Every finding on record at Ohio Living Cape May

Based on observation, staff interview and review of the facility policy, the facility failed to ensure kitchen equipment and food items were maintained and handled in a sanitary manner to prevent foodborne illness. This had the potential to affect all of the residents in the facility with the exception of one facility-identified (Resident #31) that received no food by mouth. The facility census was 21 residents. Findings include: 1. Observation on 07/06/26 at 8:10 A.M. revealed there was a ham undated and open to air in the prep table cooler. The following opened and undated items were in the reach in freezer: a bag of onion straws, a bag of fries, a bag of chicken tenders. There was brown debris in the oil of the fryer. Interview on 07/06/26 at 8:12 A.M with [NAME] #448 verified the open and undated food items in the cooler and the reach in freezer. [NAME] #448 stated that the fryer had debris in it from 07/05/26 and it needed to be cleaned. [NAME] #448 stated she used the fryer to make breakfast items on 07/06/26 without cleaning it prior to use. Review of the facility policy titled Deep Fat Fryer undated revealed fryers will be cleaned after each use. Remove food particles from the oil after each use. 2. Observation n 07/06/26 at 5:21 P.M. of the large dining room revealed there were two containers of mustard on two separate tables with expiration dates of 04/01/26. Interview on 07/06/26 at 5:22 P.M. with Registered Nurse (RN) #344 verified there were two containers of mustard on two separate tables with expiration dates of 04/01/26 which should have been discarded. 3. Observation 07/06/26 at 5:24 P.M. of the small dining room revealed there was a container of mustard on a table with expiration date of 05/20/26. Interview on 07/06/26 at 5:25 P.M. with RN verified there was a container of mustard on a table with an expiration date of 05/20/26 which should have been discarded. 4. Observation on 07/08/26 at 7:53 A.M. of the skilled nursing unit kitchenette revealed there was a gray fuzzy substance on the vent leading to the small dining room, a gray fuzzy substance hanging from the light near the steam table, and a gray fuzzy substance on the wall of the kitchen near the water filtration system by the stove. Interview on 07/08/26 at 7:53 A.M. with [NAME] #446 verified the gray fuzzy substances in the small dining room and stated they should have been cleaned. 5. Observation of meal preparation on 07/08/26 at 8:00 A.M revealed [NAME] #446 touched the microwave door with his gloved hand and then picked up a biscuit with the same gloved hand without washing his hands or changing his gloves. [NAME] #446 continued to serve other food items without changing his gloves or washing his hands and then he picked up a piece of toast from the toaster, cut it in half with a knife and placed it on a plate without washing his hands or changing his gloves. Interview on 07/08/26 at 8:05 A.M. with [NAME] #446 verified he touched the biscuit and piece of toast with his gloves without changing his gloves or washing his hands. Review of the facility policy titled Bare Hand Contact with Food and Use of Plastic Gloves undated revealed gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single use gloves should be used for only one task such as working with ready to eat food and used for no other purpose and discarded when damaged or soiled. 6. Observation on 07/08/26 at 9:01 A.M. of [NAME] #446 taking the temperatures of food items on the test tray after plating them from the steam table revealed the following temperatures: sausage was 132.5 degrees Fahrenheit (F), scrambled eggs were 125 degrees F, waffle was 117.2 degrees F. Interview on 07/08/26 at 9:01 A.M. with [NAME] #446 verified the temperatures of the sausage, eggs, and waffles and confirmed all food items should have been held above 135 degrees F. Review of the facility policy titled Food Safety undated revealed hot foods should be held at 135 degrees F or higher

