Every finding on record at National Church Residences Chillicothe

Based on observations, interviews , record review and review of facility policy and procedure, the facility failed to ensure post fall interventions were in place for one resident (#14) out of three residents (#12, #14 and #22) reviewed for falls. The census was 34. Findings include:Review of medical record for Resident # 14 revealed readmission date of 12/9/25 with diagnoses including Alzheimer's disease, dementia , Type tTo Diabetes, chronic kidney disease and multiple sclerosis .Resident #14's quarterly Minimum Data Systems (MDS) revealed a Brief Interview of Mental Status BIMS score of six indicating severe cognitive deficits. Her care plan last updated on 03/16/26 revealed she was dependent on one to two staff members for activities of daily living; she used a wheelchair for transportation.Review of the facility's Incident Report log from 04/08/26 to 04/22/26 revealed Resident #14 experienced an unwitnessed falls on 04/08/26, 04/17/26 and 04/19/26.Review of Resident #14's nurse progress notes dated 11/01/26 to 04/22/26 revealed the falls occurred during multiple times of the day.Review of Resident #14 Care Plan last updated on 03/27/26 listed fall interventions to include call light within reach, wear non-skid foot wear, and wedge cushion to wheelchair for safety and positioning. Review of Resident #14 Post-Fall Investigative Summary 04/08/26 Resident #14 was found by nursing on the floor in front of her wheelchair in her room. It was determined resident was trying to get herself-dressed for bed. New fall intervention included maintenance to drop the back part of the seat of her wheelchair to inhibit her to get out of the chair alone. Review of Resident #14 Post-Fall Investigative Summary 04/17/26 was found on floor of room near her wheelchair. It was determined resident fell out of her wheelchair when attempting to pick up her pants on the floor. New post fall intervention included Reacher Grabber Tool.Review of Resident #14 Post-Fall Investigative Summary 04/19/26 was found on her bedroom floor by bed and chair. New post fall intervention included non-skid strips to floor in front of her bed for safety.Interviews on 04/23/26 at 9:00 A.M. with Registered Nurse (RN) #112 and Certified Nurse Aid (CNA) 116 confirmed Resident #14 is very confused and must be reminded to call for assistance and to not stand or try to walk, get out of her chair and go to the bathroom alone. She needs someone to assist her.Interview with Resident #14 on 04/22/26 at 10:00 A.M. confirmed Resident #14 is pleasantly confused and could not report the day of the week or what she had for breakfast.Observation at 10:45 A.M. on 4/23/26 of Resident #14 in her room sitting in wheelchair confirmed that resident did not have a wheelchair cushion in place and the back of wheelchair was not lowered. This was verified in a concurrent interview with Registered Nurse (RN) #112. Observation on 04/23/26 at 11:01 A.M. with Maintenance #118 observed Resident #14 in her wheelchair and confirmed the wheelchairs back part of the seat was not lowered and she did not have a wedge cushion in the wheelchair. Observation for 04/23/26 at 11:45 A.M. with RN #12, Director of Nursing (DON), and the Administrator could not locate a Reacher Grabber Tool in the resident's room.Observation on 04/23/26 at 12:13 P.M. with DON confirmed there were no slip strips in front of Resident #14's bed. While in the room a CNA found the Reacher Grabber Tool in Resident #14's closet on the top shelf under two blankets where resident was unable to reach it.Review of the Facility's, Falls Management Program Policy dated 04/2024 revealed the facility strives to create the safest possible environment for residents, and promote culture of safety by minimizing the resident's risk, hazards and complications from falling. During completion of daily care routine, caregivers will observe the residents to ensure safety and fall preventions are in place as listed in the care plan.This deficiency repersents non-compliance investigated under Complaint Number 2974140.

Based on medical record review and staff interview, the facility failed to develop a plan of care for residents with diagnoses of Alzheimer's disease and dementia. This affected one (#5) of 17 residents reviewed for care plans. The facility census was 36.Findings include:Record review for Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses included seizures, aortic valve stenosis, chronic kidney disease, osteoarthritis, Alzheimer's disease, dementia, secondary Parkinsonism, convulsions, psychotic disorder, anxiety, and psychotic disorder with delusions and hallucinations. Further review of the resident's diagnoses revealed Alzheimer's disease and dementia were added as new diagnoses on 12/01/25. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severely impaired cognition.Review of Resident #5's current comprehensive care plan, last revised on 12/17/25, revealed there was no care plan put into place to address Resident #5's care needs related to Alzheimer's disease and dementia. Interview with the Director of Nursing (DON) on 12/30/25 at 3:01 P.M. verified the facility did not develop a care plan to address Resident #5's care needs related to Alzheimer's disease and dementia.

Based on medical record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR) were completed and updated to reflect a new qualifying diagnosis. This affected two (#5 and #38) of two residents reviewed for PASARR accuracy. The facility census was 36.Findings include: 1. Review of Resident #38's medical record revealed an admission date of 01/09/24. Diagnoses included acute and chronic respiratory failure with hypoxia, congestive heart failure, type II diabetes, atrial fibrillation, mild cognitive impairment of unknown etiology, dysphagia, generalized anxiety disorder, drug induced subacute dyskinesia, major depressive disorder, and fibromyalgia. Further review revealed a diagnoses with onset date of 09/26/23 of unspecified psychosis not due to a substance or known physiological condition, and fibromyalgia. Review of Resident #38's Minimum Data Set (MDS) assessment dated [DATE] revealed anxiety disorder, depression (other than bipolar), and psychotic disorder (other than schizophrenia) as diagnoses for Resident #38 under, Section I – Active Diagnoses. Review of Resident #38's Preadmission Screening and Resident Review (PASARR) Identification Screen dated 01/11/24 revealed, in section E, the diagnoses of mental disorders as mood behaviors and panic or other severe anxiety disorder only. The PASARR Identification Screen Results revealed no indications of serious mental illness nor a developmental disability. Interview on 12/31/25 at 10:32 A.M. with Social Services Leader (SSL) #199 confirmed the PASARR Identification Screen dated 01/11/24 was the most recent version of the document for Resident #38. SSL #199 confirmed that other psychotic disorder was not captured as a diagnosis under section E of the PASARR. SSL #199 confirmed that, based on Resident #38 medical diagnoses in the medical record, other psychotic disorder should be captured as a medical diagnosis under section E of the PASARR. 2. Record review for Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses included seizures, aortic valve stenosis, chronic kidney disease, osteoarthritis, Alzheimer's disease, dementia, secondary Parkinsonism, convulsions, psychotic disorder, and anxiety. Review of an updated diagnosis list revealed a new diagnosis of psychotic disorder with delusions and hallucinations added on 11/05/25. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had severely impaired cognition. Review of the most recent PASARR documentation provided by the facility for Resident #5 revealed it was completed prior to admission on [DATE], with no further documentation which reflected the addition of the new diagnosis. Interview with the Director of Nursing on 12/30/25 at 3:03 P.M. verified a new PASARR had not been completed following the addition of the new diagnosis for Resident #5.

