Every finding on record at Oak Hills Nursing Center

Based on observation and staff interview, the facility failed to maintain a building in good repair. This had the potential to affect all residents residing in the facility. The facility census was 63.Findings Include:During an environment tour on 03/03/26 from 8:02 A.M. to 8:22 A.M. revealed physical damage to resident rooms and the hallways throughout the facility. Damage included general dents and chipped paint on walls throughout the building in the hallways. Observation in the hallway outside of Resident #05's room revealed a hole in the wall near the floor behind a carpeted wall. Inside Resident #05's room revealed holes on both sides of the bathroom door. Observation of room [ROOM NUMBER], which was empty, revealed significant wall damage on the wall with the window and missing baseboards. Observation by the nursing station revealed the wall adjacent to the station had been patched however it was unpainted, the base board on the side of the nursing station was missing, and the wall surrounding the thermostat was patched however it was unpainted. Observation in the hallway by the therapy gym and smoking area revealed the ceiling had been patched however remained unpainted. Observation revealed the rubber baseboard was missing between the bathroom and the entrance to Resident #38 and #44's and Resident #11 and #32's room. Observation revealed the wall was unpainted between the bathroom and the entrance to Resident #36's room. Observation revealed a missing transition strip in the doorway of Resident #35 and #41's room. There was a large hole in the wall between the bathroom and the entrance to Resident #25 and #60's room. Resident #25 and #60's bathroom door had large holes on both sides of the door.During a follow-up tour and interview on 03/04/26 from 9:50 A.M. to 10:05 A.M. with the Director of Asset Management #895 verified the above findings. The Director of Asset Management #895 reported the maintenance director had quit.Interview on 03/04/26 at 10:14 A.M with the [NAME] President (VP) of Asset Management #896 revealed the former maintenance director had quit and they were aware of the concerns with the physical damage of the building. He reported the facility maintenance team took care of all repairs in house.This deficiency represents non-compliance investigated under Complaint Number 2719863.

Based on observation, staff and resident interview, review of the water temperature logs, and policy review, the facility failed to ensure water temperatures were within an acceptable range to promote resident comfort. This had the potential to affect 10 Residents (#05, #06, #14, #19, #21, #22, #42, #46, #54, and #64) identified as residing on the 100 hallway. The facility census was 63. Findings Included:Observation on [DATE] at 9:50 A.M., with the Regional Director of Asset Management #895 revealed Resident #05's water temperature was taken using the facility's digital thermometer in the resident's bathroom measuring at 104 degrees Fahrenheit (F). Interview on [DATE] at the time of observation with Regional Director of Asset Management #895 verified Resident #5's water temperature was not within desired range of 110-120 degrees F.Interview on [DATE] at 10:14 A.M. with the [NAME] President of Asset Management #896 revealed their maintenance director had quit about one week prior. The [NAME] President of Assessment Management #896 indicated the mixing valve had been adjusted on morning of [DATE] to adjust the temperature of water after he had reviewed the water temperature logs from [DATE] to February 2026. The [NAME] President of Asset Management #896 verified the water temperatures recorded for the 100 hall by the former maintenance director were not within an acceptable range. The [NAME] President of Asset Management #896 reported the low water temperatures could have easily been remedied by adjusting the mixing valve. He indicated he would have expected the former maintenance director to take action immediately if his monthly water temperature checks were out of range.Interview on [DATE] at 11:16 A.M. with Resident #14 stated water had been cold for at least a month in her sink in the bathroom. Resident #14 stated she just checked the water and it was a little warm.Review of water temperature logs from [DATE] and February 2026 revealed water temperatures in room [ROOM NUMBER] were checked on [DATE] at 92 degrees F, on [DATE] at 95 degrees F, on [DATE] at 97 degrees F, on [DATE] at 101 degrees F, and on [DATE] at 97 degrees F. Water temperatures in room [ROOM NUMBER] were checked on [DATE] at 85 degrees F, on [DATE] at 90 degrees F, on [DATE] at 91 degrees F, on [DATE] at 100 degrees F, and on [DATE] at 95 degrees F. Water temperatures in room [ROOM NUMBER] were checked on [DATE] at 91 degrees F, on [DATE] at 92 degrees F, on [DATE] at 90 degrees F, and on [DATE] at 100 degrees F. Water temperatures in room [ROOM NUMBER] were checked on [DATE] at 85 degrees F, on [DATE] at 90 degrees F, on [DATE] at 95 degrees F, and on [DATE] at 99 degrees F. There was no evidence of any adjustments to water temperature or follow up water temperature checks.Review of the facility policy titled Safe Water Temperatures, dated [DATE] revealed staff should report abnormal findings of water too cold or too hot to the supervisor and maintenance staff. The policy stated water temperatures would not exceed 120 degrees F however did not define a lower limit to water temperatures. Water temperatures would be checked by maintenance staff on a weekly basis.This deficiency represents non-compliance investigated under Complaint Number 2719863.