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure staff used appropriate hand hygiene and infection control practices when administering medications. This affected four (Residents #1, #8, #13, and #20) of four residents reviewed for medication administration. The facility census was 21 residents.Findings include: Observation on 07/08/26 at 7:11 A.M. of medication administration revealed Registered Nurse (RN) #342 dropped Resident #13's Lasix and potassium chloride directly onto the medication cart. After dropping each medication on the medication cart RN #342 used her hands to place the medications into the resident #13's medication cup. RN #342 did not perform hand hygiene before entering Resident #13's room to administer medications. Interview on 07/08/26 at 7:19 A.M with RN #342 confirmed she dropped Resident #13's medications onto the medication cart, placed the medications into Resident #13's medications cup with their bare hands, and administered the medications to Resident #13. RN #342 confirmed they should have wasted the medications that were touched and replaced the medications.Observation 07/08/26 at 7:30 A.M. revealed RN #342 did not perform hand hygiene before entering Resident #20's room to administer medication. Observation on 07/08/26 at 7:43 A.M revealed RN #342 did not perform hand hygiene before entering Resident #8's room to administer medication. Observation on 07/08/26 at 7:51 A.M revealed RN #342 failed to use hand hygiene before entering Resident #1's room to administer medication. Interview on 07/08/26 at 8:15 A.M with RN #342 confirmed she should have used hand hygiene before and after going into a resident's room to administer medications. Review of the facility policy titled Hand Hygiene dated 09/15/25 revealed hand hygiene was to be used before and after patient contact or in the patient's environment.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the residents code status was accurately reflected and matched in all areas of the medical record. This affected two (Residents #2 and #5) of 12 residents sampled. The facility census was 21 residents. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 05/11/26 with diagnoses including fracture of the left tibia, hypertensive heart disease, and type two diabetes mellitus. Review of the do not resuscitate comfort care arrest (DNRCCA) form scanned into Resident #2's medical record dated 01/20/23 revealed the resident's physician signed the form on 01/20/23 indicating the resident's code status was DNRCC-A. Review of the electronic physician's orders for Resident #2 revealed an order dated 05/12/26 for a code status of full code. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 05/18/26 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs.) Review of the physician's progress note for Resident #2 dated 06/06/26 per Physician #800 revealed the resident's code status was full code. Review of the face sheet for Resident #2's face sheet dated 07/07/26 revealed the resident's code status was full code. Interview on 07/07/26 at 10:15 A.M. with the Director of Nursing (DON) verified Resident #2's code status did not match in all areas of the medical record. The DON confirmed Resident #2 had an electronic physician order that indicating the resident was a full code, a physician progress note indicating the resident was a full code, and a signed DNRCCA form indicating the resident's code status was DNRCCA. 2. Review of the medical record for Resident #5 revealed an admission date of 12/02/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, type two diabetes mellitus, and vascular dementia. Review of the do not resuscitate comfort care (DNRCC) form scanned into Resident #5's medical record dated 04/16/25 revealed the form had been signed by a physician on 04/16/25 indicating the resident's code status was DNRCC. Review of the electronic physician's orders for Resident #5 dated 11/04/25 revealed the resident's code status was DNRCC. Review of the physician's progress note for Resident #5 dated 04/04/26 per Physician #800 revealed the resident's code status was DNRCC-A. Review of the MDS for Resident #5 dated 06/24/26 revealed the resident was severely cognitively impaired and dependent on staff assistance with ADLs. Review of the provider progress for Resident #5 dated 06/25/26 per Nurse Practitioner (NP) #801 revealed the resident's code status was DNRCC-A. Review of the face sheet for Resident #5 dated 07/07/26 revealed the resident code status was DNRCC. Interview on 07/07/26 at 10:16 A.M. with the DON verified Resident #5's code status did not match in all areas of the medical record. The DON confirmed Resident #5 had an electronic physician order indicating the resident was a DNRCC, physician and provider progress notes indicating the resident was a DNRCC-A, and a signed DNRCC form indicating the resident's code status was DNRCC. Review of the facility policy titled Advanced Directives dated 01/07/26 revealed the facility would document in the resident's medical record if the resident had executed an advanced directive. A copy of the advanced directive, if executed, would be scanned into the medical record.

