Every finding on record at Northridge Rehabilitation and Care Center

Based on medical record review, staff interviews, and policy review, the facility failed to ensure medications were given as prescribed. This affected two (#12 and #16) of three residents reviewed for medications. The facility census was 68.Findings include:1. Review of the medical record for Resident #16 revealed an admission on [DATE]. Diagnoses included generalized anxiety disorder, essential hypertension, and hypothyroidism. The discharge with return anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was cognitively intact. Review of the care plan dated 01/29/26 revealed Resident #16 was at risk for episodes of anxiety related to psychiatric diagnosis. Interventions included administering medications as ordered an observing for side effects.Review of the physician's orders dated 07/01/26 revealed an order for lorazepam 0.5 milligrams (mg); give one tablet by mouth three times a day related to generalized anxiety disorder.Review of the Medication Administration Record (MAR) for July 2026 revealed Resident #16 was scheduled to receive lorazepam at 6:00 A.M, 2:00 P.M., and 10:00 P.M. Resident #16 did not receive her lorazepam 0.5 mg on 07/10/26 at 10:18 P.M., 07/11/26 at 5:03 A.M., 07/11/26 at 2:15 P.M., and 07/12/26 at 6:10 A.M. The MAR revealed lorazepam 0.5mg was administered on 07/11/26 at 10:38 P.M.Review of the Controlled Medications Shift Change Log on 07/10/26 at 6:00 A.M. revealed lorazepam 0.5 mg card was removed for Resident #16.Review of the Controlled Drugs Disposition and Audit Record revealed on 07/12/26 at 11:50 A.M. lorazepam 0.5 mg one tablet was taken from the contingency supply for Resident #16.Review of the nursing progress note on 07/11/26 at 11:58 A.M. revealed Resident #16 needed a new prescription for lorazepam 0.5 mg three times a day, and that the physician on call would fax a new prescription to the pharmacy. The nursing progress notes dated 07/12/26 revealed at 6:33 A.M., the physician on call was called due to the prescription not being faxed. At 8:02 A.M., the pharmacy was called with an authorization to pull from the contingency box for lorazepam 0.5mg.Interview on 07/13/26 at 11:07 A.M. with Resident #16 revealed the facility did not administer her lorazepam 0.5 mg for three days. Resident #16 stated during that time she felt as if she was crawling out of her skin.Interview on 07/13/26 at 1:07 P.M. with the Director of Nursing (DON) confirmed Resident #16 was out of her lorazepam 0.5 mg on 07/10/26 at 10:18 P.M., 07/11/26 at 5:03 A.M., 07/11/26 at 2:15 P.M., and 07/12/26 at 6:10 A.M. The DON revealed the lorazepam 0.5 mg that was marked as given on 07/11/26 at 10:38 P.M. was not administered to Resident #16, and the DON was unsure why it documented as given. The DON confirmed the staff should have called the physician on call, and then called the pharmacy to pull the medication from the contingency supply. The DON confirmed the facility had lorazepam 0.5mg available in the contingency supply.2. Review of the medical record for Resident #12 revealed an admission on [DATE]. Diagnoses included anxiety, major depressive disorder, and cerebral palsy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact.Review of the care plan dated 02/10/26 revealed Resident #12 was at risk for episodes of anxiety related to psychiatric diagnosis. Interventions included administering medications as ordered an observing for side effects.Review of the physician's orders dated 06/27/26 revealed an order for lorazepam 0.5 milligrams (mg) give one tablet by mouth two times a day for anxiety related to anxiety disorder.Review of the facility controlled substance contingency supply form revealed the facility had five lorazepam 0.5 mg available.Review of the medication administration record (MAR) revealed on 07/13/26, Resident #12's morning lorazepam had an administration code of five noted, which meant to hold and see the nurse's notes. The MAR on 07/13/26 revealed Resident #12's lorazepam at 6:00 P.M. was marked as medication not available.Review of the nurse's progress notes on 07/13/26 revealed no nurse progress notes were noted pertaining to Resident #12's lorazepam.Interview on 07/14/26 at 7:40 A.M. with Registered Nurse (RN) #200 confirmed Resident #12's lorazepam was not administered on 07/13/26 in the morning and at 6:00 P.M, due to it not being available.Interview on 07/14/26 at 8:00 A.M. with Unit Manager (UM) #300 confirmed Resident #12 ran out of lorazepam on 07/12/26. UM #300 confirmed staff should have called the physician or pharmacy to pull the lorazepam from the contingency supply. UM #300 confirmed the facility had lorazepam 0.5 mg available in the contingency supply to pull.Review of the facility policy titled Administering Medications dated 02/2026 revealed medications are administered in accordance with prescriber orders. The individual administering the medications initials the residents MARs on the appropriate line after giving each medication.This deficiency represents non-compliance investigated under Complaint Numbers 3047633 and 3038989.

Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure a resident identified as being at risk for falls received timely and appropriate assistance during showering resulting in the resident experiencing a fall. This affected one (#16) of three residents reviewed for falls. The facility census was 68.Findings include:Review of the medical record for Resident #16 revealed an admission on [DATE]. Diagnoses included generalized anxiety disorder, essential hypertension, and hypothyroidism.Review of the care plan dated 01/09/26 revealed Resident #16 had the potential for injury and was at risk for falls. Interventions included informing Resident #16 that staff will be assisting to the bathroom and with transfers. On 06/12/26, the care plan was revised with Resident #16 had an ADL self-care performance deficit related to fluctuating ADLs, generalized weakness, impaired mobility, and poor balance. Interventions included assisting with showers.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact. Resident #16 was dependent on staff for showers, including transferring while in and out of the shower.Review of the nursing progress notes on 06/08/26 at 5:50 P.M. revealed a Certified Nursing Assistant (CNA) (#306) reported to the nurse that Resident #16 fell in the shower room. Resident #16 stated she was transferring from shower chair to wheelchair and slopped into a lunge position, however was able to get back up into the wheelchair. The nurse assessed Resident #16 for any injuries. Resident #16 stated she hit her left knee. Redness observed to left knee and small lateral hematoma measuring four centimeters (cm) in length by four cm in width. Resident #16 was administered an as needed Tylenol for pain and it was effective.Review of the Fall Investigation Report dated 06/08/26 revealed Resident #16 fell in the shower room at 10:10 A.M. on 06/08/26. Resident #16 was in the shower room, lost balance on the wet floor and fell. Resident #16 had a hematoma (bruise) to the left knee and had complaints of pain to the left knee.Interview on 07/13/26 at 11:07 A.M. with Resident #16 revealed on 06/08/26, Resident #16 went to take a shower. CNA #306 assisted Resident #16 into the shower room. Resident #16 stated once she began washing herself CNA #306 left the shower room and did not return. Resident #16 stated she was left in the shower room for approximately a half hour. Resident #16 stated she attempted to transfer herself from the shower chair to her wheelchair and fell.Interview on 07/15/26 at 9:07 A.M. with CNA #306 revealed on 06/08/26 was Resident #16's shower day. CNA #306 stated Resident #16 was able to wash herself, so after getting onto the shower chair, CNA #306 left the shower room to assist with answering call lights. CNA #306 stated she forgot that Resident #16 was in the shower and was told by another CNA that Resident #16 had fallen in the shower. CNA #306 confirmed Resident #16 had difficulty with transferring and required staff assistance in the shower.Review of the facility policy titled Activities of Daily Living (ADLs), Supporting dated 03/2018, revealed a resident's ability to perform ADLs will be measured using clinical tool, including MDS. Total Dependence required full staff performance of an activity. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently which included bathing.This deficiency represents non-compliance investigated under Complaint Number 3038989.

Based on observation, resident and staff interviews, and policy review, the facility failed to ensure food was served at safe and palatable temperatures to the residents. This had the potential to affect 66 residents who received food from the kitchen. Two residents were nothing by mouth. The facility census was 68.Findings include:Observation on 07/13/26 at 10:04 A.M. of the kitchen revealed the plates were inside of the warmer but the warmer was not plugged into the wall.Interview on 07/13/26 at 10:51 A.M. with Resident #51 revealed the food at the facility was not always served warm, and stated it depended on what staff was working and passing out the food trays. Observations on 07/13/26 from 11:45 A.M. to 12:09 P.M. revealed the temperature of the hamburgers was 191 degrees Fahrenheit (F). At 11:55 A.M., dietary staff were loading lunch trays onto the open lunch carts. At 12:09 P.M., the last tray on the 200-hall being delivered. A temperature check of the hamburger being served revealed a temperature of 117 degrees F.Interview on 07/13/26 at 12:11 P.M. with Dietary Manager (DM) #155 confirmed the hamburger temperature was 117 degrees F. DM #155 confirmed the temperature of 117 F was not an appropriate holding temperature and the appropriate temperature according to facility policy was 120 to 140 degrees Fahrenheit.Interview on 07/13/26 at 2:55 P.M. with Resident #22 revealed the food was not always served warm. Review of the facility's undated policy titled Food Temperatures revealed the point of service temperature to residents with be within the range of 120-140 degrees F.This deficiency represents non-compliance investigated under Complaint Number 3038989.

Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to maintain infection control practices after providing resident care. This had the potential to affect all 69 residents residing at the facility. The facility census was 69.Findings include:Record review for Resident #38 revealed an admission date of 12/09/21. Diagnoses included muscle weakness, unspecified dementia, and hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was dependent for toileting hygiene and was always incontinent of bowel and bladder. Record review of the care plan for Resident #38 dated 12/09/23 revealed Resident #38 experienced bowel and bladder incontinence. Interventions included to check and change Resident #38 every two hours and as needed. Staff were to provide peri-care with incontinent episodes. Observation on 09/03/25 at 1:37 P.M. with Certified Nurse Aide (CNA) #324 and CNA #341 revealed the staff members transferred Resident #38 to bed using a mechanical lift. Further observation revealed CNA #324 and CNA #341 needed to provide Resident #38 with incontinence care as well as changing the resident's brief, pants, and linen due to the items being saturated with urine. After incontinence care was completed, both CNA #324 and CNA #341 removed their gloves, each grabbed the bags of soiled linen and trash, and both left the room with the soiled items without washing their hands or using hand sanitizer. After disposing of the soiled linen and trash bags, CNA #324 went directly to the clean linen cart and obtained clean sheets, returned to Resident #38's room and placed the linen on the bed, covering Resident #38 up with the linen. CNA #341 returned the mechanical lift to the hall and disposed of the soiled bags, returned to Resident #38's room then used hand sanitizer to clean her hands. CNA #324 then went to the lounge to retrieve Resident #67 who was sitting in her wheelchair and which time CNA #324 was interviewed to review the previous observation of incontinence care. Interview with CNA #324 at approximately 1:45 P.M. confirmed she was preparing to provide care for Resident #67 and confirmed she did not use hand sanitizer or washed her hands after proving incontinence care for Resident #38. CNA #324 confirmed she obtained clean linen from a linen cart used and available for all residents after providing peri-care to Resident #38 without washing her hands or using hand sanitizer. Interview with CNA #341 at this time also confirmed she never washed her hands or used hand sanitizer after providing peri-care for Resident #38 and before exiting the room. Interview on 09/03/25 at 2:37 P.M. with the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #356 confirmed staff were expected to wash their hands or use hand sanitizer before going in a resident room, after care, and before leaving the room. Interview on 09/09/25 at 2:48 P.M. with the DON confirmed all nursing staff are able to work or have worked throughout the facility with all residents. Review of the facility policy titled, Hand Hygiene, dated October 2024, revealed the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene included use of an alcohol-based hand rub or soap and water for situations which included before and after direct contact with a resident; after contact with a resident's intact skin; after contact with bodily fluids; after contact with medical equipment; after removing gloves; and after conducting personal hygiene. The policy included the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.This deficiency represents an incidental finding discovered during investigation for Complaint Number 2572439, Complaint Number OH00165746 (1393119), and Complaint Number OH00165124 (1393117).

Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure medications were administered per the physicians orders. This affected two (#17 and #30) of 14 residents identified by the facility with orders for insulin injections via insulin pen. The facility census was 69. Findings include:1. Record review for Resident #17 revealed an admission date of 11/06/23. Diagnoses included type two diabetes mellitus with hyperglycemia and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment completed 08/16/25 revealed Resident #17 was cognitively intact. Resident #17 had impairment on one side to the upper extremity, received insulin injections, and had a diagnosis of diabetes mellitus. Review of the care plan for Resident #17 dated 11/07/23 revealed Resident #17 had potential risk for hyper/hypoglycemia due to a diagnosis of diabetes. Interventions included to administer medications as ordered. Review of the physician orders for Resident #17 dated 08/06/24 revealed an order for Novolog flex pen 100 unit/milliliter (ml) solution pen-injector to give 10 units subcutaneously three times daily before meals. Observation on 09/02/25 at 11:47 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #230 administered insulin to Resident #17 via Novolog flex pen and revealed LPN #230 primed the insulin pen prior to placing the needle on the pen. When asked, LPN #230 confirmed she primed the insulin injector pen prior to placing the needle on the pen. LPN #230 then continued (without repriming the pen) her procedure, dialed in 10 units of Novolog insulin and administered the insulin to Resident #17 via injection.2. Record review for Resident #30 revealed an admission date of 07/07/25. Diagnoses included type one diabetes mellitus with other circulatory complications, diabetic polyneuropathy, hyperglycemia, and muscle weakness. Review of the admission MDS assessment dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 had impairment on one side of the lower extremity, had a diagnosis of diabetes mellitus, and received insulin injections. Review of the care plan for Resident #30 dated 07/25/25 revealed Resident #30 had potential risk for hyper/hypoglycemia due to diagnosis of diabetes. Interventions included to administer medications as ordered. Review of the physician orders for Resident #30 revealed an order dated 07/11/25 for Novolog flex pen subcutaneous solution pen-injector 100 units per milliliter with instructions to inject 13 units subcutaneous in the evening for diabetes management. THe medication was scheduled to be given at dinner. Further review revealed an additional order for Resident #30 to receive Novolog insulin before meals, timed at 7:00 A.M., 11:00 A.M., and 4:00 P.M., via sliding scale including for the resident to receive seven units of insulin for blood sugars between 376 milligrams per deciliter (mg/dL) and 399 mg/dL. Observation on 09/02/25 at 4:00 P.M. of medication administration revealed LPN #222 assessed Resident #30's blood sugar for a result of 383 mg/dL. LPN #222 then dialed in 20 units of Novolog insulin via flex pen. LPN #222 did not prime the pen prior to dialing the amount to administer.Interview on 09/02/25 at 4:11 P.M. with LPN #222 confirmed she did not prime Resident #30's Novolog insulin pen prior to administering the insulin via the pen. LPN #222 revealed she forgot to and stated, To prime the insulin pen, take it to zero and push so you don't lose any insulin.Interview on 09/02/25 at 4:37 P.M. with the Director of Nursing (DON) revealed all insulin pens need to be primed with the needle on, and dialing the pen to two units prior to administration.Review of the facility policy titled, Insulin Pen Priming and Administration Policy, dated July 2024, revealed all injections must be administered by licensed nursing staff trained in insulin pen use. Priming is required before each injection to ensure correct dosing. A new sterile needle is required for each use. Preparation and priming included attach a new sterile needle to the insulin pen. Prime the pen, dial two units, hold the pen upright, press injection button until a drop of insulin appears at the tip. Repeat priming if no insulin appears.The deficiency represents non-compliance investigated under Master Complaint 2601734, Complaint Number 2572439, and Complaint Number OH00165746 (1393119).

Based on medical record review, incident file review, and staff interview, the facility failed to ensure comprehensive resident centered care plans were developed to address resident medical and psychosocial needs. This affected one (#70) of four residents reviewed for care plans. The facility census was 69.Findings include:Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses that included alcohol abuse, cocaine use, type II diabetes, and morbid obesity.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 was cognitively intact and required extensive assistance to complete activities of daily living. Resident #70 discharged to the community on 05/01/25.Review of a progress note dated 01/30/25 from Resident #70's emergency room physician, prior to admission to the facility, revealed Resident #70 was a [AGE] year-old male with a past medical history of polysubstance use. The note further indicated Resident #70 had been admitted to the same hospital from a substance use treatment setting.Review of the incident file for Resident #70 revealed that on 04/28/25, Resident #70 was found smoking an illicit substance in his room at the facility. When confronted, Resident #70 did not deny his drug use.Review of the care plan for Resident #70 revealed no care plans with goals or interventions related to Resident #70's history of or continued drug use.Social Worker #700 verified Resident #70's medical record lacked a care plan with goals and interventions for drug use during an interview conducted on 08/29/25 at 2:11 P.M.This deficiency represents non-compliance investigated under Complaint Number OH00165746 (1393119).

Based on observation, resident and staff interview, medical record review, review of a police report, review of facility investigation documents, and policy review, the facility failed to ensure a resident's change in condition was reported to the physician in a timely manner. This affected two (#23 and #20) of four residents reviewed for assessments and monitoring. The census was 69. Findings include:1. Record review for Resident #70 revealed an admission date of 02/04/25 and a discharge date of 05/01/25. Diagnoses included bipolar disorder, cocaine use, and alcohol abuse. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact. Resident #70 had no impairment to the upper or lower extremities, was independent with eating, used a wheelchair for mobility and was independent for wheelchair mobility. Review of a progress note dated 01/30/25 from Resident #70 ' s emergency room physician, prior to admission to the facility, revealed Resident #70 was a [AGE] year-old male with a past medical history of polysubstance use. The note further indicated Resident #70 had been admitted to the same hospital from a substance use treatment setting. Record review of Resident #70 ' s medical record for 04/28/25 through 05/01/25 revealed no documentation of Resident #70 smoking an illegal substance while inside the facility.Review of a handwritten statement signed and dated 04/28/25, untimed, completed by Certified Nurse Aide (CNA) #229 revealed at 11:15 (no A.M. or P.M. documented) the nurse aide went into Resident #70 ' s room because the nurse aide saw him roll his wheelchair into the hallway. When CNA #229 went into his room he told the nurse aide to come into the bathroom. The resident rolled into his bathroom and he told the nurse aide to look as he was unfolding a ball of toilet paper. CNA #229 noticed white chunks inside and asked Resident #229 if it was an illicit drug. Resident #70 told CNA #229 to be quiet and lifted a paper towel and exposed two pipes that were obviously used to smoke the substance in the toilet paper. CNA #229 told Resident #70 he needed to give the nurse aide everything he had but he refused. The resident then asked CNA #229 to party with him. CNA #229 immediately left the room and got Licensed Practical Nurse (LPN) #202, and LPN #358 was also called to assess Resident #70. Review of the handwritten statement signed and dated 04/28/25, untimed, completed by LPN #202 revealed she was notified by her CNA (#229) that Resident #70 was seen in the bathroom smoking an illicit drug. LPN #202 then called LPN #358 to have a witness and both nurses entered Resident #70 ' s room and witnessed Resident #70 smoking in the bathroom. LPN #358 asked Resident #70 for the substance, he refused to let go of it, he asked if he could throw it out himself.Review of the handwritten statement signed and dated 04/28/25, untimed, completed LPN #358 revealed the nurse was called to Resident #70 ' s room at approximately 11:19 P.M. She ran to his room and found Resident #70 smoking from a crack pipe and thick white smoke was coming out. As she approached him, Resident #70 blew a cloud of smoke into her face. She stepped into the bathroom and told Resident #70 he needed to give her the pipe and lighter. She grabbed onto them and he would not let go. After about 15 minutes, he let the nurse have them. The Director of Nursing (DON), police, and the Administrator were notified. The police confiscated the drug items. Review of the police incident report date 04/28/25 at 11:56:38 P.M. revealed nurses observed Resident #70 actively smoking out of a pipe. After talking to the resident, he did not know what it was and indicated he found it outside. Review of the progress note dated 04/29/25 at 2:30 P.M. completed by the Administrator revealed he and the DON presented Resident #70 with a behavior contract and the resident refused to sign it. Resident #70 informed the staff another facility would no longer accept him and the facility reviewed alternative options as his Medicaid authorization ended on 4/30/25. Interview on 09/02/25 at 4:57 P.M. with the Administrator revealed on 04/28/25 Resident #70 was found by a CNA smoking an illicit substance in the bathroom of his room. The CNA tried to confiscate the paraphernalia. Resident #70 blew smoke in the CNA ' s face. The police were called, and the CNA and the nurses went to the hospital to get checked out. The resident did give the paraphernalia to the staff, and it was found to just be residue left over. The police did not want to test the residue and said it was because it was not a chargeable amount. The Administer revealed he and the police went through the resident's room and nothing else was found. The next day, Resident #70 was presented with a contract to remain drug free. Resident #70 refused to sign the contract and discharged himself to the community on 05/01/25. The Administrator confirmed Resident #70 had a roommate at the time the incident occurred and revealed he was unaware of any restrictions or further monitoring/interventions put into place for Resident #70 to prevent further drug use while in the facility. The Administrator reiterated Resident #70 refused to sign the contract. Interview on 09/04/25 at 2:02 P.M. with the DON revealed Resident #70 went on leave of absences (LOAs) before the incident with the drugs on 04/28/25. The DON revealed there were no restrictions or interventions put into place after the incident to monitor Resident #70 from bringing and smoking paraphernalia in the facility potentially affecting other residents. The DON confirmed Resident #23 was Resident #70 ' s roommate including from 04/28/25 through 05/01/25.2. Record review for Resident #23 revealed an admission date of 07/26/14. Diagnoses included chronic obstructive pulmonary disease (COPD) , dementia, Alzheimer ' s disease, schizophrenia, chronic respiratory failure with hypoxia, and emphysema.Review of the quarterly MDS assessment dated [DATE] revealed Resident #23 was moderately cognitively impaired. Resident # 23 received continuous oxygen therapy.Review of Resident #23's physician orders for April 2025 revealed an order for oxygen at two liters per minute via nasal cannula for shortness of breath every shift related to chronic obstructive pulmonary disease and a continuous positive airway pressure device to be worn at bedtime and taken off in the morning.Review of the medical record for Resident #23 revealed there was no assessment complete on 04/28/25 after Resident #23 ' s roommate, Resident #70, was found to be smoking in the bathroom near where Resident #23 resided. Record review revealed an initial assessment dated [DATE] at 4:01 P.M. completed by Assistant Director of Nursing (ADON) LPN #336 included vital signs with a blood pressure result of 86/50 millimeters of mercury (mmhg). Record review revealed the next assessment of vital signs was completed 05/01/25.Observation on 09/02/25 at 4:19 P.M. revealed Resident #23 lying in bed. Resident #23 had his oxygen infusing via nasal cannula. Interview with Resident #23 at that time revealed he did not recall the situation on 04/28/25. Interview on 09/04/25 at 11:37 A.M. with ADON LPN #336 confirmed Resident #23 ' s initial assessment after his roommate, Resident #70, was found to be smoking was not completed until 04/29/25 at 4:01 P.M. Record review of Resident #23 ' s vital sign history with ADON LPN #336 confirmed Resident #23 ' s blood pressure of 86/50 mmhg obtained and documented on 04/29/25 at 4:01 P.M. was the lowest, both systolic and diastolic, he had during the timeframe reviewed between 01/01/25 through 04/28/25. ADON LPN #336 confirmed there was no documentation of the physician or Certified Nurse Practitioner (CNP) being notified of the abnormal vital sign. ADON LPN #336 revealed she did not recall if she notified anyone or not of the abnormal vital sign.Telephone interview on 09/04/25 at 12:55 P.M. with Certified Nurse Practitioner (CNP) #360 confirmed she was Resident #23 ' s CNP and revealed she was made aware Resident #70 was smoking illicit drugs in the bathroom and confirmed it was close proximity to Resident #23. CNP #360 revealed she was told Resident #23 was never exposed. CNP #360 revealed if a resident was exposed, she would have expected an assessment to be done on the resident immediately after the exposure and revealed the assessment should include vital signs, a respiratory assessment , and any change in condition including a mental status change and the staff would need to monitor the resident over the next hours to days depending on the amount of exposure. CNP #360 also revealed she would have expected to be notified of abnormal vital signs and confirmed she had no documentation of the notification and could not confirm if she was or was not notified of Resident #23's abnormal vital signs on 04/29/25. Telephone interview on 09/04/25 at 1:45 P.M. with Physician #361 revealed if a resident was smoking illicit drugs in the same room as another resident, he would expect staff to assess both residents' breathing, vital signs, cough, phlegm, and for a headache. The exposed resident could experience breathing problems and burning of the eyes depending on how much exposure there was. Observation on 09/04/25 at 1:55 P.M. with Maintenance Director #293 measured the distance between Resident #23 ' s bed and the bathroom and revealed the distance was approximately seven feet.Interview on 09/04/25 at 2:02 P.M. with the DON confirmed an assessment was not documented on Resident #23 until 04/29/25 at 4:01 P.M. and revealed she did not have an answer why. The DON revealed she came in the facility that night, she took over for the nurses who went to the hospital to be assessed due to exposure. Neither Resident #70 nor Resident #23 were sent to the hospital. The DON revealed she saw Resident #23 sleeping in bed and had no concerns. The DON revealed she worked the remainder of the night until 6:30 A.M. the following morning as the charge nurse and revealed Resident #23 was not woke up during that time for a physical assessment. Telephone interview on 09/04/25 at 5:13 P.M. with LPN #202 revealed on 04/28/25 she was one of the nurses who witnessed Resident #70 smoking an illegal substance in his bathroom. LPN #202 revealed the roommate (Resident #23) was lying in his bed and revealed Resident #23 was not wearing his CPAP but he had his oxygen on with his nasal cannula. LPN #202 revealed Resident #23 often refused his CPAP and revealed he may have worn it later that night but at that time he did not have it on. LPN #202 revealed Resident #70 was smoking the substance in the bathroom sitting in his wheelchair just inside the doorway of the bathroom, the door was opened, and as soon as she entered the doorway of Resident #70 ' s and Resident #23 ' s room, she could smell the odor of the illegal substance and seen Resident #70 smoking from the pipe.3. Record review for Resident #20 revealed an admission date of 03/07/25. Diagnoses included muscle weakness, peripheral vascular disease, and hereditary and idiopathic neuropathy.Review of the quarterly MDS assessment dated [DATE] for Resident #20 revealed Resident #20 was cognitively intact. Review of the care plan initiated 09/02/25 revealed Resident #20 was on antibiotic therapy related to a toe infection. Interventions included to administer medication as ordered. Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity /allergic reactions. Staff were to observe and report to the medical doctor (MD) for adverse reaction noted. Review of the physician order dated 09/01/25 for Resident #20 revealed an order for doxycycline hyclate oral tablet (antibiotic)100 milligrams (mg) with instructions to give 100 mg by mouth two times a day for infection of toe for seven days with a start date of 09/01/25 in the morning. Review of the medication administration record for Resident #20 conformed doxycycline hyclate oral tablet 100 mg was initiated 09/01/25 in the morning.Observation and interview on 09/02/25 at 9:38 A.M. revealed Resident #20 was lying in bed. Resident #20 revealed she was not feeling well, she was nauseous and vomited all her breakfast up into a bag she kept by her bed. Resident #20 revealed she had just started a new antibiotic the day before and after receiving the first dose in the morning the day before, she also vomited that one up. Resident #20 revealed she told her CNA (#341) she was not feeling well that morning and she vomited in the bag. CNA #341 removed the bag with the vomit and gave her a clean bag to use if she got sick again. Resident #20 revealed her charge nurse had not been in yet to assess her since she vomited morning of 09/02/25. Resident #20 revealed she did not tell the nurse the day before that she vomited because she felt better after she vomited. Review of the progress note dated 09/02/25 at 9:46 A.M. completed by LPN #222 revealed Resident #20 was alert and oriented to person, place, and time and tolerated by mouth medications and breakfast.Interview on 09/02/25 at 11:51 A.M. with Resident #20 revealed she still felt nauseous. Resident #20 revealed her nurse still had not been in to assess yet.Interview on 09/02/25 at 11:52 A.M. with CNA #341 confirmed Resident #20 vomited that morning in a bag and revealed she threw it away for Resident #20. CNA #341 revealed it was between 8:00 A.M. and 9:00 A.M. CNA #341 stated she had not told the charge nurse about the resident vomiting. Observation revealed CNA #341 then approached LPN #222 and reported Resident #20 vomited that morning. LPN #222 confirmed she was not aware.Review of the facility policy titled, Change in condition or status, dated August 2024, revealed the facility shall promptly notify the resident, his or her physician and representative of changes in the resident ' s medical/mental condition and or status.The deficiency represents an incidental finding discovered during investigation of Complaint Number 2600408, Complaint Number OH00165746 (1393119), and Complaint Number OH00165124 (1393117).