Based on observation, medical record review, and staff interview, the facility failed to ensure medications were administered as ordered resulting in significant medication errors. This affected two (#8 and #34) of five residents observed during medication administration. The census was 36. Findings Include:1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, cirrhosis of the liver, acquired absence of the right leg above the knee, and chronic kidney disease, stage three. Review of Resident #8's current physician orders revealed an order for insulin aspart three (3) units subcutaneously (SQ) via injector pen before meals with instructions to hold for a blood glucose level less than 200 milligrams per deciliter (mg/dL).Observation of medication administration on 12/31/25 at 8:45 A.M. revealed Licensed Practical Nurse (LPN) #201 obtained Resident #8's blood glucose level with a reading of 245 mg/dL. LPN #201 then prepared medications to administer to Resident #8 including the resident's insulin aspart 3 units SQ. Further observation revealed she did not prime the injector pen prior to dialing in the ordered dose of insulin and then injected Resident #8 with the insulin.2. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic diastolic heart failure, and atrial fibrillation.Review of Resident #34's current physician orders revealed an order for insulin lispro sliding scale insulin administered SQ via injection pen. The sliding scale orders included for blood glucose levels between 251 and 300 mg/dL, give 12 units of insulin before meals and at bedtime for diabetes.Observation of medication administration on 12/31/25 at 8:28 A.M. revealed LPN #201 obtained Resident #34's blood glucose level with a reading of 285 mg/dL. LPN #201 determined Resident #24 would require 12 units of insulin based on the sliding scale order and proceeded to dial up the required dose without first priming the injector pen. Further observation revealed LPN #201 administered the insulin to Resident #34.Interview on 12/31/25 at 9:20 A.M. with LPN #201 confirmed the insulin pens for Resident #8 and Resident #34 were not primed prior to administration and should have been which resulted in an incorrect dose being administered. Continued interview with LPN #201 revealed she could not locate the ordered ascorbic acid for Resident #20 and resulted in an omitted medication.Interview on 12/31/25 at 9:25 A.M. with the Director of Nursing (DON) stated all insulin administration injector pens should be primed after putting the needle on and before administering the dose. The DON stated the injector pens should be primed with two units of insulin and then the dose should be dialed up and given after priming it.

Based on observation, medical record review, and staff interview the facility failed to ensure medications were administered as ordered to maintain a medication error rate less than five percent (%). A total of three medication errors were observed out of 38 opportunities for a medication error rate of 7.89%. This affected three (#8, #20, and #34) of five residents observed during medication administration. The census was 36. Findings Include:1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, cirrhosis of the liver, acquired absence of the right leg above the knee, and chronic kidney disease, stage three. Review of Resident #8's current physician orders revealed an order for insulin aspart three (3) units subcutaneously (SQ) via injector pen before meals with instructions to hold for a blood glucose level less than 200 milligrams per deciliter (mg/dL).Observation of medication administration on 12/31/25 at 8:45 A.M. revealed Licensed Practical Nurse (LPN) #201 obtained Resident #8's blood glucose level with a reading of 245 mg/dL. LPN #201 then prepared medications to administer to Resident #8 including the resident's insulin aspart 3 units SQ. Further observation revealed she did not prime the injector pen prior to dialing in the ordered dose of insulin and then injected Resident #8 with the insulin.2. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic diastolic heart failure, and atrial fibrillation.Review of Resident #34's current physician orders revealed an order for insulin lispro sliding scale insulin administered SQ via injection pen. The sliding scale orders included for blood glucose levels between 251 and 300 mg/dL, give 12 units of insulin before meals and at bedtime for diabetes.Observation of medication administration on 12/31/25 at 8:28 A.M. revealed LPN #201 obtained Resident #34's blood glucose level with a reading of 285 mg/dL. LPN #201 determined Resident #24 would require 12 units of insulin based on the sliding scale order and proceeded to dial up the required dose without first priming the injector pen. Further observation revealed LPN #201 administered the insulin to Resident #34.3. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included fracture of an unspecified part of the left femur, fracture of the right pubis, Parkinson's disease, and dementia.Review of Resident #20's current physician orders revealed an order for ascorbic acid oral tablet 100 milligrams (mg) one tablet by mouth one time a day.Observation of medication administration on 12/31/25 at 8:01 A.M. revealed LPN #201 prepared medications to administered to Resident #20 and it was noted the resident's ascorbic acid was not available. LPN #201 proceeded to administer all other scheduled medications to the resident and the ascorbic acid was omitted.Interview on 12/31/25 at 9:20 A.M. with LPN #201 confirmed the insulin pens for Resident #8 and Resident #34 were not primed prior to administration and should have been which resulted in an incorrect dose being administered. Continued interview with LPN #201 revealed she could not locate the ordered ascorbic acid for Resident #20 and resulted in an omitted medication.Interview on 12/31/25 at 9:25 A.M. with the Director of Nursing (DON) stated all insulin administration injector pens should be primed after putting the needle on and before administering the dose. The DON stated the injector pens should be primed with two units of insulin and then the dose should be dialed up and given after priming it.

