial fibrillation, epilepsy, anxiety disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) for Resident #90 dated 10/06/23 revealed resident was discharged to home with a return not anticipated. Review of MDS revealed resident was cognitively intact and required supervision and touching assistance with activities of daily living. Review of the discharge paperwork for Resident #90 with home health services revealed the resident was discharged with an order dated 09/21/2, for Vancomycin once daily via intravenous (IV) for 36 days and an order for a Vancomycin level to be drawn every Friday. The paperwork did not include when Resident #90 last received a dose of IV Vancomycin or her most recent Vancomycin level laboratory results. Interview on 10/16/23 at 1:52 P.M., with Registered Nurse (RN) #123 confirmed she was the nurse who discharged resident on 10/06/23. RN #123 confirmed she was unable to send IV Vancomycin because she was awaiting the vancomycin level results and the pharmacy would not send the medication without the results. RN #123 confirmed she asked the resident to wait until they had this information and could order the Vancomycin, but the resident was anxious to leave and told the nurse she would follow up with her home health nurse about continuing the Vancomycin. RN #123 further confirmed she did not notify the home health agency regarding the pending Vancomycin laboratory results and that Vancomycin and IV supplies were not sent home with resident upon discharge. RN #123 confirmed the discharge paperwork did not include information regarding Resident #90's most recent dose of Vancomycin received. This deficiency represents non-compliance investigated under Complaint Number OH00147320.

Based on record review and staff interview, the facility failed to ensure a Registered Nurse was working at least 8 hours a day. This had the potential to affect all 89 residents. The census was 89. Findings: Review of the staff schedule for 10/08/23 through 10/14/23 revealed on Saturday 10/14/23 there was not a Registered Nurse (RN) working for at least 8 hours on this date. Interview on 10/16/23 at 3:06 P.M. with the Director of Nursing verified there was no RN working on 10/14/23. This deficiency represents non-compliance investigated under Complaint Number OH00147089.

Based on medical record review, staff interviews, and review of facility policy, the facility failed to obtain a urinalysis (urine test for infections) in a timely manner resulting in a delay of care for resident with a urinary tract infection (UTI). This affected one resident (#90) out of three residents reviewed for change in condition. The facility census was 78. Findings included: Review of the medical record for Resident #90 revealed an admitted [DATE]. Diagnoses included fracture of left femur, history of Coronavirus (COVID-19), venous insufficiency, hypotension, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #90, dated 07/20/22, revealed the resident had intact cognition. The resident had a brief interview for mental status (BIMS) score of 15. Resident #90 required extensive assistance for all activities of daily living (ADLs). The resident had no hallucinations, delusions, or rejection of care noted. Resident #90 was assessed as occasionally incontinent of bowel and bladder. Review of the plan of care for Resident #90 dated 08/16/22, revealed the resident was frequently incontinent of urine which increases the risk of skin breakdown and urinary tract infections. Interventions included monitoring/documenting signs/symptoms of UTI, checking the resident four times per shift, and perineal care with each incontinent episode. Review of the nursing notes dated 01/04/23 for Resident #90 revealed the resident had a discharge coming from his penis. Review of the physician orders dated 01/04/23 for Resident #90 revealed an order for a urinalysis related to penile discharge. Review of the medical record for Resident #90 revealed a urinalysis was not collected by the facility until 01/12/23 and sent to the lab. Review of the laboratory (lab) work dated 01/15/23 for Resident #90 revealed the resident was positive for an UTI showing three different organisms identified in the urine including Escherichia coli (E.coli). Review of the same lab work for Resident #90 revealed the urinalysis resulted and reported to the facility on [DATE] at 1:15 P.M. and was not reported to the physician until 01/17/23. Review of the physician orders dated 01/18/23 for Resident #90 revealed resident was ordered Augmentin (antibiotic) 875-125 milligrams twice daily for seven days. Interview on 01/30/23 at 3:00 P.M. with the Director of Nursing (DON), confirmed that there was a nursing note written on 01/04/23 for Resident #90 stating that he was having penile discharge. The DON confirmed the facility obtained a physician's order to check the urine of Resident #90 on 01/04/23 but did not obtain the urine and send it to the lab until 01/12/23. When the urine resulted on 01/15/23, the DON confirmed the facility staff did not notify the physician of the positive urinalysis results until 01/17/23 and then started the antibiotic for the infection on 01/18/23. The DON stated the facility should have obtained the urinalysis for the resident quicker and reported the results of the urinalysis sooner to the physician. Review of facility policy titled Urine Sample Collection, undated, revealed the facility did not implement the policy regarding the allegation. The facility is to Notify physician of results, and file results in the resident's medical record. This deficiency represents non-compliance investigated under Complaint Number OH00138987.