Every finding on record at Ohio Living Dorothy Love

Based on medical record review, staff interview, and policy review, the facility failed to ensure the physician was notified of a resident's fall. This impacted one (#53) of the three residents reviewed for falls. The facility census was 43. Review of the medical record of Resident #53 revealed an admission date of 01/12/26. The resident transferred to the hospital on [DATE] and did not return to the facility. Diagnoses included dementia, essential hypertension, congestive heart failure, history of embolism, atherosclerotic heart disease, and atrial fibrillation. The resident was noted to be a full code. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #53 had moderately impaired cognition. The resident rejected care, was independent with bed mobility, required supervision with transfers, setup/clean-up assistance with eating, and partial/moderate assistance with toileting and bathing.Review of the Fall Risk Assessment for Resident #53 dated 07/20/26, revealed the resident was at a high risk for falls. Review of physician orders dated 06/19/26 for Resident #53, revealed the resident was ordered warfarin (anticoagulant) 2.5 milligrams (mg) once daily on Tuesday, Thursday, and Saturday and warfarin 5 mg once daily on Sunday, Monday, Wednesday, and Friday.Review of a progress note for Resident #53 dated 07/29/26 at 12:15 A.M. and authored by Licensed Practical Nurse (LPN) #400, revealed the resident was found lying on the floor in her room in front of the bathroom door. The resident stated she hit her head and had a small slightly reddened raised area noted to the back of her right scalp. A full assessment was completed with no other abnormalities. Neurological (neuro) checks were initiated and within normal limits. Physician #900 was notified. During an interview on 08/24/25 at 4:49 P.M., Physician #900 stated she was out of the country and was unable to be reached on the date in question, and therefore, did not receive notification of Resident #53's fall. Physician #900 further stated her expectation was to be notified of a fall where the resident hit their head and was taking a blood thinner and, even if there was a low suspicion, she would want a computerized tomography ( CT) scan of the head completed.Further review of the medical record for Resident #53 revealed there was no documented evidence of another provider being notified of the resident's fall. During an interview on 08/25/26 at 10:17 A.M., LPN #400 stated she did not call Physician #900, but instead, placed the information on the physician communication board as she did not feel as though the situation was emergent. LPN #400 stated she had been a nurse for 15 years and stated a fall where the resident hit their head and was taking a blood thinner was not significant. During an interview on 08/25/26 at 9:41 A.M., the Administrator verified there was no confirmation of a provider being notified when Resident #53 fell on [DATE]. The Administrator stated the nurse may have just put the notification on the physician communication board. During a subsequent interview on 08/25/26 at 12:22 P.M., the Administrator verified if something was documented in the medical record as being completed, the expectation is that it was completed at the time it was documented. Review of the facility policy titled, Notification of Change, dated 01/07/26, revealed the physician/provider would immediately be notified of an accident involving the resident which results in injury and has the potential for requiring physician intervention. Review of the facility policy titled, Fall Prevention and Management, dated 01/28/25, revealed, at the time of the fall, the nurse will complete a physical assessment and notify the physician and responsible party. This deficiency represents non-compliance investigated under Complaint Number 3154965.

Based on review of the facilities Legionella Program Plan, staff interview and review of information from the Centers for Disease Control and Prevention (CDC), the facility failed to implement their water management program to reduce the risk of Legionella and/or other pathogens in their water system. This had the potential to affect all 43 residents residing in the facility. The facility census was 43. Findings include: Review of the facilities Legionella Program Plan revealed hot water tank flushing consisted of flushing the bottom drain valve on hot water tanks for five minutes at full flow. This was to be completed quarterly. An additional intervention was hot water tank inspection which included to inspect, clean, disinfect, and descale. This was to be completed annually. Further review of the Legionella documentation and paperwork provided by the facility revealed there was no documented evidence the hot water tank had been flushed or inspected per the Legionella Program Plan. Interview on 03/19/25 at 11:49 A.M. with Maintenance Technician (MT) #245 revealed he was unable to provide documentation the hot water tank had been flushed or inspected per the Legionella Program Plan. MT #245 confirmed there have been no Legionella cases in the facility but failing to complete the water management plan placed all 43 residents residing in the facility at risk for Legionella. Review of information from the CDC at https://www.cdc.gov/control-legionella/php/training/index.html revealed Centers for Medicare and Medicaid Services (CMS) now requires healthcare facilities to have water management policies and procedures to reduce the risk of Legionella and other pathogens in building water systems.

Based on observations and staff interview, the facility failed to ensure a food thermometer was cleansed/disinfected between checking food temperature on multiple food items to potentially prevent cross contamination. This had the potential to affect 19 residents (#07, #15, #18, #21, #28, #90, #91, #92, #93, #94, #95, #96, #97, #98, #100, #101, #102, #103, and #104) on the Rehab Hall. The facility census was 43. Findings include: Observation on 03/18/25 at 11:20 A.M. on Rehab Hall revealed [NAME] #239 obtained food temperature prior to serving residents on the rehab hall. The observation revealed [NAME] #239 used two different thermometers to check the temperature of the food in the steam table. [NAME] #239 was observed to take the temperature of a chicken breast in the steam table. [NAME] #239 then proceeded to insert the same thermometer into the zucchini chips without cleansing/disinfecting the thermometer prior to checking the temperature of the zucchini chips. Further observation of [NAME] #239 revealed [NAME] #239 used the second thermometer to check the temperature of the Italian wedding soup with meatballs and proceeded to check the temperature of the fish nuggets without cleansing/disinfecting the thermometer prior to checking the temperature of the fish nuggets. Interview on 03/18/25 at 11:23 A.M. with [NAME] #239 verified confirmed she did not cleanse/disinfect either thermometer in between taking the temperature of the food. [NAME] #239 confirmed the food thermometer should be cleansed/disinfected with a alcohol wipe between food items to prevent cross contamination. [NAME] #239 confirmed 19 residents (#07, #15, #18, #21, #28, #90, #91, #92, #93, #94, #95, #96, #97, #98, #100, #101, #102, #103, and #104) reside on the Rehab Hall.

Based on record review, observation, staff interview and review of the facility policy, the facility failed to timely assess a wound to determine if it was a pressure ulcer and to identify a stage of the wound. Additionally, the facility failed to properly wrap a pressure ulcer as instructed. This affected one (#97) of three residents reviewed for wound care. The facility census was 43. Findings include: Review of medical record for Resident #97 revealed admitted [DATE]. The resident was admitted with diagnoses including lymphedema, hypertension, atherosclerotic heart disease, moderate protein calorie malnutrition. The resident remained at the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 13 indicating intact cognition. She required set up for meals, was dependent with toileting hygiene, and required substantial assistance for bed mobility and transfers. A care plan for lymphedema revealed edema extending into thighs and abdomen, with several fluid filled blisters to bilateral lower extremities. Review of Resident #97's physician orders dated 03/06/25 revealed an order to the right lower extremity to apply A&D (vaseline preferably) to left after washing. Apply Adaptic with Medihoney to open areas, cover with ABD's (abdominal pad), wrap with 2-flex, change three times a week (Tuesday, Thursday and Saturday). Change on day shift, check placement and change as needed on nights. Review of Resident #97's wound note dated 03/13/25 documented right lower leg wound just below the knee which was nearly circumferential, worse on the medial and posterior aspect. Measurements were 3.9 centimeters (cm) by (x) 29 cm x 0.2 cm. The ulcer bed was documented as 60 percent (%) red/purple and blistered in areas, 40 % brown/yellow necrotic tissue and moderate amount of serosanguineous drainage. Review of the wound note revealed the wound was not classified as to the type of wound (i.e. pressure ulcer or non-pressure ulcer) and there was no staging of the wound if the wound was a pressure ulcer. Interview on 03/19/25 at 10:41 A.M. with Registered Nurse (RN) #316 revealed she rounds with the Wound Care Nurse Practitioner (WCNP) #328. RN #316 stated Resident #97's new right leg wound had been labeled as a venous ulcer, but she was unable to provide an explanation. RN #316 stated she would call WCNP #328 for clarification. A second interview on 03/19/25 at 11:12 A.M. revealed WCNP #328 had stated she was waiting until her weekly visit (next on 03/20/25) to determine the type of wound. Observation on 03/20/25 at 7:43 A.M. of the dressing change for Resident #97 with WCNP #328 revealed the wraps to her bilateral legs were started at her ankles and ended below her knees. WCNP #328 stated to Resident #97 they did not wrap your feet this time. The dressing to the right leg was removed and revealed a linear, wound which measured 0.4 cm x 4.4 cm x 0 cm. Interview on 03/20/25 at 10:10 A.M. with WCNP #328 revealed during her last visit to the facility she had been made aware by staff the right dressing for Resident #97 had rolled down and caused fluid filled blisters to form, causing a deep tissue injury. The treatment was the same as the other venous ulcers of applying Vaseline, Adaptic with Medihoney, covered with ABD pad, wrap with 2-flex. WCNP #328 mentioned the area had much improved. WCNP #329 stated education had been provided to the facility staff on the proper dressing technique and verified her feet had not been wrapped as educated. WCNP #328 confirmed Resident #97's right lower leg wound was a pressure ulcer and should have been staged. Interview on 03/20/25 at 11:17 A.M. with RN #316 acknowledged staff had been educated to wrap the bilateral legs of Resident #97 and was unsure why the treatment was not completed as instructed. Review of the facility policy Prevention, Detection and Treatment of Pressure Ulcers revised 09/14/25 revealed the assessment of the pressure ulcer would include the type of ulcer (pressure versus non pressure) and the ulcer stage.

Based on record review, observation and staff interviews, the facility failed to provide a thorough assessment following a skin tear. This affected one (#94) of three residents reviewed for wound care. The facility census was 43. Findings include: Review of medical record for Resident #94 revealed admitted [DATE]. The resident was admitted with diagnoses including stroke, hemiplegia affecting the left non-dominant hand, chronic obstructive pulmonary disease (COPD), and nausea. The resident remained at the facility. The admission Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of a 12, indicating intact cognition. She required substantial assistance with meals, was dependent for toileting hygiene, bed mobility and transfers. Review of Resident #94's physician orders revealed on order for four percent (%) Lidocaine (pain) patch apply to the area of pain. On for 12 hours and off for 12 hours with a start date of 03/04/25. Review of Resident #94's medical record revealed the Lidocaine patch was to be applied at 5:00 A.M. and removed at 5:00 P.M. Review of the progress note dated 03/15/25 revealed a Certified Nursing Assistant (CNA) had removed a Lidocaine (pain) patch off of Resident #94's neck which caused a small skin tear. Review of the electronic charting did not provide documentation a skin assessment had been completed on 03/15/24 for Resident #94's skin tear. Review of the progress notes did not reveal the physician or family notification of a skin tear. No treatment interventions had been entered for a skin tear. Interview with observation on 03/19/25 at 10:10 A.M. with Registered Nurse (RN) #275 revealed she had not been notified of a skin tear on the neck of Resident #94. RN #275 proceeded to remove the Lidocaine (pain) patch from the back of the neck of Resident #94 which revealed a small, scabbed area. The area measured approximately one centimeter (cm) by (x) one cm. Phone interview on 03/19/25 at 1:43 P.M. with Licensed Practical Nurse (LPN) #210 revealed on 03/15/25 he had been informed by CNA #292 during evening care he had removed Resident #94's lidocaine patch and inadvertently caused a skin tear. LPN #210 stated he assessed the area and noted a small skin tear. LPN #210 decided to leave the area open to air. LPN #210 verified he did not fill out a skin assessment, notify the family or physician but simply passed it along in report. Phone interview on 03/20/25 at 3:17 P.M. with CNA #292 revealed on 03/15/25, he was getting ready to get Resident #94 washed up for the night when he observed she still had a Lidocaine patch on her neck. CNA #292 shared sometimes the patches were falling off and he was able to easily remove them. CNA #292 stated that the patch that evening had a lot of adhesive on it. CNA #292 stated when he pealed the Lidocaine patch off, a piece of Resident #94's skin came off with it. Interview on 03/20/25 at 6:59 A.M. with LPN Supervisor #234 revealed she was made aware when she came into work on 03/15/25 by LPN #210 about a skin tear on the neck of Resident #94 which had been caused by CNA #292 removing her Lidocaine patch. LPN Supervisor #234 stated she did not assess the area. LPN Supervisor #234 verified CNA's cannot remove Lidocaine patches. LPN Supervisor #234 shared she did not address the incident with CNA #292 nor did she report the incident to management because LPN #210 had informed her he spoke to CNA #292 and informed him he could not remove the patches. LPN Supervisor #234 confirmed Resident #94's Lidocaine patch was to be on at 5:00 A.M. and off at 5:00 P.M. and it had not been removed as scheduled on 03/15/25.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to ensure a resident's fingernails were trimmed and without debris. This affected one (#20) out of two residents reviewed for activities of daily living (ADL's). The facility census was 43. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with medical diagnoses of Alzheimer's disease, dementia with agitation, moderate protein calorie malnutrition, depression, hypertensive heart disease with heart failure. Review of the medical record for Resident #20 revealed a quarterly Minimum Data Set (MDS) assessment, dated 12/31/24, which indicated Resident #20 had severely impaired cognition and was dependent upon staff for all ADL's. The MDS indicated Resident #20 received Hospice services. Review of the medical record for Resident #20 revealed an ADL care plan which stated Resident #20 had limited ability to complete ADL's due to impaired cognition related to the history of cerebrovascular accident and Alzheimer's disease. The ADL care plan stated Resident #20 was dependent upon staff for all ADL's. Observation on 03/17/25 at 11:24 A.M. revealed Resident #20 to be sitting in specialized wheelchair in the common area. Resident #20's fingernails were observed to be long with debris noted under the fingernails. Observation on 03/18/25 at 8:35 A.M. revealed Resident #20 being fed breakfast by facility staff. Resident #20's fingernails were observed to be long with debris noted under the fingernails. Observation on 03/19/25 at 8:24 A.M. revealed Resident #20 being fed breakfast by facility staff. Resident #20's fingernails were observed to be long with debris noted under fingernails. Interview on 03/18/25 at 8:37 A.M. with Licensed Practical Nurse (LPN) #246 confirmed Resident #20's fingernails were long with debris noted underneath fingernails. LPN #246 stated Resident #20 received bed baths from Hospice provider and the Hospice provider was supposed to trim Resident #20's fingernails. Interview on 03/19/25 at 8:26 A.M. with Certified Nursing Assistant (CNA) #236 confirmed Resident #20's fingernails were long with debris underneath the fingernails. CNA #236 stated Resident #20 received bed bathes from Hospice provider that the Hospice aide was supposed to trim Resident #20's fingernails. Review of the facility policy titled, Activities of Daily Living, effective 01/01/25 stated the facility staff are to assist each resident to the extent necessary for completion of ADL's on a daily basis and as needed.