Based on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure dependent residents received timely care and services from staff to provide activities of daily living (ADLs). This affected one (#38) of three residents reviewed for ADLs care. The facility census was 69.Findings include:Record review for Resident #38 revealed an admission date of 12/09/21. Diagnoses included cerebral infarction due to embolism of the right middle cerebral artery, muscle weakness, congestive heart failure, cardiac pacemaker, contracture of the right and left knee, unspecified moderate dementia with agitation, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact. Resident #38 had impairment on one side of the upper extremity and both sides of the lower extremities. Resident #38 required set up or clean up assist with eating, was dependent for toileting hygiene, personal hygiene, chair/bed to chair transfers, required substantial/maximal assistance for bed mobility, and was independent for wheelchair mobility. Resident #38 was always incontinent of bowel and bladder, and was assessed at risk for pressure ulcers but had no unhealed pressure ulcers or other wounds or skin problems during the assessment look-back period. Review of the care plan dated 07/18/24 revealed Resident #38 required assistance for all ADLs related to weakness, cardiovascular accident with hemiparesis, decreased range of motion (ROM) to the left hand, and bilateral knee contractures. Interventions included set up or clean up assistance for eating, and two staff assistance for toileting tasks, dressing, bathing, and hygiene.Record review of the care plan for Resident #38 dated 12/09/23 revealed Resident #38 experienced bowel and bladder incontinence. Interventions included to check and change Resident #38 every two hours and as needed. Staff were to provide peri-care with incontinent episodes.Observation on 09/03/25 at 8:49 A.M. revealed Resident #38 was sitting in her chair in the dining room. Resident #38 had dried liquid and crumbs on her shirt. Observation on 09/03/25 at 10:55 A.M. revealed Resident #38 was sleeping in her chair in the dining room. Resident #38 had her same clothes on with the dried liquid spilled on her shirt. Observation and interview on 09/03/25 at 1:33 P.M. revealed Resident #38 was sitting in her chair in the dining room. Resident #38's shirt and pants were soiled with dried food and her pants were visibly wet in the peri-area. Resident #38 had the same clothes on from the previous two observations. Resident #38 revealed the staff got her up at 7:00 A.M., placed her in the dining room, and have not checked her for incontinence or changed her all day. Resident #38 revealed she had not been moved from the dining room since staff took her there that morning and Resident #38 confirmed she was wet and stated she would prefer to lay down after breakfast and changed. Observation and interview on 09/03/25 at 1:37 P.M. with Certified Nurse Aide (CNA) #324 confirmed she was Resident #38's primary CNA that day. CNA #324 revealed she got Resident #38 up in her chair around 7:00 A.M. CNA #324 confirmed this would be the first time since 7:00 A.M. Resident #38 would be laid down and checked for incontinence or changed. CNA #324 stated, She (Resident #38) has to be up for breakfast and lunch. It's part of her daily plan so we don't lay her down until after lunch. CNA #324 again confirmed Resident #38 was not checked or changed since 7:00 A.M. and CNA #341 was also present at that time. Observation revealed CNA #324 pushed Resident #38's chair to her room, and both CNA #324 and CNA #341 transferred Resident #38 from her geriatric chair to her bed via mechanical lift. CNA #324 confirmed Resident #38's shirt and pants were soiled with dried food and drink items and confirmed Resident #38's pants were wet inside and out. The brief was heavily saturated with urine and Resident #38 had a foul odor of urine. Resident #38's buttocks had deep creases in her skin from where the brief had wrinkled and created temporary indentations in the skin where the brief was located. Resident #38's buttocks was also red. CNA #324 stated, It's just routine to not change her until after lunch. Interview on 09/03/25 at 2:37 P.M. with the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #356 revealed staff should check and change residents every two hours and as needed for incontinence. Review of the facility policy titled, Incontinence care policy, dated December 2023, revealed the policy was to provide individualized incontinence care based on a comprehensive assessment and care plan. Residents will be offered timely assistance, appropriate continence aids, and preventative skin care to promote health, comfort, and dignity. The procedures included to provide timely and respectful assistants for toileting, changing, and hygiene needs. Staff are to change incontinent products promptly when soiled to prevent odor, discomfort, and skin irritation.This deficiency represents non-compliance investigated under Complaint Number 2572439, Complaint Number OH00165746 (1393119), and Complaint Number OH00165124 (1393117).

Based on observation, staff interview, medical record review, review of a police report, and review of facility investigation documents, the facility failed to ensure a resident (#70) was properly monitored for behaviors regarding drug use following know usage in the facility and failed to timely assess a resident (#23) following exposure to illicit substances. This affected two (#23 and #70) of four residents reviewed for assessments and monitoring. The census was 69.Findings include:1. Record review for Resident #70 revealed an admission date of 02/04/25 and a discharge date of 05/01/25. Diagnoses included bipolar disorder, cocaine use, and alcohol abuse. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact. Resident #70 had no impairment to the upper or lower extremities, was independent with eating, used a wheelchair for mobility and was independent for wheelchair mobility. Review of a progress note dated 01/30/25 from Resident #70's emergency room physician, prior to admission to the facility, revealed Resident #70 was a [AGE] year-old male with a past medical history of polysubstance use. The note further indicated Resident #70 had been admitted to the same hospital from a substance use treatment setting. Record review of Resident #70's medical record for 04/28/25 through 05/01/25 revealed no documentation of Resident #70 smoking an illegal substance while inside the facility. Review of a handwritten statement signed and dated 04/28/25, untimed, completed by Certified Nurse Aide (CNA) #229 revealed at 11:15 (no A.M. or P.M. documented) the nurse aide went into Resident #70's room because the nurse aide saw him roll his wheelchair into the hallway. When CNA #229 went into his room he told the nurse aide to come into the bathroom. The resident rolled into his bathroom and he told the nurse aide to look as he was unfolding a ball of toilet paper. CNA #229 noticed white chunks inside and asked Resident #229 if it was an illicit drug. Resident #70 told CNA #229 to be quiet and lifted a paper towel and exposed two pipes that were obviously used to smoke the substance in the toilet paper. CNA #229 told Resident #70 he needed to give the nurse aide everything he had but he refused. The resident then asked CNA #229 to party with him. CNA #229 immediately left the room and got Licensed Practical Nurse (LPN) #202, and LPN #358 was also called to assess Resident #70. Review of the handwritten statement signed and dated 04/28/25, untimed, completed by LPN #202 revealed she was notified by her CNA (#229) that Resident #70 was seen in the bathroom smoking an illicit drug. LPN #202 then called LPN #358 to have a witness and both nurses entered Resident #70's room and witnessed Resident #70 smoking in the bathroom. LPN #358 asked Resident #70 for the substance, he refused to let go of it, he asked if he could throw it out himself. Review of the handwritten statement signed and dated 04/28/25, untimed, completed LPN #358 revealed the nurse was called to Resident #70's room at approximately 11:19 P.M. She ran to his room and found Resident #70 smoking from a crack pipe and thick white smoke was coming out. As she approached him, Resident #70 blew a cloud of smoke into her face. She stepped into the bathroom and told Resident #70 he needed to give her the pipe and lighter. She grabbed onto them and he would not let go. After about 15 minutes, he let the nurse have them. The Director of Nursing (DON), police, and the Administrator were notified. The police confiscated the drug items. Review of the police incident report date 04/28/25 at 11:56:38 P.M. revealed nurses observed Resident #70 actively smoking out of a pipe. After talking to the resident, he did not know what it was and indicated he found it outside. Review of the progress note dated 04/29/25 at 2:30 P.M. completed by the Administrator revealed he and the DON presented Resident #70 with a behavior contract and the resident refused to sign it. Resident #70 informed the staff another facility would no longer accept him and the facility reviewed alternative options as his Medicaid authorization ended on 4/30/25. Interview on 09/02/25 at 4:57 P.M. with the Administrator revealed on 04/28/25 Resident #70 was found by a CNA smoking an illicit substance in the bathroom of his room. The CNA tried to confiscate the paraphernalia. Resident #70 blew smoke in the CNA's face. The police were called, and the CNA and the nurses went to the hospital to get checked out. The resident did give the paraphernalia to the staff, and it was found to just be residue left over. The police did not want to test the residue and said it was because it was not a chargeable amount. The Administer revealed he and the police went through the resident's room and nothing else was found. The next day, Resident #70 was presented with a contract to remain drug free. Resident #70 refused to sign the contract and discharged himself to the community on 05/01/25. The Administrator confirmed Resident #70 had a roommate at the time the incident occurred and revealed he was unaware of any restrictions or further monitoring/interventions put into place for Resident #70 to prevent further drug use while in the facility. The Administrator reiterated Resident #70 refused to sign the contract. Interview on 09/04/25 at 2:02 P.M. with the DON revealed Resident #70 went on leave of absences (LOAs) before the incident with the drugs on 04/28/25. The DON revealed there were no restrictions or interventions put into place after the incident to monitor Resident #70 from bringing and smoking paraphernalia in the facility potentially affecting other residents. The DON confirmed Resident #23 was Resident #70's roommate including from 04/28/25 through 05/01/25. 2. Record review for Resident #23 revealed an admission date of 07/26/14. Diagnoses included chronic obstructive pulmonary disease (COPD) , dementia, Alzheimer's disease, schizophrenia, chronic respiratory failure with hypoxia, and emphysema. Review of the quarterly MDS assessment dated [DATE] revealed Resident #23 was moderately cognitively impaired. Resident # 23 received continuous oxygen therapy. Review of Resident #23's physician orders for April 2025 revealed an order for oxygen at two liters per minute via nasal cannula for shortness of breath every shift related to chronic obstructive pulmonary disease and a continuous positive airway pressure device to be worn at bedtime and taken off in the morning. Review of the medical record for Resident #23 revealed there was no assessment complete on 04/28/25 after Resident #23's roommate, Resident #70, was found to be smoking in the bathroom near where Resident #23 resided. Record review revealed an initial assessment dated [DATE] at 4:01 P.M. completed by Assistant Director of Nursing (ADON) LPN #336 included vital signs with a blood pressure result of 86/50 millimeters of mercury (mmhg). Record review revealed the next assessment of vital signs was completed 05/01/25. Observation on 09/02/25 at 4:19 P.M. revealed Resident #23 lying in bed. Resident #23 had his oxygen infusing via nasal cannula. Interview with Resident #23 at that time revealed he did not recall the situation on 04/28/25. Interview on 09/04/25 at 11:37 A.M. with ADON LPN #336 confirmed Resident #23's initial assessment after his roommate, Resident #70, was found to be smoking was not completed until 04/29/25 at 4:01 P.M. Record review of Resident #23's vital sign history with ADON LPN #336 confirmed Resident #23's blood pressure of 86/50 mmhg obtained and documented on 04/29/25 at 4:01 P.M. was the lowest, both systolic and diastolic, he had during the timeframe reviewed between 01/01/25 through 04/28/25. ADON LPN #336 confirmed there was no documentation of the physician or Certified Nurse Practitioner (CNP) being notified of the abnormal vital sign. ADON LPN #336 revealed she did not recall if she notified anyone or not of the abnormal vital sign. Telephone interview on 09/04/25 at 12:55 P.M. with Certified Nurse Practitioner (CNP) #360 confirmed she was Resident #23's CNP and revealed she was made aware Resident #70 was smoking illicit drugs in the bathroom and confirmed it was close proximity to Resident #23. CNP #360 revealed she was told Resident #23 was never exposed. CNP #360 revealed if a resident was exposed, she would have expected an assessment to be done on the resident immediately after the exposure and revealed the assessment should include vital signs, a respiratory assessment , and any change in condition including a mental status change and the staff would need to monitor the resident over the next hours to days depending on the amount of exposure. CNP #360 also revealed she would have expected to be notified of abnormal vital signs and confirmed she had no documentation of the notification and could not confirm if she was or was not notified of Resident #23's abnormal vital signs on 04/29/25. Telephone interview on 09/04/25 at 1:45 P.M. with Physician #361 revealed if a resident was smoking illicit drugs in the same room as another resident, he would expect staff to assess both residents' breathing, vital signs, cough, phlegm, and for a headache. The exposed resident could experience breathing problems and burning of the eyes depending on how much exposure there was. Observation on 09/04/25 at 1:55 P.M. with Maintenance Director #293 measured the distance between Resident #23's bed and the bathroom and revealed the distance was approximately seven feet. Interview on 09/04/25 at 2:02 P.M. with the DON confirmed an assessment was not documented on Resident #23 until 04/29/25 at 4:01 P.M. and revealed she did not have an answer why. The DON revealed she came in the facility that night, she took over for the nurses who went to the hospital to be assessed due to exposure. Neither Resident #70 nor Resident #23 were sent to the hospital. The DON revealed she saw Resident #23 sleeping in bed and had no concerns. The DON revealed she worked the remainder of the night until 6:30 A.M. the following morning as the charge nurse and revealed Resident #23 was not woke up during that time for a physical assessment. Telephone interview on 09/04/25 at 5:13 P.M. with LPN #202 revealed on 04/28/25 she was one of the nurses who witnessed Resident #70 smoking an illegal substance in his bathroom. LPN #202 revealed the roommate (Resident #23) was lying in his bed and revealed Resident #23 was not wearing his CPAP but he had his oxygen on with his nasal cannula. LPN #202 revealed Resident #23 often refused his CPAP and revealed he may have worn it later that night but at that time he did not have it on. LPN #202 revealed Resident #70 was smoking the substance in the bathroom sitting in his wheelchair just inside the doorway of the bathroom, the door was opened, and as soon as she entered the doorway of Resident #70's and Resident #23's room, she could smell the odor of the illegal substance and seen Resident #70 smoking from the pipe. The deficiency represents non-compliance investigated under Complaint Number 2600408, Complaint Number OH00165746 (1393119), and Complaint Number OH00165124 (1393117).

Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to assure residents received supplemental oxygen per physicians orders. This affected one (#72) of three residents reviewed for oxygen therapy. The facility census was 69.Findings include:Record review for Resident #72 revealed an admission date of 08/30/25. Diagnoses included anoxic brain damage, pneumonia due to methicillin resistant staphylococcus aureus (MRSA), chronic obstructive pulmonary disease (COPD), asthma, emphysema, and acute and chronic respiratory failure. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was rarely or never understood and cognitive skills were severely impaired. Resident #72 was dependent for eating, toileting hygiene, and bed mobility. Resident #72 received oxygen therapy continuous. Review of the care plan for Resident #72 dated 09/01/25 revealed the resident had potential for complications related to diagnoses of COPD, asthma, and emphysema. Interventions included to administer medications, inhalers as ordered, and to give oxygen as ordered. Review of the physician orders for Resident #72 dated 08/30/25 revealed an order for oxygen delivery via nasal cannula with a liter flow of two liters and the duration was continuous every shift for breathing. Observation on 09/03/25 at 9:56 A.M. revealed Resident #72 was lying in bed. Resident #72's eyes were closed. Observation revealed Resident #72's oxygen concentrator was running. The nasal cannula was lying on the floor under the tube feeding pole next to Resident #72's bed. Resident #72 was not receiving oxygen from the concentrator. Observation on 09/03/25 at 9:57 A.M., as surveyor was exiting the room, revealed Licensed Practical Nurse (LPN) #202 was walking towards the surveyor and entered Resident #72's room. LPN #202 confirmed she was Resident #72's primary care nurse that day. LPN #202 walked over to Resident #72's bed, proceeded to shut off the tube feeding, then exited the room without addressing Resident #72 nasal cannula on the floor at the bottom of the tube feeding pole. LPN #202 returned to the medication cart and proceeded to walk up the hall, away from Resident #72's room pushing the cart. The Surveyor immediately approached LPN #202 and requested information about Resident #72's oxygen therapy. LPN #202 revealed she was not sure if Resident #72 was supposed to receive oxygen. LPN #202 opened Resident #72's physician orders on her computer located on the medication cart and revealed Resident #72 had an order to be on oxygen continuously. After requesting LPN #202 to assess Resident #72's oxygen status, LPN #202 returned to Resident #72's room and verified the oxygen tubing was on the floor. LPN #202 then monitored Resident #72's oxygen saturation level (percentage of oxygen in the blood) via a pulse oximeter and confirmed Resident #72's oxygen saturation was between 86 percent (%) and 88%. LPN #202 revealed Resident #72's oxygen saturation level was 95% that morning when she assessed it. LPN #202 obtained new oxygen tubing and connected the tubing to the concentrator then placed the cannula in Resident #72's nostrils. LPN #202 then exited the room. Observation revealed the concentrator was set at 1.5 liters per minute. The surveyor immediately returned to LPN #202 who returned to the medication cart. When asked how many liters per minute of oxygen Resident #72 should be receiving, LPN #202 again stated she was not sure and again pulled the order up on the computer on the medication cart. LPN #202 revealed Resident #72 should be on two liters of oxygen per minute per the physician orders. LPN #202 returned to Resident #72's room and confirmed the oxygen was set at 1.5 liters per minute. Review of the facility policy titled, Oxygen Administration, revised 10/2022, revealed the purpose of the procedure was to provide guidelines for safe oxygen administration. Staff are to verify the physicians order for the procedure and turn the oxygen on as directed by the Medical Practitioner. The deficiency represents an incidental finding discovered during the investigation for Complaint Number OH00165746 (1393119).

Based on review of resident immunizations, review of personnel records, staff interview, and policy review, the facility failed to ensure residents and staff were educated on the risks, benefits, and side effects of the COVID-19 vaccine. This affected five (#14, #42, #53, #57, and #64) of five residents reviewed for immunization and seven of seven employees reviewed for immunization and had the potential to affect all residents. The facility census was 74. Findings include 1) Review of the medical record for Resident #57 revealed an admitted [DATE]. Diagnoses included anoxic brain injury, and sudden cardiac arrest. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment Review of Resident #57's undated consent form for the pneumococcal vaccine revealed a hand written note stating the resident would like the COVID-19 vaccine. There was no information sheet for the COVID-19 vaccine and no documentation the resident/representative had been provided education on the COVID-19 vaccine. 2) Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, diabetes insipidus, and peripheral vascular disease. Review of the annual MDS assessment dated [DATE] revealed the resident had impaired cognition. Review of the influenza vaccine consent form dated 10/02/24 revealed a handwritten note per the power of attorney, no COVID-19 vaccine at this time. There was no information sheet for the COVID-19 vaccine and no documentation the resident/representative had been provided education on the COVID-19 vaccine. 3) Review of the medical record for Resident #64 revealed an admitted [DATE]. Diagnoses included acute respiratory failure, anoxic brain damage, chronic lymphocytic leukemia of B-Cell type, and tracheostomy status. Review of the quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #64's influenza form dated 10/01/24 revealed a handwritten note dated 08/15/24 stating no COVID-19 vaccine wanted per the power of attorney. There was no information sheet for the COVID-19 vaccine and no documentation the resident/representative had been provided education on the COVID-19 vaccine. 4) Review of the medical record for Resident #53 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypertensive heart disease, and chronic pain syndrome. Review of the significant change MDS assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #53's pneumococcal vaccine form dated 10/01/24 revealed a handwritten note stated the resident refused the COVID-19 vaccination. There was no information sheet for the COVID-19 vaccine and no documentation the resident/representative had been provided education on the COVID-19 vaccine. 5) Review of the medical record for Resident #42 revealed an admitted [DATE]. Diagnoses included dementia, bipolar disorder and hypothyroidism. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #42's pneumococcal vaccine consent form dated 10/04/24 revealed a handwritten note stating the resident had declined the COVID-19 vaccine at this time. 6) Review of personnel files for seven staff (Certified Nursing Assistant (CNA) #331, CNA #357, Maintenance Director #400, CNA #342, CNA #341, Registered Nurse (RN) #355, Dietary Aide #344) revealed no documentation the staff had been educated regarding the COVID-19 vaccine. There was no documentation the staff had been offered or had refused the COVID-19 vaccine. Interview on 01/29/25 at 12:05 P.M. with Assistant Director of Nursing (ADON) #392 stated the staff were offered the COVID-19 vaccine at an all-staff meeting. ADON #392 stated she just offered the staff the vaccine and had not provided any education to the staff about the risks and benefits of the vaccine. ADON #392 verified only one staff member had requested the vaccine. ADON #392 also verified Residents #57, #14, #64, #53, and #42 were offered the COVID-19 vaccine but they were not provided information on the benefits, risks, and side effects. ADON #392 verified there was no separate consent form for the COVID-19 vaccine and she documented refusals on either their influenza or pneumococcal consent forms. Review of the policy titled Infection Prevention and Control Program, revised 08/01/23 revealed residents and staff would be offered the COVID-19 vaccine when vaccine supplies were available. Education about the vaccine, risks, benefits, and potential side effects would be given to residents and staff prior to offering the vaccine.