Based on medical record review, review of facility fall investigation, review of staff witness statements, staff interview, and policy review, the facility failed to ensure staff provided adequate supervision during care to prevent falls. This affected one (Resident #16) of three residents reviewed for falls. The facility census was 21 residents.Findings include: Review of the medical record for Resident #16 revealed an admission date of 07/25/25 with diagnoses including cerebral infarction, spastic hemiplegia affecting right nondominant side, and chronic pain. Review of the fall care plan for Resident #16 dated 08/18/25 revealed the resident was at risk for falls due to history of cerebrovascular accident (CVA) and a history of previous falls. Interventions included the following: scoop mattress to bed, keep call light in reach, toilet resident before and after meals. Review of the care plan for Resident #16 dated 11/11/25 revealed the resident had a self-care performance deficit due to CVA and interventions included staff should assist the resident with rolling from side to side. Review of the Minimum Data Set (MDS) assessment for Resident #16 dated 03/31/26 revealed the resident was moderately cognitively impaired, required partial to moderate assistance for all activities of daily living (ADLs), and was frequently incontinent of bowel and bladder. Review of the progress note for Resident #16 dated 07/05/26 at 11:29 A.M. per Registered Nurse (RN) #352 revealed the resident was a one person assist for all transfers and had a scoop mattress in place for fall prevention. Review of the progress note for Resident #16 dated 07/05/26 at 4:45 P.M per RN #352 revealed the resident rolled out of bed landing on her right side and sustained a skin tear to the left hand. Review of the fall investigation for Resident #16 dated 07/06/26 revealed LPN #332 was providing incontinence care to Resident #16 in the bed and turned away from the resident to grab a brief from the chair behind her and the resident fell out of bed and onto the floor. Review of the witness statement for Resident #16 dated 07/06/26 per LPN #332 revealed she turned away from Resident #16 while performing incontinence care and the resident fell out of bed when the nurse left the resident unattended. Interview on 07/06/26 at 7:50 A.M with the Director of Nursing (DON) confirmed LPN #332 did not follow the appropriate standards of nursing practice when providing incontinence care to Resident #16 on 07/06/26. The DON stated the nurse should have laid the resident back down before reaching for the brief in order to prevent the resident from falling out of bed, Interview on 07/06/26 at 9:15 A.M with LPN #332 confirmed she asked the resident to roll on her right side toward the window to provide incontinence care. LPN #332 stated she turned away from the resident to grab a brief off the chair and the resident rolled off the bed and onto the floor. Review of the facility policy titled Fall Prevention and Management dated 01/28/25 revealed the facility would assess residents for risk factors for falls and would implement interventions to prevent falls.

Based on medical record review, observation, staff interview, review of online medication resources, and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #13) of three residents reviewed for transdermal patches. The facility census was 21 residents. Findings include: Review of the medical record for Resident #13 revealed an admission date of 11/26/24 with diagnoses including cervical disc disorder, venous insufficiency, and constipation. Review of the physician's orders for Resident #13 revealed an order dated 07/13/25 for a lidocaine patch to be applied to the right middle back in the morning and removed at bedtime. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 04/22/26 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the Medication Administration Record (MAR) for Resident #13 dated July 2026 revealed it did not include a space for nurses to document removal of the lidocaine patch at bedtime. Observation on 07/08/2026 at 7:17 A.M of medication administration revealed there was an undated patch on the resident's back. Registered Nurse (RN) #342 removed the patch from the resident's back and applied a new patch to the resident's back. Interview on 07/08/226 at 10:00 A.M with RN #342 confirmed she removed the lidocaine patch from the day prior from Resident #13's back. RN #342 stated the night shift nurse should have removed Resident #13's lidocaine patch per the physician order. Review of an online reference Medscape at https://reference.medscape.com/drug/lidoderm-ztlido-lidocaine-transdermal-1000223#5 titled Lidocaine Transdermal: Warnings revealed a longer duration of application of a lidocaine patch could contribute to an increased blood concentration of the medication. Review of the facility policy titled Medication Administration dated 02/06/26 reviewed medications are to be administered in accordance with physicians' orders.

Based on medical record review and staff interview, the facility failed to ensure a bed hold notice and transfer notice were provided to a resident upon transfer to the hospital. This affected one (Resident #3) of three residents reviewed for hospitalization. The facility census was 21 residents. Findings include: Review of the medical record for Resident #3 revealed an admission date of 07/07/26 with diagnoses including gastric ulcer, peptic ulcer disease, and adjustment disorder. Review of the nurse progress note for Resident #3 dated 03/16/26 at 11:56 A.M. revealed the resident was sent to the hospital for an evaluation due to abnormal lab results and was admitted . Review of the nurse progress note for Resident #3 dated 03/19/26 at 5:38 P.M. revealed the resident was readmitted to the facility. Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 05/22/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of bed hold notices for Resident #3's bed hold dated 03/16/26 to 07/07/26 revealed neither the resident nor the resident's representative was provided a bed hold notice of the resident's discharge to the hospital on [DATE]. Review of transfer notices for Resident #3 dated 03/16/26 to 07/07/26 revealed neither the resident nor the resident's representative was provided a transfer notice of the resident's discharge to the hospital on [DATE]. Interview n 07/07/26 at 10:42 A.M. with Social Service Designee (SSD) #510 on verified neither Resident #3 nor the resident's representative was provided a bed hold notice or transfer notice upon the resident's discharge to the hospital on [DATE].