Based on medical record review and staff interviews, the facility failed to ensure a transdermal patch was removed by a qualified staff member and as physician ordered. This affected one (#94) of 12 residents reviewed for medication administration. The facility census was 43. Findings include: Review of medical record for Resident #94 revealed admitted [DATE]. The resident was admitted with diagnoses including stroke, hemiplegia affecting the left non-dominant hand, Chronic Obstructive Pulmonary Disease (COPD), and nausea. The resident remained at the facility. The admission Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 12 indicating intact cognition. She required substantial assistance with meals, dependent for toileting hygiene, bed mobility and transfers. Review of Resident #94's physician orders revealed on order for four percent (%) Lidocaine (pain) patch apply to the area of pain. On for 12 hours and off for 12 hours with a start date of 03/04/25. Review of Resident #94's medical record revealed the Lidocaine patch was to be applied at 5:00 A.M. and removed at 5:00 P.M. Review of the progress note dated 03/15/25 revealed a Certified Nursing Assistant (CNA) had removed a Lidocaine (pain) patch off of Resident #94's neck which caused a small skin tear. Phone interview on 03/19/25 at 1:43 P.M. with Licensed Practical Nurse (LPN) #210 revealed on 03/15/25 he had been informed by the CNA #292 during evening care he had removed the lidocaine patch and inadvertently caused a skin tear. LPN #210 confirmed CNA #292 is not trained in medication administration including removing transdermal patches. Phone interview on 03/20/25 at 3:17 P.M. with CNA #292 revealed on 03/15/25, he was getting ready to get Resident #94 washed up for the night when he observed she still had a Lidocaine patch on her neck. CNA #292 shared sometimes the patches were falling off and he was able to easily remove them. CNA #292 stated that the patch that evening had a lot of adhesive on it. CNA #292 stated when he pealed the Lidocaine patch off, a piece of Resident #94's skin came off with it. CNA #292 confirmed he is not trained in medication administration including removing transdermal patches. Interview on 03/20/25 at 6:59 A.M. with LPN Supervisor #234 revealed she was made aware when she came into work on 03/15/25 by LPN #210 about a skin tear on the neck of Resident #94 which had been caused by CNA #292 removing her Lidocaine patch. LPN Supervisor #234 stated she did not assess the area. LPN Supervisor #234 verified CNA's cannot remove Lidocaine patches. LPN Supervisor #234 shared she did not address the incident with CNA #292 nor did she report the incident to management because LPN #210 had informed her he spoke to CNA #292 and informed him he could not remove the patches. LPN Supervisor #234 confirmed Resident #94's Lidocaine patch was to be on at 5:00 A.M. and off at 5:00 P.M. and it had not been removed as scheduled on 03/15/25.

Based on medical record review, observations, staff and resident interviews, and policy review, the facility failed to ensure food was served at an appetizing temperature. This affected one (#97) out of 12 residents review for food concerns. The facility census in the facility was 43. Findings include: Review of medical record for Resident # 97 revealed admitted [DATE] with medical diagnoses of lymphedema, hypertension, atherosclerotic heart disease, and moderate protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #97 had a Brief Interview Mental Status (BIMS) score of 13 which indicated Resident #97 was cognitively intact. Review of the MDS revealed Resident #97 required set up for meals, was dependent upon staff for toileting hygiene, and required substantial assistance for bed mobility and transfers. Observation on 03/18/25 at 11:56 A.M. revealed [NAME] #239 obtained temperature of food in the steam table on the Rehab Hall. The temperature of the chicken breast was 126 degrees Fahrenheit (F), fish nuggets were 116 degrees F, italian wedding soup with meatballs was 140 degrees F, and zucchini chips were 120 degrees F. Further observation of [NAME] #239 retemped food on test tray and obtained same temperatures. Observation on 03/18/25 at 12:00 P.M. revealed a test tray with fish nuggets, a chicken breast, zucchini chips, and a bowl of Italian wedding soap with meatballs. The test tray looked appealing, and the food had a good flavor. However, the observation revealed the fish nuggets were cold to taste but the soup, chicken breasts, and zucchini chip was slightly warmer to taste. [NAME] #239 confirmed food items should be held/served at or above 135 degrees F to ensure that it is at the appropriate temperature. Interview on 02/17/25 at 10:05 A.M. with Resident #97 regarding food at the facility revealed she had a concern it was not always served hot. Review of undated facility policy titled, Food Temperatures reveals all hot food items must be served at a temperature of at least 135 degrees F.

Based on medical record review, observations, staff, resident and resident representative interviews, the facility failed to ensure residents were served diets as physician ordered. This affected one (#97) of two residents reviewed for dietary orders. The facility census was 43. Findings include: Review of medical record for Resident #97 revealed admitted [DATE]. The resident was admitted with diagnoses including lymphedema, hypertension, atherosclerotic heart disease, moderate protein calorie malnutrition. The resident remained at the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 13 indicating intact cognition. She required set up for meals, was dependent for toileting hygiene, and required substantial assistance for bed mobility and transfers. A care plan for dysphasia revealed she required and altered diet texture. Interventions revealed she required a mechanically altered diet, thin liquids with extra gravy of condiments. Review of the 03/09/25 progress note revealed Resident #97 had a choking episode during breakfast. She was documented to have been sitting in the recliner, coughing but had stated the item had cleared. Review of the physician orders revealed an order for a mechanical soft foods with extra gravy of condiments on meats and thin liquids with a start date of 03/11/25. Interview on 3/18/26 at 12:33 P.M. with Resident #97's spouse revealed a concern Resident #97 had a hard time eating her lunch, he shared the speech therapist told him she needed her meat ground up. He stated he had told them in the hospital she was having a hard time swallowing and they put it of onto the facility. Observations revealed an uneatened regular texture grilled chicken breast on a bun on Resident #97's lunch plate. Observation and interview on 03/18/25 at 5:52 P.M. directly following tray delivery revealed Resident #97's meal included chopped beef with gravy and mashed potatoes. Resident #97 stated she did not have a concern with this meal. Regarding her lunch she stated the chicken was good, but she was unable to eat it because it had not been cut up like this meal. Observation and interview on 03/19/25 at 8:28 A.M. with Dietary Staff #226 revealed the breakfast tray delivered to Resident #97 included one dark piece of toast, cereal a fried egg. Dietary Staff #226 stated the ticket on Resident #97's plate was for a regular diet. Dietary Staff #226 stated she had been unaware Resident #97 was on a mechanically altered diet. A second interview and observation on 03/19/25 at 8:33 A.M. in the kitchenette revealed a piece of paper taped to the wall and labeled Guest- Diets-Supplement revealed Resident #97 name listed and beside it was mechanically altered, with extra gravy or condiments.

Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure bed hold notices were provided in writing to residents and their representatives when residents were transferred to the hospital. This affected two residents (#53 and #61) of two reviewed for hospitalization . The facility census was 81. Findings Include: 1. Review of Resident #53's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #53's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #53 was cognitively intact. Resident #53 required extensive assistance with bed mobility, dressing and personal hygiene. Resident #53 was totally dependent on staff for transfers and toilet use. Review of the facility's Hospital Transfer Log revealed Resident #53 was transferred to the hospital on 05/28/22. Review of Resident #53's Census information revealed Resident #53 was transferred to the hospital on 05/28/22 and returned to the facility on [DATE]. Review of Resident #53's progress notes revealed on 05/28/22 Resident #53 was transferred to the hospital for evaluation and treatment. On 05/28/22 at 9:24 P.M. it was noted Resident #53 was admitted to the hospital. On 05/30/22 it was noted Resident #53 returned to the facility from the hospital. Review of Resident #53's Written Transfer Notification dated 05/28/22, revealed Resident #53 nor her representative were notified of Resident #53's transfer to the hospital. There was no evidence a bed hold notification was completed. Interview on 06/12/22 at 2:02 P.M. with Resident #53 revealed she was transferred to the hospital for blood sugar issues. Resident #53 reported she was not provided a bed hold notice. Interview on 06/14/22 at 10:15 A.M. with the Administrator verified neither Resident #53 nor her representative were provided a notification of bed hold with the number of bed hold days remaining and the cost per day. Review of the facility policy titled, Discharge/Transfer of the Resident, revised 06/01/20 revealed at the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specified the duration of the bed hold. 2. Review of Resident #61's medical record revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . coli] as the cause of diseases classified elsewhere, extended spectrum beta lactamase (ESBL) resistance, difficulty walking, weakness, and neuromuscular dysfunction of bladder. Review of the Minimal Data Set (MDS) dated [DATE] revealed Resident #61 had mild cognitive impairment. His functional status is listed as extensive one to two person assist for all activities of daily living. The MDS also revealed Resident #61 has an indwelling catheter for his bladder and is always incontinent of bowel. The MDS also listed the Resident has not having skin impairment. Review of the progress note dated 05/29/22 at 10:00 A.M. revealed the resident sitting up in bed. Dark circles noted, diaphoretic though common. Skin pale pink/afebrile. Breath sounds easy/quiet on room air and saturations are within normal limits. Occasional congested cough/nonproductive. Lungs with rhonchi bilaterally noting inspiration/expiration on room air. Urine mostly clear yellow. Antibiotic complete for last [CONDITION(S)] with ESBL/E.coli. Will notify physician. Physician order dated 05/29/22 revealed 10:49 AM revealed a new order to send to emergency room for evaluation/treatment. Review of the letter of transfer to the family dated 05/29/22 revealed the facility was not incompliance with this tag. The facility did not send a bed hold notice with number of days remaining and the reserve per day bed payment. Interview on 06/14/22 at 10:15 A.M. with the Administrator verified neither Resident #61 nor his representative were provided a notification of bed hold with the number of bed hold days remaining and the cost per day.

