Every finding on record at Otterbein North Shore

Based on medical record review, review of the nurse and staff report sheet, staff interview, and review of the facility policy the facility failed to ensure correct advanced directives were in the medical chart and on the nurse and staff report sheet. This affected one (Resident #7) of one resident reviewed for advanced directives. The facility census was 19.Findings include:Review of the medical record for Resident #7 revealed an admission on [DATE]. Diagnoses included unspecified dementia, hypothyroidism, and major depressive disorder.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #7 had impaired cognition. Further review of the MDS revealed Resident #7 required supervision or touching assistance with activities of daily living (ADL). Review of the care plan dated 08/20/25 revealed Resident #7 had a code status of Do Not Resuscitate Comfort Care (DNRCC). Interventions included reviewing Resident #7's overall goals for care and importance of comfort and quality of life regardless of the advance directive. Review of the Electronic Medical Chart (EMR) for Resident #7 revealed an order dated 09/11/25 for DNRCC.Review of the nurse and Certified Nursing Assistant (CNA) report sheet revealed Resident #7's code status was Do Not Resuscitate Comfort Care Arrest (DNRCCA).Interview on 03/25/26 at 8:10 A.M. with CNA #360 confirmed on the CNA report sheet Resident #7 had a code status of Do Not Resuscitate Comfort Care - Arrest (DNRCCA). CNA #360 was unsure what the code status meant and further stated if a resident were to be found not breathing, the CNAs are instructed to call the nurse. Interview on 03/25/26 at 9:00 A.M. with Director of Nursing (DON) confirmed that the CNA report sheet had Resident #7 as a DNRCCA and further confirmed Resident #7 was a DNRCC. Review of the facility policy titled Advanced Directives Policy dated 03/19/25 revealed on admission, the facility will determine whether the resident has executed an Advance Directive. The facility will record in the medical record, and any person designated will be notified.

Based on observation, medical record review, and staff interview, the facility failed to ensure nutritional supplements were provided as ordered. This affected two (#11,14) of four residents reviewed for nutrition. The facility identified 16 residents as receiving nutritional supplements. The facility census was 19.Findings include:1. Review of the medical record for Resident #11 revealed an admission on [DATE]. Diagnoses included unspecified dementia, major depressive disorder, and dysphagia. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had severe cognitive impairment. Further review of the MDS revealed Resident #11 was dependent on staff for feeding assistance. Review of the care plan dated 09/27/24 revealed Resident #11 was at risk for malnutrition related to inability to feed self. Interventions included providing feeding assistance, and staff were to feed the resident all meals and snacks. Further review of the care plan dated 07/16/20 revealed Resident #11 had an activity of daily living (ADL) self-care performance deficit related to dementia, and weakness. Interventions included feeding Resident #11 by staff or family. Resident #11 required one staff assistant to eat. Review of the physician's orders dated 04/03/25 revealed an order for a regular diet, pureed texture, mildly thick consistency. Further review of the care plan revealed an order on 08/13/25 for a health shake with meals for weight gain. Additional review of the physician's orders revealed an order on 10/23/25 for a magic cup with meals per speech therapy, alternating with bites of food. Observation on 03/27/26 at 8:20 A.M. revealed Certified Nursing Assistant (CNA) #218 feeding Resident #11 breakfast. Resident #11 had oatmeal, eggs, fruit, and thickened juice.Interview on 03/27/26 at 8:29 A.M. with CNA #218 revealed Resident #11 was given oatmeal, eggs, fruit and thickened juice for breakfast. CNA #218 confirmed that Resident #11 was to receive a magic cup but was unaware that the magic cup was to be given in between bites of food. CNA #218 was not aware that Resident #11 received a health shake with meals. Further interview with CNA #218 revealed in the kitchen there were resident diet orders and confirmed that Resident #11 was to receive a magic cup with meals, offering in between bites, and a health shake with every meal.2. Review of the medical record for Resident #14 revealed an admission on [DATE]. Diagnoses included hyperkalemia, chronic fatigue, and weakness. Review of the admission MDS dated [DATE] revealed Resident #14 had moderate cognitive impairment. Further review of the MDS revealed Resident #14 required supervision during mealtimes. Review of the care plan dated 03/08/26 revealed Resident #14 was at risk for changes to nutritional and hydration status related to hyperkalemia, acute kidney injury, and chronic kidney disease. Interventions included offer a substitute for meal intakes less than 50 percent. Further review of the care plan revealed Resident #14 received a mechanically altered diet and often refused. Diet was changed to regular diet, regular texture, with thin liquids on 03/21/26. Staff was to monitor weights weekly for one month, then monthly reporting any negative findings. Staff were to provide supplements as ordered. Additional review of the care plan revealed Resident #14 was at risk for altered nutrition status related to significant weight loss from hospital, and medical diagnoses. Interventions included nutritional supplements. Review of the physician's orders for Resident #14 revealed an order on 03/18/26 for magic cup supplement with meals. Observation on 03/27/26 at 8:15 A.M. revealed Resident #14 sitting at the dining room table eating two eggs, bacon, and toast.Interview on 03/27/26 at 8:29 A.M. with CNA #218 revealed Resident #14's diet card stated Resident #14 was to receive a magic cup with each meal. CNA #218 further confirmed Resident #14 was not offered a magic cup and that CNA #18 was not aware that Resident #14 had an order for a magic cup.Interview on 03/27/29 at 10:30 A.M. with the Administrator revealed there was not a policy on supplemental orders.This deficiency represents non-compliance investigated under Complaint Number 2780772