Based on staff interviews, policy review, and review of the facilities Self-Reported Incidents (SRI) and investigations, the facility failed to complete thorough investigations into allegations of sexual and physical abuse of residents. This affected four residents (#8, #17, #67, and #68) of seven SRIs reviewed. Findings include:1. Review of the facility's SRI number 252610 dated 10/04/24 revealed an allegation of physical abuse between Residents #17 and #68. Certified Nursing Assistant (CNA) #101 was at the nursing station and heard get out, get out from a resident room. CNA #101 immediately went to Resident #17's room and Resident #17 had his fist raised to Resident #68 asking him if he wanted hit. Resident #68 wandered into Resident #17's room. Resident #17 had his hand on Resident #68's wrist. CNA #101 intervened and redirected Resident #67 out of Resident #17's room. Resident #68 was provided one-to-one supervision until his planned discharge to home on [DATE].The investigation in SRI said they got the CNA statement and no physical signs of harm. The facilities investigation did not include an assessment of Resident #68 for any injuries and there were no resident statements from Residents #17 and Resident #68 on what occurred.Interview on 04/10/26 at 2:15 P.M. with the Administrator confirmed the facility's investigation into the allegation of physical abuse between Residents #17 and #68 did not include an assessment of #68 for any injuries and there were no resident statements from Residents #17 and Resident #68 on what occurred. 2. Review of the facility's SRI number 255177 dated 12/16/24 revealed Resident #67 alleged she dreamed of someone raping her to the floor nurse. The facility's investigation revealed Certified Nursing Assistant( CNA) #100 recently toileted Resident #67 roughly 20 minutes prior to the statement being made. CNA #100 took Resident #67 to the restroom and waited outside for her to be finished. Resident #67 stated later to the nurse that she had some crazy dreams the night before. On 12/17/24, the Director of Nursing (DON) reported Resident #67 could not recall anything from the night prior (12/16/24). The investigation did not include additional staff statements and skin assessment on Resident #67. Interview on 04/10/26 at 2:15 P.M. with the Administrator confirmed the facility did not include any additional staff statements and skin assessment on Resident #67. 3. Review of the facility's SRI number 265492 dated 09/21/25 revealed Resident #8 alleged a someone hit her earlier in the day (09/21/25).The facility's investigation revealed Resident #8 refused care throughout the shift and was combative during care. Resident #8's granddaughter stated she knew Certified Nursing Assistant (CNA) 103 and CNA #103 would not hit Resident #8. Nurse #2 witnessed the incident and stated Resident #8 was combative and CNA #103 remained professional and polite during the entire interactions. The investigation did not include skin assessment on Resident #8 and staff interviews on that shift.Interview on 04/10/26 at 2:15 P.M. with the Administrator confirmed the facility's investigation into the Resident #8's allegation of physical abuse. The Administrator confirmed the facility did not include skin assessment on Resident #8 and staff interviews on that shift.Review of the facility policy titled Abuse, Neglect Misappropriation and Crime Reporting dated 04/14/1999 revealed as part of the policy, it included the investigation of allegations or suspicion of abuse. The investigation process may include all or some of the following dependent upon the situation in question: Interview the resident/victim. Examine the resident for marks/bruises/other indications of abuse/neglect. Interview the alleged wrongdoer. Interview facility staff/employees/persons used by the facility, with first-hand knowledge of the incident, Interview other residents with first hand knowledge of the incident. Obtain written statements from all those interviewed. The interview may document a written record if there is a telephone interview. This was an incidental finding discovered during the complaint investigation.