Based on observation, medical record review, resident interview, staff interview, and review of care card, the facility failed to ensure a resident identified with communication limitations, had devices and/or communication tools or techniques implemented to ensure effective resident to staff communication. Additionally, the facility failed to ensure a resident had access to her glasses. This affected two residents (#17 and #38) of three residents reviewed for communication devices. The census was 81. Findings include: 1. Review of Resident #17's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #17 was severely cognitively impaired. Resident #17 required extensive assistance with dressing, toilet use, and personal hygiene. Resident #17 was absent of spoken words and was sometimes able to make himself understood. Resident #17 was sometimes able to understand others. Resident #17 received suctioning and [CONDITION(S)] care and hospice care at the time of the review. Resident #17's speech therapy ended 11/23/21. Review of Resident #17's care plan revised 05/17/22 revealed supports and interventions for impaired gas exchange related to laryngeal cancer and [CONDITION(S)], self-care deficit, and difficulty making self understood related to [CONDITION(S)]/laryngectomy. Approaches for difficulty being understood included [CONDITION(S)] care as ordered, encourage speaking, finger plug with pressure over stoma to create voice as much as possible, allow Resident #17 time to speak avoid interrupting, encourage verbalization, observe for signs of non-verbal signs of distress, repeat what the resident said to validate the resident, speech therapy as ordered, and when Resident #17 became frustrated provide word/phrase and reassure. Review of Resident #17's Speech Therapy (ST) Discharge Summary dated 11/23/21 revealed Resident #17 had the goal to demonstrate functional ability to communicate in social settings given assistance from trained staff/caregivers. Resident #17 had reached a 70% present level on this goal at the time of discharge. Recommended interventions included continued functional communication skills. Resident #17 was discharged due to reaching maximum potential. Observation on 06/13/22 at 2:15 P.M. of Resident #17 found him on the secured unit moving his lips and hands attempting to communicate with State tested Nursing Assistant (STNA) #702. STNA #702 directed Resident #17 to the bathroom. Resident #17 complied with the direction but returned to STNA #702 and continued to try to mouth words and move his hands. STNA #702 walked away from Resident #17 when he was trying to communicate with her. Interview on 06/13/22 at 2:18 P.M. with STNA #702 revealed Resident #17 had a [CONDITION(S)] and was not able to speak any more. STNA #702 reported he was able to understand and was cooperative with care at times. STNA #702 stated Resident #17 had no communication board or anything she was aware of to assist him with making his needs known. STNA #702 stated she was not able to understand what Resident #17 was trying to communicate. Observation on 06/13/22 at 2:22 P.M. of Resident #17 found he re-approached STNA #702 and was trying to communicate by mouthing words and using his hands. STNA #702 turned away from Resident #17 and stated to him she was not able to understand anything he was trying to say to her. Resident #17 appeared frustrated and followed STNA #702 into another resident's room trying to communicate. STNA #702 directed Resident #17 out of the resident room and closed the door. Interview on 06/13/22 at 2:43 P.M. with Resident #17 revealed he was moving his lips and whispering words. Resident #17 was asked if he had a communication board or any type of communication tools. Resident #17 shook his head indicating no he didn't have any device available while he mouthed the word no. Resident #17 was asked if staff were able to understand what he needed or wanted and Resident #17 shook his head and mouthed the word no. Observation on 06/13/22 at 2:46 P.M. with Resident #17 found Resident #17 again trying to communicate with STNA #702. STNA #702 turned away from Resident #17 and Resident #17 was observed throwing his hands up in the air and walking away from STNA #702. Interview on 06/14/22 at 7:23 A.M. with Licensed Practical Nurse (LPN) #635 revealed she had known Resident #17 since his admission and she was able to understand his type of communication. LPN #635 reported staff needed to give Resident #17 direct eye contact, pay close attention to his body language, give him time to mouth what he was trying to say and he was able to make some of his needs known. LPN #635 verified Resident #17 had no communication device or tools for helping him communicate with staff who were not familiar with him. Interview on 06/14/22 at 3:17 P.M. with LPN #630 verified it was difficult to understand what Resident #17 was trying to say and he had no communication tools available. LPN #630 reported he was supposed to be encouraged to plug his [CONDITION(S)] with his finger so he could vocalize better but he would often refuse so she would ask him yes or no questions to determine what his needs were. LPN #630 reported Resident #17 was able to understand and would follow instructions. 2. Review of Resident #38's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident scored a three on the Brief Interview for Mental Status (BIMS), indicating she had severe cognitive impairment. The resident was assessed to have moderate vision impairment and wore glasses. Resident #38 required extensive assistance of two staff for all mobility activities of daily living. The resident was assessed to be independent with eating following set up. Review of the plan of care implemented on 06/03/20 revealed Resident #38 had [CONDITION(S)] with impaired vision. The resident was unable to read any size print but was able to recognize colors and a pen light. Interventions included to keep her glasses clean and her glasses in good repair. Observation on 06/12/22 at 11:48 A.M. revealed Resident #38 was in the dining room and was served lunch. Her lunch tray included a frozen magic cup (supplement) and a chicken strip. State tested Nursing Assistant (STNA) #688 removed the resident's silverware from the napkin and cut the chicken. Resident #38 ate her chicken with her fingers. She picked up her fork and the magic cup. Resident #38 had a difficult time finding the opening to the magic cup with her fork. After several attempts she found the opening to the cup and ate the magic cup with her fork. The resident did not have glasses on. Observation on 06/13/22 at 5:05 P.M. revealed Resident #38 was sitting in her wheelchair in the dining room crying stating, I can't see. The resident did not have glasses on. Observation on 06/15/22 at 8:45 A.M. revealed Resident #38 was in the dining room and she did not have glasses on. Interview on 06/15/22 at 8:45 A.M. Resident #38 reported she wore glasses and could see better with her glasses on. She stated her vision comes and goes at times. Resident #38 reported she would have liked to have her glasses on, but she did not know where they were. Interview on 6/15/22 at 8:50 A.M. STNA #697 stated she was caring for Resident #38. STNA #697 verified the resident used to wear glasses although she had not seen the resident wear them in awhile. STNA #697 was unsure if the resident's glasses were in the facility or if the resident's family took them home. STNA #697 verified the resident did not have glasses on during breakfast. Interview on 06/15/22 at 8:55 A.M. Licensed Practical Nurse (LPN) #625 stated Resident #38 wore glasses and was unsure of where the resident's glasses were located. Interview on 06/15/22 at 9:00 A.M. Registered Nurse (RN) #611 verified Resident #38 wore glasses and verified the resident was not wearing them. Observation during the interview, revealed Resident #38's glasses were located on top of the resident's nightstand. RN #611 reported night shift staff got the resident up and ready for the day and she would educate the staff. RN #611 cleaned the glasses lens and took them to the resident in the dining room. Resident #38 allowed RN #611 to apply the glasses to her face. Resident #38 responded by saying, Now I can see you. Interview on 06/15/22 at 9:05 A.M. with the Director of Nursing verified the plan of care stated Resident #38 had [CONDITION(S)] and the resident wore glasses. The DON reported STNAs use, Care Cards, to let them know the needs of each resident. Review of the current, Care Card, for Resident #38 stated the resident was to wear glasses daily.

Based on medical review, observations, resident interview, family interview, staff interview and review of the facility bowel protocol, the facility failed to ensure wound/skin dressings were properly applied for two (#8 and #25) of two residents reviewed for skin conditions requiring dressing changes. In addition, the facility failed to implement their bowel protocol after a resident had no bowel movement for over three days. This affected one resident (#429) of one reviewed for constipation. The facility census was 81. Findings include: 1. Medical record review for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a nine on the Brief Interview for Mental Status (BIMS), indicating she had moderate cognitive deficits. She required extensive assistance of two staff for transfers. She was non-ambulatory, had occasional incontinence of urine, and was always continent of bowel. She did not have skin breakdown. Review of the plan of care dated 04/01/22 revealed the resident was at risk for skin breakdown and currently had skin tears on her lower legs. Interventions included to provide treatments and provide treatments as ordered by the physician. Review of the June 2022 physician orders revealed an order to cleanse the skin tears on the left lower leg, apply xeroform (petroleum based for skin tears) dressing, cover with ABD (extra thick secondary protective dressing), and wrap with gauze daily. Observation on 06/14/22 at 8:50 A.M. revealed Resident #8 seated in a wheelchair in the dining room with a large amount of light red drainage on her left sock. Interview on 06/14/22 at 8:55 A.M. Licensed Practical Nurse (LPN) #635 stated Resident #8 had dressing changes completed in the evenings. LPN #635 verified she was unaware of the fact the resident had a large amount of what appeared to be moist light red drainage on her sock. LPN #625 stated she would change the dressing after she was done with medication administration. Observation on 06/14/22 at 10:30 A.M. revealed Resident 8 was in the beauty shop getting her hair done. There was still a large amount of light red drainage noted on her sock. Observation on 06/14/22 at 11:05 A.M. of wound care for Resident #8 revealed LPN #625 moistened several washcloths with water. LPN #625 donned gloves and removed the resident's white mid-calf sock. The sock had a large amount of light red drainage on it. There was no dressing observed on the resident's open wounds. The resident complaint the procedure was very painful. When asked where the old dressing was, LPN #625 reported the wound nurse saw the resident's that morning and had not changed the treatment to the open areas. The resident was observed to have [CONDITION(S)] in her left lower leg and foot. The leg appeared red. LPN #625 reported the resident's lower leg was more swollen than normal and was warm to the touch. LPN #625 reported the physician saw the resident on 06/13/22 and ordered an antibiotic, which would be started 06/14/22. LPN #625 continued providing wound care to Resident #8. LPN #625 cleansed a C-shaped skin tear, a triangular shaped open area, and an open area of the posterior portion of the leg. Xeroform dressing was applied and covered with an ABD (extra thick secondary dressing) and wrapped with gauze. LPN #625 applied clean socks to the resident. LPN #625 verified there were no dressings on open areas to the residents left lower leg since approximately 9:00 A.M. when she was seen by the wound nurse. Interview on 06/14/22 at 1:20 P.M. the Director of Nursing (DON) verified a dressing should always be applied to an open wound. It was not the facility's policy to leave a dressing off a wound for another nurse to address is later. The DON reported Advanced Practice RN #807 was a wound consultant who visited weekly. The DON was unaware Advanced Practice RN #807 was leaving wounds without a dressing until a staff nurse were available to apply the dressing. 2. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed Resident #25 had moderate cognitive impairment. Resident #25 required extensive assistance for activities of daily living (ADLs). The MDS also listed the resident as having a stage III pressure area. Resident #25 utilized an indwelling catheter and was frequently incontinent of bowel. Review of Resident #25's care plan dated 06/06/22 revealed the resident was at risk for pressure ulcers. Interventions included to provide wound treatments as ordered. Review of the physician order dated 06/11/22 revealed orders to cleanse coccyx wound with normal saline, apply zinc barrier to peri-wound, apply Medi honey and calcium alginate to wound bed, cover with 4 x 4 gauze and the ABD. Secure with paper tape, change every other day until 07/03/22 and as needed. Observation on 06/14/22 at 11:30 A.M. revealed Resident #25's wound dressing to the coccyx was not in place. Measurements of the wound were 4.5 centimeters (cm) by 1.2 cm by 0.2 cm. There was moderate serous drainage with 80 percent granulation tissue and 20 percent epithelial. Interview on 06/14/22 at 11:30 A.M. revealed Registered Nurse (RN) #200 was finishing up the dressing change for Resident #25 and verified there was no dressing applied to the residents coccyx wound. RN #200 verified Advanced Practice RN #807 saw Resident #25 between 8:30 A.M. and 11:30 A.M. and left the resident's wound exposed without a dressing. RN #200 was unaware the wound was left exposed and was unsure of the exact time the wound was left exposed. Interview on 06/14/22 at 1:20 P.M. the Director of Nursing (DON) verified a dressing should always be applied to an open wound. It was not the facility's policy to leave a dressing off a wound for another nurse to address is later. The DON reported Advanced Practice RN #807 was a wound consultant who visited weekly. The DON was unaware Advanced Practice RN #807 was leaving wounds without a dressing until a staff nurse were available to apply the dressing. The DON verified Resident #25 was incontinent of bowel and could have had a bowel movement while her wound was left exposed. 3. Review of Resident #429's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #429's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #429 was cognitively intact. Resident #429 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #429 displayed no behaviors during the review period. Resident #426 was always continent of bowel. Review of Resident #429's bowel movement tracking revealed Resident #429 went from 06/06/22 to 06/13/22 (six days) with no bowel movements. Review of Resident #429's physician orders for June 2022 revealed no standing orders to treat constipation. Orders to treat constipation had been discontinued: · [MEDICATION(S)] powder 17-gram dose once daily, ordered 05/23/22 and discontinued on 05/31/22. · Senna 8.6 milligrams (mg) two tablets one daily, ordered 05/31/22 and discontinued 06/03/22. · Senna 8.6 mg two tablets once daily, ordered 06/03/22 and discontinued on 06/12/22. · Dulcolax suppository 10 mg insert rectally, ordered, and discontinued 06/06/22. Further review of physician orders revealed no additional medications/interventions added from 06/06/22 to 06/12/22. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 06/12/22 at 11:58 A.M. with Resident #429 and her niece found Resident #429 to be somewhat confused. Resident #429 reported she had not pooped in over a week. Resident #429's niece verified Resident #429 had not had a bowel movement but reported it had been about five days and not a full week. Resident #429's niece reported it was still concerning Resident #429 had not had a bowel movement and it appeared the facility had not done anything about it. Interview on 06/15/22 at 9:08 A.M. with the Director of Nursing (DON) verified Resident #429 had no bowel movements between 06/06/22 and 06/13/22 and no additional interventions were added until 06/12/22. Review of the facility policy titled, Bowel Management Protocol, revised 10/10/20 revealed the facility was to monitor and identify constipation. An oral [MEDICATION(S)] was to be administered to every resident who had not had a bowel movement in three consecutive days. If the resident had not had results from the [MEDICATION(S)] administered earlier in the day the nurse was to administer a suppository after the last medication pass. If the resident still did not experienced results from the suppository administered in the evening, the resident would be given a [MEDICATION(S)] enema in the early morning by 6:00 A.M.

