Every finding on record at Otterbein New Albany

Based on medical record review, interview and review of facility policy, the facility failed to ensure resident medications had an adequate indication for use. This affected one resident (#5) of three residents reviewed for unnecessary medication administration. The facility's census was 58. Findings include:Record review for Resident #5 revealed this resident was admitted to the facility on [DATE] for respite care, and discharged [DATE] with diagnoses including: Alzheimer's disease late onset, hypertensive heart disease, cerebral atherosclerosis, dementia, and osteoarthritis. Review of the Brief Interview for Mental Status (BIMS) exam dated 06/22/26 revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This resident was assessed to require self-care and mobility assistance.Review of the care plan of Resident #5 dated 06/18/26, revealed the resident was receiving hospice services so medications were to be administered per the hospice orders.Review of Resident #5's orders, dated 06/18/26, and discontinued 06/22/26 revealed an order for lorazepam (antianxiety) 0.5 milligrams, (mg) oral tablet as needed, every four hours for restlessness, anxiety and agitation, and an order for Morphine concentrate (opioid) 100mg/5milliters, (ml) oral solution as needed, every four hours for pain and dyspnea, or difficulty breathing.Review of Resident #5's Medication Adminsitration Record, (MAR) revealed lorazepam 0.5 milligrams, (mg) oral tablet was administered 06/19/26 at 4:00 A.M., 06/20/26 at 8:00 P.M., 06/21/26 at 8:00 P.M., 06/22/26 at 4:00 A.M. and 8:00 A.M. There was no indication in Resident #5's medical record that she was experiencing restlessness, anxiety or agitation at the time of any of the administrations. The MAR also revealed Resident #5 was administered Morphine concentrate 100mg/ml oral solution on 06/19/26 at 4:00 A.M., 06/20/26 at 4:00 P.M. and 8:00 P.M., 06/21/26 at 12:00 P.M and 8:00 P.M., 06/22/26 at 4:00 A.M. and 8:00 A.M. There was no indication in Resident #5's medical record that she was experiencing pain or dyspnea at the time of any of the administrations.During an interview with the Director of Nursing, (DON) on 08/05/26 at 11:50 A.M. The DON confirmed there was no documented evidence the resident was displaying agitation or pain at the time of the administrations of the lorazapam and Morphine. Review of the facility's policy, Medication Administration Procedure, revised 11/09/21, revealed medications are administered in accordance with written orders of the attending physician or physician extended. If a dose seems excessive or a medication order seems unrelated to the resident's current diagnoses or conditions, the nurse should obtain clarification of the order.This deficiency represents non-compliance investigated under Complaint Number 3070867.

Based on observation, interview and facility record review the facility failed to ensure temperatures were checked prior to serving food and failed to ensure food properly stored and labeled. This had the potential to affect 52 residents. The facility provided a list of two residents who receive nothing by mouth. The facility census was 54.Findings include:Review of the 300 building food log temperatures revealed temperatures were not documented on 06/17/26 for the lunch meal. Further review of the food temperature logs revealed temperatures were not completed 06/02/26, 06/03/16, 06/05/16, 06/06/16, 06/07/26, 06/09/26, and 06/10/26. The log revealed only dinner meal temperatures were checked for 06/11/26, 06/12/26, 06/13/26, and 06/14/26.Review of May 2026 food temperature logs, revealed temperatures were documented for only the dinner meal on 05/02/26, 05/03/26, 05/04/26, and 05/07/26. There were no documentated temperatures on 05/05/26 and 05/06/26.Interview with the Administrator on 06/17/26 at 3:15 P.M. confirmed Certified Nursing Assistants (CNA)'s should be checking meal temperatures prior to service for every meal.Observation on 06/17/26 at 5:00 P.M. revealed temperatures were not documented in the log for the dinner meal and the thermometer was not working properly. Observation on 06/17/26 at 5:00 P.M. of the refrigerator revealed a gallon of milk with no open date label, and sour cream with no open date label.Observation on 06/17/26 at 5:00 P.M. of the dry storage revealed a loaf of bread with an expiration date of 05/25/2), and an open can of fruit cocktail in the cabinet.Interview on 06/17/25 at 5:05 P.M. with the Administrator confirmed the items in the refrigerator should be labeled including an opened date. The Administrator also verified the the dry storage items that were expired and opened should have been disposed of.Review of the facility's policy titled Food temperatures- hot and cold policy and procedure dated 05/2013, confirmed staff should check temperature of food before serving. This deficiency represents non-compliance investigated under Complaint Number 3030544 and 3003838.

Based on observation, interview, medical record review, and facility policy review the facility failed to ensure Resident #58 was provided with a safe transfer using a hoyer lift. This affected one of three residents reviewed for Hoyer lift transfer. The facility census was 54.Findings include:Review of Resident #58's medical record revealed an admission date of 07/27/2020. Medical diagnoses include unspecified dementia, hypertensive heart disease without heart failure, unspecified psychosis, contracture right hip, functional urinary incontinence, and bilateral nonexudative age-related macular degeneration bilateral early dry stage. Review of Resident #58's care plan dated revealed 07/31/23 confirms Resident #58 required assistance to complete Activities of Daily Living (ADL's). Review of Resident #58's physician orders revealed an order for transfer with Hoyer lift dated 07/09/25. Review of Resident #58's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Resident 58's functional abilities revealed Resident #58 had impairment to both lower extremities and was dependent for transfers. Observation on 06/23/26 at 9:40 A.M. revealed Certified Nursing Assistant (CNA) #15 and CAN #19 did not inspect the Hoyer lift sling prior to use to ensure it was safe to use during the transfer. Once Resident #15 was positioned in the sling above her wheelchair, the CNA's did not lock the wheels on the Hoyer lift. CNA #15 was controlling the remote for the Hoyer lift during the transfer for Resident #58, when CNA #15 lowered Resident #58 into her wheelchair it was observed Resident #58's buttock hit the wheelchair head rest and the resident was yelling stop and ow. The CNA did not stop the transfer and lowered the resident onto the headrest of her wheelchair causing it to go forward. During the transfer it was also observed when Resident #58 was being lowered the left leg of the Hoyer lift was not flat on the ground but was rising in the air off the floor. Interview on 06/23/26 at 9:50 A.M. with CNA #15 and CNA #19 neither aide could verbalize the need to assess the Hoyer transfer sling prior to use for a transfer, and the CNA's confirmed they did not ensure the Hoyer lift transfer was completed safely stating, our transfers are never that bad. Interview on 06/23/26 at 5:00 P.M. with the Director of Nursing (DON) confirmed she expected staff to ensure the sling was safe to use prior to each use. Review of the manual for the Maxi 500 floor lift (Hoyer) dated 05/2022 confirmed the expected life for other consumable items such as batteries, fuses, slings, straps, and cords is dependent upon the care and usage of the product. This deficiency represents non-compliance investigated under Complaint Number 3030544 and 3003838.

Based on observation, interview, medical record review, and facility policy review the facility failed to ensure Resident #58 was provided with sufficient incontinence care. This affected one of three residents reviewed for incontinence care. The facility census was 54.Findings include:Review of Resident #58's medical record revealed an admission date of 07/27/2020. Medical diagnoses include unspecified dementia, hypertensive heart disease without heart failure, unspecified psychosis, contracture right hip, functional urinary incontinence, and bilateral nonexudative age-related macular degeneration bilateral early dry stage. Review of Resident #58's care plan dated revealed 07/31/23 confirms Resident #58 requires assistance to complete Activities of Daily Living ( ADL's). Review of Resident #58's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. Resident #58 was frequently incontinent of urine and bowel. Review of Resident #58's functional abilities revealed Resident #58 was dependent on staff for toileting hygiene. Observation and interview on 06/23/26 at 9:30 A.M. of incontinence care for Resident #58 revealed Certified Nursing AssistNT (CNA) # 19 did not dry Resident #58's peri area with towel after cleansing and rinsing the area. CNA #19 stated, I used to the wipes to dry, and they are not sopping wet. Interview on 06/23/26 at 9:35 A.M. with CNA#19 confirmed she did not use a towel to dry Resident #58's peri-area. Interview on 06/23/26 at 5:00 P.M. with the DIrector of Nursing (DON) confirmed she expected staff dry Residents after providing incontinence care. This deficiency represents non-compliance investigated under Complaint Number 3030544.

Based on record review, staff interview, and policy review, the facility failed to timely assess, stage and provide treatment to a pressure ulcer that was identified on admission for a resident. Actual harm occurred on 12/30/25 when Resident #5's pressure ulcer had a documented decline after there was no documented wound assessment or measurements completed by the facility for 20 days. The stage of the pressure ulcer was not documented on admission and the ulcer became larger in size and was unstageable. This affected one resident (Resident # 5) of four residents reviewed for pressure ulcers The facility census was 60.Findings include:Record review revealed Resident # 5's was admitted on [DATE] with diagnoses including end stage renal disease on hemodialysis, uterine cancer, Diabetes Mellitus Type II, obstructive uropathy, depression and retroperitoneal hematoma. Review of Resident # 5's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact. She required assistance from staff with transfers, toileting hygiene, bathing and dressing and had a pressure ulcer. Review of Resident # 5's readmission screen dated 12/10/25 revealed she had a pressure ulcer to her sacrum measuring 1.5 centimeters (cm) in width by two cm in length. There was no documented depth, stage, or description of the pressure ulcer. Review of Resident # 5's weekly skin observations dated 12/21/25 to 02/14/26 revealed no documented pressure ulcer, pressure ulcer description, or pressure ulcer measurements. Review of the skin observation dated 12/27/25 revealed Registered Nurse (RN) #118 documented the pressure ulcer as ongoing and every day wound care on the coccyx continues on buttocks with drain. Wound getting bigger and worse. Resident #5's medical record had no measurements of the of the pressure ulcer and no documentation the physician was notified of the worsening condition of the wound. Review of physician's orders for December 2025 revealed no wound care orders for sacral wound from 12/10/25 to 12/29/25 except for house barrier cream every shift and after each incontinent episode dated 12/12/24. Review of Resident # 5's wound evaluation by Wound Physician (WP #351) dated 12/30/25 revealed an unstageable pressure ulcer (not stageable due to coverage of wound bed by slough and/or eschar) on the sacrum measuring 4.8 cm in width by 14.5 cm in length by 0.3 cm deep with necrotic (dead, non-viable) tissue and slough (yellow tissue with dead cells, fibrin and bacteria). Wound care treatment was ordered for calcium alginate once daily. Review of Resident # 5's physician's orders revealed a wound care order dated 12/30/25 for a sacral wound to cleanse wound with wound cleanser or soap and water. Pat dry. Apply calcium alginate and cover with a clean dry dressing daily, every day on day shift, and as needed until resolved. Review of Resident #5's wound physician weekly wound evaluations for 01/06/26 and 01/07/26 revealed the physician visits were rescheduled due to Resident #5 being at dialysis. Review of Resident #5's weekly wound evaluation visit for 01/13/26 by WP #351 revealed the physician signed off on Resident #5's care as resident goes to dialysis during his weekly visits. Review of Resident # 5's progress note dated 01/14/26 revealed wound rounds were discontinued with the wound doctor due to the resident's dialysis schedule. The facility was to continue to follow and treat skin areas as planned and follow up with the wound doctor as needed. Review of skin observation dated 01/17/26 revealed RN # 118 documented the ulcer was ongoing and daily wound care on the coccyx and on the buttocks continues. Wound is bigger, drains and with bad smells. Resident #5's medical record had no measurements of the wound for this observation and did not document the physician was notified of the worsening condition of the wound. Reviews of the January 2026 and February 2026 physician orders revealed there had been no change to the wound care treatment for Resident #5's sacral wound. During an interview on 02/25/26 at 3:36 P.M., the Director of Nursing (DON) stated the Resident #5 was not able to be followed by the wound doctor due to wound round days and the resident's dialysis schedule. The DON stated her expectation would be that nursing would continue to assess and measure the wound and follow up with the physician as needed for Resident # 5's wound care. The DON confirmed Resident # 5's weekly skin observations had no wound assessments, or measurements completed from 12/21/25 to 02/14/26. She also confirmed Resident #5 had a documented worsening of the sacral wound on 01/17/26 by RN #118 and the physician had not been contacted. Resident #5 continued with the same wound care order since 12/30/25 despite the documented decline in the wound. Review of facility policy titled Skin Care Management Procedure, dated 12/09/22, revealed with each dressing change or at least weekly at minimum, documentation should include the date wound observed; location and staging; size, depth; and the presence, location and extent of any undermining or tunneling/sinus tract; exudates, if present; pain; wound bed color and type of tissue/character including evidence of healing or necrosis and description on wound edges as appropriate. It also states if pressure ulcer fails to show improvement within 2-4 weeks, the area and the residents over all condition should be reassessed. Reevaluation of the treatment plan should occur, and the decision made to continue or make changes to the current interventions.