Based on observation, interview, policy review, review of the Centers for Disease Control and Prevention (CDC) guidance, and record review, the facility failed to ensure staff followed appropriate enhanced barrier precautions (EBP) during high resident care activities for a resident with a wound. This affected one (Resident #4 )of three residents reviewed for wound care. The facility census was 19. Findings include:Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included orthopedic surgery fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing and malignant neoplasm of unspecified main bronchusReview of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was cognitively intact, required substantial assistance with toileting, substantial assistance with bathing, and supervision with personal hygiene.Review of the resident record flags for Resident #4 revealed EBP were in place.Review of the care plan dated 04/07/26 revealed Resident #4's problem was EBP will be maintained per facility/organization policy related to surgical wound. Observation and interview on 04/10/26 at 10:05 A.M. to 10:16 A.M. revealed there was a sign on Resident #4's door stating EBP. Licensed Practical Nurse (LPN) #1 provided care to a skin tear on Resident #4's right arm and did not have a gown on during treatment. LPN #4 confirmed she was not wearing a gown and stated no gown needs to be worn for this type of care, only when doing the surgical wound. Interview on 04/10/26 at 1:12 P.M. with the Director of Nursing (DON) confirmed staff should be wearing gloves and gown when doing patient care for residents in EBP.Review of the policy titled Enhanced Barrier Precautions dated 01/07/26 revealed wear a gown during high contact resident care. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. This deficiency represents non-compliance investigated under Complaint Number 2746877.

Based on observation, medical record review, staff interview and policy review, the facility failed to ensure a skin assessment was completed in a timely manner. This affected one (#8) of four skin impairments reviewed. The census was 21. Findings included: Medical record review for Resident #8 revealed an admitted [DATE]. His medical diagnoses included Parkinson's disease, muscle weakness, hypertension, hypertensive heart disease, foot drop left foot, and peripheral vascular disease. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact. His functional status was extensive assistance for bed mobility, transfers, and toileting. He was a supervision for eating. Review of wound documentation dated 04/03/23 revealed Resident #8 had an arterial wound on his left third toe that measured 1.0 centimeters (cm) by 1.5 cm by 0.1 cm that was eschar and dry. There wasn't any documentation of the left second toe in the record. Interview with Resident #8 on 05/30/23 at 10:24 A.M., revealed he stated he needed to take off his shoe because his toe hurt him. Observation and interview with Licensed Practical Nurse (LPN) #500 on 05/30/23 at 10:30 A.M., removed Resident #8's shoe and sock. On the tip of the second toe, there was an area observed to be a small black oval wound and on the tip of the third toe was a black spot. The nurse said Resident #8's wounds were something he wasn't aware of. Review of progress notes dated 05/30/23 and the morning of 05/31/23 revealed there wasn't any notes or assessments regarding the left second toe. Interview with the LPN #500 on 05/31/23 at 9:53 A.M., revealed he was an agency nurse, and he didn't know how to put in an assessment of a wound and verified he did not assess the wound and put it in the chart for Resident #8's left second toe. Review of the policy titled Skin Integrity assessment dated [DATE], revealed the skin should be checked at least daily and report potential or actual changes in the skin integrity. Assessment of the skin should include type, stage if any, characteristic, presences of infection or pain, and type of dressing and treatment.

Based on observation, medical record review, staff interview and policy review, the facility failed to ensure the physician was notified of a new skin condition. This affected one (#8) of four residents with skin impairments reviewed. The census was 21. Findings included: Medical record review for Resident #8 revealed an admitted [DATE]. His medical diagnoses included Parkinson's disease, muscle weakness, hypertension, hypertensive heart disease, foot drop left foot, and peripheral vascular disease. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact. His functional status was extensive assistance for bed mobility, transfers, and toileting. He was a supervision for eating. Review of wound documentation dated 04/03/23 revealed Resident #8 had an arterial wound on his left third toe that measured 1.0 centimeters (cm) by 1.5 cm by 0.1 cm that was eschar and dry. There wasn't any documentation of the left second toe in the record. Interview with Resident #8 on 05/30/23 at 10:24 A.M., revealed he stated he needed to take off his shoe because his toe hurt him. Observation and interview with Licensed Practical Nurse (LPN) #500 on 05/30/23 at 10:30 A.M., removed Resident #8's shoe and sock. On the tip of the second toe, there was an area observed to be a small black oval wound and on the tip of the third toe was a black spot. The nurse said Resident #8's wounds were something he wasn't aware of. Review of progress notes dated 05/30/23 and the morning of 05/31/23 revealed there was no documentation of a notification to the physician of the wounds. Interview with the LPN #500 on 05/31/23 at 9:53 A.M., confirmed he didn't notify the physician regarding the wound on the left second toe. Review of policy titled Change of Condition dated 09/13/22, revealed to observe, record, and report any condition change to the nurse in charge and the attending physician so proper treatment can be implemented.