Based on medical record review, staff interview, and review of facility policy, the facility failed ensure an appropriate diagnosis was obtained to justify the use of an antipsychotic medication. This affected one resident (#6) of five residents reviewed for unnecessary medications. The facility census was 81. Findings include: Review of Resident #6's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, cognitive communication deficit, major depressive disorder, and cerebral atherosclerosis (hardening of the of the walls in the arteries of the brain). Review of Resident #6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating Resident #6 was rarely or never understood. A Staff Assessment for Mental Status was completed and revealed Resident #6 had short and long term memory problems and was severely cognitively impaired. Resident #6 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #6 displayed no behaviors during the review period. Review of Resident #6's care plan revised 05/23/22 revealed Resident #6 received antipsychotic medication. Review of Resident #6's physician orders revealed an order dated 03/29/22 and discontinued 04/12/22 for [MEDICATION(S)] concentrate (antipsychotic medication) 2 milligrams (mg)/ milliliters (ml) every six hours as needed (PRN) for restlessness agitation. An order dated 05/23/22 and discontinued 05/24/22 for [MEDICATION(S)] concentrate 2 mg/ml amount administered 1 ml twice a day. No diagnosis was documented to support the use of the antipsychotic medication. An order dated 05/24/22 for [MEDICATION(S)] concentrate 2 mg/ml amount administered 1 ml twice a day. No diagnosis was documented to support the use of the antipsychotic medication. An order dated 05/18/22 and discontinued 05/18/22 for [MEDICATION(S)] concentrate 2 mg/ml amount administered 1 ml every six hours PRN. No diagnosis was documented to support the use of the antipsychotic medication. Review of the corresponding Medication Administration Record (MAR) revealed the PRN anti-psychotic was administered on 05/18/22 for hallucinations and agitation as documented by the nurse who administered the medication. An order dated 05/18/22 and discontinued 05/31/22 for [MEDICATION(S)] concentrate 2 mg/ml amount administered 1 ml every six hours PRN. No diagnosis was documented to support the use of the antipsychotic medication. Review of the corresponding Medication Administration Record (MAR) revealed the PRN anti-psychotic was administered on 05/19/22, 05/20/22, 05/28/22, and 05/30/22 for restlessness and agitation as documented by the nurse who administered the medication. An order dated 06/06/22 and discontinued 06/14/22 for [MEDICATION(S)] concentrate 2 mg/ml amount administered 1 ml every six hours PRN. No diagnosis was documented to support the use of the anti-psychotic medication. Review of the corresponding Medication Administration Record (MAR) revealed the PRN anti-psychotic was administered on 06/06/22, 06/09/22, and 06/14/22 for restlessness, anxiety, agitation and combativeness as documented by the nurse who administered the medication. An order dated 06/14/22 at 4:11 P.M. and discontinued 06/20/22 for [MEDICATION(S)] concentrate 2 mg/ml amount administered 1 ml every six hours PRN. No diagnosis was documented to support the use of the anti-psychotic medication. Review of Resident #6's physician progress note dated 06/06/22 revealed Resident #6's PRN [MEDICATION(S)] ([MEDICATION(S)]) was restarted for episodic agitation and restlessness. Interview on 06/14/22 at 4:16 P.M. with the Director of Nursing (DON) revealed the physician reviewed Resident #6 on 06/06/22 and restarted [MEDICATION(S)] for episodic agitation and restlessness which contributed to a fall risk. The DON verified agitation and restlessness was not an approved diagnosis for the use of antipsychotic medication, [MEDICATION(S)]. The DON stated she would contact the physician. Review of Resident #6's physician progress notes revealed on 06/14/22 at 4:27 P.M. a diagnosis of dementia with [CONDITION(S)] was added for Resident #6. Review of the facility policy titled, [CONDITION(S)] Medications, revised 03/01/21 revealed a resident would only receive [CONDITION(S)] drugs PRN if that medication was necessary to treat a diagnosed specific condition that was documented in the clinical record.

Based on review of Advanced Beneficiary Notices (ABN) and staff interview, the facility failed to adequately document resident representatives wishes regarding the right to appeal. This affected two residents (#67 and #73) of three residents reviewed for ABN accuracy. The census was 81. Findings include: 1. Review of the Advanced Beneficiary Notice (ABN) issued to Resident #67, revealed a call was placed to the resident's representative on 04/25/22. A message was left stating the resident's skilled services would be ending on 04/26/22 and financial liability would begin on 04/26/22. It was documented Licensed Social Worker (LSW) #796 informed the resident's representative of the right to appeal the decision and information on how to appeal, however there was no documentation indicating if the resident's representative wanted to appeal or waive the right to an appeal. Resident #67 continued to reside in the facility. 2. Review of ABN issued to Resident #73, revealed a call was placed to the resident's representative on 01/05/22. A message was left stating the resident's skilled services would be ending on 01/07/22 and financial liability would begin on 01/08/22. It was documented LSW #796 informed the resident's representative of the right to appeal the decision and information on how to appeal, however there was no documentation indicating if the resident's representative wanted to appeal or waive the right to an appeal. Resident #73 continued to reside in the facility. Interview on 06/15/22 at 10:45 A.M. LSW #796 verified there was no documentation on the ABNs for Resident #67 or Resident #73 regarding the residents' representatives' decision to request or waive the right to an appeal. LSW #796 verified Resident #67 and Resident #73 remained in the facility.