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure residents were administered medications per physician orders. This affected three (#26, #27, #13) of five residents reviewed for medication administration. The facility census was 19.Findings include:1. Review of the medical record for Resident #26 revealed an admission date of 02/13/26 and a discharge date of 02/23/26. Diagnoses included type two diabetes mellitus with hyperglycemia, chronic kidney disease, hypertension, and hypokalemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for activities of daily living. Review of the nursing notes dated 02/13/26 at 9:21 P.M. revealed the resident arrived from the hospital. Per the hospital report the resident had chronically elevated blood pressure with the systolic blood pressure as high as the 190's. The residents' medications were reviewed with the on-call provider. Review of the hospital discharge medication orders revealed Resident #26 had an order for lisinopril 20 milligrams (mg) by mouth daily, amlodipine 5 mg by mouth daily, atenolol 50 mg twice daily, hydralazine 25 mg three times a day, hydrochlorothiazide 12.5 mg daily, insulin aspart 100 units/ml per low dose sliding scale not specified, ondansetron 4 mg oral tablet by mouth every six hours as needed for nausea/vomiting, acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain, potassium chloride 10 milliequivalents by mouth two times per day, pregabalin 75 mg by mouth every day, sertraline 50 mg by mouth daily, trazodone 50 mg at bedtime, fenofibrate 67 mg by mouth daily, and cholecalciferol 50,000 international units by mouth weekly. Review of the physician orders dated 02/14/26 revealed the resident was ordered atenolol 50 mg twice daily for hypertension, hydralazine 25 mg three times daily for hypertension, amlodipine 5 mg twice daily for hypertension, hydrochlorothiazide 12.5 mg daily for hypertension and lisinopril 20 mg daily for hypertension, aspirin 81 milligrams (mg) by mouth daily, insulin aspart 100 units/ml per low dose sliding scale 151--200 given two units, 201-250 give 3 units, 251-300 give 4 units, 301-350 five 5 units, 351-400 give 6 units and 401-799 7 units and call MD, subcutaneously before meals and at bedtime for type two diabetes mellitus with hyperglycemia, ondansetron 4 mg oral tablet by mouth every six hours as needed for nausea/vomiting, potassium chloride 10 milliequivalents by mouth two times per day, pregabalin 75 mg by mouth every day, sertraline 50 mg by mouth daily, trazodone 50 mg at bedtime, fenofibrate 67 mg by mouth daily, and cholecalciferol 50,000 international units by mouth weekly. Review of the medication administration record (MAR) dated 02/13/26 revealed the resident was not administered the evening doses of the amlodipine, hydralazine and trazodone. The resident's blood sugar was not monitored, and the resident was not administered the insulin. Review of the MAR dated 02/14/26 revealed the resident was not administered hydrochlorothiazide, lisinopril, and the morning doses of amlodipine and hydralazine, atenolol, fenofibrate, pantoprazole sodium 40 mg, pregabalin, and sertraline.Review of the Medication Inventory on Hand report revealed the amlodipine, atenolol, lisinopril, hydralazine, hydrochlorothiazide, sertraline, trazodone, potassium, pregabalin, and insulin aspart were available to administer. Interview on 03/25/26 at 3:07 P.M., the Director of Nursing (DON) verified the resident's medications were not administered per physician orders. The DON revealed the nurse should have pulled the medications available on hand in the facility. The DON also revealed the nurse should have clarified which medications the resident had receiving prior to leaving the hospital. 2. Review of the medical record for Resident #27 revealed an admission date of 03/18/26. Diagnoses included Parkinson's disease with dyskinesia, hypertension, atrial fibrillation, and abnormalities of gait and mobility.Review of a Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the hospital medication orders revealed the resident had orders for carbidopa-levodopa 25/100 mg three times per day.Review of the physician orders dated 03/18/26 revealed an order for carbidopa-levodopa 25/100 mg three times per day for convulsions. Review of the MAR dated 03/18/26 revealed the resident had not been administered the evening dose and bedtime dose of the carbidopa-levodopa. Further review of the MAR revealed the resident had not been administered the bedtime dose of carbidopa-levodopa on 03/19/26. Review of the Medication Inventory on Hand report revealed the carbidopa-levodopa was available for administration. Review of the nursing notes dated 03/18/26 and 03/19/26 revealed no documentation the resident had refused the medication.Interview on 03/26/26 at 3:23 P.M., the DON verified Resident #27's medication was not administered per physician orders, and the medication was available in the facility. 