Based on record review, staff interview, Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual review, and policy review, the facility failed to complete and transmit a resident's discharge Minimum Data Set (MDS) assessment. This affected one (#11) of 12 residents reviewed for assessments. The facility census was 21. Findings include: Review of the Resident #11's medical record revealed an admission of 01/07/23, with diagnoses including: spondylolisthesis, constipation, other seizures, spinal stenosis lumbar region with neurogenic claudication, hypothyroidism, history of bariatric surgery status, difficulty in walking and lymphedema. Resident #11 discharged from the facility on 01/27/23. Review of Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #11 required limited assistance with bed mobility, and transfers. Resident #11 required extensive assistance with dressing and toileting and supervision with personal hygiene. Resident #11 was independent with eating on the MDS. Review of Resident #11's progress note dated 01/27/23 revealed Resident #11 received a copy of the discharge plans and resident verbalized understanding. Resident #11 was placed in the car by the nurse and power of attorney and left in stable condition. Review of Resident #11's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the MDS assessment was in progress and was not transmitted. Interview with the Administrator on 05/31/23 at 10:46 A.M., verified Resident #11's discharge MDS assessment dated [DATE] was not completed or transmitted. Review of the policy titled MDS Completion and Assigned Selections dated 01/10/23 revealed the MDS nurse will electronically transmit the assessments and tracking forms according to the resident assessment instrument manual. Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual v1.17.1, chapter two, page 2-37, dated 10/2019, revealed a Discharge Return Not Anticipated MDS assessment is required to be completed when a resident is discharged from a facility and is not expected to return to the facility within 30 days. The Discharge Return Not Anticipated MDS must be completed within 14 days after the discharge date and must be transmitted within 14 days after the MDS completion date.

Based on staff interview, policy review, and observation the facility failed to have a resident call system that was adequately equipped to allow residents to call for assistance when a State tested Nurse Aide and Licensed Practical Nurse did not have pagers that informed them of Residents using their call lights or pendants. This had the potential to affect 13 Residents (#1, #2, #3, #4, #5, #11, #12, #13, #14, #15, #16, #17, and #18) on the healthcare hallway. The facility census was 23. Findings include: Observation on 09/27/21 at 10:55 A.M. of Licensed Practical Nurse (LPN) #11 revealed he does not have a pager that notifies him of resident call lights or pendants going off on his person. Interview on 09/27/21 at 10:55 A.M. LPN #11 revealed he does not have a pager that notifies him of resident call lights or pendants going off. LPN #11 stated there is not a main board or auditory tone besides the pager system that tells what call lights are going off. Observation on 09/27/21 at 11:00 A.M. of State tested Nurse Aide (STNA) #12 revealed she does not have a pager that notifies her of resident call lights or pendants going off on her person. Interview on 09/27/21 at 11:00 A.M. revealed STNA #12 stated she does not have a pager that notifies her of resident call lights or pendants going off. STNA #12 stated someone took a pager home with them. STNA #12 stated there is another STNA on her hall and she is working with her to answer call lights and that the light over the door goes off when the call light or pendant is activated. Review of the 12/15/20 facility policy titled Responding to Call Lights revealed it is the basic responsibility of licensed nurse and nursing staff that all residents' needs are met in a timely manner. Every resident shall have a mechanism that sends a signal light or bell to alert staff to their need for assistance. This deficiency substantiates complaint number OH 887.