Based on medical record review, resident and resident family interview, and staff interview, the facility failed to provide care and services for the prompt treatment of a urinary tract infection. This affected one (#14) of three residents reviewed for urinary tract infections. The facility census was 36.Findings include:Record review for Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses included left femur fracture, anemia, acute respiratory failure, chronic kidney disease, falls, congestive heart failure, obesity, depression, gastro-esophageal reflux disease, and polyneuropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had no cognitive impairment. The resident was also assessed to be occasionally incontinent of bladder and frequently incontinent of bowel.Review of a nursing note dated 12/22/25 at 12:17 P.M. revealed Resident #14 began complaining of dysuria (painful urination). A urinalysis with culture and sensitivity was documented as being ordered.Review of a nursing note dated 12/24/25 at 1:11 A.M. revealed a urine specimen had been collected and placed in the refrigerator for the laboratory to pick up.Review of a nursing note dated 12/26/25 at 8:55 A.M. revealed all laboratory results were received with all parties being notified including the resident, family, and medical professional.Review of a nursing note dated 12/27/25 at 12:15 P.M. revealed facility staff were notified by the resident's daughter that the laboratory results had been reviewed on the resident's electronic medical record, and no antibiotics had been initiated for treatment of a positive urinary tract infection. An order for an antibiotic was obtained at that time for Bactrim double strength (DS) 800-160 milligrams (mg), one (1) tablet by mouth twice daily for seven days. Review of the December 2025 medication administration record (MAR) for Resident #14 revealed the first dose of the antibiotic was provided on 12/27/25 at 8:00 P.M.Interview with Resident #14 and her daughter on 12/29/25 at 10:37 A.M. revealed she first started experiencing symptoms of a urinary tract infection on 12/22/25, and it was more than five days before treatment was started with an antibiotic. Both Resident #14 and her daughter stated treatment was delayed from the beginning of symptoms which was unacceptable.Interview with the Director of Nursing (DON) on 12/30/25 at 3:05 P.M. verified there was a delay in the treatment of a urinary tract infection for Resident #14. The DON verified treatment should have been initiated sooner, considering the resident began complaining of symptoms on 12/22/25.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents received needed and routine dental services. This affected one (Resident #26) of one resident reviewed for dental services. The facility census was 34 residents. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including paroxysmal atrial fibrillation, diabetes mellitus type two, hypertensive heart disease and depression. Review of the care plan for Resident #26 initiated 05/02/23 revealed it did not include a care plan for dental/oral care. Review of Minimum Data Set (MDS) assessment for Resident #26 dated 08/30/24 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs).) Review of the physician's orders for Resident #26 dated October 2024 revealed the resident received a regular diet with regular texture and thin liquids. Review of the medical record for Resident #26 revealed it did not include any dental progress notes. Interview on 10/28/24 at 10:49 A.M. with Resident #26 confirmed he had not seen a dentist since his admission to the facility. Resident #26 stated he had poor dental health and would like to see a dentist Interview on 10/30/24 at 1:50 P.M. with Social Services Leader (SSL) #54 confirmed Resident #26 had not been seen by a dentist since admission to the facility on [DATE]. Review of the facility policy titled Dental Services dated November 2016 revealed the facility was to provide routine ancillary services including dental care.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident medications were administered as ordered by the physician. This affected two (Resident #22 and Resident #28) of five residents reviewed for unnecessary medications. The facility census was 34 residents. Findings include: 1.Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including dementia with psychotic disturbance, diabetes mellitus type two, adult failure to thrive, peripheral vascular disease, insomnia, depression, anxiety and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 08/29/24 revealed the resident #22 had moderately impaired cognition and required staff assistance with activities of daily living (ADLs.) Review of the pharmacy recommendation for Resident #22 dated 10/07/24 revealed the pharmacist recommended the resident's dose of Celexa be reduced from 20 milligrams (mg) daily to 10 mg daily. The attending physician signed in agreed and the order was written. Review of the physician progress note for Resident #22 dated 10/14/24 revealed the had been crying uncontrollably after gradual dose reduction. The physician's plan was to increase the Celexa back to 20 mg. Review of the nursing progress notes for Resident #22 dated 10/14/24 revealed the resident was tearful when the attending physician was in the facility and the physician gave an order for Celexa 20 mg. Review of the physician's orders for Resident #22 for October 2024 revealed an order dated 10/07/24 for Celexa 10 mg daily and an order dated 10/14/24 for Celexa 20 mg daily. Review of the Medication Administration Record (MAR) for Resident #22 dated October 2024 revealed the resident received two doses of Celexa 10 mg and 20 mg from 10/14/24 to 10/30/24. Interview on 10/30/24 at 1:55 P.M. with Unit Manager (UM) #52 confirmed Resident #22 received an excessive dose of Celexa with staff administering a 10 mg tablet and a 20 mg tablet daily from 10/14/24 to 10/30/24. Unit Manager #52 confirmed when the physician gave the order on 10/14/24 to increase the Celexa to 20 mg, the order for the 10 mg tablet should have been discontinued. 42728 2. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including dementia with behavioral disturbances, psychosis, and wandering. Review of the physician's orders for Resident #28 revealed an order dated 05/22/23 for Seroquel 25 mg once daily. Review of the hospice progress note for Resident #28 dated 11/15/23 revealed the hospice physician gave an order to increase the resident's Seroquel from 25 mg once daily to 25 mg twice daily. Review of the October 2024 monthly physician's orders for Resident #28 revealed the resident's Seroquel dose ordered 05/22/23 had never been increased as ordered by the physician on 11/15/23. Review of the quarterly MDS assessment for Resident #28 dated 08/09/24 revealed the resident was cognitively impaired. Interview on 10/30/24 at 2:10 P.M with the Director of Nursing (DON) confirmed the facility did not carry out the physician's order to increase Resident #28's Seroquel from 25 mg once daily to Seroquel 25 mg twice daily as ordered by the physician on 11/15/23. Review of the facility policy titled Medication Administration dated June 2014 revealed the facility staff would correctly administer resident medications as ordered by the physician.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure staff practiced proper infection control precautions during an outbreak of COVID-19. This had the potential to affect all 25 residents (#1, #3, #5, #6, #7, #11, #12, #13, #14, #15, #17, #18, #20, #21, #22, #24, #26, #28, #29, #30, #31, #32, #35, #36, and #42) who were negative for COVID-19 and resided on the same unit as Resident #10 and Resident #27. The census was 41. Findings include: Observation on 12/06/23 from 9:55 A.M. to 10:10 A.M. revealed State tested Nursing Aide (STNA) #103 walking out of Resident #10 and Resident #27's room, who were on droplet isolation precautions due to having COVID-19. She removed all of her used personal protective equipment (PPE) except for her N95 respirator prior to walking out of their room. When she got out of their room, she took her N95 respirator off with her left hand, balled it up and placed it on a plastic cart. She placed a surgical mask on her face, took the used N95 respirator and disposed of it in the trash can near the food service area, which was approximately 25 feet from where Resident #10 and Resident #27's room. Review of Resident #10 and Resident #27's medical record revealed they tested positive for COVID-19 on 12/03/23 and 12/04/23 respectively. Interview with STNA #103 on 12/06/23 at 10:10 A.M. confirmed she walked out of Resident #10 and Resident #27's room with her used N95 respirator on. She stated she should have taken it off in their room and disposed of it, but she did not. Interview with Licensed Practical Nurse (LPN) #102 on 12/06/23 at 1:03 P.M. revealed staff are to remove all PPE prior to leaving Resident #10 and Resident #27's room. Review of the facility COVID-19 protocol, dated 08/01/23, revealed doffing PPE for respiratory pathogens in the following sequence: first gloves, then goggle/face shield, then gown, then face mask/respirator. All PPE must be removed upon exit of the room. This deficiency represents non-compliance investigated under Complaint Number OH00148887.