Based on the unprecedented global Coronavirus (COVID-19) pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Nursing Home Guidance from the Centers for Disease Control (CDC), Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, review of the facility's Infection Control Special Precautions and Coronavirus (COVID-19) policies, review of the facility's COVID-19 Outbreak Timeline and COVID-19 cases, observations, medical record review, interviews with staff and the Medical Director, the facility failed to implement effective and recommended infection control practices to prevent the spread of the infectious disease and the implementation of appropriate quarantine procedures for residents exposed to COVID-19. With the spread of COVID-19 from the lack of quarantining residents, the likelihood exists for serious life-threatening harm or death related to the spread of the COVID-19 virus. This resulted in Immediate Jeopardy, when the facility failed to quarantine eight (#02, #23, #42, #47, #79, #81, #87, #93) residents who were exposed to their positive COVID-19 roommate and subsequently tested positive for COVID-19. Additionally, the facility staff failed to utilize Personal Protective Equipment (PPE) properly by not wearing the proper PPE for resident's status and performing hand hygiene after contact with a resident. Furthermore, the facility failed to further screen an employee, who had complained of not feeling well on arrival to work, and was allowed to continue to work in resident rooms. The facility failed to ensure residents were [MEDICATION NAME] social distancing and wearing masks when out in common areas of the facility. In addition, the facility failed to complete testing of non-direct care staff according to the outbreak procedures. This affected eight (#02, #23, #42, #47, #79, #81, #87, #93) residents who were negative and not placed in quarantine but then tested positive and placed an additional 46 (#01, #04, #10, #11, #12, #13, #14, #18, #20, #21, #25, #26, #27, #30, #32, #33, #37, #38, #40, #43, #48, #49, #50, #52, #53, #54, #56, #58, #59, #60, #63, #66, #68, #71, #72, #73, #74, #76, #77, #78, #83, #85, #88, #90, #91, #92) residents at risk for Immediate Jeopardy and potential serious life-threatening harm, negative health outcomes and/or death related to the spread of COVID-19 throughout the facility as the facility failed to operationalize their infection control policies and procedures. The total facility census was 92. On 12/15/20 at 4:27 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 11/26/20 when the facility failed to quarantine residents in accordance with the latest CDC guidelines dated 06/25/20, after receiving the results from the COVID-19 initial outbreak testing. Residents ' Polymerase Chain Reaction (PCR) test results started to arrive the morning of 11/27/20, after being tested on [DATE] and 11/24/20. Five confirmed residents who were positive were moved to the COVID-19 unit immediately. The facility conducted contact tracing based on the one positive test received on 11/24/20 and at that time, the facility decided to PCR test all the remaining residents in the Healthcare West unit on 11/30/20. There was a total of 31 positive residents at the end of the day on 12/03/20. All residents with positive cases were placed on droplet precautions;however, roommates of those who tested positive, and had a negative PCR result, were moved to the Rehabilitation unit and not placed in quarantine after known exposure. Eight of those residents subsequently tested positive for COVID-19. In addition, the facility was notified of staff not following droplet precautions and hand hygiene policies in the COVID-19 unit and there was an employee that continued to work in resident's rooms while not feeling well and was later determined to be positive after PCR testing was conducted that day. Observations revealed staff not correctly utilizing PPE, preforming hand hygiene, and residents not [MEDICATION NAME] social distance and wearing masks when in common areas of the facility. Furthermore, the facility was notified they were not properly testing all staff as per the positivity rate and outbreak in their community per the Center for Medicare and Medicaid Services (CMS) regulations. Testing was to be done twice a week for all staff and the facility was testing direct care staff twice a week, and non-direct care staff once every two weeks. The Immediate Jeopardy was removed on 12/17/20 when the facility completed the following corrective actions: · On 11/27/20, Housekeeper #300 reported to work and completed the screening process indicating that she did not have symptoms of COVID-19 or a fever greater than 100.4 degrees Fahrenheit (F). This employee worked cleaning resident rooms while not feeling well. The employee was PCR tested and sent home. The PCR results were positive. The employee did not return to work until after the appropriate isolation. · On 12/09/20 at 2:30 P.M., the DON or designated department head began re-education for all staff, on infection control practice of utilizing the proper PPE, preforming hand hygiene, residents social distancing, encourage residents to wear a mask and employee reporting of illness and was completed on 12/16/20. · On 12/11/20, the facility began the new testing protocol of all staff (direct and non-direct care staff) being tested twice a week. The Administrator or designee will monitor this testing requirement with audits, to ensure that all working staff are being tested twice per week. The audit will be performed twice per week for one month. The audit will begin on 12/17/20. The audits will be evaluated to determine compliance. If compliance is determined to be satisfactory, the audits will be one time per week for four weeks. This will confirm that the facility is preventing a serious outcome from occurring or re-occurring. All audits will be reviewed at the quarterly Quality Improvement Meeting for two meetings for compliance and any further recommendations. · On 12/15/20, the Droplet Policy was revised and implemented on 12/16/20 to address the negative residents who have been exposed by a positive resident and room placement. · On 12/16/20 at 3:00 P.M., all facility staff were in-serviced by Staff Development #200 and the Registered Nurse Shift Supervisor #205 on the new Droplet Policy. The in-servicing was completed by 6:00 P.M. · On 12/17/20, an audit to determine that staff are following the Infection Control Policies with special consideration to handwashing, PPE usage, residents social distancing, encouraged to wear mask and reporting illness. It will be completed by SD #200 or designee, daily for one week and will be conducted at random times. The results will be evaluated for compliance and if compliance is achieved the audit will then be three times per week for two weeks. The audits will be evaluated for compliance and if compliance is confirmed the audit will be one time per week for five weeks. This will confirm that the facility is preventing a serious outcome from occurring or re-occurring. All audits will be reviewed at the quarterly Quality Improvement Meeting for two meetings for compliance and any further recommendations. · On 12/17/20 at 10:00 A.M., the DON completed an audit of all residents to confirm that all residents who have had potential exposure to COVID-19 are currently in isolation as outlined in the revised policy. An audit will be completed by the DON or designee after each confirmed COVID-19 positive resident result to ensure that compliance is maintained. This audit will be completed by the DON or designee. This will confirm that the facility is preventing a serious outcome from occurring or re-occurring. All audits will be reviewed at the quarterly Quality Improvement Meeting for two quarterly meetings to ensure compliance and for any further recommendations. Although the Immediate Jeopardy was removed on 12/17/20, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20 revealed the Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 .We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii)). Review of the facility's undated timeline titled Timeline for Ohio Living(NAME)Love, revealed on 11/21/20 late evening, the facility rapid tested Resident #20 for COVID-19 and she was positive and was then placed into quarantine. The facility followed up with a PCR test on 11/22/20 and was notified on 11/24/20 that Resident #20 was positive for COVID-19. Resident #20 was moved to the COVID-19 unit on 11/24/20. The roommate (Resident #93) had tested negative for her COVID-19 test, and then was moved on 11/26/20, to the Rehabilitation unit and not placed into quarantine after having been exposed. On 11/27/20, a rapid COVID-19 test was performed on Resident #93 and she was positive and then moved to the COVID-19 unit. On 11/23/20, the facility's regular testing date for residents was completed and three more residents (Resident #71, Resident #73, and Resident #84) tested positive for COVID-19 and were moved to the COVID-19 unit. All three of these residents had resided in the same hall as Resident #20. On 11/24/20, Resident #58 was POC tested and placed in quarantine. On 11/29/20, the facility was notified of the positive COVID-19 results for Resident #58 and the resident was moved to the COVID-19 unit. On 11/27/20, Culinary Services #301 tested positive and worked in the Rehabilitation unit serving meals. The facility was testing non-direct care staff once every two weeks, not twice a week as their county positivity rate and community spread was determined. On 11/27/20, Housekeeper #300 reported to work symptomatic and worked in the Healthcare West unit and cleaned two rooms of Resident #03, Resident #12, and Resident #28, prior to reporting to her supervisor she needed to go home ill. Housekeeper #300 then began to feel worse and told her supervisor she needed to go home. She was then PCR tested and sent home. The results of the test came back positive for COVID-19. On 11/30/20, the facility noticed the number of positive cases on that end of the Healthcare West unit of the building and felt the need to test all remaining residents. The residents on this hall were PCR tested and 22 residents tested positive for COVID-19 (#02, #11, #12, #13, #14, #18, #21, #23, #27, #33, #38, #52, #54, #56, #63, #69, #72, #75, #76, #77, #83 and #91). Those 22 residents were put into the COVID-19 unit that was expanded to accommodate the newly positive COVID-19 residents. On 12/02/20, Resident #04 was admitted to the Rehabilitation unit from Independent Living and was tested on [DATE]. On 12/04/20, the facility was notified of the positive COVID-19 results and was then moved to the COVID-19 unit. On 12/03/20, the facility received PCR results and on the Healthcare East unit there were no positive results. All residents that had tested negative on the Healthcare West non-COVID unit, were moved to the Rehabilitation unit and they were all in private rooms, but not quarantined. All of Healthcare West unit was turned into a COVID-19 unit. On 12/03/20, Housekeeper #302 tested positive for COVID-19, which is the same employee that Housekeeper #300 had reported her symptoms of not feeling well on 11/27/20. Housekeeper #302 was last PCR tested on [DATE]. On 12/03/20, residents that were POC tested and tested positive for COVID-19 included Residents #01, #04, #42, #60 and #85. On 12/07/20, residents that had previously been negative for COVID-19 and moved to the Rehabilitation unit from the Healthcare West unit were PCR tested and were positive for COVID-19 and were then moved back to the COVID-19 unit. These residents included Residents #31 and #74. Residents that resided in the East Healthcare unit that tested positive included Residents #25, #26, #30, #32, #37, #40, #43, #48, #49, #50, #78, #79, #81 and #88. The facility then created a COVID-19 unit in the East Healthcare wing. On 12/08/20, Laundry Staff #303 and Laundry Staff #304 tested positive for COVID-19 and were last COVID-19 tested with a PCR test on 11/27/20. Review of the medical record for Resident #02 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #02 had roomed with Resident #88, who tested positive on 12/02/20. Resident #02 was not placed in quarantine. Review of the medical record for Resident #23 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #23 had roomed with Resident #44, who tested positive on 11/27/20. Resident #23 was not placed in quarantine and tested positive on 11/30/20. Review of the medical record for Resident #42 revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Resident #42 had roomed with Resident #52, who tested positive on 11/30/20. Resident #42 was not placed in quarantine and tested positive on 12/03/20. Review of the medical record for Resident #87 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #87 resided in the same room with Resident #47. Review of the medical record for Resident #47 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Residents #87 and #47 resided together on the West Unit section that was not designated as the COVID-19 unit. On 11/26/20, all residents on the West unit were rapid tested . Both Resident #87 and #47 tested negative. The residents were moved off the hall to the Rehabilitation unit in separate rooms to allow the expansion of the COVID-19 unit on the West unit. On 11/27/20, both residents were tested again through routine testing. The results came back on 12/02/20 and the two residents tested positive and were moved back to the expanded COVID-19 unit together in a room. Review of the medical record for Resident #79 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #79 had roomed with Resident #14, who tested positive on 11/30/20. Resident #79 was not placed in quarantine and tested positive on 12/07/20. Review of the medical record for Resident #81 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #81 had roomed with Resident #75, who tested positive on 11/30/20. Resident #81 was not placed in quarantine and tested positive on 12/07/20. Review of the medical record for Resident #93 revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Resident #93 had roomed with Resident #20, who tested positive on 11/24/20. Resident #93 was not placed in quarantine and tested positive on 11/27/20. Review of the facility's list of positive COVID-19 cases revealed as of 12/08/20, a total of 54 residents had tested positive for COVID-19 since the last outbreak on 11/02/20, while at the facility. A total of four residents (#47, #58, #74, and #83) have been hospitalized while positive for COVID-19. Additionally, a total of five residents (#01, #47, #58, #92 and #93) have passed away and were positive for COVID-19 at the time of death. Observation on 12/09/20 at 12:06 P.M., revealed State tested Nurse Aide (STNA) #222 entered Resident #84's room, that had droplet precautions and did not put on gloves before she entered the room. STNA #222 went to Resident #84 and repositioned her blanket on her lap and put her hand on Resident #84's right shoulder. STNA #222 walked out of the room without performing hand hygiene and then adjusted her N95 mask and glasses while she was being interviewed. Interview at this time, revealed STNA #222 verified she did not put gloves on and did not perform hand hygiene prior to leaving the room that had droplet precautions. Observation on 12/09/20 at 12:18 P.M., revealed STNA #220 in the Healthcare East dining area with an N95 mask on with the lower strap hanging below her chin and not behind her head. Interview at this time with STNA #220 verified she was not wearing the N95 mask correctly and the lower strap should be behind her head for a proper seal. Observation on 12/09/20 at 12:18 P.M., revealed STNA #223 was in Resident #74's room and had no gloves on, in a droplet precaution room for a COVID-19 positive resident. STNA #223 was observed moving a mechanical lift for Resident #74 and touching a remote control to change the batteries. STNA #223 also threw away used cups in the room. STNA #223 was observed not to perform hand hygiene before leaving the room. Interview at this time, with STNA #223 verified she was not wearing gloves and did not perform hand hygiene. Observation on 12/09/20 at 12:19 P.M., revealed Residents #02, #10, #53, #59, #66, and #90 were sitting in recliners next to each other in the lounge area of Healthcare East without masks on and not social distanced of six feet or more. Interview at this time, STNA #221 stated they were never told the residents needed to wear a mask and didn't think of the six feet social distancing. Interview on 12/10/20 at 3:10 P.M., with the DON revealed she was the facility's infection control preventionist. She stated all residents in the facility were tested every Monday by the DON with POC testing. Testing for staff was completed twice a week for direct care staff, which included nurses, STNA's, social worker, activity staff and therapy staff. Every other Friday, staff were tested with PCR testing that was state supported and were POC tested in between that time. The non-direct care staff, such as housekeeping, laundry, culinary services, and maintenance were tested on ce every other week on Fridays. The administrative personnel were tested on ce per week on Fridays. The DON stated all employees are screened prior to their shift and all residents are screened daily. If at any time they have answered yes to their screening questions, they are POC tested . The DON also verified the facility did not quarantine the eight residents (#02, #23, #42, #47, #79, #81, #87, #93) who were exposed to their positive COVID-19 roommate. Interview on 12/14/20 at 11:30 A.M., with Director of Culinary Services (DCS) #201 revealed she is COVID-19 tested on ce every two weeks as is her staff and if one of her staff came to her to report illness, she would have them take their temperature and report it to the DON so the staff could be COVID-19 tested and then sent home. Interview on 12/14/20 at 12:41 P.M., with Housekeeper #300 revealed on Thanksgiving night (11/26/20) she started to not feel good and came to work the next day on 11/27/20. Housekeeper #300 stated she had told the acting supervisor, Housekeeper #302, that she didn't feel good and had went on to perform her duties on the Healthcare West unit. Housekeeping #302 stated she cleaned two rooms and began to feel worse. She then reported to Housekeeper #302 and waited to get tested . She stated she went home by 8:00 A.M. Housekeeper #300 verified she gets tested every other Friday. She stated at the time she tested positive for COVID-19, not all of Healthcare West was COVID-19 positive. Prior to going into the COVID-19 unit she would put on her PPE. Housekeeper #300 stated she would clean the non-COVID-19 rooms first and clean the COVID-19 rooms last. Housekeeper #300 verified she did not answer yes to any of her screening questions that morning, after admitting to not feeling well and preceded to enter two non-COVID-19 rooms to clean. Interview with Housekeeper #302 on 12/16/20 at 10:17 A.M., revealed she was the acting supervisor on 11/27/20 and Housekeeper #300 had told her in passing that she wasn't feeling the greatest. She said Housekeeper #300 informed her she would take her COVID-19 test later as scheduled, depending on how she feels throughout the day. Housekeeper #302 verified she did not ask Housekeeper #300 exactly what her symptoms were, consult with a nurse or look at her screening log. Interview with Medical Director #400 on 12/16/20 at 11:41 A.M., revealed she was told the facility was testing staff twice a week. She was not aware they were testing only direct care staff twice a week and housekeeping, dietary, laundry and maintenance once every other week and administrative staff were being tested on ce every week. Medical Director #400 verified she would have told them they need to be tested more frequently at least weekly or call the local health department (LHD) to see what the requirement was. Medical Director #400 also verified she was not aware that the facility was not placing residents in quarantine after exposure to their positive COVID-19 roommates. In her opinion those residents exposed, should have been placed in quarantine with droplet precautions for 14 days from the date of exposure. Review of the policy titled Infection Control Special Precautions, revised 09/01/20, revealed the purpose was to follow the CDC guidelines regarding the types of residents requiring Special Precautions. The procedure for droplet precautions included: to place resident in a private room, or if unavailable, place in a room with a resident who has active infection (Cohorting), or if unavailable do not place in room with high risk residents; maintain spatial separation of at least three feet between the infected resident and other residents and visitors,; special air handling and ventilation are not necessary; room door may remain open; wear a mask when working within 3 feet of the resident and limit movement and transport of the resident from the room to essential purposes only. Review of the policy titled Coronavirus (COVID-19), revised 10/16/20, revealed residents that are physically and mentally capable of wearing a mask are encouraged to wear one when they are outside of their room. Contact and droplet precautions must be observed. All persons entering the patient room who has confirmed, or highly suspected COVID-19 should wear gloves, gown, goggles or face shield and an FDA approved N95 or KN95 respiratory facemask. Hands must be washed with soap and water for at least 20 seconds or a 60% and above alcohol-based hand sanitizer may be used between washing with soap and water, upon entering the patient room prior to donning gloves and when gloves are removed. If any staff members develop signs/symptoms of a respiratory infection while at work, that individual should take the following steps: Immediately discontinue working Put on a facemask Self-isolate at home Inform the facility's Infection Preventionist Provide information regarding any individuals, equipment and locations that the staff member had contact with, over the last 48 hours. Contact the local health department and follow its recommendations for next steps. Personnel will be screened each time they enter the nursing home and assisted living facility for symptoms of cough, shortness of Breath and body temperature of 100.4 and higher. Review of the CMS, COVID-19 Long-Term Care Facility Guidance, dated 04/02/20 revealed facilities should refer to CDC's guidance for long-term care facilities. Review of the CMS QSO memo 20-38 NH dated 08/20/20 revealed: Testing of Staff and Residents in Response to an Outbreak An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [MEDICAL CONDITION] transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. See CDC guidance Testing Guidelines for Nursing Homes section Non-diagnostic testing of asymptomatic residents without known or suspected exposure to an individual infected with [DIAGNOSES REDACTED]-CoV-2. For individuals who test positive for COVID-19, repeat testing is not recommended. A symptom-based strategy is intended to replace the need for repeated testing. Facilities should follow the CDC guidance Test-Based Strategy for Discontinuing Transmission-Based Precautions for residents and Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV2 Infection. Routine Testing of Staff Routine testing should be based on the extent of [MEDICAL CONDITION] in the community; therefore, facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. Reports of COVID-19 county-level positivity rates will be available on the following website by August 28, 2020 (see section titled, COVID-19 Testing): https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg Review of the CDC website COVID-19 guidelines titled, Use of Testing to Inform the Response to COVID-19 in Nursing Homes (https://www.cdc.gov/coronavirus/2019ncov/hcp/nursing-homes-responding.html), dated 04/30/20, revealed if testing capacity allows use of facility wide testing following identification of newly identified [DIAGNOSES REDACTED]-CoV-2 infected residents or healthcare personnel could be particularly important. Facility wide testing can help identify a symptomatic or pre-symptomatic resident with COVID-19 to guide movement into COVID-19 designated spaces. Review of the CDC website COVID-19 guidelines titled, Infection Control for Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, dated 06/25/20, revealed the facility should have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive) and have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them). Review of the CDC website COVID-19 guidelinestitled,Responding to COVID-19, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html,dated 04/30/20,revealed responding to residents newly infected with [DIAGNOSES REDACTED]-CoV-2includesensuringthe residentwasisolated and cared for using all recommended COVID-19 PPE.The resident should be placedin a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing.Cohortingresidents on the same unit based on symptoms alone could result in inadvertent mixing ofinfected and non-infected residents (e.g., residents who have fever, forexample, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit).IfCohortingsymptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. Review of the CDC website COVID-19 guidelines titled Preparing for COVID-19 in Nursing Homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html), dated 06/25/20, revealed the recommendations in this guideline supplement the guideline titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID19 Pandemic. These guidelines indicate under the heading Core Practices the facility should remind Health Care Providers (HCP) not to report to work when ill and reinforce adherence to standard infection prevention and control (IPC) measures including selection and correct use of PPE. Residents should wear a cloth face covering or a face mask whenever they leave their room. Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. Have a plan for how residents in the facility who develop COVID-19 will be handled. Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. Review of CDC's guidance titled, Preparing for COVID-19 in Nursing Homes, updated 11/20/20 revealed the following: If Healthcare Personnel (HCP) are ill, they should leave the workplace. Facilities should identify space in the facility that could be dedicated to monitor and care for residents with COVID-19 (this could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that would be used to cohort residents with COVID-19). Identify HCP who would be assigned to work only on the COVID-19 care unit when in use. Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive). Residents in the facility who (TRUNCATED)