Based on medical record review, review of the hospital records, staff and resident interview, and policy review, the facility failed to ensure resident safety regarding the use of marijuana products. This affected two Residents (#27 and #60) out of three reviewed. The facility census was 63.Findings Included:1. Review of medical record for Resident #27 revealed an admission date of 02/09/17 and diagnoses including schizophrenia, vascular dementia with behavioral disturbance, aphasia following cerebral infarction, and diabetes mellitus.Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #27 had moderately impaired cognition. Resident #27 required set up or clean up assistance for activities of daily living (ADLs).Review of nursing progress note dated 01/31/26 at 5:49 A.M. revealed Resident #27 was observed in his room standing in a puddle of urine. Resident #27 was assisted to the bathroom. Resident #27 stated he felt fine but was unable to make it to the toilet in time. A urinalysis was requested to rule out urinary tract infection (UTI).Review of nursing progress note dated 01/31/26 at 10:11 A.M. revealed Resident #27 had a change in mental status, difficulty with ambulating, and had been found on his hands and knees urinating on the floor. Resident #27's bed was also saturated in urine. Three staff members were needed to assist Resident #27 off the floor and to get cleaned up. Resident #27 needed much prompting to get dressed. The director of nursing (DON) and Resident #27's power of attorney (POA) were notified. Resident #27 was sent to the emergency department.Review of Emergency Department (ED) Encounter note from 01/31/26 revealed Resident #27 presented to the ED for confusion. It was noted Resident #27 was normally alert and oriented however last night mental status became altered. In the morning the nurse came to check on Resident #27 and found him on his hands and knees urinating on the floor and his bed was saturated with urine. Resident #27 was hemodynamically stable. Resident #27 received intravenous (IV) fluids and was monitored. Resident #27 became more alert and was asking for food. Lab testing had no acute findings however a urine drug screen was found to be positive for marijuana. Resident #27 was stable and was sent back to the facility.Review of nursing progress note dated 01/31/26 at 4:17 P.M. revealed Resident #27 had tested positive for tetrahydrocannabinol (THC) (the psychoactive compound in cannabis/marijuana) and would be returning to the facility.Review of nursing progress note dated 01/31/26 at 6:15 P.M. revealed Resident #27 was sitting on his bed and had removed his pants stating they were wet. Resident #27 refused to don clean pants. Resident #27 was noted to be unsteady on his feet and smiling or laughing at inappropriate times. Resident #27 was encouraged to rest and use call light if he needed assistance.Review of nursing progress note dated 03/01/26 at 3:12 P.M. revealed Resident #27 had obtained a vape pen from another resident. The interaction by the two residents was observed by the nurse. The Director of Nursing (DON) and the physician were notified. New order to monitor Resident #27's behavior closely and report any abnormal behaviors to the physician. 2. Review of the medical record for Resident #60 revealed an admission date of 09/13/24 and diagnoses including diabetes mellitus, bipolar disorder, obsessive compulsive disorder, traumatic subdural hemorrhage, and personal history of transient ischemic attack (TIA) and cerebral infarction.Review of physician order dated 08/11/25 revealed Resident #60 was permitted to take independent leaves of absence (LOA) for up to four hours per day. This order was discontinued on 03/04/26.Review of Behavior Contract dated 10/06/25 revealed Resident #60 agreed to follow all rules and policies of the facility. Rules included were residents were not permitted to use or possess illegal or unauthorized substances, all medications would be administered by staff, residents must follow physician's medication regimen, LOAs would be determined by the physician, residents agree to allow room searches at discretion of the facility to ensure safety of self and others, all visitors should sign in, the physician may order toxicology screening, and residents would adhere to facility smoking policies. Failure to follow the rules in the behavior contract could result in immediate or 30-day discharge.Review of the MDS quarterly assessment dated [DATE] revealed Resident #60 had intact cognition and was dependent on staff assistance for ADLs including bathing, dressing, and transfers.Review of nursing progress note dated 01/29/26 revealed Resident #60 went on LOA with her nephew.Review of nursing progress note dated 01/31/26 revealed Resident #60 left on LOA with her nephew.Review of nursing progress note dated 02/15/26 revealed Resident #60 left on LOA with her nephew at 8:30 P.M. and returned at 1:46 A.M.Review of nursing progress note dated 03/01/26 entered as a late entry on 03/04/26 revealed Regional Director of Clinical Services (RDCS) #894 was notified by the DON that Resident #60 had attempted to give another resident a vape pen and nursing had intervened. The vape pen was removed. Resident #60's physician was notified and gave an order to discontinue Resident #60's LOA. Any departures from the facility would be considered against medical advice (AMA) discharge.Interview on 03/02/26 at 10:29 A.M. with Resident #27 revealed no concerns with care or treatment. Resident #27 was unable or unwilling to provide any information related to drug use or the hospitalization.Interview on 03/02/26 at 10:39 A.M. with Resident #60 revealed no concerns with care or treatment. Resident #60 denied use or distribution of any drugs or substances.Interview on 03/03/26 at 3:22 P.M. with the Social Service Designee (SSD) #813 revealed he knew of rumors there was an issue with drug use in the facility. The SSD #813 stated he was unable to verify but had heard it was Resident #60. The SSD #813 stated Resident #60 had gone out on LOAs or had visitors. SSD #813 stated allegedly Resident #27 had received a drug substance from Resident #60. Resident #27 began acting differently so he was sent to the hospital. The SSD #813 stated he did not know more than that and was not helping to investigate the situation. He said he had been assisting Resident #60 with sending referrals to different nursing homes.Interview on 03/04/26 at 9:02 A.M. with Assistant Director of Nursing (ADON) #838 revealed Resident #60 had been issued a behavior contract due to possessing marijuana vape pens. ADON #838 stated this had been an ongoing issue since around October 2025 when the behavior contract was issued. ADON #838 reported there had been some recent issues with Resident #60 possessing marijuana vape pens, but she could not recall the exact dates. ADON #838 reported Resident #27 had a marijuana vape pen that belonged to Resident #60 on or around 01/31/26. ADON #838 was unsure if Resident #27 had taken the vape pen or was given it by Resident #60. ADON #838 stated Resident #27 began acting outside of his normal and was having incontinence, so he was sent to the hospital. ADON #838 stated marijuana or other drug/substance use was not permitted in the facility.Interview on 03/04/26 at 9:26 A.M. with Regional Director of Clinical Services (RDCS) #894 revealed in the past they have had to revoke Resident #60's LOA privileges due to issues with drug use. RDCS #894 stated she was notified over the weekend Resident #60 had again attempted to give Resident #27 a marijuana vape pen. RDCS #894 indicated they were unsure of where Resident #60 was obtaining the vape pens.Review of the facility's policy titled Non-Prescribed or Illegal Drug Use, dated June 2018 revealed residents may not posses or distribute illegal substances in the building or on the premises. The facility reserved the right to give a resident a discharge notice if they consume, possess, sell or distribute illegal drugs in the building or on the premises due to the potential risk to themselves or others. The policy did not define illegal drugsThis deficiency represents non-compliance investigated under Complaint Number 2719863.