Based on observations, staff interviews, and facility policy review, the facility failed to store and date food appropriately. This had the potential to affect 36 (Residents #55, #70, #23, #25, #50, #11, #28, #1, #68, #41, #61, #69, #12, #37, #4, #18, #43, #6, #16, #59, #45, #9, #5, #29, #22, #36, #2, #20, #10, #40, #13, #39, #53, #17, #54, and #42) of 48 residents reviewed for food safety. Also, the facility failed to ensure hair restraints were in place when required. This had the potential to affect 12 (Residents #8, #38, #52, #31, #58, #56, #35, #60, #62, #67, #46, and #21) of 12 residents in house one. Finally, the facility failed to ensure all food preparation tools and equipment were fully cleaned and sanitized prior to use. This had the potential to affect four (Residents #67, #52, #12, and #59) of four residents who were identified as requiring altered textured diets in house one and house three. The census was 60.Findings Include:Observation on 02/23/26 at 8:18 A.M. revealed in house three refrigerator, the following items were not stored and/or dated correctly: glass pan of gelatin covered in plastic wrap that had no date on it; a zippered plastic bag of bacon, which was not it's original packaging, and had no date on it; and a zippered plastic bag of salami, which was not in it's original packaging and had no date on it.Interview with Certified Nursing Aide (CNA) #133 on 02/23/26 at 8:24 A.M. confirmed the above items were opened and undated. She confirmed there should be a date as to when the food item was placed in the refrigerator or a date as to when the food should be discarded; she confirmed none of the food listed above had either date.Observation on 02/23/26 at 8:27 A.M. revealed in house two refrigerators, the following items were not stored and/or dated correctly: a gallon sized zippered plastic bag with cooked rice and sauce that had no date on it; a gallon sized zippered plastic bag with a cooked turkey leg that had not date on it; an opened package of one uncooked turkey leg, covered with aluminum foil, that had no date on it; and a styrofoam plate with cooked taco meat and vegetables, covered with aluminum foil, and had not date on it. Interview with CNA #161 on 02/23/26 at 8:37 A.M. confirmed the above listed items were opened, in the kitchen refrigerator, and had no dates on them. She stated all the food that was identified was food brought in by staff for themselves, but confirmed they all should have dates on them regardless.Observation on 02/23/26 at 8:43 A.M. revealed in house four refrigerators, the following items were not stored and/or dated correctly: a zippered plastic bag of multiple small dough covered food items (actual food was unknown) with no date on the bag; and a bowl of cooked tomato soup covered with plastic wrap with no date on it. Interview with Diet Technician #186 on 02/23/26 at 8:48 A.M. confirmed the above listed items were out of their original packaging, cooked/prepared, and not dated when placed in the kitchen refrigerator. He confirmed there should be dates on any left overs placed back in the refrigerator.Review of facility Food Labeling and Dating policy, dated 06/01/08, revealed if food is portioned for meal service, it is covered and labeled and dated. Review of facility Food Storage Policy, dated 10/01/09, revealed once food is removed from its original package, it is stored in a clean, covered, approved container, identified by name, and dated with month, day and year. Observation on 02/25/26 from 11:15 A.M. to 11:25 A.M. found Neighborhood Concierge (NC) #127 had a hair net on top of her head, but her long hair, that went to her waist, was hanging out unrestrained. Interview with Dietitian #350 on 02/25/26 at 11:25 A.M. confirmed NC #127's hair should have been fully restrained. Dietitian #350 reminder her that she needed to have all of her hair restrained; she put her long hair down the back side of her shirt at that time.Observation on 02/25/26 at 11:50 A.M. revealed CNA #160 finished blending chicken in the food processor. After pouring the blended chicken on to a plate, she went to the sink and rinsed the canister with warm water to remove the excess chicken. After doing this, she placed the canister back onto the blender, and was starting to pour broccoli into the canister. She had not cleaned the canister with soap and water and/or sanitizer prior to using it again. She was stopped by the surveyor at that point.Interview with CNA #160 on 02/25/26 at 11:51 A.M. confirmed she had not cleaned the canister with soap/water and/or sanitizer prior to beginning to use it again. She stated she normally would wash it in the dishwasher prior to using it again, but she was in a hurry to get everything completed.Observation on 02/25/26 at 12:40 P.M. revealed NC #127 finished blending chicken in the food processor. After pouring the blended chicken into a one portion sized bowl, she went to the sink and rinsed the canister with warm water and her gloved hand to remove the excess chicken. After doing this, she placed the canister back onto the blender, and was starting to pour broccoli into the canister. She had not cleaned the canister with soap and water and/or sanitizer prior to using it again. She was stopped by the surveyor at that point.Interview with NC #127 on 02/25/26 at 12:40 P.M. confirmed initially stated she had fully cleaned the canister prior to using it again. When asked where the soap and cloth was that she used at the sink, she then stated she did not and went on to clean the canister appropriately with soap and water.

Based on observations, medical record review, staff interview, and facility policy review, the facility failed to ensure altered texture diets were prepared in a correct and safe manner. This affected one (Resident #67) of three residents reviewed for altered texture diets. The census was 60.Findings Include:Observation on 02/25/26 from 12:20 P.M. to 12:35 P.M. revealed Neighborhood Concierge (NC) #127 blended cooked chicken in a normal blender; not a food processor. NC #127 blended the chicken for about five to six minutes and then poured the contents into one portion bowl. NC #127 stated the blended chicken was to the standard she wanted it for pureed chicken. There were clear chunks and whole pieces of chicken observed in the bowl. The chicken was tasted by the surveyor and Dietitian #350 tasted the blended chicken it was confirmed the chicken was not to their standard for a pureed consistency. aResident #67 was admitted to the facility on [DATE]. Her diagnoses were encephalopathy, dysphagia, unspecified protein calorie malnutrition, hypertensive heart disease, hyperlipidemia, vitamin D deficiency, thrombocytosis, anxiety disorder, restlessness and agitation, arthropathy, and sleep disorder. Review of her minimum data set (MDS) assessment, dated 02/02/26, revealed she had a severe cognitive impairment.Review of Resident #67 current dietary orders found that she had a puree texture diet order.Interview with Dietitian #350 on 02/25/26 at 12:35 P.M. confirmed the blended chicken should have been blended more; it was not to the standard and safety the facility wanted for puree texture food for the residents.Review of facility Neighborhood Diets Policy, dated 01/01/09, revealed a pureed texture diet was defined/described as a regular diet with texture altered to accommodate those with difficulty swallowing and/or chewing. Texture varies from thin (applesauce) to thick (mashed potatoes). Bread or bread substitute is incorporated into recipes to meet nutritional guidelines.

Based on record review, pharmacy recommendation review, and interview, the facility failed to address pharmacy recommendations. This affected one resident (Resident #55) out of five reviewed for unnecessary medications. The facility census was 60.Findings include: Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, anxiety disorder, dementia, depression and hypertensive heart disease. Review of pharmacy recommendations for Resident #55 on revealed a pharmacy recommendation on 03/14/25 that stated the resident was admitted for m the hospital on [DATE]. The hospital records indicate the resident should be receiving Norvasc (used for high blood pressure) five milligrams (mg) every day. Please clarify the status of this medication. The recommendation did not have a response from the prescriber and had no documented followed up by the facility. Review of pharmacy recommendations for Resident #55 on revealed a pharmacy recommendation on 06/16/25 that stated the resident had order for Hydroxyz (Hydroxyzine) HCL (antihistamine) tablet 50 mg one tablet by mouth every six hours as needed without a stop date which was started on 04/05/25. The recommendation was to either discontinue the medication, add a stop date or update to scheduled dosing. The recommendation did not have a response from the prescriber and had no documented followed up by the facility. Review of pharmacy recommendations for Resident #55 on revealed a pharmacy recommendation on 10/16/25, that stated the resident had an order for Donepezil tablet (used for dementia) five mg one tablet by mouth daily for dementia. The recommendation documented he manufacturer's recommendations suggest Start five mg at bedtime for four to six weeks then increase to 10 mg at bedtime. Unless clinically contraindicated at tis time could we please consider to increase the dose to 10 mg at bedtime or a dose preferred by prescriber. The recommendation did not have a response from the prescriber and had no documented followed up by the facility. Review of pharmacy recommendations for Resident #55 on revealed a pharmacy recommendation on12/18/25 that stated the resident had an order for Donepezil tablet five mg one tablet by mouth daily for dementia. The recommendation documented he manufacturer's recommendations suggest Start five mg at bedtime for four to six weeks then increase to 10 mg at bedtime. Unless clinically contraindicated at tis time could we please consider to increase the dose to 10 mg at bedtime or a dose preferred by prescriber. The recommendation did not have a response from the prescriber and had no documented followed up by the facility. Interview with Director of Nursing (DON) on 02/25/26 at 2:15 P.M. confirmed the above listed pharmacy recommendations were not did not have a response from the prescriber and should have been followed up on.