Based on observation, record review, interview and facility policy review, the facility failed to ensure five residents (#3, #5, #15, #34 and #41) indwelling urinary catheter collection bag was covered for privacy. This affected five of seven residents reviewed for indwelling urinary catheters. The facility identified seven residents with indwelling urinary catheters. The facility census was 42. Findings Include: 1. Review of the medical record for Resident #3 revealed an initial admitted [DATE] with the latest readmission of 04/05/23 with diagnoses including chronic respiratory failure, atrial fibrillation, emphysema, hypertension, chronic kidney disease, anemia, basal cell carcinoma of skin of right upper limb, obstructive and reflux uropathy, osteoarthritis, hyperlipidemia and gastro-esophageal reflux disease. Review of the plan of care dated 01/23/23 revealed the resident was admitted to the facility with an indwelling urinary catheter in place for obstructive uropathy. Interventions included size 18 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's quarterly Minimum Data Set (MDS) assessment indicated the resident had a moderate cognitive impairment. The resident required extensive assistance of two staff for toilet use, had an indwelling urinary catheter and was always incontinent of bowel. Review of the monthly physician orders for November 2023 identified orders dated 01/20/23 indwelling urinary catheter to straight drain and provide catheter care every shift for urinary retention, change indwelling urinary catheter and catheter collection bag as a unit for blockage, leakage or malfunction as needed, 03/27/23 following peri-care per facility protocol, apply calmoseptine to bilateral buttocks and coccyx every shift and as needed, 07/24/23 maintain indwelling urinary catheter size 18 FR with 10 ml balloon to straight drain for diagnosis of obstruction every shift. Observation on 11/06/23 at 6: 21 A.M. of Resident #3 revealed the resident's indwelling urinary catheter collection bag was not contained in a privacy bag and urine was visible from the hallway. Interview on 11/06/23 at 6:35 A.M. with Licensed Practical Nurse (LPN) #109 verified the indwelling urinary catheter collection bag was not covered for privacy and urine was visible from the hallway. 2. Review of the medical record for Resident #15 revealed an initial admitted [DATE] with the latest readmission of 10/26/23 with diagnoses including periprosthetic fracture around internal prosthetic right knee joint, removal of internal fixation device, diabetes mellitus, emphysema, protein calorie malnutrition, retention of urine, seizures, neuromuscular dysfunction of bladder, urinary tract infection, sepsis due to E-coli, hypertension, gout, gastro-esophageal reflux disease, major depressive disorder and visual loss. Review of the plan of care dated 08/14/23 revealed the resident was admitted to the facility with an indwelling urinary catheter in place for neurogenic bladder. Interventions included size 16 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's state optional MDS assessment dated [DATE] revealed the resident had no cognitive impairment. The resident required extensive assistance of two staff for toilet use. Review of the monthly physician orders for November 2023 identified orders dated `0/27/23 indwelling urinary catheter to straight drain, maintain and provide indwelling urinary catheter care every shift, change indwelling urinary catheter and drainage bag as a unit for blockage leakage or malfunction and maintain indwelling urinary catheter size 16 FR with 10 ml balloon to straight drain for diagnosis of neurogenic bladder. Observation on 11/06/23 at 8:55 A.M. of Resident #15 revealed the resident's indwelling urinary catheter collection bag was not contained in a privacy bag and urine was visible from the hallway. Interview with State tested Nursing Assistant (STNA) #102 verified the indwelling urinary catheter collection bag was not covered for privacy and urine was visible from the hallway at the time of the observation. 3. Review of the medical record for Resident #34 revealed an initial admitted [DATE] with the diagnoses including ataxia following cerebral infarction, aphasia, dysphagia, dementia, hypertension, diabetes mellitus, retention of urine, hypothyroidism, neuromuscular dysfunction of bladder and insomnia. Review of the plan of care dated 08/22/23 revealed the resident was admitted with an indwelling urinary catheter in place for neurogenic bladder, voiding trial attempted at hospital without success. Interventions included size 18 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's comprehensive MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of two staff for toilet use. The assessment indicated the resident had an indwelling urinary catheter and was frequently incontinent of bowel. Review of the monthly physician orders for November 2023 identified orders dated 08/19/23 indwelling urinary catheter to straight drain, maintain and provide indwelling urinary catheter care every shift, 10/12/23 maintain indwelling urinary catheter size 18 FR with 10 ml balloon to straight drain for diagnoses of neurogenic bladder and 11/03/23 change indwelling urinary catheter and drainage bag as a unit for blockage, leakage or malfunction. Observation on 11/06/23 at 9:28 A.M. of Resident #34 revealed the resident was sitting up on the side of her bed. The resident's indwelling urinary collection bag was laying on the floor with no privacy cover and urine was visible from the hallway. Interview on 11/06/23 at 9:36 A.M. with Registered Nurse (RN) #116 verified the indwelling urinary collection bag had no privacy cover and urine was visible from the hallway. 4. Review of the medical record for Resident #41 revealed an initial admitted [DATE] with the diagnoses including nonalcoholic steatohepatitis, palliative care, Parkinsonism, diabetes mellitus, hypertension, gastro-esophageal reflux disease, and neuromuscular dysfunction of bladder. Review of the clinical admission assessment dated [DATE] revealed the resident was alert and oriented. Review of the functional abilities and goals dated 10/23/23 revealed the resident required maximal assistance with toilet use. Review of the plan of care dated 10/23/23 revealed the resident was admitted with indwelling urinary catheter in place for neurogenic bladder. Interventions included size 16 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's MDS list revealed the comprehensive MDS dated [DATE] revealed the assessment was not completed. Review of the monthly physician orders for November 2023 identified orders dated 10/20/23 indwelling urinary catheter to straight drain, maintain and provide catheter care every shift, change indwelling urinary catheter [NAME] as a unit for blockage, leakage or malfunction as needed and maintain indwelling urinary catheter size 16 FR with 30 ml balloon to straight drain for diagnoses of neurogenic bladder. Observation on 11/06/23 at 9:30 A.M. revealed Resident #41's indwelling urinary catheter bag had no privacy cover and urine was visible from the hallway. Further observation revealed the indwelling urinary catheter bag was hanging on the side rail above the resident's bladder. Interview on 11/06/23 at 9:36 A.M. with Registered Nurse (RN) #116 verified the indwelling urinary collection bag had no privacy cover and urine was visible from the hallway. 5. Review of the medical record for Resident #5 revealed an initial admitted [DATE] with the latest readmission of 10/10/23 with diagnoses including severe protein calorie malnutrition, gastrostomy, chronic respiratory failure, diabetes mellitus, congestive heart failure, chronic kidney disease, peripheral venous insufficiency, urinary tract infection, major depressive disorder, atrial fibrillation, obstructive and reflux uropathy, hypertension, gout, carpal tunnel syndrome, anemia and osteoarthritis. Review of the plan of care dated 05/22/23 revealed the resident had an indwelling urinary catheter in place for urinary obstruction. Interventions included size 14 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's comprehensive MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of two staff for toilet use. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. Review of the monthly physician orders for November 2023 identified orders dated 09/21/23 indwelling urinary catheter to straight drain, maintain and provide catheter care every shift, change indwelling urinary catheter [NAME] as a unit for blockage, leakage or malfunction as needed and maintain indwelling urinary catheter size 14 FR with 30 ml balloon to straight drain for diagnoses of neurogenic bladder. Observation on 11/06/23 at 9:34 A.M. of Resident #5 revealed the resident's indwelling urinary catheter had no privacy bag and urine was visible from the hallway. Further observation revealed the resident's indwelling catheter bag was hanging on the bed side rail above the resident's bladder. Interview on 11/06/23 at 9:36 A.M. with Registered Nurse (RN) #116 verified the indwelling urinary collection bag had no privacy cover and urine was visible from the hallway. Review of the facility policy titled, Catheter-Urinary Female and Male, last revised 03/19 revealed the indwelling catheter drainage bag was to be placed in a catheter bag cover. This deficiency represents non-compliance investigated under Complaint Number OH00147383.