Based on medical record review, observation, staff interview and policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during a wound treatment. This affected one (Resident #16) out of three reviewed for pressure ulcer treatment. The facility census was 63.Findings Included:Review of the medical record for Resident #16 revealed an admission date 09/24/25. Diagnosis included muscle weakness, pressure ulcer of right buttock, infrarenal abdominal aortic aneurysm and restless legs syndrome.Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had memory impairment. He was dependent on staff for all activities of daily living (ADL's). He was always incontinent of bowel and bladder.Review of the physician orders revealed on 02/24/26 gloves and a gown were to be worn when providing treatment to Resident #16's sacral wound. The treatment was to cleanse the sacrum with normal saline, pat dry with gauze, apply calcium alginate (a debridement treatment), cover with super absorbent dressing every-day shift and as needed dated 02/11/26.Observation on 03/03/26 at 2:15 P.M. of Resident #16's wound care with Licensed Practical Nurse (LPN) #838 and LPN #833 revealed there was a sign posted outside of Resident #16's room stating Resident #16 was on enhanced barrier precautions (EBP). LPN #838 and LPN #833 gathered treatment supplies and walked into Resident #16 room. Both nurses put gloves on but had not put on a gown and completed the wound treatment.Interview on 03/03/26 at 2:35 P.M., LPN #838 verified Resident #16 was on EBP's and she should have put an isolation gown on while completing Resident #16's treatment.Interview on 03/03/26 at 2:36 P.M., LPN #833 verified she had not put on a gown when they were doing a treatment on Resident #16. LPN #833 was unable to state why she should have had a gown on. She stated all she thought she had to wear was gloves. Review of the facility policy titled Transmission-Based (Isolation) Precautions, dated 09/01/22 revealed EBP are to be worn when completing a dressing change on a wound/pressure ulcer. This deficiency represents non-compliance investigated under Complaint Number 2790510 and 2719863.

Based on observation, staff interview, review of the dishwashing machine temperature logs and review of the facility policy, the facility failed to maintain appropriate dishwasher temperatures to ensure clean and sanitary dishware. This had the potential to affect all 59 residents who received food from the kitchen. The facility census was 59. Findings include: Review of the low-temperature dishwashing machine logs from 03/01/25 through 06/03/25 revealed wash temperatures were not to be below 120 degrees Fahrenheit (F) and were to be checked once per shift. During the time period reviewed, wash temperatures were documented to be below 120 degrees F on 83 occasions. During an observation on 06/04/25 at approximately 1:35 P.M. with Dietary Supervisor (DS) #471 revealed the last load of dishes following the lunch meal was in the process of being washed using the low-temperature, chemical-sanitation dishwashing machine. The dishwashing machine reached a maximum temperature of 112 degrees F for both the wash and the rinse cycles. The dishwashing machine was run numerous times and there was no increase in the temperature. Concurrent interview with DS #471 verified the dishwashing machine did not reach the appropriate temperature for the wash or the rinse cycle. DS #471 reported the machine was supposed to reach at least 120 degrees F for each cycle. DS #471 stated sometimes the machine reached 120 degrees F and sometimes it did not. Review of the facility policy titled, Dish Machine Temperatures, undated, revealed chemical sanitizing machines, which were low-temperature, were to have a wash and a rinse temperature between 120 and 140 degrees F.

Based on observation and staff interview, the facility failed to ensure garbage and refuse was disposed of properly. This had the potential to affect all 59 residents residing in the facility. The census was 59. Findings include: Observation on 06/02/25 at approximately 8:50 A.M. with Dietary Supervisor (DS) #471 revealed two exterior dumpsters with trash laying around the dumpsters. The trash included an empty cheese wrapper, disposable gloves, an aluminum can, disposable plastic lids, clear plastic bags, empty bread bags, an empty salad dressing bottle, crumbled aluminum foil, an empty nutritional shake bottle, empty sugar packets, empty Styrofoam cups, plastic eating utensils, and more than 50 cigarette butts on the ground. Further observation revealed more than 10 clear-plastic garbage bags filled with trash including briefs and gloves. Concurrent interview with DS #471 verified the debris on the ground around the dumpster and further stated the facility had various animals in the area.

Based on observation, staff interviews and resident interviews the facility failed to ensure the facility was maintained in good repair. This affected six (#1, #7, #19, #41, #52 and #56) of nine residents reviewed for environment. The facility census was 59. Findings included: 1. Observation on 06/03/25 at 8:18 A.M. of Resident #7's room revealed the wall to the right of the air conditioning unit had an unknown black substance and the drywall was crumbling. Additionally, there were brown stains on the wall above the air conditioning unit. Interview on 06/05/25 at 10:22 A.M. with Director of Maintenance (DOM) #428 verified the wall around the air conditioning was crumbling and a black mold-like substance was present. DOM #428 confirmed the brown stains on the wall above the air conditioning unit and stated the brown stains were the result of a water leak. 2. Observation on 06/02/25 at 9:19 A.M. of Resident #52's bathroom revealed four tiles on the wall were missing and the sink was pulled away from the wall by approximately 1.5 inches. Interview on 06/05/25 at 10:18 A.M. with DOM #428 verified the missing wall tiles and the sink was pulling away from the wall in Resident #52's bathroom. 3. Observation on 06/02/25 at 10:00 A.M. of Resident #19's room revealed deep gouges in the wall and the base molding was coming off the wall near the bathroom door. Interview on 06/05/25 at 10:36 A.M. with DOM #428 verified the deep gouges in the wall and the base molding was coming off the wall near the bathroom. DOM #428 stated it needed to be repaired. 4. Observation on 06/02/25 at 10:30 A.M. of Resident #41's room revealed an area approximately four by four feet in size of a glue-like substance on the wall behind the bed. Interview on 06/05/25 at 10:32 A.M. with DOM #428 revealed there used to be a plastic protective board on the wall behind Resident #41's bed, but the resident pulled it off the wall. DOM #428 verified he was aware the plastic board had been removed and further confirmed the adhesive had not been cleaned up. 5. Observation on 06/02/25 at 10:50 A.M. of Resident #1's room revealed deep gouges in the wall and the base molding was coming off the wall by the bathroom door. Interview on 06/05/25 at 10:44 A.M. with DOM #428 verified the wall had deep gouges and the base molding was coming off the wall. 6. Observation on 06/02/25 at 11:38 A.M. of Resident #56's room revealed the rubber base molding by the bathroom door was coming off, with an unknown black substance, and the drywall was crumbling. Inside the bathroom, there was one missing wall tile with an unknown black substance on the wall. Interview on 06/05/25 at 10:15 A.M. with DOM #428 verified the base molding was coming off the wall, missing tile and the bathroom, and confirmed the black substance was mold. Review of the facility policy titled, Preventative Maintenance Program dated 03/01/25, revealed a preventative maintenance program would be developed and implemented to ensure the provision of a safe, functional, sanitary and comfortable environment for residents, staff and the public. This deficiency represents non-compliance investigated under Complaint Number OH00164448.