Based on record review, interview, and facility policy review, the facility failed to have a justified diagnosis for the use of a psychiatric medication. This affected one resident, (Resident #55), out of five residents reviewed for unnecessary medication. The facility census was 60.Findings include: Review of the medical record for Resident #55 revealed an admission date of 01/15/25 with diagnoses including but not limited to, anxiety (01/15/25), insomnia (01/15/25), major depressive disorder (03/20/25), unspecified dementia (03/20/25), and unspecified mood affective disorder (03/20/25). Review of Resident #55's physician orders on 02/24/26 revealed an order for Olanzapine (antipsychotic) five milligrams (mg) one tablet by mouth at hour of sleep for schizophrenia beginning 12/16/25, and Olanzapine 2.6 mg one tablet by mouth every day for schizophrenia beginning 12/17/25. Review of annual Minimum Data Set (MDS) 3.0 section C, dated 01/26/26, on 02/24/26 revealed a Brief Interview for Mental Status (BIMS) of nine. Further review under section I revealed no diagnosis of schizophrenia. Review of PASRR completed 04/03/25 on 02/24/26 revealed no diagnosis of schizophrenia. Interview with Director of Nursing (DON) on 02/25/26 at 12:10 P.M. confirmed Resident #55 did not have a diagnosis in the record of schizophrenia but was receiving medication for it. Interview with the Administrator on 02/25/26 at 2:25 P.M. revealed the diagnosis of schizophrenia was identified after Resident #55's admission at the behavioral health hospital 03/14/25. However, further interview revealed the paperwork the facility obtained from the behavioral health hospital post discharge confirmed there was no diagnosis of schizophrenia. Review of the facility's Psychotropic Medication Management Policy dated 03/05/25 revealed an unnecessary drug is any drug when used without adequate indications for use. Further review of the policy also revealed when psychotropic medications are ordered or increased the facility will ensure a specific diagnosis is documented in the medical record.

Based on observation, interview, record review, and facility policy review, the facility failed to display proper Enhanced Barrier Precaution (EBP) signage. This affected two residents (Resident #23 and Resident #70). Furthermore, the facility failed to follow proper infection control procedures during dressing change for #39. This affected three residents of five reviewed for infection control. The facility census was 60.Findings include: 1.Review of Resident #23's medical record revealed an admission date of 01/06/26 with diagnoses that included but were not limited to hypertension, diabetes, and hyperlipidemia. Review of Resident #23's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of mental status score of 15 indicating the resident was cognitively intact. Further review of the MDS revealed the resident had a multidrug resistant organism and isolation/quarantine for an active infectious disease. Observation of Resident #23 on 02/23/26 at 11:25 A.M. revealed an EBP tote outside of their room. There was no signage on the residents' door identifying them as being on EBP or further precautions. 2.Review of Resident #70's medical record revealed an admission date of 01/14/26 with diagnoses that included but were not limited to coronary artery disease, hypertension, and diabetes. Review of Resident #70's Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of mental status score of 14 indicating the resident was cognitively intact. Further review of the MDS also identified the resident as being on oxygen and intravenous (IV) medications. Observation of Resident #70 on 02/23/26 at 11:25 A.M. revealed an EBP tote outside of their room with no signage identifying the resident as being on EBP or further precautions. Review of the facility's list of residents on EBP on 02/23/26, provided by the facility on 02/23/26, revealed Resident #23 and Resident #70 were on EBP. Interview with the Director of Nursing (DON) on 02/24/26 at 8:27 A.M. confirmed both Resident #23 and Resident #70 were on EBP and did not have signage on their door indicating EBP precautions were required on 02/23/26. The DON confirmed the signage should have been on the room door for both Resident #23 and Resident #70. Review of the facility's Infection Prevention and Control Program revised 11/05/21, on 02/24/26, revealed part of the facility's practice to prevent and control onset and spread infection is to use standard and transmission-based precautions. Further review of the policy revealed the facility was to implement practices consistent with accepted standards to help reduce the spread of infections. 3. Review of Resident # 39's medical record revealed an admission date of 01/15/26 with diagnoses that included but were not limited to osteomyelitis of the right ankle and foot, Diabetes Mellitus Type II with neuropathy, acquired absence of left leg below the knee and stage four sacral pressure ulcer. Review of Resident # 39's Minimum Data Set MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11. He required assistance from staff with transfers, toileting hygiene and dressing. Review of Resident # 39's physicians orders dated February 2026 revealed the following sacral wound care order: cleanse wound with normal saline or wound cleanser. Pat dry. Apply calcium alginate and cover with a clean dry dressing daily every day shift and as needed. Observation on 02/25/26 at 8:35 A.M. of Resident # 39's sacral wound care with Licensed Practical Nurse (LPN) # 179 revealed LPN # 179 gathered a calcium alginate dressing, wound cleanser and a bordered gauze and placed them on the resident's bedside table. LPN # 179 and Certified Nursing Assistant (CNA) # 124 sanitized their hands and applied gowns and gloves. With gloved hands LPN # 179 removed the soiled dressing from Resident # 39's sacrum and carried it to the bathroom to dispose of it. He returned carrying a small trash can from the bathroom which he placed on the floor bedside him. LPN # 179 then proceeded with wound treatment by spraying the wound with wound cleanser, he applied the calcium alginate dressing and then applied a clean dry dressing. Interview on 02/25/26 at 8:47 A.M. with LPN # 179 confirmed while completing Resident # 39's sacral wound treatment he did not wash his hands or change his gloves after removing the soiled dressing and touching a trash can. He also verified he did not dry the wound area per order prior to applying calcium alginate and a clean dry dressing to Resident #39's sacral wound.

Based on medical record review, staff interview, and facility policy review, the facility failed to provide parameters for as needed pain medications. This affected one (Resident #39) of five residents reviewed for unnecessary medications. The census was 60.Findings Include:Resident #39 was admitted to the facility on [DATE]. His diagnoses were acute osteomyelitis, direct infection of right ankle, hypertensive heart and chronic kidney disease, Type II Diabetes, atrial fibrillation, sleep apnea, major depressive disorder, acute kidney failure, hyperlipidemia, hypertension, and pressure ulcer of sacral region (stage IV). Review of his minimum data set (MDS) assessment, dated 01/19/26, revealed he had a mild cognitive impairment. Review of Resident #39's physician orders found the following as needed pain medications orders: Oxycodone HCl (opioid) five milligrams (mg), one tablet every six hours as needed for pain; Oxycodone HCl five mg, two tablets every six hours as needed for pain; Acetaminophen (analgesic) 325 mg, give 650 mg every four hours as needed for pain/fever; and Morphine sulfate (opioid) 100 mg/5 milliliters (mL), 0.25 mL every four hours as needed for pain and shortness of breath. For all three as needed pain medication orders, there were no parameters documented as to when each medication should be administered.Review of Resident #39's January 2026 medication administration record (MAR), revealed the following medications were administrated and the pain levels associated with the pain medication: Acetaminophen was administered twice for pain levels six and seven; Oxycodone five mg, one tablet was administered nine times for pain levels one to eight; and Oxycodone five mg, two tablets was administered six times for pain levels between six to eight. Review of Resident #39's February 2026 MAR, revealed the following medications were administered and the pain levels associated with the pain medication: Morphine was administered 27 times for pain levels between 0 and 10, including two administrations for pain levels of zero; Oxycodone five mg, one tablet was administered five times for pain levels five to nine; and Oxycodone five mg, two tablets was administered 14 times for pain levels between four to ten. Interview with Licensed Practical Nurse (LPN) #190 on 02/26/26 at 11:50 A.M. confirmed there should be parameters on all as needed pain medications. Typically they will administer high strength pain medication, like Oxycodone, for pain levels that are six or higher, and they will administer a lower strength pain medication, like Acetaminophen, for pain levels one to five. She also confirmed as needed pain medication should not be administered for a pain level of zero.Interview with Director of Nursing (DON) on 02/26/26 at 11:52 A.M. confirmed as needed pain medication should be administered as ordered. She stated the nurses can use their judgement or the resident (if cognitively intact) can tell the nurse which medication they want when they have pain. But, she confirmed there are typically parameters for as needed pain medication.Review of facility Pain Management policy, dated 12/28/21, revealed after consultation with the physician and resident (or resident representative), medication and dosage schedules will be established based on the characteristics of the resident's pain.