3. Review of the medical record for Resident #13 revealed an admission date of 03/10/26. Diagnoses included acute systolic heart failure, acute pulmonary edema, cardiomegaly, and hypertension.Review of the admission MDS assessment dated [DATE] revealed Resident #13 had intact cognition. Review of the hospital discharge medication orders revealed an order for carvedilol 6.25 mg, one tablet two times per day.Review of the physician order dated 03/10/26 revealed an order for carvedilol 6.25 mg two times a day for hypertension. Hold for systolic blood pressure less than 100 and hold if pulse was less than 60 beats per minute. Review of a nursing note dated 03/10/26 at 2:48 P.M. revealed the resident had arrived at the facility. Review of the vital sign record dated 03/10/26 at 8:20 P.M. revealed the residents' blood pressure was 116/59 with a heart rate of 84 beats per minute. Review of the MAR dated 03/10/26 revealed the evening dose of the carvedilol was not administered.Review of the nursing notes dated 03/10/26 revealed no documentation the resident had refused the medication. Review of the Medication Inventory on Hand report revealed the facility had carvedilol available for administration. Interview on 03/26/26 at 3:23 P.M., the DON verified Resident #13's medication was not administered per physician orders, and the medications were available in the facility. Review of the facility policy Medication Administration Procedure, revised 11/09/21, revealed medications were administered in accordance with written orders of the attending physician or physician extender. Review of the facility policy MedBank System Policies and Procedures, dated 10/23/25 revealed the on hand medication supply would be used for the first dose use and other situation where medication was not readily available from the pharmacy until the next scheduled delivery. This deficiency represents non-compliance investigated under Master Complaint Number 2780772 and Complaint Number 2720892.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure residents were free of significant medications errors. This affected three (#26, #27, #13) of five residents reviewed for medication administration. The facility census was 19.Findings include:1. Review of the medical record for Resident #26 revealed an admission date of 02/13/26 and a discharge date of 02/23/26. Diagnoses included type two diabetes mellitus with hyperglycemia, chronic kidney disease, hypertension, and hypokalemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for activities of daily living. Review of the nursing notes dated 02/13/26 at 9:21 P.M. revealed the resident arrived from the hospital. Per the hospital report the resident had chronically elevated blood pressure with the systolic blood pressure as high as the 190's. The residents' medications were reviewed with the on-call provider. Review of the hospital discharge medication orders revealed Resident #26 had an order for lisinopril 20 milligrams (mg) by mouth daily, amlodipine 5 mg by mouth daily, atenolol 50 mg twice daily, hydralazine 25 mg three times a day, and hydrochlorothiazide 12.5 mg daily.Review of the physician orders dated 02/14/26 revealed the resident was ordered atenolol 50 mg twice daily for hypertension, hydralazine 25 mg three times daily for hypertension, amlodipine 5 mg twice daily for hypertension, hydrochlorothiazide 12.5 mg daily for hypertension and lisinopril 20 mg daily for hypertension. Review of the medication administration record (MAR) dated 02/13/26 revealed the resident was not administered the evening dose of the atenolol and the evening dose of the hydralazine.Review of the MAR dated 02/14/26 revealed the resident was not administered hydrochlorothiazide, lisinopril, and the morning doses of amlodipine, hydralazine, and atenolol.Review of the vital sign report revealed on 02/13/26 at 6:45 P.M. the resident's blood pressure was 165/81. On 02/14/26 at 12:31 P.M. the resident's blood pressure was 169/79. On 02/14/26 at 9:16 P.M., the resident's blood pressure was 193/99. On 02/24/26 at 11:38 P.M., the residents' blood pressure was 153/79. Review of a late-entry nurses note for 02/14/26 at 10:27 P.M. documented on 02/19/26 at 12:39 P.M. revealed the resident's blood pressure was elevated and her medication had just arrived from the pharmacy. The resident's family member was at the bedside and concerned about the resident's blood pressure. The nurse discussed sending the resident to the emergency room, but the family member chose to see if the medication would be effective within 60 minutes. The nurse planned to update the family with blood pressure results over the next two to four hours. Further review of the progress note revealed the medication was effective and updates were provided to the family throughout the shift and the family agreed no further action was needed at this time.Review of the Medication Inventory on Hand report revealed the amlodipine, atenolol, lisinopril, hydralazine, and hydrochlorothiazide were available to administer. Interview on 03/25/26 at 3:07 P.M., the Director of Nursing (DON) verified the resident's medications were not administered per physician orders. The DON revealed the nurse should have pulled the medications available on hand in the facility. The DON also revealed the nurse should have clarified which medications the resident had receiving prior to leaving the hospital. 