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure resident code status was accurately documented throughout the resident's medical record. This affected one (#8) of one resident reviewed for Advance Directives. The facility census was 59. Findings include: Review of the electronic medical record (EMR) for Resident #8 revealed an admission date of 12/02/22. Diagnoses included leukemia, chronic obstructive pulmonary disease (COPD) and heart disease. Further review revealed Resident #8's code status was Do Not Resuscitate Comfort Care-Arrest (DNRCCA). Review of the physician order dated 11/12/24 revealed Resident #8 was a DNRCCA code status. Review of Resident #8's hard chart revealed a red paper stating DNRCC (Do Not Resuscitate Comfort Care). Further review revealed the physician signed advanced directive stated Resident #8 was a DNRCC code status. Interview on 06/03/25 at 3:30 P.M. with Register Nurse (RN) #476 revealed a resident's code status should match throughout the resident's EMR and hard chart to ensure appropriate care was provided during a code status. Further interview with RN #476 verified Resident #8's EMR documented the resident's code status as DNRCCA while the hard chart indicated the resident had a DNRCC code status. RN #476 confirmed Resident #8's code status was not accurately documented throughout the resident's medical record. Review of the facility policy titled, Communication of Code Status, dated 03/01/23, revealed when an order was written pertaining to a resident's presence or absence of an Advance Directive, the directions would be clearly documented in designated sections of the medical record.

Based on observation, interview, and policy review, the facility failed to implement their resident smoking policy related to the outside smoking area. This had the potential to affect Residents #4, #8, #12, #13, #17, #21, #25, #27, #29, #30, #32, #34, #35, #36, #40, #41, #42, #46, #54, #56 and all facility residents. The facility census was 58. Findings Include: Observation of the outside smoking area on 04/05/25 at 1:30 P.M. with the Administrator revealed approximately 75 to 100 cigarette butts on the ground. Multiple piles of leaves were also noted on the ground with cigarette buts intertwined in the piles of leaves. Additionally six cigarette receptacles made of combustible plastic were observed in the area and were all approximately 75% or more full. A seventh receptacle container made out of a plastic bucket from a local big box home improvement store was also used as a cigarette receptacle and was over ninety percent filled to the top with cigarette butts. In total approximately three to four hundred cigarettes butts were present in the area on the ground and in the receptacle containers. Interview with the Administrator verified the findings at the time of observation. The facility identified twenty residents (Residents #4, #8, #12, #13, #17, #21, #25, #27, #29, #30, #32, #34, #35, #36, #40, #41, #42, #46, #54, and #56) who actively smoked. Review of the policy Resident Smoking dated 01/16/25 revealed It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non smoking residents. Additionally the policy noted Safety measures for the designated smoking area will include, but not limited to: Provision of ashtrays made of noncombustible material and safe design.

Based on medical record review and staff interview, the facility failed to ensure as needed (PRN) psychotropic medications were monitored by a physician and had a stop date after 14 days of use. This affected one (#1) of three sampled residents reviewed for unnecessary medications. The facility census was 58. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, anxiety, and insomnia. Review of the quarterly Minimum Data Set assessment dated [DATE] identified the resident as cognitively impaired. Review of Resident #1's prescribed medications list for 10/01/24 through 11/24/24 identified an order dated 10/16/24 for Ativan (anti-anxiety) oral tablet 0.5 milligrams every eight hours as needed for anxiety. The Ativan was active as of 11/25/24. An interview on 11/25/24 at 3:20 P.M. with the Director of Nursing verified the Ativan was ordered to be given as needed beginning on 10/16/24 and did not have a stop date. This deficiency represents non-compliance investigated under Complaint Number OH00159442.

Based on medical record review, review of census records, review of financial records, and staff interview, the facility failed to ensure a final accounting and disbursal of funds was completed timely following a resident death. This affected one (#1) of four residents reviewed for funds disbursement upon death or discharge. The facility census was 59. Findings Include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, dementia, and altered mental status. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and required extensive assistance for his activities of daily living. Further review of the medical record revealed Resident #1 expired at the facility on [DATE]. Review of census records for Resident #1 revealed he was admitted under private pay with Medicare as secondary insurance. Review of financial records revealed Resident #1's responsible party wrote a check for $8,005.44 (one month's private pay rate) on [DATE] for the upcoming month's care and services for Resident #1. Review of a detailed accounting statement for Resident #1 revealed Resident #1 had a credit of $7,115.04 upon his death at the facility on [DATE]. Further review of business office records revealed a check in the amount of $7,115.04 was sent to Resident #1's responsible party on [DATE]. Interview with Regional Business Office Manager (RBOM) #100 on [DATE] revealed the facility was waiting on potential Medicare coverage for some of Resident #1's stay at the facility. RBOM #100 stated a formal denial of payment from Medicare was received on [DATE]. There was no evidence of communication between the facility's billing department and Resident #1's responsible party regarding the status of Resident #1's refund. RBOM #100 verified Resident #1's refund was sent out on [DATE] which was outside the requirement for final disbursement of funds upon death or discharge within 30 days. This deficiency represents non-compliance investigated under Complaint Number OH00154348.