Based on record review, review of self reported incidents (SRI), interview, and policy and procedure review, the facility failed to ensure residents received appropriate assistance with transfers and failed to ensure a sit to stand lift was used appropriately during a transfer. This affected two residents (#29 and #58) of five residents reviewed. The census was 56. Actual physical harm occurred to Resident #29 on 04/15/25 when staff failed to have the sling to the sit to stand lift applied appropriately under the resident during a transfer and the resident sustained bruising, a hematoma, fractured ribs resulting in the resident being transferred and admitted to the hospital with diagnoses of hematoma, bruising, rib fractures, and anemia from blood loss. The resident complained of increased pain as a result of the incident and was hospitalized for seven days for treatment following the incident. Actual physical harm occurred to Resident #58 on 02/22/25 when a Certified Nursing Assistant (CNA), without the use of a gait belt, assisted the resident to ambulate to the bathroom, the resident started to fall and the CNA grabbed the resident and held the resident up by the resident's arms causing a dislocated shoulder as the resident was laid on the ground. The resident was transferred and admitted to the hospital with a diagnosis of a dislocated right shoulder with surgery recommendation for repair. Findings include: 1. Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, diabetes, atrial fibrillation, left above knee amputation, morbid obesity, non pressure ulcer of the left leg, lymphedema, chronic kidney disease and absence of right toes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29's cognition was intact. The assessment revealed the resident was independent with eating, required (staff) set up or clean up assistance with oral hygiene, substantial/maximal staff assistance with toileting, partial/moderate staff assistance for bathing/showering, and personal hygiene and staff supervision/touching assistance for turning and repositioning. She was dependent on staff for sit/to stand, chair to bed, toilet transfer, and tub/shower transfer. The resident was occasionally incontinent of bowel and frequently incontinent of urine. Review of Resident #29's Functional Abilities assessment dated [DATE] revealed the resident was dependent on staff for toileting hygiene, shower/bathing, dressing, personal hygiene, turning and repositioning, sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. Resident #29 was non-ambulatory. Review of the nursing note dated 04/19/25 at 8:20 P.M. revealed Resident #29 complained of pain around arm pit and axillary area, when checked, bruising and swelling was noted. The physician was notified and ordered ICE and massaging the area. Review of the facility investigation dated 04/20/25 revealed Resident #29 reported discomfort and pain on her left arm pit, when the resident was assessed and the nurse inspected the area, the nurse identified a hardened purplish bruise. When the resident was asked what had happened she revealed she had gotten the bruise from the sit to stand sling when she was going to bed on 04/15/25. She had not reported pain or discomfort at the time of the incident when asked if she felt pain when it happened. The area measured 11 centimeters (cm) by six cm. The resident's physician was notified and ordered no sling uses until re-evaluation, ICE (Rest, Ice, Elevation and Massage). Review of the nursing note dated 04/21/25 at 6:18 P.M. revealed the resident was seen by the physician. A new order was received to hold Eliquis (oral anticoagulant medication) four doses due to bruising around the arm pit and axillary area and prednisone (steroid) 30 milligrams (mg) everyday for three days then back to 10 mg everyday. The nursing note revealed bruising was persistent and monitoring to occur every shift, no bleeding noted, area intact. When needed pain medications given as ordered. Review of the nursing note dated 04/23/25 at 4:48 P.M. revealed the resident complained of not feeling well, dizziness, weakness, no void (urine output) since midnight. Resident #29 requested to be sent to the hospital and was admitted for bruising, anemia (requiring blood transfusion) and rib fractures. On 05/12/25 at 12:42 P.M. interview with Resident #29 revealed the aide used the sit to stand lift (on 04/15/25) to put her to bed and the sling that goes around her was twisted. The resident indicated she had no pain (at first) but the next day as the day wore on it became more painful, then the next day it was quite painful. They finally sent the resident out and her hemoglobin was a six (6), the resident had a huge hematoma, bruising under her arm and fractured ribs. The resident was admitted and received three units of blood. Further interview with Resident #29 on 05/13/25 at 9:35 A.M. revealed she was transferred on 04/15/25 with the sit to stand lift by one CNA. The resident stated that's what they did all the time with the sit to stand lift. Review of the Hospital After Summary Visit form revealed Resident #29 was hospitalized from 04/24/25 to 05/01/25. On 05/12/25 at 2:24 P.M. interview with the Assistant Administrator revealed on 04/15/25, one CNA was operating the sit to stand lift to transfer Resident #29. The CNA no longer worked at the facility as of this date. Per the Assistant Administrator, CNA #128 was trained on the proper use of the sit to stand lift after the incident was brought to the facility's attention. 2. Record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses that included heart failure, chronic obstructive heart disease, diabetes, depression, and chronic kidney disease (CKD). Review of the admission MDS dated [DATE] revealed Resident #58's cognition was intact. The resident was assessed to be independent with eating, required staff set up or clean up assistance with oral hygiene, toileting, partial moderate staff assistance for showering/bathing, dressing, personal hygiene and turning and repositioning and supervision and touching assistance for transfers. The resident was occasionally incontinent of urine and frequently incontinent of bowel. Review of the nursing note dated 02/22/25 at 5:54 A.M. revealed Resident #58 was found on the floor laying on her back and her head down, with the walker on top of her, nurse called out her name but the resident was not responding to simple commands at the time. The nurse initiated a breathing treatment, elevated the resident's head and called 911. The nurse stayed with the resident. No visible injuries were noted at the time. The paramedics arrived and took over care of the resident. The resident was transferred to the emergency room for further evaluation. Review of a self reported incident (SRI) form dated 02/25/25 revealed Resident #58 claimed a CNA pushed her on 02/22/25 when getting up to go to the bathroom. Review of the investigation statement form revealed CNA #146 stated it was a fall, per CNA #146 on 02/22/25, Resident #58 was agitated all night and had wet incontinence product on. The resident had her call light on and the CNA told the resident she would change the resident in the bed since her left foot was also swelling and the resident was already incontinent, but the resident became agitated and hoisted herself up. CNA #146 revealed she went to the other side of the bed, fixed the bed and gave the resident the walker. CNA #146 revealed Resident #58 was walking very quickly to the bathroom and she was behind the resident holding onto the walker and the resident was about to fall into the wall of the bathroom and CNA #146 was behind her and laid the resident down on the ground. CNA #146 revealed she did not have a gait belt on Resident #58 when she was assisting the resident to the bathroom, the CNA just laid her down by holding her up under her arms and laying her down. Review of an Orthopedic Surgery Consult Note dated 02/22/25 revealed she was found to have a right shoulder glenohumeral joint dislocation. Provisional reduction was performed in the emergence room, however it was unstable and continued to re-dislocate. There was tentative plans for surgical management, however the resident and family declined surgery. On 05/13/25 at 10:08 A.M. interview with the Administrator verified on 02/22/25 Resident #58 was up with a walker ambulating to the bathroom with the assistance of CNA #146 when the resident was about to fall into the wall so CNA #146 laid the resident down causing the resident to sustain a shoulder dislocation. The Administrator verified CNA #146 did not use a gait belt when assisting Resident #58 to ambulate to the bathroom. Review of the facility policy Use of Gait Belt dated 10/13 revealed the gait belt should be used by the Elder Assistant and/or nurse during every transfer and during ambulation of an elder that requires assistance. This deficiency represents non-compliance investigated under Complaint Number OH00165495.

Based on observation and staff interview, the facility failed to prepare, distribute and serve food following proper infection control. This had the potential to affect the 12 of 12 residents residing in House 6690. The census was 56. Findings include: On 05/12/25 observations in the kitchen between 11:50 A.M. and 12:16 P.M. revealed Certified Nurse Aide (CNA) #100 washed her hands, put her hair up in a hair net, then put on gloves, gathered baked beans and hot dogs, removed her gloves and put on new gloves without washing her hands. CNA #100 opened the hot dogs and placed them in a pan of water and puts on the stove. She removed her gloves and put on new gloves without washing her hands and opened the baked beans and placed them in a pan. CNA #100 then removed her gloves and washed her hands. At 12:12 P.M. CNA #100 again put on a hair net and then gloves without washing her hands, added brown sugar to the baked beans using her gloves, removed her gloves and her hair net and walked down the hall without washing her hands. At 12:16 P.M. observation revealed CNA #151 washed her hands and put on a hair net and then gloves, gathered silverware and napkins and passed out to the residents, removed gloves and put on new gloves and prepared the drinks. Interview with CNA #100 and CNA #151 on 05/12/25 at 12:50 P.M. verified they had not washed their hands in between glove changes and after putting on their hair nets. This deficiency represents incidental findings of non-compliance investigated under Master Complaint Number OH00165495.

Based on medical record review, staff interview and facility policy and procedure review, the facility failed to follow physician orders for obtaining weekly weights to monitor weight gain related to congestive heart failure. This affected one resident (#29) of five resident record reviews. The census was 56. Findings included: Review of Resident #29's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, diabetes, atrial fibrillation, left above knee amputation, morbid obesity, non pressure ulcer of the left leg, lymphedema, chronic kidney disease and absence of right toes. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact. She was independent with eating, required set up or clean up assistance with oral hygiene, substantial/maximal assistance with toileting, partial/moderate assistance for bathing/showering, and personal hygiene and supervision/touching assistance for turning and repositioning. She was dependent on staff for sit/to stand, chair to bed, toilet transfer, and tub/shower transfer. The resident was occasionally incontinent of bowel and frequently incontinent of urine. Review of the physician orders revealed an order dated 01/19/25 to check the resident's weight weekly and notify physician if weight was up five pounds in one week. The resident was to be weighed one time a day every seven days for congestive heart failure, weight gain. Further record review revealed documented weights of 01/21/25 at 256 pounds (lbs), 02/01/25 at 256.4 lbs, 02/19/25 at 256.4 lbs, 03/12/25 at 267 lbs, 03/18/25 at 267 lbs, 04/03/25 at 265.2 lbs and 4/10/2025 at 265.5 lbs. Interview on 05/13/25 at 10:00 A.M. with the Director of Nursing verified weekly weights had not been obtained according to physician orders. Review of the undated facility policy and procedure Weights if weekly weights are requested, they will be done on a daily basis or weekly based on the day the initial weight was obtained. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00165495.