Based on staff interview, policy review, and observation the facility failed to have a Resident call system that was adequately equipped to allow Residents to call for assistance when a State tested Nurse Aide and Licensed Practical Nurse did not have pagers that informed them of Residents using their call lights or pendants. This had the potential to affect 13 Residents (#1, #2, #3, #4, #5, #11, #12, #13, #14, #15, #16, #17, and #18) on the healthcare hallway. The facility census was 23. Findings include: Observation on 09/27/21 at 10:55 A.M. of Licensed Practical Nurse (LPN) #11 revealed he does not have a pager that notifies him of Resident call lights or pendants going off on his person. Interview on 09/27/21 at 10:55 A.M. with Licensed Practical Nurse (LPN) #11 revealed he does not have a pager that notifies him of Resident call lights or pendants going off. LPN #11 stated there is not a main board or auditory tone besides the pager system that tells what call lights are going off. Observation on 09/27/21 at 11:00 A.M. of State tested Nurse Aide (STNA) #12 revealed she does not have a pager that notifies her of Resident call lights or pendants going off on her person. Interview on 09/27/21 at 11:00 A.M. revealed State tested Nurse Aide (STNA) #12 stated she does not have a pager that notifies her of Resident call lights or pendants going off. STNA #12 stated someone took a pager home with them. STNA #12 stated there is another STNA on her hall and she is working with her to answer call lights and that the light over the door goes off when the call light or pendant is activated. Review of the 12/15/20 facility policy titled responding to call lights revealed it is the basic responsibility of licensed nurse and nursing staff that all Residents' needs are met in a timely manner. Every Resident shall have a mechanism that sends a signal light or bell to alert staff to their need for assistance. This deficiency substantiates complaint number OH 887.

Based on observation, staff interview, and facility policy review the facility failed to maintain essential mechanical equipment in safe operating order when the kitchen stove hood and filters were dirty and covered with grease. This had the potential to affect all 27 facility residents. Findings include: Observation of the main kitchen on 02/19/19 at 9:40 A.M. revealed grease running down the hood, hood filters, and the back wall overtop the cooking area. Interview with Dietary Worker #35 at the time of the observation verified there was grease running down the hood, hood filters, and the back wall overtop the cooking area. Review of an undated facility policy titled cleaning hoods and filters revealed stove hoods and filters will be cleaned at least monthly and according to the cleaning schedule.

Based on observation, staff interview and facility policy review the facility failed to ensure foods were stored in accordance with professional standards when they stored food scoops in the containers. This had the potential to affect 26 Residents who ate from the kitchen. The facility identified Resident #10 who did not eat anything by mouth. The facility census was 27. Findings include: Observation of the main Kitchen on 02/19/19 at 9:40 A.M. revealed scoops were stored in the food containers for flour, rice, and sugar. The scoops were stuck in the food items with the scoop handle visible. Interview with Dietary Worker #35 at the time of the interview verified the food scoops were stored inside the flour, rice and sugar containers and the scoops were stuck in the food with the scoop handle visible. Review of a facility undated food storage policy revealed scoops are not to be stored in food containers but are kept in a protected area near or in the containers.

Based on medical record review and staff interview the facility failed to ensure residents received the appropriate Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form when they were cut from skilled services and remained in the facility. This affected two (#20 and #22) of three residents reviewed for beneficiary notices. The facility census was 27. Findings include: 1. Medical record review for Resident #22 revealed an admitted [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Notice of Medicare Non Coverage (NOMNC) form dated 02/15/19 revealed Resident #22 was cut from nursing and therapy services on 02/18/19 and remained in the facility. Interview with the Director of Nursing (DON) on 02/21/19 at 1:05 P.M. verified that Resident #22 remained in the facility and had skilled nursing days remaining. The DON verifed the resident did not received the SNFABN. 2. Record review for Resident #20 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a NOMNC dated 09/13/18 revealed Resident #20 was cut from nursing and therapy services on 09/17/18 and remained in the facility. Interview with the DON on 02/21/19 at 1:05 P.M. verified Resident #20 remained in the facility and had skilled nursing days remaining. The DON verified the resident did not receive SNFABN.