Based on facility record review, policy review, review of the Nursing Home Guidance from the Centers for Disease Control (CDC), review of the Department of Health and Human Services Centers for Medicare & Medicaid (CMS) Memos, and interviews with staff and medical director, the facility failed to conduct staffing testing to prevent the spread of COVID-19. This had the potential to affect 27 (#02, #06, #07, #8, #10, #15, #16, #24, #29, #31, #35, #36, #40, #41, #44, #45, #46, #53, #57, #59, #62, #64, #67, #68, #82, #86 and #90) of 27 residents identified by the facility as not contracting COVID-19 since the pandemic started. The facility census was 92. Findings include: Review of the facility staff testing logs revealed non-direct care staff were tested on [DATE], 11/13/20, 11/27/20 and 12/11/20. Review of the(NAME)County positivity rate on CMS COVID-19 Nursing Home Data website revealed on 10/28/20 was 19.8%, 11/04/20 was 26.2%, 11/11/20 was 26.5%, 11/18/20 was 24.8%, 11/25/20 was 21.9% and 12/02/20 was 23.4%, indicating the required testing would be twice per week for all staff. Review of the facility list of residents identified 27 (#02, #06, #07, #8, #10, #15, #16, #24, #29, #31, #35, #36, #40, #41, #44, #45, #46, #53, #57, #59, #62, #64, #67, #68, #82, #86 and #90) who have not contracted COVID-19 since the pandemic started Interview on 12/10/20 at 3:10 P.M., with the Director of Nursing (DON) revealed she was the facility's infection control preventionist. She stated all residents in the facility were tested every Monday by the DON with POC testing. Testing for staff was completed twice a week for direct care staff, which included nurses, STNA's, social worker, activity staff and therapy staff. Every other Friday, staff were tested with PCR testing that was state supported and were POC tested in between that time. The non-direct care staff, such as housekeeping, laundry, culinary services, and maintenance were tested on ce every other week on Fridays. The administrative personnel were tested on ce per week on Fridays. The DON stated all employees are screened prior to their shift and all residents are screened daily. If at any time they have answered yes to their screening questions, they are POC tested . Interview on 12/14/20 at 11:30 A.M., with Director of Culinary Services (DCS) #201 revealed she is COVID-19 tested on ce every two weeks as is her staff and if one of her staff came to her to report illness, she would have them take their temperature and report it to the DON so the staff could be COVID tested and then sent home. Interview with the Medical Director #400 on 12/16/20 at 11:41 A.M., revealed she was told the facility was testing staff twice a week. She was not aware they were testing only direct care staff twice a week and housekeeping, dietary, laundry and maintenance once every other week and administrative staff were being tested on ce every week. Medical Director #400 verified she would have told them they need to be tested more frequently at least weekly or call the local health department (LHD) to see what the requirement was. Review of CMS, COVID-19 Long-Term Care Facility Guidance, dated 04/02/20 revealed facilities should refer to CDC's guidance for long-term care facilities. Review of the CMS QSO memo 20-38 NH dated 08/20/20 revealed: Testing of Staff and Residents in Response to an Outbreak An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [MEDICAL CONDITION] transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. See CDC guidance Testing Guidelines for Nursing Homes section Non-diagnostic testing of asymptomatic residents without known or suspected exposure to an individual infected with [DIAGNOSES REDACTED]-CoV-2. For individuals who test positive for COVID-19, repeat testing is not recommended. A symptom-based strategy is intended to replace the need for repeated testing. Facilities should follow the CDC guidance Test-Based Strategy for Discontinuing Transmission-Based Precautions Discontinuing Transmission-Based Precautions for residents and Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV2 Infection. Routine Testing of Staff Routine testing should be based on the extent of [MEDICAL CONDITION] in the community; therefore, facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. Reports of COVID-19 county-level positivity rates will be available on the following website by August 28, 2020 (see section titled, COVID-19 Testing): https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg Review of the CDC website COVID-19 guidelines titled, Use of Testing to Inform the Response to COVID-19 in Nursing Homes (https://www.cdc.gov/coronavirus/2019ncov/hcp/nursing-homes-responding.html), dated 04/30/20, revealed if testing capacity allows use of facility wide testing following identification of newly identified [DIAGNOSES REDACTED]-CoV-2 infected residents or healthcare personal could be particularly important. Facility wide testing can help identify a symptomatic or pre-symptomatic resident with COVID-19 to guide movement into COVID-19 designated spaces.

Based on medical record review, observation, resident and staff interviews, review of the Director of Nursing (DON) statement, review of facility Self-Reported Incidents (SRI's) and review of facility policy, the facility failed to report an allegation of abuse to the state agency. This affected one (#30) out of three residents reviewed for abuse. The facility census was 100. Findings include: Review of Resident #30's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #30's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating Resident #30 was cognitively intact. Interview on 10/19/20 at 2:10 P.M. Licensed Practical Nurse (LPN) #215 confirmed there was an incident between Resident #30 and State tested Nurse Aides (STNA) #205 and #210. LPN #215 confirmed the incident was not witnessed by LPN #215. LPN #215 confirmed incident was reported to the DON. Interview on 10/19/20 at 2:15 P.M. Resident #30 reported two (#205 and #210) STNA's were rough with her. Resident #30 stated STNA #205 and #210 grabbed her and forced her to use the restroom. Resident #30 reported the main aggressor to be STNA #210 and Resident #30 did not want STNA #210 to provide care moving forward. Observation on 10/19/20 at 1:44 P.M. Resident #30 showed one elongated, purple bruise to Resident #30's right forearm and one dark purple bruise on Resident #30's left hand. Resident #30 reported the bruises were from staff grabbing her. Interview on 10/20/20 at 3:10 P.M. the DON stated Resident #30 never reported STNA #205 or STNA #210 were rough with Resident #30. The DON further reported Resident #30 never stated Resident #30 had bruises from staff. The DON verified the incident was not reported or investigated as abuse because Resident #30 never claimed staff were rough or Resident #30 had bruises due to staff being rough. Review of the DON's typed statement dated 10/13/20 revealed Resident #30 reported staff were rough with her. The statement further quoted Resident #30, She tried to get me up and I told her no .She grabbed my wrist. I am black and blue from it. Interview on 10/21/20 at 2:22 P.M. the DON verified the statement dated 10/13/20 was the DON's statement. Interview on 10/22/20 at 8:47 A.M. the DON verified her statement dated 10/13/20 included statements from Resident #30 claiming staff were rough and Resident #30 had bruises. The DON verified a SRI was not completed. Review of SRI's revealed no evidence the incident between Resident #30 and STNA #205 and STNA #210 being reported on 10/13/20 or 10/14/20. Review of facility policy titled, Abuse, Neglect Misappropriation and Crime Reporting, revised 11/04/19 revealed any time resident abuse was alleged the proper authorities would be notified immediately. This deficiency substantiates Complaint Number OH 390.

Based on medical record review, observation, resident and staff interviews, review of the Director of Nursing (DON) statement, review of facility Self-Reported Incidents (SRI's) and review of facility policy, the facility failed to thoroughly investigate an allegation of abuse. This affected one (#30) out of three residents reviewed for abuse. The facility census was 100. Findings include: Review of Resident #30's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #30's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating Resident #30 was cognitively intact. Interview on 10/19/20 at 2:10 P.M. Licensed Practical Nurse (LPN) #215 confirmed there was an incident between Resident #30 and State tested Nurse Aides (STNA) #205 and #210. LPN #215 confirmed the incident was not witnessed by LPN #215. LPN #215 confirmed incident was reported to the DON. Interview on 10/19/20 at 2:15 P.M. Resident #30 reported two (#205 and #210) STNA's were rough with her. Resident #30 stated STNA #205 and #210 grabbed her and forced her to use the restroom. Resident #30 reported the main aggressor to be STNA #210 and Resident #30 did not want STNA #210 to provide care moving forward. Observation on 10/19/20 at 1:44 P.M. Resident #30 showed one elongated, purple bruise to Resident #30's right forearm and one dark purple bruise on Resident #30's left hand. Resident #30 reported the bruises were from staff grabbing her. Interview on 10/20/20 at 3:10 P.M. the DON stated Resident #30 never reported STNA #205 or STNA #210 were rough with Resident #30. The DON further reported Resident #30 never stated Resident #30 had bruises from staff. The DON verified the incident was not reported or investigated as abuse because Resident #30 never claimed staff were rough or Resident #30 had bruises due to staff being rough. Review of the DON's typed statement dated 10/13/20 revealed Resident #30 reported staff were rough with her. The statement further quoted Resident #30, She tried to get me up and I told her no .She grabbed my wrist. I am black and blue from it. Interview on 10/21/20 at 2:22 P.M. the DON verified the statement dated 10/13/20 was the DON's statement. Interview on 10/22/20 at 8:47 A.M. the DON verified her statement dated 10/13/20 included statements from Resident #30 claiming staff were rough and Resident #30 had bruises. The DON verified other residents were not interviewed to see if they had any rough encounters with staff. Interview on 10/22/20 at 10:00 A.M. the Administrator verified alleged staff had not been sent home on 10/22/20 pending an investigation. The Administrator further verified the allegation had not been investigated as abuse. Review of SRI's revealed no evidence the incident between Resident #30 and STNA #205 and STNA #210 being reported on 10/13/20 or 10/14/20. Review of facility policy titled, Abuse, Neglect Misappropriation and Crime Reporting, revised 11/04/19 revealed any time resident abuse was alleged an immediate investigation would take place. Further review revealed any suspected employee would be removed from service until the investigation was completed. This deficiency substantiates Complaint Number OH 390.