Based on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to obtain resident weighs as ordered, failed to thoroughly assess Resident #103's nutritional status and contributing factors to nutritional deficits, and failed to provided double portioned food items as ordered to prevent malnutrition/weight loss. Additionally, the facility failed to ensure supplements were provided to Resident #20 as ordered and failed to re-weigh the resident following a significant change to the resident's weight per (facility) policy. Actual harm occurred on 08/14/24 when Resident #103 was identified to sustain a severe 8.8 percent (%) weight loss (16 pounds) since admission to the facility on [DATE] without evidence of comprehensive or individualized interventions being implemented to prevent or timely identify the weight loss. This affected two (#20 and #103) of six residents reviewed for nutrition. The facility census was 52. Findings include: 1. Review of the medical record for Resident #103 revealed an admitted [DATE] with diagnoses including quadriplegia, type two diabetes mellitus, depression, atherosclerosis of other arteries, osteoarthritis, spinal stenosis, paroxysmal atrial fibrillation, and neuromuscular dysfunction of the bladder. Review of Resident #103's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #103 had moderately impaired cognition. The resident had one unstageable pressure ulcer (obscured full-thickness skin and tissue loss) and one stage four pressure ulcer (full-thickness skin and tissue loss). Review of Resident #103's physician order dated 07/19/24 revealed an order for a regular diet with double meat portions. Review of Resident #103's physician order dated 07/20/24 revealed she was to get weekly weights for four weeks due to risk for malnutrition. Review of Resident #103's weights revealed on 07/20/24 she weighed 181 pounds and on 07/29/24 she weighed 177.8 pounds. Review of Resident #103's nutritional assessment dated [DATE] revealed the resident had reported her current body weight of 177.8 pounds as her usual body weight. She was totally dependent on staff for eating and consumed 51 percent (%) to 100% of her meals. The resident was on a regular diet with regular texture. Her estimated calorie needs were 2,000 to 2,240 calories, 80 to 96 grams of protein, and 2,400 milliliters of fluid. Her medications were reviewed, and no recommendations were given. Review of the assessment revealed no mention of Resident #103's wounds or diet order for double meat portions. Review of Resident #103's medication administration record (MAR) for July 2024 revealed her weekly weight was 181 pounds on 07/20/24 and marked as 'not applicable' on 07/27/24. Review of Resident #103's meal intake records since admission revealed the resident consumed 0% to 25% of her meal on four occasions, 26% to 50% of her meal on 14 occasions, 51% to 75% of her meal on 23 occasions, and 76% to 100% of her meal on 28 occasions. Review of Resident #103's plan of care dated 08/02/24 revealed she was at risk for changes to nutrition and hydration due to past medical history and quadriplegia, she was to receive a regular diet with thin liquids. Interventions included educating the resident on the importance of adequate calorie intake, encouraging to her to drink fluids, encouraging to her to eat and drink by offering food and fluid she likes, encouraging calorically dense foods, encouraging her to eat plenty of protein, encouraging participating in menu planning, helping at meals and snack time by assisting as needed, and offering a substitute as needed. Review of Resident #103's MAR for 08/01/24 to 08/13/24 revealed no weekly weight was obtained on 08/03/24 and it was marked as 'not applicable' on 08/10/24. Review of Resident #103's weights revealed on 08/14/24 she weighed 165 pounds. This was a severe 8.8% (16 pounds) loss over less than thirty days. Interview on 08/12/24 at 11:55 A.M. with Resident #103 revealed she felt as though she had lost a lot of weight. She reported she did not think she got double portions of meat, and she would not eat them if she did. Resident #103 reported nobody spoke to her about her weight, but she would like ice cream to supplement her intake. Observation of the lunch meal on 08/13/24 beginning at 12:05 P.M. revealed Resident #103 received regular meat portions (tuna salad). Interview on 08/13/24 after the lunch observation at 12:40 P.M. with State tested Nurse Aide (STNA) #172 verified Resident #103 received a regular diet with regular portions, and reported Resident #103 was on a regular diet and had been for her entire stay. STNA #172 reported meals were prepared using the diet list hanging in the kitchen, which indicated she was a regular diet. Review of the diet list provided on 08/13/24 at 12:40 P.M. by STNA #172 revealed the diet list was dated 08/09/24 and Resident #103 was not listed as requiring double meat portions. Interview on 08/14/24 at 11:11 A.M. with Diet Technician #309 and Regional Diet Technician #305 revealed Diet Technician #309 was new to the building. They verified Resident #103 had an order for double meat portions. Diet Technician #309 verified she had completed the nutrition assessment dated [DATE]. The assessment did not address the double meat portions or Resident #103's wounds. The dietitian was to assess residents with pressure ulcers. Regional Diet Technician #305 revealed she had just introduced the new diet technician to the wound nurse so the wound nurse could update them on who has wounds. She verified Resident #103's wounds were not addressed in her assessment. The Diet Technicians additionally verified Resident #103's weekly weights were not completed as ordered. Interview on 08/19/24 at 2:12 P.M. with Regional Dietitian #311 verified he had not yet evaluated Resident #103 who had pressure ulcers. He was unaware Resident #103's most recent weight was a significant weight change. Review of the policy titled, Weight Policy, dated 12/02/21, revealed residents were to be weighed weekly for the first four weeks to establish a baseline weight. Monthly weights were to be taken by the fifth of the month and recorded in the electronic medical record. 2. Review of the medical record revealed Resident #20 was admitted to facility on 05/22/23 with diagnoses that included traumatic subdural hematoma, Parkinson's disease, heart failure, hemiplegia, hemiparesis, depressive disorder, and seizures. Review of Resident #20's MDS 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 01, indicative of severe impairment for daily decision making. The MDS 3.0 assessment indicated Resident #20 received a substantial to maximal level of assistance with eating and had lost a significant amount of weight as of 07/02/24. Review of the nutrition progress note on 07/18/24 revealed that Resident #20 had lost a significant amount of weight, but that he was now stabilized, with a weight range of between 155 pounds to 158 pounds and accepting Ensure nutritional supplements three times daily. Further medical record review revealed on 07/29/24, Resident #20 had a weight of 158 pounds. Review of weight status revealed that on 08/05/24, Resident #20 had a weight of 150 pounds, indicative of an eight-pound weight loss, or a five percent significant weight loss, in seven days. As of 08/13/24, the medical record was silent for acknowledgment of the eight-pound weight loss. An interview on 08/14/24 at 9:10 A.M. with Regional Diet Technician #305 revealed the state tested nurse aides (STNAs) are responsible for distributing the Ensure nutritional supplements, and the nurses are responsible for recording the amount of Ensure consumed on the medication administration record. Interview with Regional Diet Technician #305 confirmed the facility did not follow their weight policy, which was to re-weigh residents with significant weight changes by the tenth day of the month. Regional Diet Technician #305 stated the facility would re-weigh Resident #20 on 08/14/24. On 08/14/24, Resident #20 was observed to not be offered his Ensure nutritional supplement. The Ensure was scheduled to be delivered to Resident #20 between the hours of 8:00 A.M. and 11:00 A.M. An interview with Resident #20 on 08/14/24 revealed that Resident #20 stated that he was hungry and wanted a snack. Resident #20 confirmed that he had not received Ensure nutritional supplement on 08/14/24. On 08/14/24 at 11:06 A.M., Resident #20 was observed to be weighed by STNA #45 and STNA #196. Resident #20's weight was observed to be 150 pounds, confirming the eight-pound weight loss identified on 08/05/24. An interview on 08/14/24 at 11:16 A.M. with STNA #45 confirmed that Resident #20 was not offered his Ensure supplement, which was scheduled to be delivered between 8:00 A.M. and 11:00 A.M. STNA #45 stated Resident #20 did not like Ensure nutritional supplement, so it was not offered. On 08/14/24 at 11:20 A.M., Resident #20 was observed to be served a fruit plate as a snack by STNA #45. On 08/14/24 at 12:59 P.M., Resident #20 was observed to be drinking chocolate flavored Ensure nutritional supplement, which was well accepted. There was an order for the second Ensure nutritional supplement of the day to be served between the hours of 12:00 P.M. and 3:00 P.M. Review of facility weight policy, created 12/02/21, revealed that the Food Coordinator, the Director of Nursing, and/ or the Dietitian or Diet Technician will request a reweigh for those persons with significant weight changes and or fluctuations of three to five pounds. The reweighs will be completed by the tenth of the month. If a significant weight change is noted, the dietitian or diet technician will then proceed with the following as appropriate: review current diet order, request weekly weights, speak with the resident at mealtime, evaluate the above data, make recommendations for interventions, and document the above in the medical record. 50008

Based on observation, medical record review, staff interview, review of facility menu, and review of a dietary initiative, the facility failed to follow the menus and recipes for meals. This had the potential to affect all residents with the exception of Resident #8 who the facility identified as not eating anything my mouth. The facility census was 52. Findings include: 1. Review of the menu for 08/13/24 revealed residents were to receive tuna salad on croissant (one each), half a cup of mixed vegetables, five to eight crackers and cheese, one orange push pop, and milk. Observation in House #400 on 08/13/24 of the lunch meal at 11:17 A.M. revealed State tested Nurse Aide (STNA) #172 preparing tuna salad while not using any measuring utensils. Interview on 08/13/24 at 11:29 A.M. with STNA #172 revealed lunch would be tuna salad, crackers, cheese, and mixed vegetables. Observation on 08/13/24 at 12:05 P.M. revealed STNA #172 preparing resident meals. The meals included a small bowl of fruit, four to five slices of cheese, and five to eight crackers. STNA #172 then used a regular spoon to scoop tuna salad on to each of the resident plates. When she had prepared six plates, she reported she did not have enough for the last plate, she took tuna salad from some of the other plates and put it on the last plate. The resident's tuna salad portion varied from golf ball sized to a little bigger than a golf ball. All seven (#11, #14, #26, #33, #102, #103, and #104) residents were served this meal. Interview on 08/13/24 at the end of the 12:05 P.M. observation with STNA #172 revealed mixed berries were given instead of mixed vegetables because the residents had received mixed vegetables the previous night. She reported the meal called for croissants; however, the wrong croissants had been ordered so she did crackers instead. STNA #172 verified she had not used any measurements to portion the amount of tuna the residents received. STNA #172 reported she had not followed a recipe for tuna salad. There were some recipes in a book in the kitchen; however, she reported they could search for a recipe online or make it from memory if they knew how to make it. STNA #172 additionally verified that the residents did not receive dessert, and stated they would be given to the residents later and it would not be push pops as most residents did not like them. 2. Review of the menu for 08/14/24 revealed residents were to receive a half a cup of loaded potato soup, a soft pretzel with cheese, half a cup of green beans, half a cup of mixed berries, and milk. Observation in House #300 on 08/14/24 of the lunch meal at 12:47 P.M. revealed residents were served soup, berries, a pretzel, green beans, and juice. Residents were not provided milk or cheese. Interview on 08/14/24 at 1:39 P.M. with STNA #126 verified residents were not given cheese with their pretzel. She additionally revealed residents only received milk at breakfast. 3. Review of the regular menu and the soft and bite sized menu from 08/02/24 to 08/19/24 revealed several instances of food being omitted from the soft and bite sized diet and not replaced. Review of the dinner menu for 08/04/24 revealed residents on a regular diet received beef stroganoff, steamed cauliflower, dinner roll, and chocolate cake. For dinner on 08/04/24 residents on a soft and bite sized diet received beef stroganoff, steamed cauliflower, and chocolate cake soaked in milk. Review of the lunch menu on 08/06/24 revealed residents on a regular diet received two chicken or beef tacos, chips and salsa, sweet roasted corn, and pineapples. For lunch on 08/06/24 residents on a soft and bite sized diet received ground beef with cheese and sour cream, half a baked potato with no skin, and pineapple chunks. Review of the lunch menu on 08/07/24 revealed residents on a regular diet received pepper steak, white rice, peppers and onions, and mandarin oranges. For lunch on 08/07/24 residents on a soft and bite sized diet received cream of mushroom soup, peppers and onions, and mandarin oranges. Review of the dinner menu on 08/09/24 revealed residents on a regular diet received stuffed green peppers, buttered noodles, Italian bread and pudding. For dinner on 08/09/24 residents on a soft and bite sized diet received stuffed green peppers, buttered noodles, and pudding. Review of the lunch menu on 08/14/24 revealed residents on a regular diet received loaded potato soup, soft pretzel with cheese, green beans, and mixed berries. For lunch on 08/14/24 residents on a soft and bite sized diet received loaded potato soup, green beans, and mixed berries. Review of the lunch menu on 08/16/24 revealed residents on a regular diet received chicken noodle soup, baguette or French bread, parmesan baked carrots, and blueberries. For lunch on 08/16/24 residents on a soft and bite sized diet received chicken noodle soup (broth only), steamed carrots, and strawberries. Review of the dinner menu on 08/16/24 revealed residents on a regular diet received goulash, sauteed zucchini and mushrooms, a dinner roll, and pudding. For dinner on 08/16/24 residents on a soft and bite sized diet received goulash, steamed zucchini and mushrooms, and pudding. Review of the lunch menu on 08/17/24 revealed residents on a regular diet received a shredded chicken quesadilla, black bean soup, fajita peppers and onions, and peaches. For lunch on 08/17/24 residents on a soft and bite sized diet received quesadilla chicken and cheese with no tortilla, steamed fajita peppers and onions, and peaches. Review of the dinner menu on 08/18/24 revealed residents on a regular diet received vegetable lasagna, garlic bread, green beans, and sugar cookies. For dinner on 08/18/24 residents on a soft and bite sized diet received vegetable lasagna, steamed green beans, and dessert of choice. Review of the lunch menu on 08/19/24 revealed residents on a regular diet received turkey burger sliders, tater tots, green beans, apple pie a la mode, and grapes. For lunch on 08/19/24 residents on a soft and bite sized diet received turkey burger sliders, tater tots, and green beans. Interview on 08/19/24 at 2:12 P.M. with Dietitian #311 revealed the menus provided were 'as served.' Residents on a soft and bite sized diet should always receive substitutions on things from the regular menu they are unable to eat. He reported the nurse aides knew how to use the fork test to determine what they could serve the residents. He verified the menu 'as served' was approved by him. He indicated residents on a soft and bite sized diet should always receive dessert. Review of the International Dysphagia Diet Standardization Initiative (IDDSI) description of the soft and bite sized diet (provided as facility policy) revealed food could be tested with the fork pressure diet to ensure it was soft and bite sized. To make sure food is soft enough press down on the fork until the thumbnail blanches to white, then lift the fork to see that the food is completely squashed and does not regain shape. 4. On 08/13/24 at 11:53 A.M., observation of STNA #126 revealed she opened eight cans of tuna and placed it in a clear glass bowl. STNA #126 had no recipe to follow for preparing the tuna salad for lunch. She then cut up a large purple onion and placed in the tuna, then placed an unmeasured amount of mustard and mayonnaise in the bowl and mixed the tuna. Interview at the time of the observation with STNA #126 stated she used a recipe she got off Youtube for the meal. 5. Review of the medical record for Resident #23 revealed an initial admitted [DATE] with the diagnoses including but not limited to cerebral atherosclerosis, disorder of thyroid, anxiety disorder, dementia, diverticulosis of large intestine, slow transit constipation, anxiety disorder, chronic pain, osteoarthritis, hearing loss, and generalized muscle weakness. Review of Resident #23's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident had no known weight loss and was not receiving a mechanically altered diet. Review of the plan of care dated 07/15/24 revealed Resident #23 was receiving hospice care/comfort related to doesn't eat enough to prevent decline and declines tube feeding or intravenous therapy. Interventions included assist resident at meal and snack time as needed, communicate with hospice routinely and as needed, encourage to eat and drink by offering food and fluids that resident likes, encourage family to bring food and fluids in the resident likes, offer substitutes when does not like what is served, observe for signs/symptoms of dehydration, observe ability to feed herself at meals and recommend therapy screen as needed, observe intakes, weights, labs and skin condition routinely and report as needed, provide the diet as ordered and provide medications as ordered. Review of Resident #23's monthly physician orders for August 2024 identified an order dated 05/23/24 for a regular diet, soft and bite sized texture, thin liquid consistency with pleasure foods. Review of the facility's weekly menu revealed Resident #23 was to receive two sliders cut up without the bun, green beans, tator tots, and milk. Further review revealed the resident had no soft food to replace the apple pie or grapes. On 08/19/24 at 12:20 P.M., observation of STNA #350 preparing Resident #23's lunch meal revealed the resident was on a soft, bite size, finger food diet. The STNA opened a container of chicken salad and used a tablespoon and placed an unmeasured amount of the chicken salad on the resident's plate. The STNA then opened a box of bite size crackers and placed an unmeasured amount on the resident's plate. The STNA then opened an individual container of applesauce and placed on the resident's plate. The resident was given juice with her meal. STNA #350 verified during interview at the time of the observation they had not followed the menu and did give the resident what soft food was available in the house. 32654