2. Review of the medical record for Resident #27 revealed an admission date of 03/18/26. Diagnoses included Parkinson's disease with dyskinesia, hypertension, atrial fibrillation, and abnormalities of gait and mobility.Review of a Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the hospital medication orders revealed the resident had orders for carbidopa-levodopa 25/100 mg three times per day.Review of the physician orders dated 03/18/26 revealed an order for carbidopa-levodopa 25/100 mg three times per day for convulsions. Review of the MAR dated 03/18/26 revealed the resident had not been administered the evening dose and bedtime dose of the carbidopa-levodopa. Further review of the MAR revealed the resident had not been administered the bedtime dose of carbidopa-levodopa on 03/19/26. Review of the Medication Inventory on Hand report revealed the carbidopa-levodopa was available for administration. Review of the nursing notes dated 03/18/26 and 03/19/26 revealed no documentation the resident had refused the medication.Interview on 03/26/26 at 3:23 P.M., the DON verified Resident #27's medication was not administered per physician orders, and the medication was available in the facility. 3. Review of the medical record for Resident #13 revealed an admission date of 03/10/26. Diagnoses included acute systolic heart failure, acute pulmonary edema, cardiomegaly, and hypertension.Review of the admission MDS assessment dated [DATE] revealed Resident #13 had intact cognition. Review of the hospital discharge medication orders revealed an order for carvedilol 6.25 mg, one tablet two times per day.Review of the physician order dated 03/10/26 revealed an order for carvedilol 6.25 mg two times a day for hypertension. Hold for systolic blood pressure less than 100 and hold if pulse was less than 60 beats per minute. Review of a nursing note dated 03/10/26 at 2:48 P.M. revealed the resident had arrived at the facility. Review of the vital sign record dated 03/10/26 at 8:20 P.M. revealed the residents' blood pressure was 116/59 with a heart rate of 84 beats per minute. Review of the MAR dated 03/10/26 revealed the evening dose of the carvedilol was not administered.Review of the nursing notes dated 03/10/26 revealed no documentation the resident had refused the medication. Review of the Medication Inventory on Hand report revealed the facility had carvedilol available for administration. Interview on 03/26/26 at 3:23 P.M., the DON verified Resident #13's medication was not administered per physician orders, and the medications were available in the facility. Review of the facility policy Medication Administration Procedure, revised 11/09/21, revealed medications were administered in accordance with written orders of the attending physician or physician extender. Review of the facility policy MedBank System Policies and Procedures, dated 10/23/25 revealed the on hand medication supply would be used for the first dose use and other situation where medication was not readily available from the pharmacy until the next scheduled delivery. This deficiency represents non-compliance investigated under Master Complaint Number 2780772 and Complaint Number 2720892.

Based on observation, medical record review, staff interview, and review of the facility policy the facility failed to ensure proper personal protective equipment (PPE) was worn during care for a resident on enhanced barrier precautions (EBP). This affected one (Resident #18) resident reviewed for EBP. The facility identified four residents on EBP precautions. The census was 19.Findings include:Review of the medical record for Resident #18 revealed an admission on [DATE]. Diagnoses included Alzheimer's Disease, unspecified protein-calorie malnutrition, and occlusion and stenosis of unspecified carotid artery. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had impaired cognition. Further review of the MDS revealed Resident #18 had a pressure ulcer dressing. Review of the care plan dated 02/18/26 revealed Resident #18 had an actual unstable wound to the coccyx. Resident #18 was at risk for further skin breakdown related to impaired mobility and incontinence. Interventions included turning and repositioning and weekly skin screening of Resident #18's body. Review of the care plan dated 12/07/25 revealed no care plan for Enhanced Barrier Precautions (EBP). Review of the physician's orders for Resident #18 revealed no orders for EBP. Observation on 03/25/26 at 1:14 P.M. revealed Resident #18 had a sign on the bedroom door stating EBP precautions. Staff were to wear down and gloves for high contact resident care. Observation on 03/26/25 at 8:13 A.M. of Certified Nursing Assistant (CNA) #218 and CNA #121 providing incontinence care revealed both CNA #218 and CNA #121 did not have on personal protective equipment (PPE). Interview on 03/26/25 at 8:24 A.M. with CNA #218 and CNA #121 confirmed Resident #18 was on EBP and were not wearing PPE. Interview on 03/26/25 at 10:00 A.M. with the Administrator confirmed Resident #18 was on EBP and further confirmed there were no orders in Resident #18's medical chart for EBP precautions. Review of the facility policy titled Isolation Precautions Process, dated 03/26/25 revealed Enhanced Barrier Precautions will be utilized for residents with any of the following during their entire stay: wounds. Elements of Enhanced Barrier Precautions include gloves and gowns should be worn during high contact resident care including providing hygiene, dressing, and wound care.