Based on review of staff schedules, review of screening logs, review of nursing assignment sheets, staff interviews, facility policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure all staff were screened for COVID-19 exposure risk and signs/symptoms of COVID-19 prior to entering the facility. This had the potential to affect all 59 residents in the facility. The facility census was 59. Findings include: Review of the staff schedules and screening log, dated 08/05/22 through 08/11/22, on 08/25/22 from 1:45 P.M. to 2:15 P.M. with the Assistant Director of Nursing (ADON) and Director of Nursing revealed several employees did not complete the screening process for COVID-19 prior to working on the following days: Review of the nursing assignment sheet and screening log for 08/05/22 revealed Licensed Practical Nurse (LPN) #101 and State tested Nursing Assistant (STNA) #116 did not complete the screening process for COVID-19 prior to working their shift. Review of the nursing assignment sheet and screening log for 08/06/22 revealed LPN #114, STNA #116, Hospitality Aide (HA) #117, and STNA #118, did not complete the screening process for COVID-19 prior to working their shift. Review of the nursing assignment sheet and screening log for 08/07/22 revealed LPN #114 and STNA #119 did not complete the screening process for COVID-19 prior to working their shift. Review of the nursing assignment sheet and screening log for 08/08/22 revealed HA #121, STNA #116, STNA #119, and STNA #122 did not complete the screening process for COVID-19 prior to working their shift. Review of the nursing assignment sheet and screening log for 08/09/22 revealed LPN #101, LPN #120, and STNA #124, did not complete the screening process for COVID-19 prior to working their shift. Review of the nursing assignment sheet and screening log for 08/10/22 revealed LPN #101, LPN #120, and STNA #124, did not complete the screening process for COVID-19 prior to working their shift. Review of the nursing assignment sheet and screening log for 08/11/22 revealed LPN #114 and STNA #119 did not complete the screening process for COVID-19 prior to working their shift. Interview on 08/25/22 at 1:14 P.M. with Receptionist #110 revealed she works from 8:00 A.M. to 4:00 P.M. and employees screen themselves, however, when she is on duty, she tells visitors and reminds staff to complete the screening. Interview on 08/25/22 at 2:45 P.M. with the ADON verified the above staff did not screen prior to work and stated the facility expected staff to screen themselves prior to work. Review of facility policy titled Staff and Visitor Screening, dated 01/04/21, revealed in accordance with Centers for Disease Control (CDC), local, state, and federal guidance all visitors entering the facility (staff, residents, visitors, outside healthcare workers, vendor, etc.) will be screened for exposure risk and signs and symptoms of COVID-19. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated 02/02/22, revealed to establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed: a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2, symptoms of COVID-19, or close contact with someone with [CONDITION(S)]-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP). This deficiency substantiates Complaint Number OH 892 and is an example of the continued noncompliance from the survey dated 08/04/22.

Based on observations, staff interviews, medical record reviews, and policy review, the facility failed to ensure supplies necessary for proper personal protective equipment (PPE) usage were readily accessible and signage for specified PPE needs were posted. This affected two (#213 and #217) of two residents reviewed for transmission-based precautions. The facility also failed to ensure staff properly wore PPE while in patient care areas throughout the facility. This directly affected one (#17) resident observed with the potential to affect all residents. The facility census was 65. Findings include 1. Interview on 08/01/22 at 10:49 A.M., with Licensed Practical Nurse (LPN) #434 indicated only Resident #213 was on transmission-based precautions (TBP). LPN #434 indicated there are usually bins for PPE or a door hanger and signs indicating type of precautions. LPN #434 verified when looking down hallway towards Resident #213's room and no PPE bin or signage was observed. Observation on 08/01/22 at 10:56 A.M., revealed LPN #434 placing bins for PPE and Transmission Based Precautions (TBP) signage for Resident #213 and Resident #217. Review of the medical record for Resident #213 revealed admitted [DATE] and order for isolation for 14 days related to non-vaccinated. The order was set to expire on 08/05/22. Review of the medical record confirmed no evidence of COVID-19 vaccination. Review of the medical record for Resident #217 revealed admitted [DATE] and order for isolation for 14 days related to non-vaccinated. The order was set to expire on 08/07/22. Review of the medical record confirmed no evidence of COVID-19 vaccination. Interview on 08/01/22 at 10:56 A.M., with LPN #434 and Director of Nursing (DON) revealed Resident #213 and #217 should be on TBP for new admission with unvaccinated COVID-19 status. DON verified there was no signage to indicate TBP status and Resident #213 and #217's rooms lacked readily available PPE. Interview on 08/01/22 at 11:24 A.M., with Assistant Director of Nursing/Infection Preventionist (ADON/IP) revealed all of nursing staff are responsible for putting TBP into place when a resident is admitted . ADON/IP indicated Resident #213 and #217 were to be on TBP related to new admissions not COVID-19 vaccinated. ADON/IP indicated she was unaware of the lack of PPE and signage for TBP was not posted. Review of facility policy, Isolation Precautions, dated 05/27/22 revealed when TBP isolation was implemented an isolation cart would be used for supplies. The policy indicated the cart would be kept stocked with supplies used to minimize risk for cross-contamination and a sign placed on resident door indicating type of precautions and personal protective equipment required. 2. Observation on 08/03/22 at approximately 2:50 P.M., of Receptionist #438 standing behind the receptionist desk with her mask pull down exposing her nose and mouth. Observations of Resident #17 at this time, revealed the resident was sitting in her wheelchair on the other side of the receptionist desk. Interview on 08/03/22 at 2:53 P.M., with Receptionist #438 verified the observation. 3. Observation on 08/04/22 at approximately 10:15 A.M., of the Director of Maintenance (DM) #470 sitting at the nurses' station with his face mask pulled down exposing his nose and mouth and observed two sets of glasses on top of his head. Another unidentified staff was observed standing next to DM #470 taking his blood pressure and Resident #17 was sitting in her wheelchair next to the nursing station. Interview at the time of the observation with DM #470 verified the observation and pulled up his mask.