Based on observation, record review, interview and facility policy review, the facility failed to ensure three residents (#5, #34 and #41) indwelling urinary catheter collection bag was properly positioned to facilitate optimal drainage of urine. This affected three of seven residents reviewed for urinary catheter. The facility identified seven residents with indwelling urinary catheters. The facility census was 42. Findings Include: 1. Review of the medical record for Resident #34 revealed an initial admitted [DATE] with the diagnoses including ataxia following cerebral infarction, aphasia, dysphagia, dementia, hypertension, diabetes mellitus, retention of urine, hypothyroidism, neuromuscular dysfunction of bladder and insomnia. Review of the plan of care dated 08/22/23 revealed the resident was admitted with an indwelling urinary catheter in place for neurogenic bladder, voiding trial attempted at hospital without success. Interventions included size 18 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's comprehensive minimum data set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of two staff for toilet use. The assessment indicated the resident had an indwelling urinary catheter and was frequently incontinent of bowel. Review of the monthly physician orders for November 2023 identified orders dated 08/19/23 indwelling urinary catheter to straight drain, maintain and provide indwelling urinary catheter care every shift, 10/12/23 maintain indwelling urinary catheter size 18 FR with 10 ml balloon to straight drain for diagnoses of neurogenic bladder and 11/03/23 change indwelling urinary catheter and drainage bag as a unit for blockage, leakage or malfunction. Observation on 11/06/23 at 9:28 A.M. of Resident #34 revealed the resident was sitting up on the side of her bed. The resident's indwelling urinary collection bag was laying on the floor with no privacy cover and urine was visible from the hallway. Interview on 11/06/23 at 9:36 A.M. with Registered Nurse (RN) #116 verified the indwelling urinary collection bag was laying on the floor preventing optimal drainage of urine. 2. Review of the medical record for Resident #41 revealed an initial admitted [DATE] with the diagnoses including nonalcoholic steatohepatitis, palliative care, Parkinsonism, diabetes mellitus, hypertension, gastro-esophageal reflux disease, and neuromuscular dysfunction of bladder. Review of the clinical admission assessment dated [DATE] revealed the resident was alert and oriented. Review of the functional abilities and goals dated 10/23/23 revealed the resident required maximal assistance with toilet use. Review of the plan of care dated 10/23/23 revealed the resident was admitted with indwelling urinary catheter in place for neurogenic bladder. Interventions included size 16 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's MDS list revealed the comprehensive MDS dated [DATE] revealed the assessment was not completed. Review of the monthly physician orders for November 2023 identified orders dated 10/20/23 indwelling urinary catheter to straight drain, maintain and provide catheter care every shift, change indwelling urinary catheter [NAME] as a unit for blockage, leakage or malfunction as needed and maintain indwelling urinary catheter size 16 FR with 30 ml balloon to straight drain for diagnoses of neurogenic bladder. Observation on 11/06/23 at 9:30 A.M. revealed Resident #41's indwelling urinary catheter bag had no privacy cover and urine was visible from the hallway. Further observation revealed the indwelling urinary catheter bag was hanging on the side rail above the resident's bladder. Interview on 11/06/23 at 9:36 A.M. with Registered Nurse (RN) #116 verified the indwelling urinary collection bag was hanging above the bladder preventing optimal draining of urine. 3. Review of the medical record for Resident #5 revealed an initial admitted [DATE] with the latest readmission of 10/10/23 with diagnoses including severe protein calorie malnutrition, gastrostomy, chronic respiratory failure, diabetes mellitus, congestive heart failure, chronic kidney disease, peripheral venous insufficiency, urinary tract infection, major depressive disorder, atrial fibrillation, obstructive and reflux uropathy, hypertension, gout, carpal tunnel syndrome, anemia and osteoarthritis. Review of the plan of care dated 05/22/23 revealed the resident had an indwelling urinary catheter in place for urinary obstruction. Interventions included size 14 FR indwelling urinary catheter with 10 milliliter (ml) balloon, position catheter bad and tubing below the level of the bladder and away from entrance room door, change as needed for leakage/blockage, ensure tubing is free of kinks, follows with urology and nephrology, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter and monitor/record/report to physician any signs or symptoms of urinary tract infection. Review of the resident's comprehensive MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of two staff for toilet use. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. Review of the monthly physician orders for November 2023 identified orders dated 09/21/23 indwelling urinary catheter to straight drain, maintain and provide catheter care every shift, change indwelling urinary catheter [NAME] as a unit for blockage, leakage or malfunction as needed and maintain indwelling urinary catheter size 14 FR with 30 ml balloon to straight drain for diagnoses of neurogenic bladder. Observation on 11/06/23 at 9:34 A.M. of Resident #5 revealed the resident's indwelling urinary catheter had no privacy bag and urine was visible from the hallway. Further observation revealed the resident's indwelling catheter bag was hanging on the bed side rail above the resident's bladder. Interview on 11/06/23 at 9:36 A.M. with Registered Nurse (RN) #116 verified the indwelling urinary collection bag was hanging above the bladder preventing optimal draining of urine. Review of the facility policy titled, Catheter-Urinary Female and Male, last revised 03/19 revealed the are to be hung below the level of the bladder and do not hang on bed rail. This deficiency represents non-compliance investigated under Complaint Number OH00147383.

Based on observation, resident interview, staff interview, and medical record review the facility failed to identify and monitor a resident's skin with regards to bruising and a discolored area. This affected one (Resident #04) of four sampled residents reviewed for skin conditions non-pressure. The facility census was 32. Findings include: Review of Resident #04's medical record revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #04's quarterly Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #04 had minimal difficulty hearing, had a hearing aid, her speech was clear, she made herself understood, understands others, and her cognition was intact. Resident #04 had minimal depression, had no indicators of [CONDITION(S)], had no behaviors, and did not reject care. Resident #04 required extensive assistance of two staff for bed mobility, to transfer, and to walk. Resident #04 had no skin conditions. Review of Resident #04's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #04's skin assessment dated [DATE] revealed a new skin tear on Resident #04's right leg that measured 0.7 centimeter (cm) by 0.7 cm. Review of Resident #04's progress notes from 05/01/22 to 05/12/22 revealed no bruises or other skin abnormalities. Observation of Resident #04 on 05/09/22 at 10:14 A.M. revealed a scabbed area on her right leg, a dark circular area on her left leg, and a bruise on her left forearm. The areas were observed on 05/10/22 at 1:54 P.M., 05/11/22 at 8:49 A.M., and 05/12/22 at 10:11 A.M. Interview of Resident #04 on 05/09/22 at 10:14 A.M. revealed the bruise on her left arm happened a few days earlier when she was hugged by staff. The bruise was an accident. Interview of Resident #04 on 05/12/22 at 2:26 P.M. revealed she had a scabbed area on inner left calf, outer right calf, and a bruise on left forearm. Interview of Registered Nurse (RN) #141 on 05/13/22 at 7:46 A.M. confirmed she was not aware of the bruise or the area on Resident #04's left leg. RN #141 stated she was not sure what the area was on Resident #04's left leg, but the doctor would be in today and would look at it.