Based on record review, review of personnel job descriptions, review of personnel files, review of the facility's infection control program, resident, staff, and family interview, and interview with the local health department (LHD), the administration team lacked involvement to ensure staff and resident reports of staff mistreatment were not dismissed before investigating the allegations, did not identify an issue with the resident's medical records being accurate and factual, and did not ensure adequate staffing was maintained to meet the needs of their residents and according the facility's assessment. Administration did not ensure routine care conferences were being held routinely with the residents and resident representatives and did not ensure routine written notices of transfer and bed hold notices were completed upon the resident's transfer to the hospital. Additionally, the administration team demonstrated inaction and failed to perform their job responsibilities to ensure infection control policies and guidelines were implemented to ensure contact tracing was completed to identify close contacts of residents positive for COVID-19, failed to ensure COVID-19 testing was completed for residents and staff identified as close contacts, and furthermore failed to implement broad based testing of staff during a COVID-19 outbreak within the facility. This affected 49 residents (#2, #4, #7, #9, #11, #13, #17, #20, #21, #23, #24, #26, #27, #29, #32, #34, #35, #37, #42, #44, #45, #46, #50, #51, #52, #53, #54. #55, #57, #59, #61, #65, #66, #67, #68, #74, #76, #78, #79, #80, #81, #82, #135, #173, #177, #179, #181, #182, and #183) reviewed during the annual survey and had the potential to affect all 74 residents residing in the facility. Findings include: 1) The facility did not implement effective and recommended infection control practices beginning on [DATE] when two residents (#78 and #32) tested positive for COVID-19. The facility did not complete timely contact tracing to identify close contacts of COVID-19 positive residents and staff, timely reporting of a COVID-19 outbreak to the local health department (LHD), and a system to ensure all staff and residents were tested for COVID-19 per Centers for Disease Control and Prevention (CDC) guidelines and facility policy to prevent the potential spread of COVID-19 to vulnerable residents within the facility. This affected 26 residents who resided throughout the facility (#2, #4, #7, #9, #11, #20, #21, #26, #27, #32, #34, #37, #42, #45, #50, #52, #55, #57, #59, #67, #68, #79, #80, #81, #82, and #177) and three staff (Certified Nursing Assistant (CNA) #357, CNA #366, Licensed Practical Nurse (LPN) #369) who tested positive for COVID-19 and had the potential to affect all residents. In addition, the facility did not ensure the residents and staff were educated on the risks, benefits, and side effects of the COVID-19 vaccine. This affected five (#14, #42, #53, #57, and #64) of five residents reviewed for immunization and seven of seven employees reviewed for immunization and had the potential to affect all residents. Interview on [DATE] at 12:05 P.M. with Assistant Director of Nursing (ADON) #392 stated the staff were offered the COVID-19 vaccine at an all-staff meeting. ADON #392 stated she just offered the staff the vaccine and had not provided any education to the staff about the risks and benefits of the vaccine. ADON #392 verified only one staff member had requested the vaccine. ADON #392 also verified Residents #57, #14, #64, #53, and #42 were offered the COVID-19 vaccine but they were not provided information on the benefits, risks, and side effects. ADON #392 verified there was no separate consent form for the COVID-19 vaccine and she documented refusals on either their influenza or pneumococcal consent forms. Interview on [DATE] at 11:30 A.M. with Regional Nurse (RN) #410 verified no contact tracing or testing of staff caring for residents who had tested positive had been completed. RN #410 verified the facility policy indicated the facility would follow CDC guidelines to test close contacts. RN #410 verified the facility had not completed contact tracing for staff to identify close contacts and had not completed testing of staff. Subsequent interview on [DATE] at 7:35 A.M. with RN #410 stated the facility had not maintained assignment sheets to track staff assignments and was looking into why the building was not completing staff assignment sheets which would assist with contact tracing. Also, some staff could not be determined to have been close contacts as they may not have documented care. Further interview on [DATE] at 8:32 A.M., RN #410 stated the facility should have completed contact tracing and COVID-19 testing on days one, three, and five for the staff and residents identified as close contacts of the COVID-19 positive residents. RN #410 stated as the outbreak expanded throughout all four halls, the facility should have conducted broad-based testing every three to seven days until there were no new positive for two weeks. RN #410 verified the facility stopped testing residents on [DATE] and should have continued testing for one additional week. Interview on [DATE] at 1:46 P.M. with Local Health Department (LHD) Staff #500 revealed all nursing homes were sent an email on [DATE] with directions on reporting and managing a COVID-19 outbreak with a line listing to record positive cases for submission to the LHD. LHD Staff #500 stated COVID-19 was a Class B reportable infectious disease, and the facility was legally required to report COVID-19 cases by the end of the following business day. LHD #500 stated the facility had not reported a COVID-19 outbreak until [DATE]. LHD #500 stated she had reviewed her emails and the facility never submitted a line listing of positive COVID-19 cases. 2) Administration did not identify an issue with the resident's medical records being accurate and factual. 2a. Resident #177's medical record did not have documentation of a physician order for Hospice Services, no documentation of any discussion by the facility of family regarding initiation of hospice services and no documentation of Hospice services initiated. The record review also revealed no documentation of the physician being notified on [DATE] at 1:00 P.M. when Resident #177 began to have a change in condition. Resident #177 expired in the facility on [DATE]. 2b. Resident #54 had ongoing issues for approximately six months with moisture-associated skin damage (MASD) and there was no documentation in the medical records of this MASD. 2c. Resident #57 had been tested for COVID-19 during a COVID-19 outbreak at the facility on [DATE] and [DATE] and there was no documentation in Resident #57's medical record this was completed. Regional Nurse (RN) #410 verified there was no documentation in the medical record of COVID-19 testing on [DATE] and [DATE] for Resident #57. 2d. Resident #35 had been tested for COVID-19 at the facility on [DATE] and there was no documentation in the resident's medical this was completed. RN #410 verified there was no documentation in the medical record of COVID-19 testing on [DATE] for Resident #38. 2e. Resident #53 had been tested for COVID-19 at the facility on [DATE] and [DATE] and there was no documentation in the medical record this was completed. RN #410 verified there was no documentation in the medical record of COVID-19 testing on [DATE] and [DATE] for Resident #53. 3) Administration did not ensure adequate staffing was maintained to meet the needs of their residents and according the facility's assessment. The Payroll Based Journal (PBJ) Staffing Data Report for the fourth quarter for 2024 revealed excessively low weekend staffing was triggered (Submitted Weekend Staffing data was excessively low). Review of the Facility Assessment (FA) dated [DATE] revealed the FA included staffing needs as per shift using the ratio of staff to residents. The staffing time sheets were reviewed with Human Resource Director #325 for [DATE] through [DATE] which included department heads who picked up to work on the floor revealed the facility did not meet their staffing needs according to the FA 19 times for RN and CNA coverage over the shifts. Interview with the Regional Licensed Nursing Home Administrator (LNHA) on [DATE] at 3:30 P.M. confirmed the FA required staffing ratios for the care of residents residing at the facility was not met for each shift on any of the days reviewed [DATE] through [DATE]. Regional LNHA verified the facility had low weekend staffing for the fourth quarter of 2024. 4) Resident #51 did not have a care conference since [DATE]. Licensed Social Worker (LSW) #330 confirmed Resident #51 or his responsible party did not have a care plan meeting at all in 2024. LSW #330 stated several other residents also did not have a care plan meeting or did not have quarterly care plan meetings in 2024 prior to [DATE]. LSW #330 provided a list which included residents who did not have all quarterly care plan meetings in 2024 and new admission residents. LSW #330 identified all residents, with the exception of new admissions (Resident #17, #18, #23, #24, #29, #34, #45, #51, #53, #59, #61, #66, #65, #135, #179, #181, #182, and #183) did not have the annual and quarterly care plan meetings. 5) Residents #44, #46, #76, and #78 were not provided written notice of transfer/discharge and a bed hold notice when sent to the hospital. Interview on [DATE] at 11:08 A.M. with Regional Administrator (RA) #408 verified the facility had not provided a written notice of transfer/discharge or bed hold notices to Residents #44, #46. #76, and #78 and/or resident representative when the residents went to the hospital. RA #408 stated the facility identified the issue on the first day of the annual survey on [DATE] and stated the residents who went to the hospital since ,d+[DATE] were not provided written notice of transfer/discharge when sent to the hospital. Refer to F-623 and F-625 for full details. 6) Residents #13 and #74 were not treated with respect and dignity. Resident #13 stated Licensed Practical Nurse (LPN) #346 was always saying things that were sarcastic and rude. Resident #13 also reported being pretty sure LPN #346 cursed at her on an unknown date. Interview on [DATE] at 10:45 A.M. with Former Licensed Practical Nurse (LPN) #405 revealed they previously worked as a nurse at the facility. LPN #405 reported observing LPN #346 demanding Resident #74 to open their mouth to take medications, pushing the resident because they had been leaning, and shoving the medications into the resident's mouth. Interview on [DATE] at 4:28 P.M. with the Administrator stated they were unaware of any concerns regarding LPN #346 treating the residents. Interview on [DATE] at 11:06 A.M. with Registered Nurse (RN) #355 stated LPN #346 cursed a lot and would yell at residents. RN #355 reported they heard LPN #346 yelling at an unknown resident stating take your medications mother-explicit. RN #355 verified they did not report the observation of LPN #346 yelling at the resident because everyone knew of how LPN #346 treated residents and the administrative staff did not do anything. Interview on [DATE] at 11:38 A.M. with LPN #315 stated the staff member observed LPN #346 yelling at residents and used to report it. LPN #315 was unable to report any specific resident name and/or date of incidents. Interview on [DATE] at 8:00 A.M. with Regional Administrator #407 and Regional RN #408 stated the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #392, and LPN #346 were suspended related to multiple allegations of dignity issues and not following policies and procedures for following up on concerns related to residents and families. The Regional staff stated Administration members were suspended in order to complete a thorough investigation without interference. Review of the Administrator's job description signed by the Administrator on [DATE] revealed the primary purpose of the job position was to direct the day-to-day function of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to ensure the highest degree of quality care was provided to the residents. Ensure all employees follow established policies and procedures which included infection control. Review and check competence of work force and make necessary adjustments/corrections as required or that may become necessary. Review of the DON's job description signed [DATE] revealed the primary purpose of the position was to plan, organize, develop, control and direct the overall operation of the nursing department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure the highest level of quality care was maintained at all times. The DON would be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines pertaining to long-term care. Review of ADON #392's job description signed [DATE] revealed the primary purpose of the position was to assist the DON in planning, organizing, developing, and directing the day-to-day functions of the nursing department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the DON, Administrator and the Medical Director, to ensure the highest level of quality care was maintained at all times. Also to participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel. This deficiency represents non-compliance investigated under Complaint Number OH00161487 and Complaint Number OH00161986.

Based on review of the medical record, review of a COVID-19 outbreak log, review of staffing schedules, review of staff timecards, review of the staff call-off log, staff and resident interview, observation, interview with the Local Health Department (LHD), review of the Centers for Disease Control and Prevention (CDC) infection control guidance, and policy review, the facility failed to implement an effective and recommended infection control practices, including timely contact tracing to identify close contacts of COVID-19 positive residents and staff, timely reporting of a COVID-19 outbreak to the LHD, and a system to ensure all staff and residents were tested for COVID-19 per CDC guidelines and facility policy to prevent the potential spread of COVID-19 to vulnerable residents within the facility. This affected 26 residents who resided throughout the facility (#2, #4, #7, #9, #11, #20, #21, #26, #27, #32, #34, #37, #42, #45, #50, #52, #55, #57, #59, #67, #68, #79, #80, #81, #82, and #177) and three staff (Certified Nursing Assistant (CNA) #357, CNA #366, Licensed Practical Nurse (LPN) #369) who tested positive for COVID-19 and had the potential to affect all residents. Additionally, the facility failed to ensure infection control procedures were followed during tracheostomy care. This affected one (#54) of three residents reviewed for respiratory care. The facility identified three residents with a tracheostomy. The facility census was 74. Findings include: 1) Review of the medical record for Resident #79 revealed an admitted [DATE] and a discharge date of [DATE]. Review of a nurse's note dated 12/31/24 at 9:20 A.M. revealed the resident was discharged to another facility. The other facility notified the facility the resident tested positive for COVID-19 upon arrival. Review of census documentation revealed Resident #79 had a roommate (#134) who was admitted to the hospital on 12/29/24. Review of the medical record for Resident #32 revealed an admitted [DATE]. Review of a nurses progress note dated 12/31/24 at 10:02 P.M., revealed the hospital notified the facility the resident was positive for COVID-19 and a urinary tract infection. The resident was being sent back to the facility. Resident #32's roommate (#51) was tested and was negative. Review of the medical record for Resident #51 revealed an admitted [DATE]. Review of the nurse's note dated 12/31/24 and 01/01/25 revealed no documentation the resident was tested for COVID-19 after his roommate (#32) tested positive for COVID-19 on 12/31/24. Review of a COVID-19 outbreak log revealed two residents (#79, #32) residing on the 300-hall tested positive for COVID-19 on 12/31/24. Review of the staffing schedules and employee timecards revealed 11 staff (Licensed Practical Nurse (LPN) #405, LPN #303, LPN #420, LPN #369, LPN #361, Certified Nurse Assistant (CNA) #305, CNA #324, CNA #397) had provided care for Resident #79 and Resident #32 on 12/30/24 and 12/31/24. Further review of the outbreak documentation revealed no staff contact tracing or testing for COVID-19 was completed for staff identified as close contacts of the two residents. Review of the COVID-19 outbreak log revealed an additional three residents (#177, #80, #68) residing on the 100, 300, and 400 halls had tested positive for COVID-19 on 01/02/25. No contact tracing or staff testing was completed. Review of the COVID-19 outbreak log revealed an additional 21 residents (#57, #7, #81, #9, #50, #11, #26, #2, #67, #21, #27, #59, #52, #82, #37, #20, #4, #45, #55, #34, #42) residing on the 100, 200, 300, and 400 halls tested positive for COVID-19 from 01/03/25 through 01/14/25. There was no documentation staff were tested . CNA #357 and CNA #366 tested positive on 01/02/25. LPN #369 tested positive on 01/05/25. Review of the employee call-off log revealed on 12/30/24 and 12/31/24 one staff member had called off from work, on 01/01/25 five staff had called off, and on 01/02/25 four staff had called off. On 01/03/25 nine staff had called off and five staff called off on 01/04/25. Two staff called off on 01/05/25 and five staff called off on 01/06/25. On 01/07/25 eight staff called off and on 01/08/25 four staff had called off. On 01/09/25 three staff had called off and five staff called off on 01/10/25. On 01/11/25 two staff had called off and on 01/12/25 there were six staff who called off. There was one staff call off on 01/13/25. The type of call offs from 12/30/24 through 01/13/25 were listed as sick or other with two listed as no call no show. Review of census rosters dated 01/02/25, 01/07/25, 01/10/25, 01/14/25, and 01/17/25 revealed all the residents had a plus or minus by their name indicating if the resident had tested positive or negative for COVID-19 that day. Resident #2 was listed on 01/02/25 with a minus. Resident #35, Resident #38, and Resident #53 were listed with minuses on all five testing dates. Review of the medical records revealed there was no documentation Resident #57 was tested on [DATE]. Resident #57 was positive for COVID-19 on 01/03/25 after family requested testing due to respiratory symptoms. The medical record for Resident #35 revealed there was no documentation the resident was tested for COVID-19 on 01/02/25 and 01/17/25. The medical record for Resident #38 revealed there was no documentation the resident was tested for COVID-19 on 01/07/25. The medical record for Resident #53 revealed there was no documentation the resident was tested for COVID-19 on 01/10/25 and 01/17/25. Interviews with staff revealed the following: on 02/03/25 at 2:06 P.M. with CNA #357 stated she tested herself at home and was positive for COVID-19 on 01/02/25. On 02/04/25 at 1:51 P.M., CNA #340 stated she had not been tested during the COVID-19 outbreak. CNA #340 further revealed facility management had poor communication with staff. CNA #340 stated management were directing staff not to tell anyone if they tested positive for COVID-19 as they would not have enough staff. CNA #340 could not pinpoint which management staff as it worked its way down and made it to all the aides. On 02/04/25 at 3:41 P.M., CNA #362 stated the facility had not tested her for COVID-19 during the COVID-19 outbreak. On 02/04/25 at 3:46 P.M., CNA #368 stated the facility had not tested her for COVID-19 during the COVID-19 outbreak. On 02/05/25 at 7:51 A.M., LPN #318 stated the facility had not tested her for COVID-19 during the outbreak. Interview on 02/03/25 beginning at 2:20 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #392 stated staff were tested on [DATE] but there was no documentation of the testing. The DON stated staff would only need tested if they were symptomatic per the facility policy. The DON and ADON #392 revealed the last day residents were tested was on 01/17/25. Interview on 02/04/25 at 11:30 A.M. with Regional Nurse (RN) #410 verified no contact tracing or testing of staff caring for residents who had tested positive had been completed. RN #410 verified the facility policy indicated the facility would follow CDC guidelines to test close contacts. RN #410 verified the facility had not completed contact tracing for staff to identify close contacts and had not completed testing of staff. Interviews with the residents revealed the following: on 02/04/25 at 1:47 P.M., Resident #38 stated he had only been tested twice during the COVID-19 outbreak, once when it first started and then once a couple days later. On 02/04/25 at 12:56 P.M., Resident #35 stated testing for COVID-19 was completed maybe twice during the COVID-19 outbreak. On 02/04/25 at 2:13 P.M., Resident #53 stated only being tested two or three times during the COVID-19 outbreak. Interview on 02/05/25 at 7:35 A.M. with RN #410 stated the facility had not maintained assignment sheets to track staff assignments and was looking into why the building was not completing staff assignment sheets which would assist with contact tracing. Also some staff could not be determined to have been close contacts as they may not have documented care. Further interview on 02/05/25 at 8:32 A.M., RN #410 stated the facility should have completed contact tracing and COVID-19 testing on days one, three, and five for the staff and residents identified as close contacts of the COVID-19 positive residents. RN #410 stated as the outbreak expanded throughout all four halls, the facility should have conducted broad-based testing every three to seven days until there were no new positive for two weeks. RN #410 verified the facility stopped testing residents on 01/17/24 and should have continued testing for one additional week. Interview on 02/05/25 at 7:58 A.M. with LPN #369 stated she was assigned to work on all the halls in the facility. LPN #369 stated she tested positive at home on 01/05/25 then went to the facility the same day and tested positive again. Interview on 02/05/25 at 9:11 A.M. with ADON #392 stated she thought she had notified the local health department (LHD) of the COVID-19 outbreak on 01/02/25. ADON #392 stated the LHD had not asked for a line listing of COVID-19 positive residents. ADON #392 stated she thought the LHD indicated to conduct contact tracing. ADON #392 verified staff were not tested on [DATE]. ADON #392 stated she left out COVID-19 tests and encouraged the staff to test themselves. ADON #392 stated staff were not checked if they had tested as we could not force anyone to test themselves. Interview on 02/05/25 at 1:46 P.M. with Local Health Department (LHD) Staff #500 revealed all nursing homes were sent an email on 04/01/24 with directions on reporting and managing a COVID-19 outbreak with a line listing to record positive cases for submission to the LHD. LHD Staff #500 stated COVID-19 was a Class B reportable infectious disease and the facility was legally required to report COVID-19 cases by the end of the following business day. LHD #500 stated the facility had not reported a COVID-19 outbreak until 01/08/25. LHD #500 stated she had reviewed her emails and the facility never submitted a line listing of positive COVID-19 cases. Interview on 02/06/25 beginning at 11:00 A.M., RN #410 verified there was no documentation in the medical record of COVID-19 testing on 01/02/25 for Resident #57 and Resident #35, on 01/10/25 for Resident #53, and on 01/17/25 for Resident #38 and Resident #57. Review of the facility policy titled Infection Prevention and Control Program, revised 08/01/23, revealed the facility would implement a system of surveillance for prevention, identification, reporting, investigating, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services according to accepted national standards. Residents with close contact with someone with SARS-CoV-2 (COVID-19) infection should have a series of three viral tests for SARS-CoV-2 infection. Testing recommended immediately (but not earlier than 24 hours after exposure) and if negative, again 48 hours after first negative test and if negative, again 48 hours after the second negative test. Typically, on day one, day three, and day five. If healthcare-associated transmission is suspected or identified, the facility may consider expanded testing of health care personnel (HCP) and resident as determined by the distribution and number of cases throughout the facility and ability to identify close contacts. If expanded testing approach is taken and testing identified additional infections, testing should be expanded more broadly. If possible, testing should be repeated every three to seven days until no new cases were identified for at least 14 days. Review of the facility policy COVID-19 Prevention, Response and Reporting, revised 06/01/24, revealed a close contact was being within six feet for a cumulative total of 15 minutes or more over a 24-hour period with someone with SARS-CoV-2 infection. If a COVID-19 threat was detected, the facility would respond promptly and implement emergency and/or outbreak procedures. The facility would perform viral testing for SARS-CoV-2 as per national standards such as CDC recommendations. Review of the CDC Infection Control Guidance: SARS-CoV-2 dated 06/04/24, revealed the approach to an outbreak investigation involves either contact tracing or a broad-based approach. A broad-based approach was preferred if all potential contacts could not be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close-contacts or on the affected units if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day one, day three and day five. 42011 2) Record review for Resident #54 revealed an admitted d of 05/30/23. Diagnoses included tracheostomy, cerebral infarction, and acute respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was rarely or never understood. Resident #54 was dependent on staff for activities of daily living (ADLs). Resident #54 received oxygen, had a tracheostomy and required suctioning. Review of the care plan dated 12/18/23 revealed Resident #54 had a tracheostomy. Resident #54 was at risk for complications including respiratory distress, increased secretions, and infection. Interventions included to follow facility protocol for enhanced barrier precautions and suction as necessary. Review of the physician orders for Resident #54 revealed a number six shiley uncuffed trach and trach care every shift and as needed initiated 05/18/24. Additional orders included tracheostomy suction as needed for excessive secretions initiated 05/30/23. Observation and interview on 02/04/25 at 3:50 P.M. of trach suctioning for Resident #54 with Licensed Practical Nurse (LPN) #361 revealed on the entrance door for Resident #54's room was a sign which revealed Resident #54 was on Enhanced Barrier Precautions (EBP). The information on the sign included providers must clean their hands, including before entering and leaving the room, providers and staff must also wear gloves and a gown for the following high contact resident care activities which included tracheostomy care. Observation revealed LPN #361 did not wash her hands prior to entering Resident #54's room. LPN #361 also did not don a gown or mask. LPN #361 walked over to Resident #54's bed, opened up sterile gloves (did not wash her hands prior to opening or putting on the gloves) then completed trach suctioning for Resident #54. After completing this task, LPN #361 removed her gloves then exited the room (did not wash her hands) then walked back towards the nursing station. LPN #361 confirmed she did not wash her hands prior to or after going in Resident #54's room. LPN #361 also confirmed she did not wash her hands before or after trach care for Resident #54. LPN #361 confirmed Resident #54 was on EBP and confirmed she did not wear a gown or mask while providing trach (respiratory) care for Resident #54. Review of the facility's undated policy titled Suctioning Tracheostomy revealed tracheostomy suctioning removes thick mucous and secretions from the traches and lower airway that the resident is not able to clear by coughing. To reduce the possibility of contamination, a sterile technique is essential. The procedure included to wash hands and tell the resident what you are doing, assemble the equipment, position the resident and wash hands thoroughly. Open the suction kit, it is very important to keep everything as clean as possible to prevent infection. After suction has been completed, wash hands. This deficiency represents non-compliance investigated under Complaint Number OH00161986 and Complaint Number OH00161487.