Based on observations, resident and staff interviews, the facility failed to maintain an environment that was clean and in good repair in the vending area leading to the smoke area. The facility also failed to ensure the wall near Resident #31's bed was in good repair. This directly affected one resident and had the potential to affect an undetermined number of residents that may utilize the vending machine areas. The facility census was 65. Findings include: Observation on 08/02/22 at 8:44 A.M., of the wall around the air conditioner (AC) unit near Resident #31's bed revealed it was in disrepair. Interview at this time, Resident #31 stated it had been that way for a long time. Observation and interview on 08/02/22 at 1:38 P.M., with Director of Maintenance (DM) #470 of Resident #31's wall around the AC unit verified the wall was in disrepair and further observation revealed a wire coming out wall on the lower right side. Observation 08/03/22 at 3:26 P.M., with Housekeeping Director (HD) #479 of the vending machine area that leads to the outside smoke area, revealed several dead bugs on the light fixture above, dead bugs on the curtains, and the black carpet in front of the doorway was dirty. Interview at this time, with HD #479 verified the observation. Observation on 08/04/22 at 8:00 A.M., with HD #479 of the vending area that leads to the smoke area revealed the dead bugs were cleaned off the light fixture and curtain except the top portion of curtain there were still dead bugs. Also observed the wall to the left were two areas near the molding where the plaster was crumbling with holes. Near this wall were three Hoyer lifts and an old looking, dusty buffer. Interview at this time, with HD #479 verified the observation and stated he had to get permission to throw out the buffer and would inform DM #470 of the holes in the wall.

Based on medical record review, staff interview, and review of facility's policy, the facility failed to ensure showers were completed for residents who required assistance with bathing. This affected two (#11 and #59) of three residents reviewed for bathing. The facility identified 62 residents who require assistance or were dependent on staff with bathing. The facility census was 66. Findings include 1. Review of the medical record for Resident #59 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/23/22, revealed Resident #59 had impaired cognition. The resident required the extensive assistance of one staff for personal hygiene. No assistance level was listed for bathing as the activity had not been completed. A prior quarterly MDS assessment dated [DATE] revealed the resident was dependent on one staff for bathing. Review of the shower schedule dated 03/01/22 revealed Resident #59's showers were scheduled four times per week on Mondays, Tuesdays, Fridays and Saturdays on second shift. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed an order to shower and shave Resident #59 on Wednesdays and Fridays. Review of the shower sheets from 03/01/22 through 03/24/22 revealed Resident #59 received showers on 03/01/22, 03/13/22, 03/14/22, 03/18/22, 03/20/22, and 03/22/22. There was no documentation the resident received showers on 03/02/22, 03/04/22, 03/11/22, 03/16/22, and 03/23/22 per the physician order. Review of point of care task documentation from 03/01/22 through 03/25/22 revealed the resident's bathing preference was completed on 03/01/22, 03/09/22, 03/15/22, 03/18/22, 03/20/22. Resident #59 refused on 03/07/22, 03/13/22, 03/21/22 and 03/22/22. The task documentation did not state whether a shower or bath was provided. Review of a nurse's note dated 03/14/22 at 6:05 A.M. revealed the resident refused the morning shower. Interview on 03/25/22 at 12:39 P.M. with the Director of Nursing (DON) revealed the resident's family wanted the resident showered on Wednesdays and Fridays. The DON verified there was no documentation Resident #59 was provided showers on 03/02/22, 03/04/22, 03/11/22, 03/16/22, and 03/23/22. 2. Review of the medical record for Resident #11 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on one staff for bathing. Review of the shower schedule dated 03/2022, revealed Resident #11 was scheduled for showers on Tuesdays and Saturdays. Review of the shower sheets from 03/01/22 through 03/25/22 for Resident #11 revealed no documentation the resident received showers on 03/12/22 (Saturday) and 03/19/22 (Saturday). Review of the point of care bathing preference task documentation from 03/01/22 through 03/24/22 revealed no documentation of the resident's bathing preference on 03/12/22 and 03/19/22. Also, there was no documentation the resident had refused showers on 03/12/22 and 03/19/22. Interview on 03/25/22 at 8:02 A.M. with Resident #11 revealed he wanted two showers per week. Resident #11 revealed he had to bug staff for the shower during the week but was not getting his second shower scheduled on Saturdays. Resident #11 further revealed there were about four weeks he had not received his Saturday shower and he would always tell them about it. Interview on 03/25/22 at 12:30 P.M. with the Director of Nursing (DON) verified there was no documentation Resident #11 received Saturday showers on 03/12/22 and 03/19/22. Review of the facility's policy titled Bathing, dated 07/2018, revealed a bath or shower may be given at any time the resident chooses. Residents incontinent of urine and/or stool may need personal hygiene more than once a day. This deficiency substantiates Complaint Number OH 001.