Based on medical record review and staff interview the facility failed to ensure residents had the right to refuse or discontinue treatment when they failed to have matching cardiopulmonary resuscitation code status documentation. This affected three (#3, #5 and #7) of 16 residents reviewed for code status. The facility census was 27. Findings include: 1. Medical record review of Resident #5 revealed an admitted : [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a paper Do Not Resuscitate (DNR) comfort care form dated [DATE] revealed the resident was requesting a Do No Resuscitate Comfort Care-Arrest (DNR-CCA) code status. Review of Resident #5's electronic medical record on [DATE] at 5:02 P.M. revealed a current Physicians Order for the Resident to be a full code and receive cardiopulmonary resuscitation (CPR). Interview with the Director Of Nursing (DON) on [DATE] at 5:34 P.M. verified the code status was different on the Physician order [REDACTED]. 2. Medical record review for Resident #3 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a paper DNR comfort care form dated [DATE] revealed the resident was requesting a DNR-CCA code status. Record review of a Physician order [REDACTED]. Interview with the DON on [DATE] at 5:34 P.M. verified the code status was different on the Physician order [REDACTED]. 3. Medical record review of Resident # 7 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a paper DNR comfort care form dated [DATE] revealed the resident was requesting a DNR-CCA code status. Record review of a Physician order [REDACTED].M. revealed the Resident was requesting a DNRCC code status. Interview with the DON on [DATE] at 5:34 P.M. verified the code status was different on the Physician order [REDACTED].

Based on medical record review and staff interview the facility failed to ensure residents records were accurate when the code status was not accurate. This affected three (#3, #5 and #7) of 16 residents reviewed for code status. The facility census was 27. Findings include: 1. Medical record review of Resident #5 revealed an admitted : [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a paper Do Not Resuscitate (DNR) comfort care form dated [DATE] revealed the resident was requesting a Do No Resuscitate Comfort Care-Arrest (DNR-CCA) code status. Review of Resident #5's electronic medical record on [DATE] at 5:02 P.M. revealed a current Physicians Order for the Resident to be a full code and receive cardiopulmonary resuscitation (CPR). Interview with the Director Of Nursing (DON) on [DATE] at 5:34 P.M. verified the code status was different on the Physician order [REDACTED]. 2. Medical record review for Resident #3 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a paper DNR comfort care form dated [DATE] revealed the resident was requesting a DNR-CCA code status. Record review of a Physician order [REDACTED]. Interview with the DON on [DATE] at 5:34 P.M. verified the code status was different on the Physician order [REDACTED]. 3. Medical record review of Resident # 7 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a paper DNR comfort care form dated [DATE] revealed the resident was requesting a DNR-CCA code status. Record review of a Physician order [REDACTED].M. revealed the Resident was requesting a DNRCC code status. Interview with the DON on [DATE] at 5:34 P.M. verified the code status was different on the Physician order [REDACTED].

Based on observation, staff interview and facility training audit form the facility failed to dispose of garbage and refuse properly when they left the dumpster lids open and had trash around the dumpster area. This had the potential to affect all 27 residents residing in the facility. Findings include: Observation on 02/21/19 at 10:55 A.M. revealed the dumpster lids were open and there was a wooden pallet and trash on the ground beside the dumpster. Interview with Dietary Worker #35 at the time of the observation verified the dumpster lids were open and there was a wooden pallet and trash on the ground beside the dumpster. Review of an undated facility form titled Dining Food Safety and Training audit revealed the dumpster is maintained to minimize sanitation issues, and lids are on the dumpster.

Based on observations, staff interview and review of the Food and Drug Administration Code, the facility failed to provide sanitary precautions while being around food in the kitchen. This had the potential to affect all 25 residents who reside in the facility and receive food from the kitchen. Facility census was 25. Findings include: Observation on 12/29/17 at 9:40 A.M., revealed Culinary Services (CS) #200 putting away dishes in the kitchen with no hair net. CS #210 was putting food away in the refrigerator in the main kitchen with no hair net. CS #220 was washing dishes in the main kitchen with no hair net. Observation on 12/29/17 at 10:00 A.M., revealed no signs in the kitchen stating hair nets are only used when food is being cooked. Interview on 12/29/17 at 1:00 P.M., with Culinary Director (CD) #250 revealed the facility uses the county guidelines which states hairnets are not needed in the kitchen when food is not being served. CS #200, CS #210 and CS#220 verified wearing no hair net. Review of the Code of Federal Regulations (CFR) Title 21, Volume 2, Revised as of April 1, 2017 CITE: 21 CFR 110.10 from the US FDA states: All persons working in direct contact with food, food-contact surfaces, and food-packaging materials shall conform to hygienic practices while on duty to the extent necessary to protect against contamination of food. The methods for maintaining cleanliness include, but are not limited to: wearing, where appropriate, in an effective manner, hair nets, headbands, caps, beard covers, or other effective hair restraints.