Based on resident interview, staff interview, and medical record review the facility failed to provide treatment and services to a resident who had a decline in both urinary and bowel continence. This affected one resident (Resident #14) of two sampled residents reviewed for bowel and bladder incontinence. The facility census was 32. Findings include: Review of Resident #14's medical record revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's annual Minimum Data Set (MDS) dated [DATE] revealed the following. Resident # 14's speech was clear, she had herself understood, understands others, and her cognition was intact. Resident #14 had minimum depression, had no indicators of [CONDITION(S)], had no behaviors, and did not reject care. Resident #14 required extensive assistance of two staff for bed mobility, to transfer, and did not walk. Resident #14 had no toileting program, was frequently incontinent of urine and was always continent of bowel. Review of Resident #14's quarterly MDS dated [DATE] revealed the following changes Resident #14 had mild depression, was dependent on two staff to transfer, was always incontinent of urine and frequently incontinent of bowel. There was no comprehensive assessment conducted when Resident #14's bladder incontinence worsened, and her bowel continence declined. Resident 14's monthly bladder and bowel assessment did not identify the decline in her continence or the potential cause of the decline. Resident #14's medical record contained no evidence of measures to restore, to the extent possible, her bowel and bladder continence. Interview of State tested Nursing Assistant (STNA) #100 on 05/11/22 at 1:39 P.M. revealed Resident #14 was continent of bowel and sometimes she was incontinent of bladder. Resident #100 used to ask for bed pan, then she just stopped and use her adult incontinence product. STNA #100 stated there was no reason she was aware of why Resident #14 stopped asking for it. STNA #100 stated the only in Resident #14's life was her mother passed but nothing else. Interview of Registered Nurse (RN) #118 on 05/11/22 at 2:12 P.M. confirmed no comprehensive assessment of Resident #14's bowel and bladder continence decline was conducted and no treatment and services were provided to restore as much normal function as possible were provided for Resident #14. Interview of Resident #14 on 05/12/22 at 8:28 A.M. revealed she no longer use the bed pan; she just used the incontinence brief and tells the staff when she was wet. She did not provide and answer as to why she did not ask for the bed pan for a bowel movement.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility ' s policy and procedure, record reviews, observations, and staff interviews, the facility failed to appropriately implement the use of Personal Protective Equipment (PPE) and isolation procedures to prevent the spread of the [CONDITION(S)]-CoV-2 virus (COVID-19) among facility residents. This resulted in Immediate Jeopardy when three Residents (#02, #15, and #18), who had active infection with COVID-19 and were on isolation precautions, were observed in the communal dining and activity area of the facility with other residents who were identified as not having COVID-19. Staff members were observed to provide care and services to the three COVID-19 positive residents without donning the appropriate PPE and then proceeded to provide care and services to the remaining residents in the facility without changing their N-95 masks or cleansing their eye protection. This placed the 13 Residents (#01, #03, #04, #06, #08, #12, #16, #21, #22, #23, #24, #29, and #30), who had not had an active infection with COVID-19 in the past 90 days, at potential risk for serious life-threatening negative health outcomes. The facility census was 30. On 01/27/22 at 4:15 P.M., the Administrator was notified Immediate Jeopardy began on 01/27/22 when three Residents (#02, #15, and #18), who had active COVID-19 infections and were on isolation precautions, were observed sitting in the communal dining and activity room of the facility with five residents (#01, #04, #12, #21, and #24) who had not had an active infection with COVID-19 in the past 90 days. State tested Nursing Assistant (STNA) #110 and STNA #120 were observed to sit down directly beside Resident #02 and Resident #18 and assist them to eat their lunch meal while wearing an N-95 mask and eye protection. STNA #110 and STNA #120 then proceeded to deliver the lunch meal to the remaining residents in their rooms, which included eight residents (#03, #06, #08, #16, #22, #23, #29, and #30) who had not had active infections with COVID-19 in the past 90 days, without changing their N-95 masks or cleansing their eye protection. The Immediate Jeopardy was removed on 01/28/22 when the facility implemented the following corrective actions: · On 01/27/22 at 4:30 P.M., the Director of Nursing (DON) validated Resident #02, Resident #15, and Resident #18 had been placed in their rooms in appropriate isolation precautions. · On 01/27/22, Regional Director of Clinical Services (RDCS) #900 provided re-education to the DON regarding requirements of proper isolation and quarantine procedures for residents infected with [CONDITION(S)]-COV-2 or exposed to [CONDITION(S)]-COV-2 as well as proper PPE to be worn while providing care to residents infected with the [CONDITION(S)]-COV-2 virus. · On 01/27/22 at 5:00 P.M., the DON provided one-on-one education to all nursing staff currently working who were providing direct care to residents regarding proper PPE to be worn while providing care to residents infected with the [CONDITION(S)]-COV-2 virus and proper isolation procedures. · On 01/27/22, all residents not infected with the [CONDITION(S)]-COV-2 virus were tested for infection and were placed on quarantine precautions. No further positive results were noted. · On 01/28/22, the DON and designee provided re-education to all staff regarding proper isolation and quarantine procedures for residents infected with the [CONDITION(S)]-COV-2 virus or those exposed to the [CONDITION(S)]-COV-2 virus as well as proper PPE to be worn while providing care to residents infected with the [CONDITION(S)]-COV-2 virus. · On 01/28/22, the DON or licensed nurse began to conduct random audits utilizing the COVID Isolation/PPE audit tool daily for five days, then three times a week for four weeks. The Administrator or designee began to conduct audits of the dining room daily during mealtimes for five days, then three times a week for four weeks. The Quality Assurance Performance Improvement (QAPI) committee would then review the results of the audits at the end of the four-week period to determine the need to conduct further audits. · Interviews on 01/28/22 from 11:00 A.M. through 12:30 P.M. with Registered Nurse (RN) #300, Licensed Practical Nurse (LPN) #300, STNA #110, STNA #120, STNA #130, Speech Therapist #400, and Life Enrichment Assistant #425 revealed they had all received in-servicing regarding appropriate isolation precautions and PPE to be worn while caring for residents infected with the [CONDITION(S)]-CoV-2 virus. All staff interviewed were knowledgeable regarding the use of isolation and PPE. · On-site observations on 01/28/22 revealed all residents with active infection with the [CONDITION(S)]-COV-2 virus were on appropriate isolation precautions in their rooms and staff were observed wearing appropriate PPE while providing care for those residents. Although the Immediate Jeopardy was removed on 01/28/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #02 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) assessment, dated 12/01/21, revealed this resident had severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 02 (13 to 15 points: intact cognition. 8 to 12 points: moderately impaired cognition. 0-7 points: severely impaired cognition). This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. The resident was assessed to require supervision with physical assistance of one staff member for eating. Review of the medical record for Resident #15 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 01/05/22, revealed this resident had severely impaired cognition evidenced by a BIMS assessment score of 03. This resident was assessed to require limited assistance from one staff member for transfers and was dependent on one staff member for locomotion off the unit. The resident was assessed to require supervision with set up assistance from staff for eating. Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment, dated 01/20/22, revealed the resident was rarely/never understood. Resident #18 was assessed to be dependent on two staff members for transfers and toileting and dependent on one staff member for locomotion of the unit. This resident was assessed to require limited assistance of one staff member for eating. Review of the facility list of COVID-19 positive residents in the last 90 days revealed Resident #02, Resident #15, and Resident #18 had tested positive for COVID-19 on 01/18/22. Observation on 01/27/22 at 10:30 A.M. revealed Resident #02, Resident #15, and Resident #18 sitting in the communal dining and activity area of the facility. The doors to the rooms of Resident #02, Resident #15, and Resident #18 were observed to have isolation precaution signs and PPE equipment hanging on them. Interview with STNA #110 on 01/27/22 at 10:45 A.M. revealed Resident #02, Resident #15, and Resident #18 were on isolation precautions due to active infections with COVID-19. STNA #110 stated the residents were not independently ambulatory and staff had to assist them up and into the communal dining and activity room every day. Interview with RN #300 on 01/27/22 at 11:20 A.M. revealed residents who had active infections with COVID-19 were to be on isolation precautions for ten days. Observation of the lunch meal being served on 01/27/22 from 12:00 P.M. through 12:35 P.M. revealed Resident #02, Resident #15, and Resident #18 continued to be in the communal dining and activity area. STNA #110 was observed to hand Resident #15 her lunch meal tray and assist in setting the tray up while wearing an N-95 and eye protection. STNA #110 did not change the N-95 mask or clean the eye protection after being in close proximity to Resident #15 prior to delivering lunch meal trays to additional residents in the communal dining area. STNA #130 sat down in a chair beside Resident #18 and proceeded to assist the resident to consume her lunch meal while wearing an N-95 mask and eye protection. STNA #120 sat down in a chair beside Resident #02 and proceeded to assist the resident to consume her lunch meal while wearing an N-95 mask and eye protection. Once Resident #02 and Resident #18 were finished eating, STNA #120 and STNA #130 assisted STNA #110 to deliver the lunch meal trays to all residents remaining in their rooms without changing the N-95 mask or cleaning the eye protection they were wearing. Interview with STNA #120 on 01/27/22 at 12:42 P.M. verified she had not donned additional PPE prior to assisting Resident #02 to consume her lunch meal and had not changed her N-95 mask or cleansed her eye protection prior to providing care and services to residents who did not have a known active infection with COVID-19. Interview with STNA #130 on 01/27/22 at 12:50 P.M. verified she had not donned additional PPE prior to assisting Resident #18 to consume her lunch meal and had not changed her N-95 mask or cleansed her eye protection prior to providing care and services to residents who did not have a known active infection with COVID-19. STNA #130 stated staff were to cover their N-95 masks with a surgical mask and don a gown prior to entering the room of a resident on isolation precautions for infection with COVID-19 and was unsure why staff did not have to wear additional PPE around the residents when they were outside their room. Interview with LPN #200 on 01/27/22 at 1:40 P.M. revealed she did not don any additional PPE when administering medications to residents infected with COVID-19 when they were in the communal dining and activity area as she was not sure how she would don and doff the PPE appropriately. Interview with the DON on 01/27/22 at 1:50 P.M. revealed the three Residents (#02, #15, and #18) had active infections with COVID-19 and were in isolation precautions but were brought out to the communal dining and activity area due to being high fall risks or at risk for choking. The DON confirmed the residents could be fed in their room while staff were wearing appropriate PPE. Review of the online CDC guidance for long-term care facilities titled Infection Control Guidance, updated 09/10/21, revealed the facility should limit transport and movement of the patient outside of the room to medically essential purposes and Healthcare Personnel (HCP) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covered the front and sides of the face). Review of the facility policy titled COVID-19 Resident Suspected or Confirmed Case, not dated, revealed residents who tested positive for COVID-19 should be immediately placed in isolation in a single-person, private room with the door closed with a dedicated bathroom and a limited number of trained, dedicated employees should be assigned to strictly adhere to Standard, Contact, and Airborne Precautions with appropriate PPE while caring for the resident. This deficiency substantiates Complaint Number OH 609.