Based on review of the medical record, staff interview, and policy review, the facility failed to notify the physician and resident representative of changes in condition. This affected one (#26) of one resident reviewed for change in condition. The facility census was 19.Findings include: Review of the medical record for Resident #26 revealed an admission date of 02/13/26 and a discharge date of 02/23/26. Diagnoses included type two diabetes mellitus with hyperglycemia, chronic kidney disease, hypertension, and hypokalemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for activities of daily living. Review of the nursing notes dated 02/13/26 at 9:21 P.M. revealed the resident arrived from the hospital. Per the hospital report the resident had chronically elevated blood pressure with the systolic blood pressure as high as the 190's. The residents' medications were reviewed with the on-call provider. Review of the hospital discharge medication orders revealed Resident #26 had an order for lisinopril 20 milligrams (mg) by mouth daily, amlodipine 5 mg by mouth daily, atenolol 50 mg twice daily, hydralazine 25 mg three times a day, and hydrochlorothiazide 12.5 mg daily.Review of the physician orders dated 02/14/26 revealed the resident was ordered atenolol 50 mg twice daily for hypertension, hydralazine 25 mg three times daily for hypertension, amlodipine 5 mg twice daily for hypertension, hydrochlorothiazide 12.5 mg daily for hypertension and lisinopril 20 mg daily for hypertension. Review of the medication administration record (MAR) dated 02/13/26 revealed the resident was not administered the evening dose of the atenolol and the evening dose of the hydralazine.Review of the MAR dated 02/14/26 revealed the resident was not administered hydrochlorothiazide, lisinopril, and the morning doses of amlodipine, hydralazine, and atenolol. There was no documentation the physician and family were notified the medications were not administered. Review of the vital sign report revealed on 02/13/26 at 6:45 P.M. the resident's blood pressure was 165/81. On 02/14/26 at 12:31 P.M. the resident's blood pressure was 169/79. On 02/14/26 at 9:16 P.M., the resident's blood pressure was 193/99. On 02/24/26 at 11:38 P.M., the residents' blood pressure was 153/79. There was no documentation the resident's blood pressure was monitored in the morning on 02/14/26. There was no documentation the physician was notified of the resident's elevated blood pressure of 193/99 after not receiving her blood pressure medications.Review of a late-entry nurses note for 02/14/26 at 10:27 P.M. documented on 02/19/26 at 12:39 P.M. revealed the resident's blood pressure was elevated and her medication had just arrived from the pharmacy. The resident's family member was at the bedside and concerned about the resident's blood pressure. The nurse discussed sending the resident to the emergency room, but the family member chose to see if the medication would be effective within 60 minutes. The nurse planned to update the family with blood pressure results over the next two to four hours. Further review of the progress note revealed the medication was effective and updates were provided to the family throughout the shift and the family agreed no further action was needed at this time. Review of the Medication Inventory on Hand report revealed the amlodipine, atenolol, lisinopril, hydralazine, and hydrochlorothiazide were available to administer. Interview on 03/25/26 at 3:07 P.M., the Director of Nursing (DON) verified Resident #26's medications were not administered per physician orders. The DON revealed the nurse should have pulled the medications available on hand in the facility. The DON also revealed the nurse should have clarified which medications the resident had receiving prior to leaving the hospital. Further interview on 03/27/26 at 7:50 A.M., the DON verified the nurse should have notified the physician and family of the missed medications and elevated blood pressure. Review of the facility policy Notification of Change of Condition, revised 11/21/25, revealed the facility would notify the physician and resident representative of a change in the resident's condition. Review of the facility policy Medication Administration Procedure, revised 11/09/21, revealed medications would administered per physician orders and the physician would be notified of medications withheld. This deficiency represents non-compliance investigated under Master Complaint Number 2780772.

Based on review of the medical record, interview, and policy review, the facility failed to ensure skin breakdown was timely identified and reported. Additionally, the facility failed to ensure weekly wound evaluations and weekly skin assessments were completed. This affected one (#4) of one resident reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. The facility census was 19.Findings include:Review of the medical record for Resident #4 revealed an admission date of 03/27/25. Diagnoses included Alzheimer's disease, osteoarthritis, hypertension, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was at risk for skin breakdown and had a stage three pressure ulcer. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. The resident was dependent on staff for toileting and required substantial/maximal assistance for bed mobility and transfers. Review of a physician order dated 10/04/25 revealed the resident was admitted to hospice services. Review of a skin risk assessment completed 10/17/25 revealed the resident was at moderate risk for skin breakdown. Review of the medical record revealed the nurses had not completed weekly skin assessments from 10/12/25 through 11/06/25.Review of a physician wound progress note dated 10/24/25 revealed the resident had a stage two pressure ulcer (partial-thickness skin loss with exposed dermis) of the left buttock measuring 0.9 centimeters (cm) in length, one cm in width, and 0.1 cm in depth with moderate serosanguinous drainage. Review of a physician wound progress note dated 10/31/25 revealed the resident's wound evaluation was rescheduled as the resident was asleep in the recliner and nursing requested to reschedule as the resident had not slept in two days. Further review of the medical record revealed no wound follow up wound evaluation was completed from 10/25/25 through 11/06/25.Review of body audit shower sheets dated 10/31/25 and 11/05/25 revealed no documentation of new skin breakdown for the resident.Review of a physician wound note dated 11/07/26 revealed the pressure ulcer to the left buttock had resolved. The resident was found with a new stage three pressure ulcer (full thickness loss of skin, in which subcutaneous fat may be visible and granulation tissue present) to the sacrum measuring two cm in length, 2.5 cm in width, 0.1 cm in depth with moderate serous exudate with no signs of infection. The wound was noted as present for greater than five days. A wound treatment was ordered.Review of the plan of care revised 11/07/25 revealed the resident had a stage three pressure ulcer to the sacrum. Interventions included administering treatments as ordered, assist and reposition frequently with rounding and as needed, complete weekly skin screen, nutritional supplements as ordered, pressure reduction chair cushion and low air loss mattress to the bed.Interview on 03/26/26 at 10:40 A.M., Certified Nursing Assistant (CNA) #222 revealed skin changes should be marked on the body audit form and reported to the nurse. Interview on 03/26/26 at 11:38 A.M., the Director of Nursing (DON) verified the facility had not reattempted to complete a weekly wound evaluation after rescheduling with the wound physician. The DON also verified that the nursing staff had not completed a weekly skin assessment to identify new skin breakdown. The DON revealed the wound should have been discovered during incontinence care and reported. The DON revealed at the time that the resident had another buttock wound, and the nursing assistants may have thought it was the same wound, so it was not reported.Interview on 03/26/26 at 2:14 P.M., Wound Physician (WP) #700 revealed on 11/07/26 the resident was identified with a new stage three pressure ulcer to the coccyx. WP #700 revealed the resident was on hospice and underweight. WP #700 revealed the depth of the wound was minimal and would not have been a stage three in a person of average weight, however, the resident was thin and the minimal depth was into the subcutaneous tissue requiring the wound to be categorized as a stage three pressure ulcer. WP #700 revealed the pressure ulcer to the resident's left buttock was noted as healed during the same visit. WP #700 revealed the resident had been spending more time in the recliner to offload pressure on the buttocks and this could be how the coccyx pressure area developed. WP #700 revealed the documentation noting the wound duration as greater than five days was her educated guess as the wound was not present during the last wound evaluation. Review of the facility policy Skin Assessment Policy, revised 11/17/22, revealed the nurse would complete a thorough head to toe skin assessment of the resident upon admission, weekly, with significant changes and as needed. The CNAs would observe skin during bathing and personal care and report skin abnormalities to the nurse. Review of the facility policy Skin Care Management Procedure, revised 12/09/22, revealed weekly skin assessments would be completed and documented in the medical record to identify new or potential areas of concern or the absence of any areas. Further review of the policy revealed a weekly wound evaluation would be completed and documented. The physician would be notified of all skin areas of concern and consulted for treatment orders.