Based on medical record review, observation, resident and staff interview, review of the Director of Nursing (DON) statement and review of facility policy, the facility failed to ensure a residents bruising was assessed and documented in the medical record. This affected one (#30) out of three residents reviewed for bruising. The facility census was 100. Findings include: Review of Resident #30's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #30's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating Resident #30 was cognitively intact. Review of Resident #30's Skin Assessments dated 09/21/20, 10/05/20 and 10/12/20 revealed no bruises listed. Review of Resident #30's Progress Notes dated from 09/02/20 to 10/21/20 revealed no evidence Resident #30 had bruises. Interview on 10/19/20 at 2:15 P.M. Resident #30 confirmed she had two bruises, one on Resident #30's right arm and one on Resident #30's left hand. Observation on 10/19/20 at 2:15 P.M. revealed Resident #30 had two purple bruises, one located on Resident #30's right arm and one located on Resident #30's left hand. Interview on 10/21/20 at 9:29 A.M. the DON confirmed Resident #30 received weekly skin assessments. The DON confirmed the expectation would be if any bruising was observed, it would be documented on the skin assessment. The DON verified Resident #30's Skin Assessments dated 09/21/20, 10/05/20 and 10/12/20 revealed no bruises listed. The DON further confirmed the bruising as noted on 10/13/20 was not documented in Resident #30's medical record. Further review of DON's statement dated 10/13/20 indicated Resident #30 had bruising. However, further review of the statement revealed the location of the bruising was not noted and there was no further assessment of the bruising. The statement documented the facility felt the bruising was present prior to 10/13/20. Review of policy titled, Skin Observation Bath Form Policy, with revision date on 09/30/20 revealed the nurse would complete a skin assessment for the resident weekly and the weekly skin condition evaluations would assess skin color, moisture, temperature, integrity and turgor. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on clinical record review, review of a Self Reported Incident (SRIs) and facility's investigation, staff interview, and review of the facility's abuse policy, the facility staff failed to implement their abuse policy and timely report an abuse allegation to the Administrator and State Survey Agency. This affected one (Resident #1) of three residents reviewed for abuse. The facility census was 109. Findings include: Clinical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 01/09/20, revealed the resident had moderately impaired cognition. Review of a Self Reported Incident (SRI), dated 01/30/20, revealed an anonymous person contacted the Administrator and requested information regarding Resident #1's statement that a guy came in and put his hand up her shirt. The Administrator initiated an investigation at that time which unsubstantiated sexual abuse. Review of the facility's investigation of the SRI revealed the Administrator interviewed the evening shift Registered Nurse (RN) #112 on 01/31/20 which revealed she heard the resident comment a man came in at night and touched her breast and she didn't like it. RN #112 stated after that the resident was saying random things that sounded confused and her oxygen was low. RN verified she did not report the allegation of abuse. Interview with the Administrator on 01/12/20 at 12:15 P.M. verified RN #112 did not report the sexual abuse allegation when the resident said a man came in at night and had touched her breast and she didn't like it. The Administrator stated RN #112 did not remember the date and did not consider the statement an abuse allegation. Review of the facility's policy titled Abuse, Neglect Misappropriation and Crime Reporting, revised on 11/04/19, revealed sexual abuse was non-consensual sexual contact of any type with a resident. At any time resident abuse was suspected or alleged, all allegations of abuse were reported immediately to the staff nurse, supervisor in charge, Unit Manager, Director of Nursing or Administrator. The supervisor immediately notified the Administrator, Director of Nursing and/or Executive Director of allegations of abuse who directed the action taken. The state agency was notified of all abuse allegations within 24 hours.

Based on observation, resident and staff interviews, review of the steam table owner's manual, review of documentation from the American Burn Association and review of the facility's servery policies, the facility failed to provide a safe environment free from accident hazards when steam tables were observed unattended in three of four serveries in the facility. This resulted in Immediate Jeopardy for 17 independently mobile residents (#15, #62, #89, #156, #59, #18, #141, #73, #114, #60, #124, #56, #33, #49, #8, #76, and #57) who reside on the Healthcare East (HCE) and Healthcare West (HCW) Wings. Additionally, the facility failed to secure chemicals and hazardous materials in locked storage closets on the HCE Wing. This placed three residents (#89, #59 and #18) identified by the facility as confused and independently mobile at risk for more than minimal harm that was not Immediate Jeopardy. On 08/28/12 at 4:56 P.M., the administrator was notified Immediate Jeopardy began on 08/28/12 at 2:00 P.M., when a steam table in the servery on the HCE Wing was observed unattended with hot water visibly boiling in it. Further inspection revealed the HCW Wing servery and Buckeye Cafe servery were left unattended when the steam tables were on and contained hot water. This placed all 17 residents at risk for third degree burns which penetrates the entire thickness of the skin and destroys the skin tissue. The Immediate Jeopardy was removed on 08/29/12 at 5:15 P.M., when the facility implemented the following corrective actions: ? On 08/28/12 at 6:24 P.M., staff turned off the HCE and HCW Wing and the Buckeye Cafe servery steam tables following the dinner meal service and allowed them to cool down. ? On 08/28/12, locks were installed on all of the serveries in the facility. ? On 08/28/12, the facility revised their policy regarding appropriate use of steam tables. The new procedure revealed the serveries will be locked when not in use by a staff member. If the servery is not able to be locked, the steam tables will not be left unattended. ? On 08/28/12, the Administrator began inservicing all staff on the new steam table policy and procedure. Staff was instructed to keep the serveries locked when no staff was present. ? On 08/29/12 between 7:53 A.M. and 4:15 P.M., Licensed Practical Nurse (LPN) #24, LPN #25, State tested Nurse Aide (STNA) #20, STNA #21, STNA #22, Housekeeper #3, and Dietary Aides #17, #18, #19, #26 and #27 all demonstrated knowledge of the new servery procedures during staff interviews. ? On 08/29/12 at 5:15 P.M., the facility completed the mandatory all staff inservice regarding the new servery policy and procedure. Although the Immediate Jeopardy was removed when the facility secured the steam tables in a manner to prevent resident access, the facility remained out of compliance at Severity Level 2 (no actual harm, with the potential for more than minimal harm that is not Immediate Jeopardy) because the facility failed to ensure the environment was free of accident hazards regarding chemical and hazardous material storage. Findings include: 1. On 08/28/12 at 2:00 P.M., the HCE Wing servery door was observed to be open and unattended. The steam table was filled with water and had steam coming from it. The flat lid from the steam table was hot to touch and could only be removed with a hot pad. The water temperature in the steam table was obtained by two surveyors and measured 180 degrees Fahrenheit (F). On 08/28/12 at 2:06 P.M., the steam table in the Buckeye Cafe servery was also filled with hot water that measured 130 degrees F. Interview with Dietary Aide #12 at this time revealed the servery is always left unlocked and the steam tables stay on until after the evening meal. She verified the serveries are not always supervised throughout the day. On 08/28/12 at 2:15 P.M., the HCW Wing servery was observed to have steam tables with hot water in them that measured 200 degrees F and was visibly boiling. During interview with Dietary Aide #8 at this time revealed the residents have a couple of refrigerators in the serveries they can use so the doors are kept open for them to access. Dietary #8 verified the steam tables remain on throughout the day until after the evening meal. On 08/28/12 at 2:46 P.M., a tour began with two surveyors and Supervisor of Nutritional Services #1 to obtain the flat surface temperatures of the lids and the water temperatures in the steam tables in the serveries. The observations were conducted between the lunch and dinner meal service. The HCW Wing servery steam table lids were hot to touch with temperatures ranging from 110 degrees F to 115 degrees F. There was no staff present in the area and the door was unlocked. Supervisor of Nutritional Services #1 stated the steam tables are left on during the day. Further inspection of the steam table revealed the flat lids easily shifted off and fell into the hot water below in the steam table. The temperature of the visibly boiling water measured 205 degrees F. Inspection of the steam tables in the Buckeye Cafe servery revealed the temperature of the lids measured between 83 degrees F and 112 degrees F, varying between lids and the temperature settings of each steam table. The hot water in the steam tables measured between 86 degrees F and 149 degrees F. Finally, the HCE Wing servery steam table contained hot water that measured 131 degrees F to 157 degrees F. The temperature of the lids on the steam tables measured 86 degrees F to 115 degrees F. Supervisor of Nutritional Services #1 indicated the fourth servery in the facility is located in the dementia unit which has always been kept locked when staff was not present due to the confused residents in the unit. Interview with Supervisor of Nutritional Services #1 on 08/28/12 at 3:00 P.M., verified the steam tables in the serveries remain on throughout the day until after the evening meal has been served. In addition, she verified the doors to the serveries remain open for resident access but they are not allowed to come in while food preparation or serving is going on. On 08/28/12 at 5:00 P.M., the HCE Wing servery was observed opened with no staff present. Continuous observation of the servery revealed Dietary Staff #16 entered and began the serving of the evening meal. The steam table was turned off at 5:47 P.M. by Second Shift Dietary Supervisor #14 and Dietary Aide #28. At 6:05 P.M., ice was added to the steam tables which were then cool to the touch at 6:24 P.M. On 08/28/12 at 5:46 P.M., the cooling of the steam tables in the HCW Wing servery began. Dietary Aide #15 stated before staff empties the steam tables, they must cool it down to around 100 degrees so it does not melt the drain. She indicated that before this evening, staff would just close the door to the servery before leaving, without locking the area. At 6:20 P.M., Dietary Aide #15 left the server and locked the door to it. Observation on 08/28/12 at 5:50 P.M. revealed Dietary Aide #9 placing ice in the Buckeye Cafe servery steam tables to begin the cooling off process. The steam tables were cool to the touch by 6:00 P.M. Review of the operator's manual regarding the steam tables used in the serveries indicated all units are designed for 145 degrees F to 175 degrees F operation or 140 degrees F to 170 degrees F product temperature. According to the American Burn Association, the severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees Fahrenheit. At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur. When the temperature of a hot liquids is increased to 140 degrees F it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 degrees F, resulting in almost instantaneous burns that will require surgery. Since immediate removal of the hot liquid from the skin may lessen severity, splash and spill burns may not be as deep as burns suffered in a bathtub. Review of the facility's policy and procedure regarding appropriate use of the steam tables, dated August 2011, revealed that to promote resident centered care with an environment that is homelike, the serveries on the HCE Wing and HCW Wing will not be locked. Residents can use the refrigerators in the serveries for storage of food with appropriate storage containers and labeling. The facility revised their policy and procedure regarding appropriate use of the steam tables on 08/28/12. The new procedure revealed the serveries will be locked when not in use by a staff member. If the servery is not able to be locked, the steam tables will not be left unattended. On 08/29/12 at 7:25 A.M., observations made by three different surveyors revealed the HCE Wing servery had a lock on the door and a note posted that the servery door was to remain locked unless staff is present. On 08/29/12 at 7:46 A.M., the Buckeye Cafe servery had staff present assisting with the breakfast meal. On 08/29/12 at 7:52 A.M., the HCW Wing servery was observed open with dietary staff present. A note was also posted on the door to keep the area locked unless staff was present. On 08/29/12 at 9:23 A.M., no staff was noted in the HCE Wing server; however, the door was found locked. Review of facility incident and accident logs dated 07/11/2011 to 08/29/12 revealed no incidents of residents being burned. On 08/29/12 between 8:47 A.M. and 10:45 A.M., 14 of the 17 independently ambulatory residents (#15, #62, #156, #59, #18, #73, #114, #70, #87, #119, #74, #154, #49 and #76) were interviewed. All of the residents reported they have never been in the serveries. Observation of the residents at the time of the interviews revealed no visible burns. 2. On 08/28/12 during the initial tour of the facility from 8:15 A.M. to 9:00 A.M., two storage closets on the HCE Wing were observed unlocked and unattended. The first storage closet located across from Room #24 contained a chemical bottle entitled "Oasis 499 HBV Disinfectant" which was sitting on the floor. There was also an unlocked cabinet that contained a bottle of antimicrobial skin cleanser. A second unlocked and unattended storage closet located to the left of the first closet was observed to have a bottle of window and door insulating foam and a container of premixed grout mixture sitting on a lower shelf to the right when the door was opened. Each of the products in the unlocked storage closets contained a precautionary label indicating to keep out of reach of children. During interview on 08/28/12 at 8:40 A.M., STNA #1 verified the chemical products were left unattended and in unlocked storage rooms. STNA #1 verified the products should be locked in a cabinet within the storage room. STNA #1 proceeded to lock the chemicals within the cabinet. The facility identified three residents (#89, #59 and #18) on the HCE Wing that are confused and independently mobile.