Based on review of the log of hot water temperatures, policy review and staff interview, the facility failed to ensure a safe and comfortable environment by measuring and accurately recording hot water temperatures. This had the potential to affect 63 of 63 residents in the facility. The census was 63. Findings include: Review of the Test and Log of Hot Water Temperatures, dated December 2022 to February 2022, revealed weekly test and log of the hot water temperature varied from 117.9 to 124.6 degrees Fahrenheit. Of the 52 logged temperatures, 40 logged water temperatures were above 120.0 degrees Fahrenheit. Interview on 02/16/22 at 2:54 P.M., with Maintenance Director #202 revealed the temperatures on the water temperature log were not an accurate account of the water temperatures. He stated the previous Maintenance Director taught him that water temperatures were to be up to 122 degrees Fahrenheit and was told to just write a number in under a 122 degrees. Review of facility policy titled, Safe Water Temperature, dated 2021, revealed water temperatures will be set to a temperature of no more than 120 degrees Fahrenheit, maintenance staff will check water heater temperature controls and the temperature of the tap water in all hot water circuits weekly and as need, and documentation of testing will be maintained for three years.

Based on observation, staff interview and review of facility policy the facility failed to ensure housekeeping and maintenance services were provided to maintain a clean environment. This affected six Residents (#12, #16, #28, #36, #50, #260) of 22 sampled residents. The facility census was 60. Findings include: Observation on 08/14/19 at 12:05 P.M. revealed Resident #16's room (room [ROOM NUMBER]) had plastic baseboard hanging loose from the wall. The area measured approximately 12 inches. The bathroom tile around the toilet was also observed as stained with a dark substance. This encircled the entire base of the toilet base. Observation on 08/14/19 at 12:06 P.M. revealed Resident #50's room (room [ROOM NUMBER]) had a large window next to the resident's bed. The area between the outer window glass and screen was covered with spider webs and dead insects. Observation on 08/14/19 at 12:07 P.M. revealed Resident #260's room (room [ROOM NUMBER]) had a large section of damaged drywall on the right side of the room. The section measured approximately 2 feet by 6 inches. In addition, the area had five round holes approximately 1 inch in circumference above the damaged section of drywall. Observation on 08/14/19 at 12:09 P.M. revealed Resident #36's room (room [ROOM NUMBER]) had a section of baseboard in the bathroom that was peeling from the wall. In addition, the toilet base caulk was noted to be dirty and was rust colored. Observation on 08/14/19 at 12:10 P.M. revealed Resident #12's room (room [ROOM NUMBER]) toilet had dark discoloration in the toilet bowl. Observation on 08/14/19 at 12:11 P.M. of Resident #28's room (room [ROOM NUMBER]) revealed the sink was clogged and the water would not run freely down the drain. In addition, the toilet seat was loose and moved freely when the weight was applied to the toilet seat. Interview with Maintenance Director #167 on 08/14/19 at 1:08 P.M. confirmed the rooms mentioned above were in need of repair. Interview with Housekeeping Manager #146 on 08/14/19 at 3:10 P.M. revealed the window in Resident #50's room was cleaned by housekeeping on the inside, but the facility had failed to clean the outside area. Housekeeping Director #146 confirmed the window was in need of cleaning. Review of the facility policy titled Quality of Life - Homelike Environment revealed the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting.

Based on observation, staff interview and review of a facility policy, the facility failed to remove expired food items from the kitchen. This had the potential to affect all residents who resided in the facility except three (#1, #37, #311) residents identified by the facility who did not receive meals from the kitchen. The facility census was 60. Findings include: Observation of the kitchen on [DATE] at 9:35 A.M. revealed two loafs of Nickels white bread with a use by date of [DATE] and a third loaf dated [DATE]. The bread in one of the two packages dated [DATE] was observed to be approximately 80% covered with a green substance. A package of 12 hotdog buns dated [DATE], one with with three hotdog buns dated [DATE], one with eight hotdog buns dated [DATE], and a package of 12 hamburger buns dated [DATE] were also observed. Interview on [DATE] at 9:50 A.M., Dietary Manger (DM) #401 revealed it was the facility policy to not use bread after the printed date on the package regardless to whether is was an expiration date or a use by date. The date printed on the package was considered the expiration date. DM #401 confirmed there were two loafs of Nickels white bread with a use by date of [DATE] and a third loaf dated [DATE], a package of 12 hotdog buns dated [DATE], one with with three hotdog buns dated [DATE], one with eight hotdog buns dated [DATE], and a package of 12 hamburger buns dated [DATE]. DM #401 confirmed the white bread in one of the two packages dated [DATE] was covered approximately 80% with a green substances. DM #401 stated the substance was mold and she was concerned the expired bread was on shelves mixed with fresh bread. Review of a facility policy titled, Food Storage (Dry, Refrigerated, and Frozen), dated (YEAR), revealed the facility was to store food using appropriate methods to ensure the highest level of food safety. Staff were to rotate products so the oldest were used first and staff were supposed to be instructed to use products with the earliest expiration date before those with a later date. Further review revealed staff were to discard food that was passed the expiration date.

Based on medical record review, observation, review of bathing schedules, review of bathing documentation, staff interview and facility policy review, the facility failed to ensure a resident's choice of bathing. This affected one (#260) of two residents reviewed for choices. The facility census was 60. Findings include Medical record review revealed Resident #260 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the North and South Hall Shower Schedule revealed Resident #260 was scheduled for showers on second shift on Sundays and Thursdays. Further review of the shower schedules revealed for the nurses and nursing assistants to document shower refusals. Review of the shower sheets revealed there were no documented shower/tub bath/bed bath sheets for Resident #260 until 08/14/19. Further review of the bathing sheet revealed no documentation of the type of bathing Resident #260 had received. Review of Resident #260's nurses' notes from admission till 08/14/19 revealed no documentation the resident had refused any showers. Observations on 08/12/19 at 10:49 A.M. revealed Resident #260's hair was oily in appearance and not combed. Interview at the time of the observation with Resident #260 revealed she had not received a shower since she had been admitted to the facility. Resident #260 revealed she had received bed baths but she preferred showers. Observations on 08/13/19 at 3:23 P.M. and on 08/14/19 at 8:59 A.M. revealed Resident #260's hair remained unwashed. Interview with the resident at the time of the observations revealed she had not received a shower and needed her hair washed. Interview on 08/14/19 at 1:43 P.M. with the Assistant Director of Nursing (ADON) #201 verified there was no shower documentation for Resident #260 from 07/31/19 through 08/13/19. Interview on 08/15/19 at 9:37 A.M. with Activities Directors (AD) #405 revealed it was very important to the resident to choose her type of bathing. Review of the policy, Resident Care, last revised 06/2018 revealed residents would be bathed or assisted to shower per their preference.