Based on medical record review, observation, staff interviews, and review of the manufacturer's instructions for the facility's mechanical lift, the facility failed to ensure resident safety when using the mechanical lift for transfers. This affected one (Resident #501) of two residents reviewed for the use of mechanical lifts. The facility census was 15.Findings include: Review of the medical record for Resident #501 revealed she was admitted on [DATE] with diagnoses including macular degeneration, dementia, osteoporosis, arthropathy, abnormalities of gait and mobility, and muscle weakness. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #501 was unable to speak, had severe cognitive impairment and was staff dependent for all care and transfers. Review of the care plan dated 04/14/25 revealed Resident #501 required the use of a mechanical lift with the assistance of two staff members for all transfers. Observation of Certified Nursing Assistant (CNA) #106 on 09/22/25 at 7:50 A.M. revealed she was using a mechanical lift independently to transfer Resident #501 from her bed to her wheelchair. There was no other staff present assisting with Resident #501's transfer. Interview with CNA #106 on 09/22/25 at 7:53 A.M. confirmed she was using the mechanical lift independently to transfer Resident #501 and typically used the mechanical lift independently to transfer residents. Interview with the Administrator on 09/22/25 at 8:28 A.M. revealed two staff members were required when utilizing the mechanical lift to transfer residents. Interview with the Director of Nursing on 09/22/25 at 2:10 P.M. revealed nursing staff were trained during orientation on the proper use of a mechanical lift. The training included the facility-implemented requirement of two staff members while transferring a resident with a mechanical lift. Review of the manufacturer's instructions for Maxi Move mechanical lift revealed circumstances should dictate the need for two-assist transfers and the facility, based on unique circumstances, was responsible for determining when the use of two-assist transfers was appropriate. This deficiency represents non-compliance investigated under Complaint Number 2609933.

Based on observation, staff interview, and review of the facility policies, the facility failed to ensure food items were stored, labeled and dated and ensure refrigerators and freezers did not contain expired food items. This had the potential to affect all 17 residents who received food from the facility kitchens. The facility census was 17. Findings include: 1. Observation on [DATE] beginning at 7:37 A.M. of refrigerators and freezers located in the Cornerstone Cottage with Certified Nursing Assistant (CNA) #303 revealed the following findings and CNA #303 verified the below findings: - One unlabeled container of fruit cocktail which expired on [DATE]. - One unlabeled container which contained an unknown white substance and expired on [DATE]. - One unlabeled and undated container which contained an unknown white substance. - One unlabeled and undated container which contained an unknown brown substance. - One unlabeled and undated bowl, which contained several pastries. - One unlabeled and undated container which contained cake. - One unlabeled and undated zip-lock bag which contained two donuts. - One unlabeled and undated zip-lock bag which contained 10 sausage patties. - One unlabeled and undated package of sliced lunchmeat. - One unlabeled and undated package of sliced bacon. - One unlabeled and undated container of potato casserole. - One unlabeled and undated plate wrapped in plastic wrap which contained an unknown meal. - One unlabeled and undated zip-lock bag which contained cooked bacon strips. - One unlabeled and undated container which contained oats. - Numerous unlabeled and undated slices of cheese wrapped in plastic wrap. - No thermometer was in the refrigerator located in the kitchen area. Review of the facility policy titled Personal Food Storage Policy and Procedure revised [DATE] revealed all refrigerators would have internal thermometers. 2. Observation on [DATE] beginning at 8:10 A.M. of the dry storage area located in the [NAME] House revealed there were eight boxes which contained nutritional shakes which were stacked and stored directly on the floor. In addition, there were five boxes of tube feeding formula which were stacked and stored directly on the floor. An interview on [DATE] at 8:31 A.M. with Registered Nurse (RN) #317 verified the nutritional shakes and tube feeding formula boxes were stored stacked and directly on the floor. 3. Observation on [DATE] beginning at approximately 8:15 A.M. of refrigerators and freezers located in the [NAME] House revealed the following: - Two unlabeled bags of sausage patties which expired on [DATE]. - One unlabeled and undated cup of soup. - One unlabeled and undated container of cottage cheese. - One unlabeled and undated container which contained sliced peaches. - One unlabeled and undated bowl of coleslaw. - One unlabeled and undated container of an unknown substance which was brown and red. - One unlabeled and undated package of raw sliced bacon. - One unlabeled paper bag which was dated [DATE] and contained a container of soup and a paper box with moldy bread. An interview on [DATE] at 8:31 A.M. with Registered Nurse #317 verified there were multiple bags and containers of food undated and unlabeled in the refrigerator and freezers in the [NAME] house. Review of the facility policy titled Food Storage Policy & Procedure, revised [DATE], revealed prepared food would be covered, dated, and labeled with the month and day on which it was prepared. The policy also stated the label would indicate the use by date which was four to seven days after the food was prepared. The policy further stated food containers would be stored at least six inches off the floor.