Based on observation review of food storage temperature logs, and staff interview, the facility failed food was stored in a safe and sanitary manner. This had the potential to affect all 51 residents receiving food from the facility. The facility identified Resident #8 as eating nothing by mouth. The census was 52. Findings include: 1. Observation on [DATE] from 9:06 A.M. to 9:49 A.M., in House #300, revealed food debris was noted in both the pantry refrigerator and the kitchen refrigerator. Observation of the refrigerator in the pantry revealed it felt warm and the sensor connected to it read 72 degrees Fahrenheit (F). State tested Nurse Aide (STNA) #126 pointed out the internal temperatures which indicated the refrigerator was 54 degrees F and the freezer was 24 degrees F. The refrigerator contained milk, eggs, cheese, coleslaw, and pasta salad. The freezer contained frozen vegetables, chicken, lasagnas, ground turkey, and pierogies, and these foods were starting to soften. Interview with STNA #126 at the time of the observation revealed the refrigerator was connected to a sensor and the dietitian received the results. STNA #126 initially reported the dietary staff came around and read the temperatures every morning, and later said everyone documented the temperatures in the log. STNA #126 was unable to find a filled in temperature log for House #300. STNA #126 had not checked temperatures that morning and was unsure how long the refrigerator had been down. 2. Observation on [DATE] from 9:06 A.M. to 9:49 A.M., in House #200, revealed expired foods were noted, including thousand island dressing dated [DATE], mozzarella cheese dated [DATE], hot dog buns dated [DATE], and sour cream dated [DATE] Interview with STNA #45 verified the foods were expired at the time of the observation. 3. Observation on [DATE] from 9:06 A.M. to 9:49 A.M., in House #100, revealed expired foods were noted, including chip dip dated [DATE], coleslaw dated [DATE], carrots dated [DATE], and hamburger buns dated [DATE]. Observation of the pantry refrigerator and freezer had food debris, splatter, and what appeared to be hair on the bottom of the shelf. Interview with STNA #63 verified the findings at the time of the observation. 4. Observation on [DATE] from 9:06 A.M. to 9:49 A.M., in House #500, revealed expired foods were noted, including wheat bread dated [DATE], coleslaw dated [DATE], burrito tortillas dated [DATE], two packages of flour tortillas dated [DATE] and [DATE], sandwich sauce dated [DATE], provolone cheese dated [DATE], and a container of swish cheese that was open, undated, and hardened. Interview with STNA #7 verified the findings at the time of the observation. 5. Observation on [DATE] from 9:06 A.M. to 9:49 A.M., in House #400, revealed expired foods were noted, including bread dated [DATE], caramel topping dated [DATE], and ham dated [DATE]. Additionally, observation of the pantry refrigerator revealed a large liquid stain and other food debris. Interview with STNA #190 verified the findings at the time of the observation. STNA #190 indicated nurse aides were supposed to document food temperatures in a log kept in the kitchen; however, she was unable to find an [DATE] log. Refrigerator and freezer temperatures had not been obtained that morning. 47569

Based on observation, medical record review, and resident and staff interview, the facility failed to change and date oxygen tubing and supplies as ordered and failed to store respiratory equipment in a safe and sanitary manner. This affected four (#13, #42, #154, and #155) of seven residents reviewed for respiratory care. The census was 52. Findings Include: 1. Review of the medical record for Resident #154 revealed initial admitted [DATE] and re-admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and other diseases of the bronchus. Resident #154 had intact cognition and required limited assist from staff for activities of daily living (ADLs) tasks and medication administration. Review of the respiratory care plan for Resident #154 dated 05/31/24 revealed oxygen used as ordered and breathing treatments as ordered. Review of the physician orders for Resident #154 revealed an order dated 08/02/24 to change oxygen tubing weekly every night shift every seven days, and an order dated 08/02/24 for humidified oxygen at five liters per minute continuous to maintain oxygen levels 90 percent (%) or greater. Review of medication administration record (MAR) for Resident #154 dated 08/02/24 to 08/12/24 revealed the order for humidified oxygen at five liters per minute to maintain oxygen levels at 90% or greater was marked as being administered as ordered. Review of treatment administration record (TAR) for Resident #154 dated 08/02/24 to 08/12/24 revealed the order for changing oxygen tubing weekly every night shift every seven days for maintenance was marked as being completed on 08/09/24. Observation on 08/12/24 at 11:43 P.M. revealed Resident #154 receiving oxygen therapy via nasal cannula, there was no date on the oxygen tubing to reflect that last time the tubing had been changed. Resident #154 stated she did not know when the staff changes the oxygen tubing. 2. Review of the medical record for Resident #155 revealed admitted [DATE] with diagnoses including acute respiratory failure, pleural effusion, and anxiety. Resident #155 had intact cognition and required assistance from staff for ADLs. Review of the respiratory care plan for Resident #155 dated 08/13/24 revealed oxygen therapy received as ordered. Review of the physician orders for Resident #155 revealed an order dated 08/02/24 for oxygen at four liters per minute continuous via nasal cannula to keep oxygen levels at 90% or greater, and an order dated 08/07/24 to change and date oxygen tubing weekly every night shift every seven days. Review of the MAR for Resident #155 dated 08/02/24 to 08/12/24 revealed the oxygen at four liters per minute continuous via nasal cannula to keep oxygen levels at 90% or greater had been marked as being completed by staff twice daily, and change and date oxygen tubing weekly every night shift every seven days for maintenance as having been changed on 08/07/24. Observation on 08/12/24 at 10:35 A.M. revealed Resident #155 siting at edge of bed with oxygen nasal cannula in place and the oxygen tubing attached to an oxygen concentrator sitting beside the day. There was no date noted on the oxygen tubing. Resident #155 stated she had only been at the facility a short time and did not know when the oxygen tubing was to be changed. Interview on 08/12/24 at 2:17 P.M. with Regional Registered Nurse #300 confirmed the oxygen tubing was not properly changed and dated for Resident #154 and Resident #155. 3. Review of the medical record for Resident #13 revealed an initial admitted [DATE]. Diagnoses including but not limited to acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), Parkinson's disease, restlessness and agitation, anxiety disorder, major depressive disorder, seizures, and hypertension. Review of the plan of care dated 05/30/23 revealed Resident #13 had COPD. Interventions included continuous oxygen at two liters as tolerated, elevate head of the bed due to shortness of breath, when out of bed keep upright in a chair during episodes of difficulty breathing, give supplements if needed to maintain adequate nutrition, give medications as ordered, monitor for anxiety, monitor for dyspnea, monitor for signs/symptoms of acute respiratory distress, monitor/report as needed any signs/symptoms of respiratory infection and occupational consult as ordered. Review of Resident #13's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors, however had wandering behaviors. The assessment indicated the resident received oxygen therapy. Review of Resident #13's monthly physician orders for August 2024 identified orders dated 01/05/24 for continuous oxygen at two liters and monitor oxygen saturation throughout the day, and on 04/23/24 to change aerosol tubing/mask every Tuesday for maintenance, change oxygen tubing weekly on Tuesday for maintenance. Review of the August 2024 treatment administration record (TAR) revealed the facility nurse initialed Resident #13's oxygen tubing was changed on 08/06/24 and 08/13/24, also the aerosol tubing/mask was changed on 08/06/24 and 08/13/24. On 08/12/24 at 10:59 A.M., observation of Resident #13 revealed the resident's oxygen tubing was dated 07/13/24 and the nebulizer delivery system was laying on the machine outside of a protective cover. On 08/12/24 at 11:17 A.M., Regional Nurse #300 verified Resident #13's oxygen nasal cannula was dated 07/12/24 and not changed as physician ordered. Regional Nurse #300 also verified the nebulizer delivery system was not in a protective cover. On 08/13/24 at 9:08 A.M., observation of Resident #13 revealed he was sitting in his recliner with legs elevated with oxygen in place. Further observation revealed the resident's oxygen nasal cannula was dated 07/13/24. 4. Review of Resident #42's medical record revealed an initial admitted [DATE] with the latest readmission of 02/16/24. Diagnoses included but not limited to Parkinson's disease, vascular dementia, abnormalities of gait and mobility, hypercholesterolemia, major depressive disorder, obstructive sleep apnea, benign neoplasm of peripheral nerves and autonomic nervous system, spinal stenosis, cervical disc disorder, and adult failure to thrive. Review of the plan of care dated 12/01/23 revealed Resident #42 had altered respiratory status/difficulty breathing related to sleep apnea. Interventions included to administer medications as ordered, monitor for side effects and effectiveness, elevate head of the bed when having difficulty breathing while lying flat, monitor for signs/symptoms of respiratory distress, and continuous positive airway pressure (CPAP) machine settings specified and delivered via mask nightly and with naps. Review of Resident #42's quarterly MDS assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of Resident #42's monthly physician orders for August 2024 identified the resident to sleep with CPAP at night and during naps for sleep apnea. On 08/13/24 at 9:56 A.M., observation of Resident #42's CPAP machine revealed the mask remained in the basket without a protective covering. On 08/12/24 at 11:17 A.M., Regional Nurse #300 verified Resident #42's CPAP machine mask was not in a protective covering. 32654