Based on medical record review, observations and staff and Medical Director interviews, the facility failed to ensure medications were administered according to the medication instructions resulting in two medication errors out of 25 opportunities or an eight percent (%) medication error rate. This affected one (#20) of the five residents observed for medication administration. The facility census was 38. Findings include: Record review for Resident #20 revealed this resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 01/14/21, revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of three. This resident was assessed to require set up assistance and supervision for bed mobility, transfers, and toileting. Review of the active physicians orders for Resident #20 revealed this resident was ordered one Potassium Chloride 10 milliequivalent (mEq) Extended Release tablet once a day for low potassium levels and one [MEDICATION NAME] 240 Milligram (mg) Extended Release tablet once a day for hypertension. Observation of medication administration on 03/03/21 from 8:30 A.M. through 9:20 A.M. revealed 25 medications administered observed for four residents, administered by Licensed Practical Nurse (LPN) #113, with two medication errors observed. On 03/03/21 at 8:53 A.M. LPN #113 was observed to prepare medications for administration to Resident #20 which included one tablet each of Potassium Chloride 10 mEq Extended Release and [MEDICATION NAME] 240 mg Extended Release medication. LPN #113 was then observed to crush all medications, mix them in pudding, and administer them to Resident #20. Observation on 03/03/21 at 9:10 A.M. of the packaging for the Potassium Chloride Extended Release tablets and [MEDICATION NAME] Extended Release tablets revealed both medication packages contained the instructions Do not crush or chew medications. This was verified with LPN #113 at the time of the observation. Interview with Medical Doctor (MD) #777 on 03/03/21 at 2:00 P.M. revealed extended release medications should not be crushed or chewed. MD #777 stated when a resident required medication to be crushed any extended release medications should be discontinued and short acting medications ordered to replace them. This deficiency substantiates Complaint Number OH 089.

Based on record review and staff interview,the facility failed to ensure residents had the right to refuse or request treatment when the resuscitation status for a resident was documented as do not resuscitate and full code both in the medical record. This affected one (#36) of 24 residents reviewed during the initial pool. The facility census was 70. Findings include: Record review of Resident #36 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the 03/28/19 significant change Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired. Review of Resident #36 medical record revealed on the electronic face sheet the advanced directives showed both full code and do not resuscitate comfort care status. There was a paper face sheet in the chart that showed Resident #36 was a full code. The DNR identification paper form dated 04/19/19 showed Resident #36 was a do not resuscitate comfort care and was signed by the physician. Interview with the Director of Nursing (DON) 05/15/19 11:10 A.M., verified Resident #36 had numerous code status listed in her medical record. The DON verified the electronic face sheet documented the advanced directives showed both full code and do not resuscitate comfort care status. The DON verified the paper face sheet in the chart that showed Resident #36 was a full code. The DON verified the DNR identification paper form dated 04/19/19 showed Resident #36 was a do not resuscitate comfort care.