Based on medical record review and staff interview, the facility failed to develop a care plan for dehydration for a resident who was at risk and a history for dehydration. This affected one (Resident #2) of one resident reviewed for hospitalization . The facility census was 17. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included dementia and dysphagia. Her physician orders included a puree diet with mildly thickened liquids. Review of the annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #2 had severe cognitive impairment and was dependent on staff for feeding. Review of Resident #2's hospital discharge orders dated 03/10/25 revealed a diagnosis of dehydration and orders for one to one and a half liters of water intake daily. Review of the comprehensive care plan dated 04/14/25 for Resident #2 revealed no goals or interventions for the prevention of dehydration. Interview on 04/16/25 at 1:13 P.M. with Registered Nurse #315 confirmed Resident #2's care plan did not have measurable goal(s) and intervention(s) for the prevention of dehydration.

Based on medical record review and staff interview, the facility failed to ensure a resident who was on a stool softener daily received the care and services related to absence of bowel movements for six days in a row. This affected one (Resident #6) of five residents reviewed for unnecessary medications. The facility census was 17. Findings include: Review of the medical record for Resident #6 revealed an admitted [DATE]. Diagnoses included dementia, generalized muscle weakness, thoracic disc degeneration, aphasia, and osteoporosis. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #6 was severely cognitively impaired, continent of bowel, and required substantial to maximum assistance with toileting. Review of the physician orders dated 11/27/24 revealed an order for Docusate Sodium oral tablet 100 milligrams (mg) one tablet two times a day for constipation. Review of Resident #6's bowel and bladder elimination records revealed there were six days in a row where Resident #6 did not have a recorded bowel movement on 03/25/25, 03/26/26, 03/27/25, 03/28/25, 03/29/25, and 03/30/25. The medical record did not include any nursing intervention and/or physician notification of Resident #6 not having a bowel movement for six days. There were no physician orders for a bowel protocol for Resident #6. Interview on 04/15/25 at 11:19 A.M. with the Director of Nursing (DON) confirmed Resident #6 did not have a bowel movement for six days in a row from 03/25/25 to 03/30/25 and there was no nursing intervention and/or physician notification of Resident #6 not having a bowel movement for six days. Subsequent interview on 04/15/25 at 2:30 P.M. with the DON confirmed six days was too long for a resident to go without a bowel movement and nursing interventions should have been initiated. The DON confirmed the facility did not have a bowel protocol in place for Resident #6.

Based on medical record review, observations, and staff interviews, the facility failed ensure there was a policy and procedure and staff were in knowledgeable on reverse isolation the physician ordered due to the resident being immunocompromised (at increased risk for infection). This affected one (Resident #13) of one resident reviewed for reverse isolation. The facility census was 17. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included pancytopenia, immunodeficiency due to drugs, and heart failure. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #13 had a mild cognitive impairment and required assistance from staff for all activities of daily living. Review of the facsimile dated 03/24/25 revealed the physician responded to Resident #13's laboratory results that Resident #13 should be in reverse isolation. Review of Resident #13's nursing progress notes dated 03/24/25 revealed the resident had a critical white blood cell and platelet count. There were new orders from the physician for reverse isolation. Review of the active physician orders for April 2025 identified an order dated 03/24/25 for reverse isolation. Observation on 04/14/25 at 10:21 A.M. revealed the door to Resident #13's room had a sign which read STOP Please see nurse. There was also a three-drawer bin which contained personal protective equipment including masks. At 10:22 A.M., Certified Nursing Assistant (CNA) #310 entered Resident #13's room without donning any personal protective equipment such as a mask, gown, or gloves. Interview on 04/14/25 at 10:25 A.M. with CNA #310 stated the staff were previously wearing a surgical mask into Resident #13's room to protect the resident but stated staff were no longer wearing a mask into the resident's room. Interview on 04/14/25 at 3:14 P.M. with Registered Nurse (RN) #317 verified Resident #13 currently had an order for reverse isolation due to previously going out for radiation appointments. RN #317 reported they believed reverse isolation meant the resident could not have any live flowers in their room or anything like that. RN #317 reported staff had not been required to wear any personal protective equipment such as a mask into the room. RN #317 reported Resident #13 no longer received radiation, so the reverse isolation could likely be discontinued. Observation on 04/14/25 at 5:05 P.M. revealed the signage was no longer on the door of Resident #13's room and the personal protective equipment was no longer in the room. Interview on 04/15/25 at 11:36 A.M. with CNA #307 stated Resident #13 had been on reverse isolation, which required staff to