Based on medical record review, review of a determination summary reports from the Ohio Bureau of Pre-Admission Level two Screening and Resident Review (PASRR), and staff interview, the facility failed to assess a resident with a serious mental illness accurately. This affected one resident (#46) of two reviewed for PASRR. The facility census was 60. Findings included: Medical record review revealed Resident #46 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Sets (MDS) assessment dated [DATE], section A1500, revealed the facility assessed Resident #46 as not having serious mental illness and or intellectual disabilities as determined by PASRR level two screening. Review of the PASRR Level two screening determination summary, dated 04/15/18, revealed Resident #46 was determined to have serious mental illness. Interview on 08/15/19 at 10:13 A.M., Licensed Practical Nurse (LPN) #205 revealed she was responsible for completing resident's MDS assessments. LPN #205 confirmed section A1500 of the resident's comprehensive MDS assessment, dated 07/15/19, was coded wrong and did not reflect the resident's PASRR determination of serious mental illness.

Based on observation, record review, resident interview and staff interview, the facility failed to effectively assess and manage pain during a dressing change for one (#57) of three residents reviewed for pressure ulcers. This resulted in actual harm when Resident #57 yelled out and experienced pain during a dressing change [MEDICATION NAME] approximately 30 minutes and staff continued to complete the dressing change. The facility census was 68. Findings include: Review of the clinical record revealed Resident #57 was initially admitted to the facility on [DATE], with a readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated he was severely cognitively impaired. He had other behavioral symptoms not directed toward others and required the extensive assistance of one to two staff for activities of daily living. The assessment indicated Resident #57 had one Stage III pressure sore and received as needed pain medication as well as non medication interventions. Review of the current monthly physician orders for Resident #57 revealed an order for [REDACTED]. On eight of the 18 occasions, Resident #57 was also given an anti-anxiety medication concurrently. Review of Resident #57's pain assessment monitoring tool for October 2014, indicated pain was to be assessed each shift. The tool was inconsistently completed and had multiple blanks. The tool identified Resident #57 had pain on 11 of the shifts even though the resident received 18 doses of narcotic pain medication. The tool indicated if an as needed medication was used, a corresponding progress note was to be written. Review of the progress notes and clinical pain assessments for this time frame revealed the nursing staff were not consistent in completing the corresponding assessments or progress notes. Review of the current plan of care related to pain, indicated Resident #57 would experience relief of pain as evidenced by verbal reports of pain and less autonomic responses to pain. The interventions indicated to assess the location, severity, type, frequency, precipitating factors and relief factors. Teach to request pain medication before pain becomes severe. Establish which non-pharmacological interventions work best and provide these prior to medicating. Evaluate for effectiveness or need to have pain medication changed. Offer [MEDICATION NAME] per physician orders and refer to physical or occupational therapy for pain. The dressing change to Resident #57's Stage III pressure ulcer was scheduled for 10/29/14 at 10:00 A.M. Registered Nurse (RN) #10 asked Resident #57 if he was having pain and he indicated he was having pain. RN #10 requested Licensed Practical Nurse (LPN) #12 administer pain medication to Resident #57 prior to the dressing change. Interview with RN #10 on 10/29/14 at 10:30 A.M. reported the need to wait about 30 minutes prior to completing the dressing change for the medication to become effective. Observation on 10/29/14 beginning at 11:20 A.M., revealed RN #10 was assisted by State tested Nurse Aide (STNA) #12 to complete Resident #57's dressing change to his mid back. RN #10 asked Resident #57 if he was having any pain and he denied the presence of pain. As RN #10 squirted the normal saline onto the wound the resident jerked and yelled out "God dammit stop it." She tried to comfort him and asked if he was okay which he confirmed. When RN #10 measured the pressure ulcers using a paper ruler, the resident yelled out "owe" when the paper measuring device touched each area. STNA #12 was holding Resident #57 on his side as RN #10 was opening packages. Resident #57 yelled out "God dammit, owe", "ahh God dammit" and "come on God dammit." While RN #10 and STNA #12 verbally comforted him and there was no attempt to offer to provide any other interventions. On 10/29/14 at 11:30 A.M., Resident #57 yelled "come on God dammit." As RN #10 continued the dressing change, Resident #57 continued to yell out with every touch of his skin. When the dry sterile dressing was applied over both areas he yelled out "hurry!" and "come on God dammit." On 10/29/14 at 11:50 A.M., a third area of breakdown was identified on Resident #57's back. RN #10 cleansed the area using normal saline and the resident yelled out "ahh, ow" in pain. Interview with RN #10 on 10/29/14 at 11:53 A.M., verified Resident #57 yelled out in pain throughout the entire process. Review of the nursing notes for Resident #57 dated 10/30/14 at 10:26 A.M., revealed the nurse obtained a new order for two narcotic pain relievers to be given one hour prior to doing treatments for complaints of increased pain with treatments. Review of the facility policy titled "Skin Care," revised in May 2014, indicated to attempt to assess for signs and symptoms and perception of pain using the tool stipulated by the facility, implement measures to reduce fear and anxiety, implement measures to promote rest, administer [MEDICATION NAME] per order before activities and procedures that can cause pain, and before pain becomes severe, implement measures to decrease pain, evaluate resident for [MEDICATION NAME] effectiveness and document the findings, consult the physician if pain [MEDICATION NAME] was inadequate for the resident's pain, and discuss pain management with the resident and the family.