Based on observation, resident, family, and staff interview, record review, and review of the facility assessment, the facility failed to provide sufficient staffing to consistently meet the resident's needs. This affected three (Residents #55, #181, and #182) and had the potential to affect all 74 residents residing at the facility. Findings include: 1) There was inadequate staff to complete timely incontinence care and bathing/showering for the residents. 1a. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #181 was cognitively intact. Resident #181 required partial/moderate assistance with toileting hygiene. Resident #181 was occasionally incontinent of urine and frequently incontinent of bowel. Interview on 01/29/25 at 3:25 P.M. with Certified Nursing Assistant (CNA) #309 stated at times the facility did not have enough staff to complete resident's care timely including incontinence care and not being assisted to bed timely. CNA #309 stated yesterday (01/28/25), while she went to the dining room to assist with meals, that only left one CNA on the floor to assist the residents. Last Thursday (01/23/25), the assigned CNA #399 refused to change Resident #181 during dinner service. Resident #181 had diarrhea and needed changed. At 5:20 P.M., Resident #181 passed a meal tray by CNA #399. CNA #399 told her she could not change her while dinner was being passed. Resident #181 tried to refuse her dinner tray hoping she would then be able to be changed. CNA #399 said no she had to pass trays. CNA #309 was in the dining room, and Resident #181's husband came and got her (CNA #309) around 6:15 P.M. and CNA #309 changed her. Resident #181 had stool everywhere. Interview on 01/29/25 at 3:40 P.M. with Resident #181 stated she had diarrhea really bad last Thursday (01/23/25) and after she put her call light on, an unidentified CNA came into her room, turned her call light off and said she was giving a shower. Resident #181 said it took a few hours for her to receive incontinence care. Resident #181 stated it was very upsetting and embarrassing when she had to sit in diarrhea, and no one would help her. Resident #181 stated there were times staff did not assist timely when she requested care. Interview on 01/29/25 at 4:03 P.M. with Licensed Practical Nurse (LPN) #364 confirmed she worked the previous Thursday (01/23/25) at dinner time when Resident #181 had diarrhea and needed changed. LPN #364 stated Resident #181 said she needed changed, CNA #399 went in there, and told Resident #181 it was dinner. LPN #364 explained during dinner, generally they do not change residents, and the residents need to wait until after the meal. Interview on 02/06/25 at 11:10 A.M. with Regional Nurse (RN) #410 stated if a resident was incontinent and staff were passing trays, she would expect the staff member to get assistance so the resident could be changed at the time the resident was incontinent. The resident should not have to wait until after meal service to receive incontinence care. 1b. Review of the quarterly MDS assessment dated [DATE] revealed Resident #55 was severely cognitively impaired. Resident #55 had impairment on both sides of the upper and lower extremities. Resident #55 was dependent on staff for toileting hygiene and was frequently incontinent of urine and always incontinent of bowel. Review of the physician orders for Resident #55 dated 01/14/25 revealed to check and change Resident #55 every two hours to offload coccyx - peri area. Resident #55 was to be up in the Broda chair (a chair that provides comfort, support, and mobility) for a maximum of four hours a day. An order dated 07/10/24 revealed to encourage Resident #55 to let staff put him back to bed after lunch. Interview and observation on 01/30/25 at 11:14 A.M. with Resident #55's wife revealed she visited Resident #55 frequently. Resident #55 was supposed to be changed every two hours, the staff get him up at 5:00 A.M. every morning and he would sit in the chair all day without being laid down or changed. Observation with Resident #55's wife revealed Resident #55 was sitting in the Broda chair in an upright position sleeping in the dining room. Observations revealed on 01/30/25 at 11:56 A.M., Resident #55 was still sitting in the Broda chair in an upright position sleeping in the dining room. On 01/30/25 at 12:55 P.M., Certified Nursing Assistant (CNA) #401 pushed Resident #55's Broda chair from the dining room to the lounge. Continuous observations on 01/30/25 from 1:28 P.M. through 2:23 P.M. revealed Resident #55 stayed in the lounge in the Broda chair in the upright position with his feet dangling. No staff addressed Resident #55 to offer care. Observation and interview on 01/30/25 at 2:24 P.M. revealed CNA #357 and #395 assisted Resident #55 to his room. CNA #357 confirmed she was Resident #55's primary CNA and stated she assisted Resident #55 up out of bed at 6:30 A.M. that day (01/30/25) CNA #357 confirmed this was the first time today she laid Resident #55 down and confirmed she did not check or change him until now. CNA #357 stated she was busy and did not have time. 1c. Review of the physician orders for Resident #182 dated 11/24/24 revealed skin checks weekly with showers on Mondays and Thursdays. Review of the shower/bath schedule for Resident #182 revealed Resident #182 was scheduled to receive a shower 11 times on 11/25/24, 11/28/24, 12/02/24, 12/05/24, 12/09/24, 12/12/24, 12/16/24, 12/19/24 12/23/24, 12/26/24 and 12/30/24. Review of the Shower/Tub Bath/Bed Bath Sheets provided by Regional Registered Nurse (RRN) #410 revealed Resident #182 was not offered a shower/bath six times on 11/25/24, 11/28/24, 12/05/24, 12/09/24, 12/12/24, 12/23/24, and 12/30/24. There were no other records indicating the resident was offered a shower or bath on other days of the week. Interview on 02/03/25 at 2:00 P.M. with Resident #182 stated he was admitted to the facility to recuperate from a shattered femur. Resident #182 stated 15 days went by before he was even offered a shower or bath. Interview on 02/06/25 at 11:40 A.M. with RRN #410 stated each resident was scheduled showers/baths weekly. Resident #182 was scheduled two showers/baths a week. RRN #410 confirmed only four Shower/Tub Bath/Bed Bath Sheets were completed for Resident #182 confirming Resident #182 was offered a shower/bath only four of the scheduled 11 to be offered. Interview on 02/06/25 at 12:00 P.M. with CNA #307 confirmed she cared for Resident #182 during his stay at the facility. CNA #307 stated some days there were enough staff to offer showers and other days there were not. CNA #307 stated if there was not enough staff then showers were not done because there was just not enough time to get to them. 2) Review of the Payroll Based Journal (PBJ) Staffing Data Report for the fourth quarter for 2024 revealed excessively low weekend staffing was triggered (Submitted Weekend Staffing data was excessively low). Review of the Facility Assessment (FA) dated 11/22/24 approved by Administrator and Medical Director #614 and reviewed by Quality Assurance and Assessment (QAA) Committee dated 11/26/24 revealed the purpose of the assessment is to determine what resources are necessary to care for our residents competently both day to day operations (including nights and weekends) and emergencies. The assessment addressed the following elements: The facility's resident population, including but not limited to the number of residents and the facility's resident capacity. The care required by the resident population using evidence-based data, data driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within the population, consistent with and informed by individual resident assessments. The FA included staffing needs as per shift using the ratio of staff to residents: Night shift: registered nurse (RN) 1:40, LPN 1:40, and CNA 1:14 Day shift: RN 1:22, LPN 1:22, and CNA 1:8 Evening shift: RN 1:22, LPN 1:22, and CNA 1:8 Review of the staffing time sheets with Human Resource Director #325 for 01/03/25 through 01/09/25 which included department heads who picked up to work on the floor revealed the facility did not meet their staffing needs according to the FA on the following days and shifts: On 01/03/25, the RN ratio for night shift was 1:78 (FA was 1:40); CNA ratio on evening shift was 1:11 (FA was 1:8), CNA ratio for night shift was 1:15 (FA was 1:14). On 01/04/25, CNA ratio on day shift was 1:16 (FA was 1:8) and CNA ratio for evening shift was 1:16 ( FA was 1:8). On 01/05/25, RN ratio on evening shift was 1:79 (FA was 1:22), CNA ratio on day shift was 1:13 (FA was 1:8) , on CNA ratio on evening shift was 1:15 (FA was 1:8). On 01/06/25, the RN ratio night shift was 1:81 (FA was 1:40) and CNA ratio on night shift was 1:20 (FA was 1:14) On 01/07/25, the RN ratio on night shift was 1:80 (FA was 1:40), CNA ratio on day shift was 1:11 (FA was 1:8), and CNA ratio on evening shift was 1:13 (FA was 1:8). On 01/08/25, the RN ratio on night shift was 1:78 (FA was 1:40), CNA ratio on day shift was 1:14 (FA was 1:8), and CNA ratio on evening shift was 1:16 (FA was 1:8). On 01/09/25, the RN ratio on night shift was 1:72 (FA was 1:40), CNA ratio on day shift was 1:10 (FA was 1:8) and CNA ratio on evening shift was 1:12 (FA was 1:8). Interview with the Regional Licensed Nursing Home Administrator (LNHA) on 02/05/25 at 3:30 P.M. confirmed the FA required staffing ratios for the care of residents residing at the facility was not met for each shift on any of the days reviewed 01/03/25 through 01/09/25. Regional LNHA verified the facility had low weekend staffing for the fourth quarter of 2024. This deficiency represents non-compliance investigated under Complaint Numbers OH00161986 and OH00161487.