32654 Based on observation, medical record review, staff interview and facility policy review, the facility failed to develop a comprehensive plan of care to address resident needs and conditions as required. This affected four (#13, #26, #35, and #42) of 25 sampled residents reviewed. The facility census was 52. Findings Include: 1. Review of the medical record for Resident #13 revealed an initial admitted [DATE] with the latest readmission of 08/8/24. Diagnoses including but not limited to acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), Parkinson's disease, restlessness and agitation, anxiety disorder, major depressive disorder, seizures, hypertension, hyperlipidemia, insomnia, dementia, and atrial fibrillation. Review of Resident #13's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors, however had wandering behaviors. The assessment indicated the resident was always incontinent of bowel and frequently incontinent of bladder. Review of Resident #13's monthly physician orders for August 2024 identified an order dated 08/10/24 to apply Xeroform dressing, absorbent pad, and Kerlix to the right forearm every morning until healed. Review of Resident #13's plan of care revealed no care plan addressing the wound to the resident's right forearm. On 08/12/24 at 10:59 A.M., observation of Resident #13 revealed a dry and intact dressing to the resident's right forearm. On 08/19/24 at 11:34 A.M., interview with the Director of Nursing (DON) verified the resident had no care plan addressing the wound to the resident's right forearm. 2. Review of Resident #42's medical record revealed an initial admitted [DATE] with the latest readmission of 02/16/24. Diagnoses included but not limited to Parkinson's disease, vascular dementia, abnormalities of gait and mobility, hypercholesterolemia, major depressive disorder, obstructive sleep apnea, benign neoplasm of peripheral nerves and autonomic nervous system, spinal stenosis, cervical disc disorder, adult failure to thrive, hypothyroidism, progressive supranuclear ophthalmoplegia and vitamin D deficiency. Review of the plan of care dated 12/01/23 revealed Resident #42 was incontinent of bladder related to dementia. Interventions included the resident used disposable briefs and were changed frequently and as needed, cleanse peri-care with each incontinence episode, check as required for incontinence care, wash, rinse and dry perineum, change clothing as needed after each episode and monitor for signs/symptoms of urinary tract infection (UTI). Review of the bowel and bladder screen dated 04/02/24 revealed Resident #42 was frequently incontinent of both bowel and bladder. Review of Resident #42's functional abilities and goals dated 04/02/24 revealed the resident required substantial/maximal assistance with toileting and dressing. Review of Resident #42's quarterly MDS assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors, including rejection of care. The assessment indicated the resident was always incontinent of both bowel and bladder and was not on a toileting program. Review of Resident #42's monthly physician orders for August 2024 identified and order dated 01/22/24 wear thrombo-embolic deterrent (TED) hose daily every shift for deep vein thrombosis (DVT) prevention, may removed for bathing/hygiene, on in morning and off at bedtime. Review of the current plan of care revealed no care plan addressing Resident #42's incontinence of bowel or thrombo-embolic deterrent (TED) hose use. On 08/19/24 at 11:40 A.M., interview with the Director of Nursing (DON) verified there was no comprehensive plan of care developed to address Resident #42's bowel incontinence and TED hose use. 3. Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type two diabetes mellitus, major depressive disorder, peripheral vascular disease, and hypothyroidism. Review of Resident #26's comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition. Review of Resident #26's physician order dated 02/02/24 revealed an order for the diuretic Lasix oral tablet 20 milligrams (mg) one time a day every other day for edema related to hypertension. Review of Resident #26's plan of care on 08/15/24 revealed no care plan related to diuretics or hydration. Interview on 08/15/24 at 1:55 P.M. with Regional Nurse #300 verified Resident #26 did not have a plan of care related to potential fluid imbalance related to diuretics. 4. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, type II diabetes mellitus, dementia, anemia, and polyosteoarthritis. Review of Resident #35's MDS 3.0 assessment dated [DATE] revealed the resident had an unhealed unstageable pressure ulcer (obscured full-thickness skin and tissue loss) that was not present on admission. Review of Resident #35's care plan revealed he developed a deep tissue injury (DTI) on 06/24/24 to his right heel. Review of the wound evaluation dated 07/16/24 revealed Resident #35 had a stage four pressure ulcer (full-thickness skin and tissue loss) to the right heel. A care plan for a stage four pressure ulcer to the right heel was initiated on 08/13/24. The care plan had been silent for identifying the stage four pressure ulcer from its identification as a stage four pressure ulcer on 07/16/24 through 08/13/24. An interview with Regional MDS Nurse #307 on 08/14/24 at 3:33 P.M. confirmed Resident #35 had a stage four pressure ulcer to his right heel on 07/16/24, but that the care plan for the stage four pressure ulcer was not initiated until 08/13/24. Review of the facility policy titled, Comprehensive Care Planning Policy, dated 11/13/17, revealed the interdisciplinary team would develop, implement and evaluate the comprehensive person centered plan of care which includes measurable objectives and timeframes to meet a resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment. 43064

Based on observation, medical record review, and staff interview, the facility failed to maintain infection control during a dressing change, failed to implement enhanced barrier precautions, and failed to maintain sanitary placement of a urinary catheter bag. This affected seven (#8, #11, #25, #102, #103, #154, and #155) of eight residents reviewed for infection control practices. The facility census was 52. Findings Include: 1. Review of the medical record for Resident #8 revealed an admitted [DATE] with the diagnoses including Down syndrome, obstructive sleep apnea, chronic respiratory failure, asthma, and stage four pressure injury to right buttock. Resident #8 was dependent for all care, personal hygiene needs, and administration of medications and treatments. Resident #8 had impaired cognition and required a wheelchair for mobility. Review of the physician orders for Resident #8 revealed an order dated 07/04/24 for a right ischial wound with instructions to change wound vacuum three times a week with continuous suction at 125 millimeters of mercury (mmHg) every day shift every Tuesday, Thursday, and Saturday for wound care until resolved. Observation on 08/15/24 at 2:40 P.M. revealed Licensed Practical Nurse (LPN) #59 completing a wound dressing change for Resident #8. LPN #59 gathered the supplies, including a pair of bandage scissors, and entered Resident #8 room. LPN #59 placed the supplies on the chair sitting in the corner across form the bed. LPN #59 assisted in repositioning Resident #8 onto her left side, changed gloves, washed hands, and donned a new pair of gloves. LPN #59 then removed the soiled dressing and placed in the trash can. LPN #59 removed gloves and then donned a new pair of gloves without washing hands prior to donning the new pair of gloves. LPN #59 removed the bandage scissors and a piece of green dressing foam, and began cutting the dressing foam with the scissors to fit the wound bed. The scissors were not cleaned prior to cutting of the dressing foam. LPN #59 completed the dressing change, removed the used supplies' packaging and trash, removed the gloves, and exited the room. Upon arrival to the medication cart, LPN #59 used hand sanitizer to cleanse hands and placed the bandage scissors back into the top drawer of the medication cart without cleaning the scissors. Interview on 08/15/24 at 3:10 P.M. with LPN #59 confirmed the bandage scissors were not cleaned prior to cutting the green dressing foam and LPN #59 did not wash hands between glove changes during the dressing change procedure for Resident #8. 2. Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses including stomach cancer, adult failure to thrive, esophagus cancer, dysphasia, and high blood pressure. Resident #25 required assistance from staff for activities of daily living (ADL) tasks, medication administration, and personal hygiene. Resident #25 had impaired cognition, was hard of hearing, and received nutrition and medications via a peg tube. Review of the physician orders for Resident #25 revealed an order dated 08/06/24 for enhanced barrier precautions (EBP). Further review of Resident #25's treatment administration record (TAR) dated 08/06/24 to 08/15/24 revealed documentation of completion for the order of enhanced barrier precautions. Review of the medical record for Resident #154 revealed an initial admitted [DATE], and re-admitted [DATE], with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, other diseases of the bronchus, and a wound requiring dressing changes. Resident #154 had intact cognition and required limited assist from staff for ADLs tasks and medication administration. Review of the physician orders for Resident #154 revealed an order dated 08/14/24 for EBP with instructions for gloves and gown to be worn with treatment and/or care. Review of the medical record for Resident #155 revealed an admitted [DATE] with diagnoses including acute respiratory failure, pleural effusion, sepsis, and anxiety. Resident #155 had intact cognition and required assistance from staff for ADLs tasks. Resident #155 received antibiotic medications via peripherally inserted central catheter (PICC) line located in the upper right arm. Review of the physician orders for Resident #155 revealed an order dated 08/12/24 for EBP with instructions for gloves and gown to be worn with treatment and or care related to PICC line. Observations on 08/12/24 from 9:15 A.M. to 10:50 A.M. revealed Resident #25, Resident #154, and Resident #155 did not have any signage or notification located on the outside door or inside the room for EBP and there was no personal protective equipment (PPE) available outside the rooms for staff or visitors to put on when entering the room. Interview on 08/12/24 at 11:30 A.M. with Regional Nurse #300 confirmed the lack of signage and notification for EBP and the lack of PPE for Resident #25, Resident #154, and Resident #155. 3. Review of the medical record for Resident #102 revealed an admitted [DATE] with diagnoses including adult failure to thrive, hypertensive heart disease with heart failure, acute respiratory failure with hypoxia, and restlessness and agitation. Review of Resident #102's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and an indwelling catheter. Review of the plan of care revised 08/08/24 revealed Resident #102 had an indwelling catheter. Interventions included positioning catheter bag and tubing below the level of the bladder and away from room door, changing catheter as ordered, checking tubing for kinks frequently each shift, monitoring and documenting intake and output according to facility policy, monitoring pain or discomfort due to catheter, monitor for signs of discomfort on urination, and monitor and report to the physician signs of a urinary tract infection. Observation on 08/12/24 at 10:30 A.M. and 10:48 A.M. revealed Resident #102's catheter bag wrapped in a trash bag and hanging of her trash can. The trash can was observed to have trash inside it. Interview on 08/12/24 at 10:30 A.M. with Resident #102's family revealed the facility staff always placed the catheter bag on the trash can. Interview on 08/12/24 at 10:50 A.M. with State tested Nurse Aide (STNA) #172 verified the catheter bag was hanging on the trash can. STNA #172 indicated the nurse would need to address whether or not this was appropriate. Interview on 08/12/24 at 11:11 A.M. with LPN #400 verified the catheter bag was hanging on the trash can, and reported this was because staff was unsure where else to hang it while she was up in her recliner. Observation on 08/13/24 at 11:38 A.M. revealed Resident #102's catheter bag remained hanging off the trash can. The trash bag and all trash had been removed from the bin. 4. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including ulcerative colitis, hypertension, type two diabetes mellitus, neuromuscular dysfunction of the bladder, dysuria, and chronic pain. Review of Resident #11's quarterly MDS)3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition and an indwelling catheter. Review of Resident #11's physician order dated 11/07/23 revealed an order for EBP. Staff were to use gloves and gowns with treatment or care. Review of the medical record for Resident #102 revealed an admitted [DATE] with diagnoses including adult failure to thrive, hypertensive heart disease with heart failure, acute respiratory failure with hypoxia, and restlessness and agitation. Review of Resident #102's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and an indwelling catheter. Review of Resident #102's physician order dated 07/25/24 revealed an order for EBP. Staff were to use gloves and gowns with treatment or care. Review of the medical record for Resident #103 revealed an admitted [DATE] with diagnoses including quadriplegia, type two diabetes mellitus, depression, atherosclerosis of other arteries, osteoarthritis, spinal stenosis, paroxysmal atrial fibrillation, and neuromuscular dysfunction of the bladder. Review of Resident #103's comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #103 had moderately impaired cognition. Resident #102 had an indwelling catheter, a stage four pressure ulcer (full-thickness skin and tissue loss), and an unstageable pressure ulcer (obscured full-thickness skin and tissue loss). Review of Resident #103's physician order dated 07/29/24 revealed an order for EBP. Staff were to use gloves and gowns with treatment or care. Observation on 08/12/24 on five occasions from 10:18 A.M. to 2:00 P.M. revealed EBP were not in place for Resident #11, Resident #102, and Resident #103. All three residents were observed to have catheters in place. There were no signs indicating EBP and no PPE was observed in or around the rooms. Interview on 08/12/24 at 3:44 P.M. with STNA #172 revealed there was nobody in the house Resident #11, Resident #102, and Resident #103 resided in that required transmission-based precautions or EBP. Interview on 08/12/24 at 3:53 P.M. with Regional Nurse #300 verified Resident #11, Resident #102, and Resident #103 should be on EBP and were not. 43064