Based on medical record review and staff interview, the facility failed to ensure a hospice resident received medications as prescribed by the physician. This affected one (#3) of three hospice residents reviewed. The facility identified fourteen residents receiving hospice services. The facility census was 74. Findings include: Review of medical record for Resident #3 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident was totally dependent on staff for all activities of daily living and was receiving hospice services. Review of physician orders on 10/28/18 revealed the resident's pain medications were changed to a different concentration to decrease the amount of solution for the resident to swallow and an as needed order for break through pain if the routine pain medication was not effective the four hours. The new orders were to administer [MEDICATION NAME] concentrate 20 milligrams (mg.)/one milliliters (ml.) of solution, and administer 0.75 ml. (15 mg.) every four hours at midnight (12:00 A.M.), 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M., for pain. In addition, administer [MEDICATION NAME] 20 mg /one ml. solution, administer one ml. (20 mg.) every two hours as needed for breakthrough pain. Review of the Medication Administration (MAR) for (MONTH) (YEAR) and the Controlled Drug Record for (MONTH) (YEAR) revealed Resident #3 did not receive pain medication as ordered. Review of the resident's [MEDICATION NAME] pain medication revealed the concentration was five mg./five ml. (one mg./one ml.). Further review of the MAR and Controlled Drug Record revealed Licensed Practical Nurse (LPN) #26 documented on 10/29/18 at midnight 12:00 A.M. he administered 0.75 ml. (0.75 mg.) of the scheduled [MEDICATION NAME] instead of the ordered 15 mg. On 10/29/18 at 2:00 A.M., LPN #26 documented he administered one ml. (one mg.) of the as needed [MEDICATION NAME] instead of the ordered 20 mg. On 10/20/18 at 4:00 A.M., LPN #26 documented he administered 0.75 ml. (0.75 mg.) of the scheduled [MEDICATION NAME] instead of the ordered 15 mg. Review of the medical progress notes revealed on 10/29/18, Hospice Nurse RN #69 documented she received a phone call from the resident's daughter on 10/28/18 at 11:45 P.M., that resident was restless and uncomfortable. Upon arrival at 2:00 A.M., the resident was lying in bed head slightly elevated and oxygen on per nasal cannula. She was restless at times this visit but wasn't grimacing or moaning in pain. The resident was repositioned for comfort. The daughters were at bedside and concerned about client being restless at times. She encouraged the family to dim lights and try to keep the environment calm with minimal stimulation. The daughter verbalized understanding but continued to keep lights on in resident's room. She spoke with facility LPN #26 and he gave her a dose of as needed medication for pain which she tolerated well, and it seemed to be effective. The resident seemed to be comfortable and was snoring when she left the faciliy. Interview with Resident #3's daughter on 10/29/18 at 9:22 A.M., revealed the resident was restless during the night and moving more and not sleeping as well but the resident would deny having any pain. The daughter stated the resident will sometimes answer yes or no but does not have conversation. Interview with another of Resident #3's family on 10/29/18 at 4:01 P.M., revealed all the family visited last night. They thought she would not make it until the morning. She stated her mother was more restless, so they called the hospice nurse and she came in and saw her and thought all the visitors was causing the restlessness. She stated after the family left, her mother calmed down and the lights were turned down. The daughter denied the resident was in pain. On 10/29/18 at 3:31 P.M., a telephone interview was conducted with LPN #26 and revealed the family called the hospice nurse because they did not think she would make it through the night. Several family members came in and some had to stand in the hallway because there was not enough room in the resident's room. The LPN felt the resident did not appear in pain. The physician changed the concentration of the pain medication the evening of 10/28/18 so the resident could swallow smaller amounts of liquid. She administered the pain medication according to the orders on the MAR and she was not aware she had made a medication error until the DON notified her that day. She said then she realized the bottle of [MEDICATION NAME] was five mg./five ml. not the new ordered concentration of 20 mg./ml. She stated she feels terrible the resident did not get the prescribed amount of pain medication. Review of the facility policy titled Medication Administration, dated (MONTH) 2005, revised (MONTH) 2014 revealed the purpose was to correctly administer resident medications. Under number 12, it stated to give the resident the correct medication, correct dosage, by correct route, and position resident properly. This deficiency substantiates Complaint Number OH 646.

Based on staff interviews and medical record review the facility failed to monitor blood pressure for one resident. This affected one (#29) of five residents reviewed for medications. The facility census was 76. Findings include: Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 02/17/18, the resident had moderate cognitive impairment. Review of physician's orders [REDACTED].) twice daily for hypertension; an order, dated 09/16/17, [MEDICATION NAME] 10 mg. tablet twice daily for hypertension and [MEDICAL CONDITION], and an order, dated 10/24/17, [MEDICATION NAME] 50 mg. every six hours for hypertension. Hold medication if systolic blood pressure was under 90 mm Hg. or diastolic blood pressure was under 50 mm Hg. Review of a care plan, dated 10/24/17, revealed the resident had a [DIAGNOSES REDACTED]. Interventions included to administer [MEDICATION NAME] per orders, administer medications per orders, and monitor blood pressure per orders. Medical record review revealed there was no evidence the resident's blood pressure was monitored as physician ordered. An interview on 04/25/18 4:26 P.M. with Associate Director of Nursing (ADON) #6 verified Resident #29's blood pressure was not being monitored and stated she notified the physician that Resident #29 blood pressure was not being monitored.

Based on record reviews, observations, and staff interviews, the facility failed to follow physician orders [REDACTED]. This affected one (#126) of one residents reviewed for nutrition. The facility identified 16 residents who receive adaptive equipment. The facility census was 76 residents. Findings include: A record review revealed Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) assessment, dated 04/13/18, revealed Resident #126 was cognitively impaired and was assessed as limited one person assist for eating. Review of the electronic physician order, dated 04/10/18, revealed an order to provide built up utensils to enhance the ability to feed self. Review of the resident's nutritional plan of care, dated 04/10/18, revealed Resident #126 had contracture right hand and a history of left wrist fracture with increased difficulty feeding self. Interventions, dated 04/10/18, stated to provide the resident with built up utensils to enhance the ability to feed self and staff to assist with cutting up foods. Review of the dietary note, dated 04/10/18, revealed a care conference occurred that addressed Resident #126 had difficulty cutting up food due to the contracture of the right hand and an old fractured left wrist and the the resident did well with built up utensils. On 04/24/18 at 8:41 A.M., observation of Resident#126 revealed the resident was seated in his room struggling to open a straw for juice served with breakfast. When asked if the resident needed help, the resident stated he could do it. It was noted there were no built up utensils on the breakfast tray. On 04/24/18 at 1:04 P.M., observation revealed Resident #126 was utilizing regular utensils to eat lunch at the dining room table. On 04/25/18 at 12:12 P.M., observation of Resident #126 was seated in a wheelchair at the table in the dining room for lunch. The resident was served a regular diet of pork steak with gravy, noodles, and cauliflower with fruit pudding for desert. The pork steak was not cut up. The resident had regular utensils. The resident was observed poking the meat with a fork and attempted to cut it up. Resident #126 was unable to cut the pork steak up. The resident attempted to fork up some noodles but was unsuccessful. On 04/25/18 at 12:15 P.M. an interview with Registered Nurse #13 confirmed resident should have built up utensils and meat cut up. She then went to the kitchenette and asked for the built up utensils and took them to the resident and cut up the pork steak . The dietary meal ticket in the kitchenette revealed the resident should have all food items cut up and to use built up utensils for all meals.

Based on observations, resident and staff interview, and medical record review, the facility failed to provide range of motion exercises for one (#11) of four residents reviewed for range of motion. The facility identified five residents receiving range of motion. The facility census was 76. Findings include: Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 04/19/18, revealed the resident had moderate cognitive impairment and was totally dependent on staff and required two-person assist with bed mobility, transfers, and toileting. Review of a care plan, dated 03/09/18, revealed the resident was at risk for a decline in upper extremity range of motion due to decreased mobility. The goal was for the resident maintain current level of functioning. Interventions included if the resident refused to participate, to re-offer restorative program at a later time, notify the restorative nurse of consistent refusal, provide skills practice for 15 minutes a day, six or seven days a week and provide verbal cues and physical prompts as needed to complete task. Review of restorative nursing assessments and practices revealed range of motion exercises were not completed for Resident #11 from 03/23/18 through 04/21/18. An interview and observation on 04/24/18 1:42 P.M. with Resident #11 stated she had limited range of motion in her arms and legs and the staff have not done range of motion exercises with her. Resident #11 was observed to move her hands and arms slightly but could not move her legs or feet. An interview on 04/26/18 3:07 P.M. with the Director of Nursing (DON) confirmed no range of motion exercises had been completed on Resident #11 from 03/23/18 through 04/21/18.