Based on medical record review, observations, staff interview, physician interview, review of a facility policy, and review of information from the Mayo Clinic regarding dehydration, the facility failed to timely address a resident's poor fluid consumption with accompanying diarrhea and a change in health status. This resulted in actual harm when the resident developed dehydration and required hospitalization for intravenous (IV) re-hydration. In addition, the facility also failed to have fluids available at the resident's beside when the resident was capable of drinking fluids on her own and was at risk for dehydration. This affected one (#105) of two residents reviewed for hydration status. The facility identified two residents who are at risk for dehydration. The total facility census was 93. Findings include: Review of Resident #105's medical record revealed the resident was originally admitted to the facility on [DATE], and had a more recent re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a nutritional assessment with a completion date of 04/19/12, documented Resident #105's nutritional needs regarding fluids recommendation were to be 1,377 milliliters (ml) per day and that the resident's current diet was appropriate. The nutritional assessment further documented at that time Resident #105 was receiving nectar thick liquids; she was receiving a thick shake at lunch (180 ml of fluid); fortified pudding at supper (120 ml of fluid), and four ounces of med plus twice daily between meals (totaling 240 ml of fluid). The nutritional assessment concluded the resident was at moderate risk for dehydration. Review of Resident #105's physician orders [REDACTED]. Subsequently on 05/27/12 at 3:09 P.M., nursing progress noted documented staff reported the resident had several loose stools and was complaining of diarrhea for two days. The physician was notified and a culture was ordered to screen for [MEDICAL CONDITION] (a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon). Review of Resident #105's record revealed a document entitled "Event" dated 05/27/12 regarding diarrhea. The "Event" indicated the resident was noted to have loose stools for three days and the physician was notified and a culture to test for [MEDICAL CONDITION] would be taken. The "Event" documented interventions to monitor and record temperature every shift; the "Event" lacked information regarding to increase or encourage fluids. The "Event" further documented notes which revealed the continuation of loose stools up to 06/13/12 at 8:03 A.M., when the resident's blood pressure reading was 84/48 (normal is 120/80), she was weak, she continued with poor oral intake, she required increased assistance with activities of daily living and the resident required admission to the hospital. The "Event" notes failed to address the resident's poor oral intake or specific actions/interventions by the staff regarding the poor fluid intake and loose stools. According to Resident #105's nursing progress notes on 05/29/12 at 4:30 P.M., orders were received to treat the resident with oral medication ([MEDICATION NAME]) for a positive [MEDICAL CONDITION] culture readings. Nursing progress notes on 05/31/12 at 10:19 A.M., documented the resident stated, "I don't feel good," loose stools continued. On 06/06/12 at 2:16 P.M., loose stools continued; the resident's blood pressure was noted to be lower than normal (80/43) and the physician was notified of the blood pressure reading. There was confusion also noted at times. On 06/07/12 at 12:00 P.M., the resident refused to come out for lunch and refused to eat. On 06/07/12 at 8:49 P.M., the resident refused dinner, had complaints of feeling "tired" and loose stools continued. On 06/10/12 at 11:15 A.M., loose stools continued. On 06/12/12 at 10:15 A.M., the resident continued with loose mucous-like stools. On 06/12/12 at 10:30 P.M., continued with loose stools. The nurse documented a note was left on the physician's board and a blood pressure reading continued to be low at 93/58. On 06/13/12 at 8:03 A.M., Resident #105 was sitting up at the dining room table; her blood pressure reading was 84/48; she was pale, weak and continued with poor oral intake. The nurse documented staff reported increased needs with transfers and the physician was notified. On 06/13/12 at 12:15 P.M., Resident #105 was transferred to the hospital and directly admitted for dehydration. The review of the nursing progress notes concluded the staff acknowledged the resident's loose stools and treatment of [REDACTED]. and poor oral/fluid intake and measures to prevent dehydration. According to a physician progress notes [REDACTED].M., Resident #105 had no acute changes; she continued to have loose stools; she had just finished [MEDICATION NAME], had a blood pressure of 98/55 and would re-test for [MEDICAL CONDITION]. There was a lack of information that the staff reviewed the poor oral and fluid consumption with the physician or any actions/interventions. On 06/13/12 at 11:55 A.M., a physician progress notes [REDACTED]. The review of the physician progress notes [REDACTED]. Review of the physician's orders [REDACTED]. Further review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to Resident #105's MAR's and meal/snack time intake totals, the resident's total daily fluid intake was less than the estimated daily total recommendations (1,377 ml/day) from 06/06/12 through 06/13/12. The intakes were as follows: -On 06/13/12; 440 ml at meals + 120 ml supplement = 560 ml daily total -On 06/12/12; 350 ml at meals + 120 ml supplement = 470 ml daily total -On 06/11/12; 560 ml at meals + 120 ml supplement = 680 ml daily total -On 06/10/12; 880 ml at meals + 120 ml supplement = 1,000 ml daily total -On 06/09/12; 360 ml at meals + 120 ml supplement = 480 ml daily total -On 06/08/12; 660 ml at meals + 120 ml supplement = 780 ml daily total -On 06/07/12; 120 ml at meals + 120 ml supplement = 240 ml daily total -On 06/06/12; 680 ml at meals + 120 ml supplement = 800 ml daily total Review of Resident #105's output record from 06/06/12 to 06/13/12, revealed the following urine and bowel outputs: -On 06/13/12; no urine output and one medium loose stool -On 06/12/12; one small and three medium urine output and five large stools -On 06/11/12; two medium and two large urine output and one small stool -On 06/10/12; two large urine output and one large loose stool -On 06/09/12; two large urine output; no stool according to output; however, according to the nursing progress notes at 7:06 P.M. and 2:22 P.M. the nurses documented reports of continued loose stools -On 06/08/12; one medium and two large urine outputs and two medium and one large stools -On 06/07/12; one medium urine output and one large stool -On 06/06/12; two medium and one large urine output and one medium loose stool Review of the hospital's history and physical (H&P) dated 06/13/12, documented the resident was experiencing weakness and diarrhea. According to the H&P, Resident #105 had diarrhea for the past three weeks or so and was positive for [MEDICAL CONDITION]. The H&P further documented the resident was experiencing anorexia and not eating or drinking well. The resident was getting weaker and oral intake was not negligible and she was admitted for IV fluid re-hydration. Impressions concluded the resident had dehydration, possible [MEDICAL CONDITION], diarrhea, dementia, hypertension by history and [MEDICAL CONDITION] disorder. Resident #105's pertinent laboratory (lab) values were reviewed. Lab values taken on 04/24/12, showed a blood uric nitrogen (BUN) level of 21 (normal reference 6-20) and a creatinine level of 0.8 (normal reference 0.4-1.1). Lab work taken on 06/13/12, when Resident #105 was admitted to the hospital showed a BUN reading at 21 (normal reference 7-22) and an elevated creatinine level of 1.4 (normal reference 0.5-1.2). A BUN taken on 06/16/12 showed a value of 4 (normal reference 7-22) and a creatinine of 0.6 (normal reference 0.5-1.2). Creatinine and BUN tests are performed to measure renal function, filtration and over all organ health. Review of Resident #105's most recent significant change minimum data set (MDS) assessment dated [DATE], revealed the resident had dehydration and had no swallowing issues. Review of a comprehensive, initially created on 09/14/10, documented the resident is at risk for dehydration. The care plan documented to offer thick fluids as needed; to assess for dehydration (dizziness on sitting/standing/change in mental status, decreased urine output, concentrated urine, poor skin turgor, cracked lips, dry mucous membranes, sunken eyes, constipation, fever, infection, electrolyte imbalance); provide supplements as ordered; record acceptance/refusal of supplements. On 08/29/12 at 4:43 P.M., Resident #105 was observed in her wheelchair in her room. At the time of the observation there was no water pitcher or glass for fluids within the resident's room. On 08/30/12 at 8:24 A.M., Resident #105 was observed in bed; there were no fluids available within the resident's room. On 08/30/12 at 12:00 P.M., Resident #105 was in her wheelchair in the dining room; she required some assistance from the staff with her lunch meal but was capable of picking up a coffee cup and drinking thickened coffee without any difficulties. During the observation, Resident #105 had no difficulties swallowing the provided thickened liquids. On 08/30/12 at 5:40 P.M., Resident #105's room was observed without fluids available at the bedside for the resident to consume on her own. On 08/29/12 at 4:44 P.M., during an interview with State tested Nurse Aides (STNA) # 4 and #5, they revealed that Resident #105 is currently on hospice and that she receives thickened liquids. STNAs #4 and #5 stated that Resident #105 doesn't like to consume fluids and that if she doesn't consume fluids between meals they report this to the nurse. STNAs #4 and #5 stated they normally don't keep fluids at Resident #105's bedside because she is on thickened liquids but didn't know why because they stated the resident does not choke or have problems drinking the thickened liquids. STNAs #4 and #5 further stated that if the resident wanted something to drink between meal/snack time she would have to ask a staff member. During interview on 08/30/12 at 5:40 P.M., the Director of Nursing (DON) verified the facility does not keep fluids at Resident #105's bedside because she is on thickened liquids. The DON verified the resident is capable of drinking fluids on her own and that she is at risk for dehydration. On 08/31/12 at 11:55 A.M., during an interview with Registered Nurse (RN) #2 she verified Resident #105 was on antibiotic for respiratory tract infection and subsequently developed [MEDICAL CONDITION]/loose stools and was not consuming fluids well and developed dehydration. RN #2 further stated back in May/June 2012 when Resident #105 had [MEDICAL CONDITION], her output was more than normal due to her having excessive diarrhea. RN #2 stated she remembered Resident #105's blood pressure reading was lower than normal during that period. RN #2 stated that if the facility completed a dehydration/hydration status assessment and addressed this with the physician/family it would be in the medical record. RN #2 stated any actions or interventions attempted regarding encouraging of fluids or discussions regarding poor oral intake would also be found in the medical record. On 08/31/12 at 3:06 P.M., an interview with Physician #6 verified he cares for Resident #105. Physician #6 stated that in May 2012, the resident was on antibiotics for a respiratory tract infection and then developed [MEDICAL CONDITION]. The physician stated he felt the resident's condition was fairly stable up until the time of her hospital admission. A review of the physician's progress note dated 06/09/12, revealed he did not address the resident's poor fluid consumption as he indicated the staff did not address that with him. Physician #6 stated that Resident #105 was admitted to the hospital based on her clinical signs and symptoms when he assessed her on 06/13/12. Review of the facility's policy entitled "Change of Condition: observing, recording and reporting" with a revision date of 07/2005, revealed the immediate notification of the resident, if known, the resident's legal representative or interested family member, and the resident's physician will be completed for the following situations: a significant change in the resident's physical, mental, or psychosocial status (i.e. a deterioration in health, mental, or psychosocial status in either life- threatening condition or clinical complications); or a need to alter treatments significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Information from the Mayo Clinic found at www.MayoClinic.com was reviewed regarding dehydration. According to the Mayo Clinic dehydration occurs when you lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal function. If you don't replace lost fluids, you may get dehydrated. Common causes of dehydration may include intense diarrhea. Anyone may become dehydrated, but older adults and people with chronic illnesses are at most risk. You can usually reverse mild to moderate dehydration by drinking more fluids, but severe dehydration needs immediate medical treatment. The safest approach is prevention of dehydration. Monitor your fluid lose during illness and drink enough liquids to replace what you lose.