Based on resident and staff interview, record review, and review of the facility policy, the facility failed to have routine/scheduled care plan meetings for the residents and/or resident representative in 2024. This affected one (Resident #51) of one resident reviewed for care plan meetings. The facility identified all residents residing at the facility with the exception of 18 residents admitted after November 2024 (Residents #17, #18, #23, #24, #29, #34, #45, #51, #53, #59, #61, #66, #65, #135, #179, #181, #182, and #183) did not have care conferences in 2024. The facility census was 74. Findings include: Record review for Resident #51 revealed an admitted [DATE]. Diagnoses included displaced midcervical fracture of the left femur, atrial fibrillation, and hemiplegia and hemiparesis following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was moderately cognitively impaired. Resident #51 had impairment on both sides of the lower extremities. Interview on 01/28/25 at 2:08 P.M. with Resident #51 stated he was not invited to a care plan meeting that he could recall. Record review for Resident #51 revealed the last care plan meeting was documented 08/18/23 at 8:03 A.M. Interview on 02/03/25 at 12:47 P.M. with Licensed Social Worker (LSW) #330 confirmed Resident #51 or his responsible party did not have a care plan meeting at all in 2024. LSW #330 stated several other residents also did not have a care plan meeting or did not have quarterly care plan meetings in 2024 prior to November 2024. LSW #330 provided a list which included residents who did not have all quarterly care plan meetings in 2024 and new admission residents. LSW #330 identified all residents, with the exception of new admissions (Resident #17, #18, #23, #24, #29, #34, #45, #51, #53, #59, #61, #66, #65, #135, #179, #181, #182, and #183) did not have the annual and quarterly care plan meetings. Interview on 02/03/25 at 1:10 P.M. with Regional Director of Clinical Services (RDCS) #615 confirmed care plan meetings were not consistently completed for residents residing in the facility in 2024. RDCS #615 revealed the meetings should have been completed at the minimum quarterly for each resident. Review of the facility policy titled titled Care Planning-Resident Participation dated 06/01/24 revealed the facility will discuss the plan of care with the resident and or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. This deficiency represents non-compliance investigated under Complaint Number OH00161487 and Complaint Number OH00161986.

Based on observations, resident, family, and staff interviews, and record review, the facility failed to ensure medical records were accurate and factual. This affected eight (Residents #26, #35, #38, #53, #53, #55, #57, and #177) of 27 residents medical records reviewed during the annual survey. The facility census was 74. Findings include: 1 Review of the medical record for Resident #26 revealed an admitted [DATE]. Diagnoses included left hand contracture. Review of the physician orders for February 2025 revealed palm protective splint to left hand on in the PM and off in the AM, activated 01/20/23. Review of the plan of care revealed assistance needed for activities of daily living (ADL) related to decreased range of motion to left hand. Interventions included palm protective splint to left hand on in the PM and off in the AM. Review of the Treatment Administration Record (TAR) for February 2025 revealed treatment for palm protector splint to left hand was marked that it was put on 02/04/25 and signed off that the splint was in place and taken off. Observation and interview on 02/04/25 at 2:51 P.M. with Resident #26 stated she was to have a palm protector on her left hand at night and the staff have not been putting the splint on for months. Observation and interview on 02/05/25 at 5:40 A.M. revealed Resident #26 was still in bed, not wearing her left palm splint. The resident stated the certified nursing aide did not put her splint on when she went to bed. An interview on 02/05/25 at 5:40 A.M. with Licensed Practical Nurse (LPN) #367 stated Resident #26 was to have a splint or rolled up towel in her left hand at night. LPN #367 verified Resident #26 was not wearing her splint and did not have a rolled-up washcloth in her hand. LPN #673 stated she did not look to see if the splint was on and just signed off the order on the TAR. 42011 2) Record review for Resident #55 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, dementia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 was severely cognitively impaired. Resident #55 had impairment on both sides of the upper and lower extremities. Resident #55 was dependent on staff for toileting hygiene, personal hygiene, and transfers. Resident #55 required substantial/maximal assistance for bed mobility and was frequently incontinent of urine and always incontinent of bowel. Resident #55 used a wheelchair with assistants for mobility. Review of the care plan for Resident #55 dated 05/15/23 and revised 07/17/24 revealed Resident #55 was totally dependent and does not participate in locomotion in wheelchair, provide incontinence care with routine rounds and as needed. Apply ted hose in the morning and remove them at night. Review of the physician orders for Resident #55 dated 01/14/25 revealed to check and change Resident #55 every two hours to offload coccyx - peri area. Resident #55 to be up in the Broda chair for a maximum of four hours a day dated 01/14/25. The physician orders also included to encourage Resident #55 to let staff put him back to bed after lunch dated 07/10/24 and to apply ted hose knee high on in the morning and off in the evening for (deep vein thrombosis) DVT prophylactic dated 03/27/24. Interview on 01/30/25 at 11:14 A.M. with Resident #55's wife revealed she visited Resident #55 frequently. Resident #55 was supposed to be changed every two hours, the staff get him up at 5:00 A.M. every morning and he would sit in the chair all day without being layed down or changed. Observation with Resident #55's wife revealed Resident #55 was sitting in the Broda chair in an upright position sleeping in the dining room. Observations on 01/30/25 revealed at 11:56 A.M., Resident #55 was still sitting in the Broda chair in an upright position sleeping in the dining room. The meal was not served. At 12:54 P.M., Resident #55 was still sitting in the Broda chair in an upright position sleeping in the dining room. The meal was completed and the tray was removed. At 12:55 P.M., Certified Nursing Assistant (CNA) #401 pushed Resident #55's Broda chair from the dining room to the lounge. CNA #401 did not offer Resident #55 to lay down after lunch, after taking him in the lounge, she left leaving Resident #55 in the Broda in the upright position. Resident #55's feet were dangling, observation revealed Resident #55 did not have ted hose on. From 1:28 P.M. through 2:23 P.M., continuous observations revealed Resident #55 stayed in the lounge in the Broda chair in the upright position with his feet dangling. No staff addressed Resident #55 to offer care. Record review on 01/30/25 at 2:17 P.M. of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for 01/30/25 revealed Licensed Practical Nurse (LPN) #353 signed the orders as completed for Resident #55 to check and change Resident #55 every two hours to offload coccyx - peri area, to be up in the Broda chair for a maximum of four hours a day, to encourage Resident #55 to let staff put him back to bed after lunch, and to apply ted hose knee high on in the morning and off in the evening for DVT prophylactic. Further review of the MAR/TAR for the entire month of January 2025 revealed all orders for the month were signed as completed. Observation and interview on 01/30/25 at 2:24 P.M. revealed CNA #357 and #395 assisted Resident #55 to his room. CNA #357 confirmed she was Resident #55's primary CNA and stated she assisted Resident #55 up out of bed at 6:30 this A.M. Both CNA #357 and #395 stated Resident #55 never wore ted hose, they had both worked with him over the past six months and he never wore ted hose. CNA #357 confirmed this was the first time today she laid Resident #55 down and confirmed she did not check or change him either until now. CNA #357 stated she thought hospice was in earlier and changed him. CNA #357 stated she was busy and did not have time. Observation of incontinence care provided by CNA #357 and #395 revealed Resident #55's brief was saturated with urine. Resident #55's pants were also wet and CNA #395 confirmed the seat cushion in the Broda chair was also wet with urine. Resident #55's scrotum and peri area were red. CNA #357 stated Resident #55 gets up again before dinner and will stay up until laid down by the next shift. Interview on 01/30/25 at 2:37 P.M. with LPN #353 confirmed she was Resident #55's Charge Nurse. LPN #353 stated the hospice aide was in today and provided care for Resident #55 then left between 7:00 A.M. and 7:30 A.M. LPN #353 confirmed Resident #55 was supposed to wear ted hose daily but she was not sure if they were on him because she does not look. LPN #353 stated she was not sure how long Resident #55 was to be up in the chair, maybe two or three hours. Observation on 02/04/25 at 4:52 P.M. with Registered Nurse (RN) Supervisor #308 confirmed Resident #55 was sitting up in his chair. Resident #55 did not have his ted hose on. RN Supervisor #308 stated she told the CNA earlier in the day to apply the ted hose, the CNA informed her there was none in his room to apply so she told the CNA she would get him some out of stock but she just had not done it yet. Observation with RN Supervisor #308 revealed Resident #55 did not have any ted hose available in his room to be applied. RN Supervisor #308 confirmed the ted hose was signed in the medical record as being applied in the A.M. and this was inaccurate. Record review of the TAR revealed the orders to apply the ted hose in the A.M. was signed for Resident #55 as completed. 3) Record review for Resident #177 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #177 had a hospital stay from 01/05/25 through 01/11/25. Diagnoses included diastolic congestive heart failure (CHF), hypertensive heart and chronic kidney disease with heart failure, Parkinsonism, emphysema, vascular dementia, bradycardia, muscle weakness, atrial fibrillation, and chronic obstructive pulmonary disease (COPD). Review of the quarterly MDS assessment dared 11/11/24 revealed Resident #177 was cognitively intact. Resident #177 had no chronic condition, or chronic disease that may result in a life expectancy of less than six months. Review of the physician orders for Resident #177 revealed orders dated 01/11/25 for enteral feed order every shift osmolite 1.5 at 60 cubic centimeters per hour continuous. Review of the progress note for Resident #177 dated 01/14/25 at 1:00 P.M. completed by RN #345 revealed family member at bedside. Made this nurse aware Resident #177 began to spit up TF. Resident was suctioned and repositioned. Hospice nurse entered room at this time and stated to hold TF at this time, working on admission. Review of the medical record including the census for Resident #177 revealed no documentation of a physician order for Hospice Services, no documentation of any discussion by the facility of family regarding initiation of hospice services and no documentation of Hospice services initiated. The record review also revealed no documentation of the physician being notified on 01/14/25 at 1:00 P.M. when Resident #177 began to spit up TF. Interview on 02/03/25 at 9:32 A.M. with Business Office Manager (BOM) #610 revealed Hospice came in on 01/14/24 to assess Resident #177, the family was going to sign the paperwork, but they did not because Resident #177 passed and hospice never picked her up. Interview on 02/03/25 at 9:41 A.M. with Registered Nurse (RN) Supervisor #308 and Regional RN #410 revealed the physician should have been notified on 01/14/25 at 1:00 P.M. when Resident #177 was spitting up TF. Regional RN #410 confirmed there was no further documentation of hospice services in the medical records. Interview on 02/04/25 at 10:30 A.M. with RN #345 stated Resident #177 declined very quickly after returning from the hospital that was why hospice was called to assess the resident. Interview on 02/04/25 with Regional RN #410 revealed the facility spoke with Hospice Services and they picked Resident #177 up for about an hour before passing. Regional RN #410 confirmed they were unaware Hospice picked her up until they called Hospice services themselves. 4) Record review for Resident #54 revealed an admitted d of 05/30/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side and muscle weakness. Review of the quarterly MDS assessment dated [DATE] revealed Resident #54 was rarely or never understood. Resident #54 was dependent on staff for activities of daily living (ADL's). Resident #54 had an indwelling catheter and was always incontinent of bowel. Resident #54 had moisture associated skin damage (MASD) and received applications of ointments/medications. Interview on 01/28/25 at 12:44 P.M. with Resident #54's spouse revealed she was concerned about the rash on Resident #54's bottom, she felt Resident #54 was not being changed enough. Interview on 01/30/25 at 12:01 P.M. with CNA #395 revealed Resident #54 had an indwelling catheter and only needed changed if he had a bowel movement. Resident #54 had not had a bowel movement so there was no need to change him today. Observation and interview on 02/05/25 at 11:07 A.M. revealed Resident #54's brief was changed by CNA #357 and #395. Resident #54 was wet with sweat on his shirt and in his brief. CNA #357 and #395 stated Resident #54 always sweats and that was why his bottom was wet and very red. Resident #54's bilateral buttocks was deep red/discoloration with open excoriated areas to bilateral buttocks. CNA #357 and #395 stated Resident #54 was unable to move without assistance. Interview on 02/05/25 at 12:58 P.M. with Wound Care Certified Nurse Practitioner (CNP) #611 confirmed she assessed Resident #54 on this day and observed the buttocks was discolored and diagnosed with moisture associated skin damage (MASD); MASD was caused by moisture, the moisture could be caused by the sweating, and the area needed to be kept clean and dry. Record review of the medical record for Resident #54 revealed no documentation of excoriation to the buttocks or MASD. Interview on 02/06/25 at 11:36 A.M. with Regional RN #410 confirmed there was no documentation of MASD in Resident #54's medical record describing the wound and measurements including when it healed and when it returned and revealed it looked like it comes and goes because the venelex external ointment, ordered in November 2023 was used for the MASD. Regional RN #410 stated each time Resident #54 had MASD, the nurses should have measured, monitored, and documented the areas. Interview on 02/06/25 at 11:56 A.M. with LPN #361 revealed the excoriation (MASD) comes and goes on Resident #54's buttocks for at least six months. 35033 5) Review of the medical record for Resident #57 revealed an admitted [DATE]. Diagnoses included anoxic brain damage, and sudden cardiac arrest. Review of the annual Minimum Data Set (MDS) assessment revealed SR #57 had impaired cognition. Review of census rosters dated 01/02/25, 01/07/25, 01/10/25, 01/14/25, and 01/17/25 revealed all the residents had a plus or minus by their name indicating if the resident had tested positive or negative for COVID-19 that day. Review of the nurse progress notes dated 01/02/25 and 01/17/24 revealed no documentation Resident #57 had been tested for COVID-19. Interview on 02/06/25 beginning at 11:00 A.M. with Regional Nurse (RN) #410 verified there was no documentation in the medical record of COVID-19 testing on 01/02/25 and 01/17/25 for Resident #57. 6) Review of the medical record for Resident #35 revealed an admitted [DATE]. Diagnoses included heart failure, hypertension, atrial fibrillation, chronic kidney disease, and type two diabetes mellitus. Review of census rosters dated 01/02/25, 01/07/25, 01/10/25, 01/14/25, and 01/17/25 revealed all the residents had a plus or minus by their name indicating if the resident had tested positive or negative for COVID-19 that day. Resident #35 was listed with minuses on all five testing dates. Review of the nurse progress notes dated 01/02/25 through 01/18/25 revealed there was no documentation Resident #35 had been tested for COVID-19 on 01/02/25. Interview on 02/06/25 beginning at 11:00 A.M. with Regional Nurse (RN) #410 verified there was no documentation in the medical record of COVID-19 testing on 01/02/25 for Resident #35. 7) Review of the medical record for Resident #38 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease and chronic pain syndrome. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of census rosters dated 01/02/25, 01/07/25, 01/10/25, 01/14/25, and 01/17/25 revealed all the residents had a plus or minus by their name indicating if the resident had tested positive or negative for COVID-19 that day. Resident #38 was listed with minuses on all five testing dates. Review of the nurse progress notes dated 01/02/25 through 01/18/25 revealed no documentation Resident #38 had been tested for COVID-19 on 01/17/25. Interview on 02/06/25 beginning at 11:00 A.M. with Regional Nurse (RN) #410 verified there was no documentation in the medical record of COVID-19 testing on 01/17/25 for Resident #38. 8) Review of the medical record for Resident #53 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, and post-traumatic stress disorder. Review of a significant change assessment dated [DATE] revealed the resident had intact cognition. Review of census rosters dated 01/02/25, 01/07/25, 01/10/25, 01/14/25, and 01/17/25 revealed all the residents had a plus or minus by their name indicating if the resident had tested positive or negative for COVID-19 that day. Resident #53 was listed with minuses on all five testing dates. Review of the nurse progress notes dated 01/02/25 through 01/18/25 revealed no documentation Resident #53 had been tested for COVID-19 on 01/10/25 and 01/17/25. Interview on 02/06/25 beginning at 11:00 A.M. with Regional Nurse (RN) #410 verified there was no documentation in the medical record of COVID-19 testing on 01/10/25 and 01/17/25 for Resident #53. Review of the facility policy titled Documentation in Medical Record, revised 11/12/24, revealed the medical record would contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members would document all assessments, observations, and services provided in the resident's medical record in accordance with state law. Documentation would be completed at the time of service, but no later than 24/48 hours in which the assessment, observation, or care service occurred.