Based on observation, record review and interview the facility failed to implement a comprehensive and individualized restorative nursing program for Resident #14 and Resident #18, following the residents' discharge from therapy. Harm occurred when Resident #14 demonstrated a decline, from extensive assistance to total dependence in activities of daily living. The resident also identified, during an interview on 06/22/16 that due to the lack of services provided, she sustained increased joint stiffness, loss of functional ability, deterioration in transfer ability and pain. This affected two residents (Resident #14 and #18) of four residents reviewed for therapy services. Findings include: 1. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day admission Minimum Data Set (MDS) 3.0 assessment, dated 01/16/16 revealed Resident #14 required extensive assistance of two persons for bed mobility, transfers, walking in and out of room, and toileting. The resident required extensive assistance of one person for dressing and personal hygiene and was totally dependent on one staff for bathing. Resident #14 had impaired range of motion to bilateral upper and lower extremities. Record review revealed the resident received physical and occupational therapy from 01/04/16 through 03/23/16. Review of the physical therapy discharge summary revealed during therapy the resident was provided exercises to improve bilateral lower extremity strength, activity tolerance and to increase range of motion. Transfer and bed mobility training to increase safety and level of independence was also completed as well as gait training to increase ambulatory distance using a front wheeled walker. Review of the occupational therapy discharge summary revealed passive range of motion and upper extremity strengthening and activity of daily living retraining including self feeding, posture retraining, transfer training and balance endurance training were provided. Both physical therapy and occupational discharge summaries revealed the resident had met her maximum potential with therapy and would receive staff assistance as needed. There was no evidence any type of restorative nursing program being recommended or implemented following the resident's discharge from therapy to maintain her current functional level or prevent any type of decline in activities of daily living. Review of the quarterly MDS 3.0 assessment, dated 04/09/16 revealed Resident #14 was totally dependent on two persons for bed mobility, transfers, dressing, toileting and bathing. This reflected a decline in the resident's functional status from the assessment completed on 01/16/16. The resident was assessed to require extensive assistance of two persons for personal hygiene. Resident #14 had impaired range of motion to bilateral upper and lower extremities. Record review revealed following the completion of this MDS assessment, the resident was not evaluated for any type of comprehensive or individualized restorative nursing program. Record review revealed a plan of care for the potential for self care deficit was was initiated on 05/31/16 related to the resident's [DIAGNOSES REDACTED]. The resident will stand, pivot and transfer with use of a walker and two person assist. Review of the plan of care revealed it did not include any type of bed mobility, transfer or range of motion exercises. Record review revealed the resident was placed back in physical therapy, on 06/10/16 to assess the safety of the patients own person lift system and to create and train staff on a restorative program. The therapist noted the necessity for increasing patient and caregiver safety with lift and creating a restorative nursing program to main patient's current level of function. Without therapy the patient was at risk for decline in functional mobility, independence, and increased risk of fall and injury. A therapy note dated 06/10/16 stated a plan of care was developed and skilled treatment recommended for creating a restorative program and training staff on safety with patients lift and on the restorative program. A therapy noted dated 06/16/16 stated passive range of motion to bilateral lower extremities, all joints, and all planes times 10 to improve bilateral lower extremity range of motion to prevent risk of contracture and skin breakdown. STNA education provided on passive range of motion technique and provided with visual and verbal demonstration. A discharge therapy note dated 06/16/16 stated training of the state tested nursing assistant (STNA) staff and discussion with the MDS nurse on the restorative program recommendations for patient to continue to maintain current level of function to decrease risk of decline. On 06/22/16 at 11:50 A.M. interview with the director of physical therapy (PT) revealed Resident #14 was originally admitted to the facility following a hospitalization for skilled therapy services. The PT director indicated the resident's discharge plans were unknown at the time of admission. The resident received skilled therapy until March 2016. The PT director indicated he was aware the resident had appealed her discharge from therapy and was interested in receiving additional therapy services. The PT director revealed the resident recently had been picked back up by therapy because she purchased her own lift device and staff training was necessary. On 06/22/16 at 11:58 A.M. interview with Resident #14 revealed she was diagnosed with [REDACTED]. The resident shared she had been in therapy but was no longer receiving therapy services. The resident shared she had gone through the appeal process to receive additional therapy and was currently waiting for a decision. The resident voiced concern that staff did not stretch her muscles and her ability to transfer and move had gotten worse. The resident stated she had lost much movement that would not return and was very upset about this. The resident revealed she frequently asked staff to stretch her but that the STNAs never did and complained to her when she asked. The resident also identified due to the lack of services provided, she sustained increased joint stiffness, loss of functional ability, deterioration in transfer ability and pain during the interview. During the time of the interview, Resident #14 was observed seated in a personal recliner chair with the seat of the chair in a lifted position allowing the resident's feet to rest on the floor in her room. An over bed table was observed in front of the resident. The resident's shoulders were observed to be slightly raised and her hips were slightly shifted under her. The resident appeared to have limited ability to maneuver her body and her extremities appeared somewhat rigid and stiff. The resident did not communicate verbally, but rather by using an electronic computer device. The resident was observed to have limited mobility of her wrist and fingers as she used the device to communicate, by tapping keys with one finger in a dragging motion. On 06/22/16 at 3:30 P.M. a follow up interview with the PT director verified Resident #14 had been seen by therapy from 06/10/16 through 06/16/16 for transfer training with a lift device that was purchased by the resident. The director verified the resident would benefit from a restorative nursing program and that one was recommended following the resident's discharge on 06/16/16. During the interview, it could not be determined why no restorative nursing program was recommended following the resident's discharge from therapy in March 2016. Although, the PT director did mention the facility did not have restorative nursing services. On 06/22/16 at 4:00 P.M. interview with the Director of Nursing (DON) revealed she was aware Resident #14's limitations to functional mobility and [DIAGNOSES REDACTED]. The DON stated no restorative program had been implemented because the facility did not provide restorative nursing. The DON also verified the resident had been most recently been discharged from physical therapy on 06/16/16 and the facility was currently working on getting a restorative nursing program started for the resident. The DON verified as of 06/22/16, no program had been initiated. On 06/22/16 at 4:45 P.M. interview with the Licensed Social Worker (LSW) revealed she became aware of Resident #14's concerns about not receiving any kind of therapy services in May 2016. Although there was limited documentation in the resident's medical record, the LSW provided email communication between herself and the resident related to the possibility of therapy services being provided by other providers. The LSW was unable to obtain services for the resident. There was no evidence any type of restorative nursing program was pursued for the resident following her discharge from therapy. On 06/22/16 at 5:15 P.M. interview with the administrator and DON verified the MDS assessment completed on 04/09/16 reflected a deterioration in the resident's activities of daily living without evidence any type of services had been in place following the resident's discharge from therapy on 03/23/16. The administrator and DON also verified as of 06/22/16 no restorative nursing program had been implemented for Resident #14 because the facility did not have any restorative nursing. 2. Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE]. Record review revealed on 04/28/16 a physician order [REDACTED]. An order was written for therapy services three times per week for four weeks for therapeutic exercise, therapeutic activity, gait, neuromuscular re-education, patient education and wheelchair management. The resident was discharged from therapy services on 05/25/16 with discharge plans including for the resident to remain long term care with a functional mobility program in place to maintain current level of function and ambulation. Review of a care update notification form, dated 05/25/16 and completed by the PT director revealed the following functional maintenance program: Walk resident to all meals, and every two hours during day. Daily Nustep (a stationary bike) level 2-3 for 15 to 20 minutes. During group exercise, resident will need one on one attention to complete. The notification form was signed by two unidentified employees on 05/27/16. Record review revealed no evidence this program was being implemented. There were no delivery grids for the parts of the program. There was no nursing assessment related to the development or provision of the program or documentation related to who was supposed to provide the program. There was no evaluation of the status of the program or the resident's ability to complete the program. Additionally, there was no evidence the program was individualized for the resident including how far the resident was walk every two hours. How often the resident was to use the Nustep or anything specific to how often group exercise was to be provided or the type of exercises the resident was to be completing. On 06/22/16 at 4:15 P.M. Resident #18 was observed seated in a recliner chair in the common area of the unit. The resident's eyes were closed and her legs were covered with a blanket. Interview with the two STNAs assigned to the unit at that time revealed the resident exhibited confusion and was dependent on staff for activities of daily living. The STNAs revealed the resident frequently sat in the recliner in the common area so staff could keep a better eye on her. The STNAs indicated they were responsible for making sure the resident walked from the recliner to the table for dinner. The STNAs denied providing any other type of functional program for the resident. On 06/22/16 at 5:00 P.M. interview with the DON revealed she was unable to provide any evidence of a comprehensive and individualized restorative functional maintenance program for the resident. The DON indicated the facility did not currently have any type of restorative nursing program. This deficiency substantiates Complaint Number OH 991.