Based on staff interview, record review, and review of the facility policy, the facility failed to ensure a care plan was completed for Resident #61 to include depression, anxiety, and the use of psychotropic medications. This affected one (Resident #61) of 27 residents reviewed for care plans. The facility census was 74. Findings include: Review of the medical record for Resident #61 revealed an admitted [DATE]. Diagnoses included delirium, dementia without behavioral disturbance, psychotic disturbance and mood disturbance, and major depressive disorder. Review of Resident #61's care plan initiated on 11/13/24 revealed the resident's anxiety, depression, behaviors, and use of antipsychotic and psychotropic medications were not addressed in the comprehensive care plan. Review of the physician orders revealed the following psychotropic medications: on 11/04/24, an order for quetiapine 50 milligrams (mg) at bedtime for anxiety. On 11/09/24, an order for Zoloft 25 mg in the morning for dementia and anxiety and Depakote sprinkles 125 mg at bedtime for delirium, dementia and anxiety. On 11/28/24 the order for the quetiapine was updated for the diagnosis of unspecified dementia and anxiety. On 01/22/25, the Zoloft diagnosis was noted as depression. On 01/22/25, the Depakote sprinkles had a diagnosis for behaviors. Interview on 02/04/25 at 9:48 A.M. with Minimum Data Set (MDS) Nurse #354 stated she began working in the facility three weeks ago and did not have a chance to review all the previous care plans. MDS Nurse #354 verified Resident #61 had no care plan in place for depression, anxiety, behaviors, and for the use of antipsychotic and psychotropic medications. Review of the policy titled Comprehensive Care Plans, revised 06/01/24, revealed the comprehensive care plan would include the service to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on review of the medical record, staff interview and policy review, the facility failed to ensure a resident's family was notified of a resident's decline in condition. This affected one (#178) of four residents reviewed for change in condition. The facility census was 74. Findings include: Review of the closed medical record for Resident #178 revealed an admitted [DATE], a readmitted [DATE] and a discharge date of [DATE]. Diagnoses included pneumonia, hypertension, and acute and chronic respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #178 had impaired cognition. Review of a physician order dated [DATE] revealed Resident #178's code status was Do Not Resuscitate Comfort Care (DNRCC). Review of nurse's note dated [DATE] at 11:16 A.M. revealed the nurse went to assess and provide resident medication and resident was noted with respiratory distress. The resident's pulse oximetry level was 80 percent on four liters via trach collar. The resident was suctioned with copious amount of thick clear sputum. Pulse oximetry level increased to ,d+[DATE] percent. The resident's inner cannula and tracheostomy care were completed and an as needed aerosol was administered. Pulse oximeter level increased to 85 percent. Resident resting comfortably with eyes closed. The nursing dated dated [DATE] at 1:02 P.M. revealed the resident had an absence of vital signs at 10:55 A.M. There was no documentation the family was notified of Resident #178's change in condition. Interview on [DATE] at 11:47 A.M., Licensed Practical Nurse (LPN) #353 stated Resident #178 had been declining. LPN #353 revealed she went to administer the residents medications around 8:30 A.M. to 8:45 A.M. and noticed the resident was in respiratory distress. LPN #353 stated she increased the resident's oxygen, suctioned the resident, and changed the inner cannula and administered an aerosol treatment. LPN #353 stated the resident had a DNRCC code status. LPN #353 stated she notified the Assistant Director of Nursing (ADON) #392 and the Director of Nursing (DON) who then administered suctioning again and another aerosol treatment. LPN #353 stated the DON and ADON #392 notified her the resident's oxygen level came back up. LPN #353 stated she periodically kept checking the resident while passing medications to other residents. LPN #353 verified she had not called the family to notify them of the decline in the resident's condition. LPN #353 stated she thought ADON #392 was going to notify the family. LPN #353 also verified she had not documented the progress note until after the resident had expired. Interview on [DATE] at 12:02 P.M. with ADON #392 and the DON stated the nurse requested assistance for Resident #178. ADON #392 and the DON stated they suctioned the resident, changed the inner cannula and provided an aerosol treatment and the resident's pulse oximetry increased to 93 percent. The DON stated LPN #353 was notified the resident's oxygen level was back up. The DON stated she then went to a meeting and was notified ten to 20 minutes later the resident had passed away. The DON verified the care she provided to the resident with ADON #392 had not been documented in the medical record. The DON stated, too many hands were in the pot. Interview on [DATE] at 3:31 P.M. stated ADON #392 stated she did not notify the resident's family when Resident #178 had a decline in condition. Interview on [DATE] at 11:35 A.M. with the DON verified there was no documentation Resident #178's family was notified of the decline in condition. Review of the policy titled Notification of Changes, revised [DATE], revealed the facility would notify a resident's family member or legal representative when there was a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status. This deficiency represents non-compliance investigated under Complaint Number OH00161986.

Based on medical record review, observation, resident and staff interviews, and policy review, the facility failed to ensure all residents' call lights were within reach. This affected three (Residents #14, #34, and #42) of 74 residents reviewed for call lights within reach. The facility census was 74. Findings include: 1) Review of the medical record for Resident #42 revealed an admitted [DATE]. Review of the plan of care dated 04/19/21 revealed Resident #42 was at a potential risk for falls related to dementia, bipolar and decreased safety awareness. Interventions included to ensure call light was within reach. Observation on 01/28/25 at 11:10 A.M. revealed Resident #42's call light laying on floor at the bottom of bed. Resident #42 was unable to reach the call light. Interview on 01/28/25 at 11:15 A.M. with Certified Nursing Assistant (CNA) #334 verified Resident #42's call light was at the bottom of bed and out of reach. CNA #334 stated staff were to ensure call lights were within reach and residents were able to use the call light. 2) Review of the medical record for Resident #14 revealed an admitted [DATE]. Review of the plan of care dated 02/06/24 revealed Resident #14 was at potential risk for falls related to dementia, incontinence and safety awareness. Intervention included to ensure call light was within reach. Observation on 01/28/25 at 10:49 A.M. of Resident #14's call light cord laying on the floor by the wall at the bottom of the bed. Resident #14 was unable to reach the call light. Interview on 01/28/25 at 11:11 A.M. with Certified Nursing Assistant (CNA) #334 verified Resident #14's call light was not within reach. CNA #334 stated staff were to ensure call lights were within reach and residents were able to use the call light. 3) Review of the medical record for Resident #34 revealed an admitted [DATE]. Review of the plan of care dated 02/05/24 revealed Resident #34 was at potential risk for falls related to brain damage and seizures. Intervention included to ensure call light was within reach. Observation on 01/28/25 at 10:47 A.M. of Resident #34's call light not within reach and Resident #34 stated she hurt and would like a pain medication. Interview on 01/28/25 at 11:13 A.M. with Certified Nursing Assistant (CNA) #334 verified Resident #34's call light was on the floor at the bottom of the bed and out of reach. CNA #334 stated staff were to ensure call lights were within reach and residents were able to use the call light. Review of the facility policy titled Call Lights: Accessibility and Timely Response, dated 04/01/22 revealed with each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured.

Based on medical record review, and resident and staff interview, the facility failed to ensure residents were treated with dignity and respect. This affected two (Resident #13 and #74) of four residents reviewed for dignity. The facility census was 74. Findings include: 1. Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnoses included psychosis, depression, anxiety, delusional disorders, altered mental status, heart failure, chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact. Interview on [DATE] at 1:22 P.M. with Resident #13 stated Licensed Practical Nurse (LPN) #346 was always saying things that were sarcastic and rude. Resident #13 also reported being pretty sure LPN #346 cursed at her on an unknown date. 2. Review of the medical record for Resident #74 revealed an admitted [DATE]. The resident expired in the facility on [DATE]. Diagnoses included hypertensive heart and chronic kidney disease, heart failure, depression, anxiety, and insomnia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #74 had intact cognition. Interview on [DATE] at 10:45 A.M. with Former Licensed Practical Nurse (LPN) #405 revealed they previously worked as a nurse at the facility. LPN #405 reported observing LPN #346 demanding Resident #74 to open their mouth to take medications, pushing the resident because they had been leaning, and shoving the medications into the resident's mouth. Interview on [DATE] at 4:28 P.M. with the Administrator verified they were unaware of any concerns regarding LPN #346 treating the residents. Interview on [DATE] at 11:06 A.M. with Registered Nurse (RN) #355 stated LPN #346 cursed a lot and would yell at residents. RN #355 reported they heard LPN #346 yelling at an unknown resident stating take your medications mother-explicit. RN #355 verified they did not report the observation of LPN #346 yelling at the resident because everyone knew of how LPN #346 treated residents and the administrative staff did not do anything. Interview on [DATE] at 11:38 A.M. with LPN #315 stated the staff member observed LPN #346 yelling at residents and used to report it. LPN #315 was unable to report any specific resident name and/or date of incidents. This deficiency represents non-compliance investigated under Complaint Number OH00161986 and Complaint Number OH00161487.