wear a surgical mask into the resident's room to protect the resident. Interview on 04/16/25 at 11:15 A.M. with RN #316 stated she was the staff member who was the nurse on duty on 03/24/25. On 03/24/25, RN #316 saw Resident #13's white blood cell count was really low so she called the physician and left a message. The physician then sent a faxed order for reverse isolation. There was no conversation regarding what the expectation for reverse isolation was. The nurse placed the stop sign on Resident #13's door, put the bin with personal protective equipment in the room, let staff know the resident was on reverse isolation, and let the oncoming nurse and the resident know the resident was on reverse isolation. RN #316 reported staff were to wear a surgical mask, a gown, and gloves when going into Resident #13's room. Interview on 04/16/25 at 12:21 P.M. with Physician #400 revealed the physician had ordered the reverse isolation for Resident #13. Physician #400 reported Resident #13's white blood cell count had been critically low, so he ordered reverse isolation to protect the resident when staff were going into the room to make sure they were practicing hand hygiene and being extra cautious with the resident. Physician #400 reported whether staff wore personal protective equipment into the room would depend on the facility's policy for reverse isolation. Physician #400 reported if there was personal protective equipment present in the room, he would assume staff should be wearing it. Interview on 04/16/25 at 1:45 P.M. with the Director of Nursing (DON) who was also the facility's Infection Preventionist revealed the DON was unsure of what the facility's procedure for reverse isolation was. The DON reported they thought that reverse isolation meant Resident #13 needed to wear a mask when going out to appointments. The DON verified the facility had not clarified what the physician's order for reverse isolation was supposed to encompass. Interview on 04/16/25 at 2:04 P.M. with the Administrator verified the facility did not have a policy that covered reverse isolation. The Administrator also reported the facility would obtain more clarification on physician orders going forward.

Based on medical record review, staff interviews, and review of facility policy, the facility failed to offer annual influenza immunizations to the residents during the 2024-2025 influenza season. This affected two (#1 and #6) of five residents reviewed for immunizations. The facility census was 17. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. There was no evidence that Resident #1 was offered an annual influenza immunization during the 2024-2025 influenza season. Review of the medical record for Resident #6 revealed an admitted [DATE]. There was no evidence that Resident #6 was offered an annual influenza immunization during the 2024-2025 influenza season. Interview on 04/17/25 at 3:45 P.M. with the Administrator and Director of Nursing (DON) confirmed annual influenza immunizations had not been offered to Resident#1 nor Resident #6 during the 2024-2025 influenza season. Review of the facility policy titled Influenza and Pneumococcal Immunization dated 06/19/19 revealed the facility would offer the influenza immunization annually between October first and March 31st.

Based on medical record review, observations, and staff interviews, the facility failed to ensure the call lights were within the resident's reach. This affected one (Resident #1) of one resident reviewed for call lights. The facility census was 17. Findings include: Medical record review revealed Resident #1 was admitted on [DATE]. Diagnoses included Alzheimer's disease, osteoporosis, osteoarthritis, hyperlipidemia, heart failure, and anxiety. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired, used a wheelchair, and required moderate assistance with dressing, personal hygiene, toileting, showering, and transferring. Observation on 04/14/25 at 11:09 A.M. revealed Resident #1 was in her room lying in bed and did not have a call light pendant within reach. Interview on 04/14/25 at 11:15 A.M. with Wellness Director #310 confirmed Resident #1 did not have a call light pendant within reach. Observation on 04/16/25 at 8:30 A.M. during medication administration for Resident #1 revealed the resident was in her room resting in her bed and did not have a call light pendant within reach. Interview on 04/16/25 at 10:35 A.M. with Registered Nurse (RN) #316 confirmed Resident #1 did not have a call light pendant within reach when she entered Resident #1's room to administer medications at 8:30 A.M. Observation on 04/16/25 at 10:35 A.M. in the common area of Cornerstone Cottage revealed Resident #1 was sitting in her wheelchair and her call light pendant was not within reach. Subsequent interview with RN #316 and the Director of Nursing (DON) confirmed Resident #1 did not have her call pendant around her neck and it should be.

Based on observation and staff interview, the facility failed to ensure nurse staffing information was posted as required. This affected all 10 (#1, #2, #5, #6, #8, #9, #10, #11, #171, and #172) residents who resided in the Cornerstone Cottage. The facility census was 17. Findings include: Observation upon arrival at the facility on 04/14/25 at approximately 7:30 A.M. revealed the facility was comprised of two houses, one being the Cornerstone Cottage and the other being the [NAME] House. Observation on 04/16/25 at approximately 10:12 A.M. of all facility common areas and hallways revealed there was no daily nurse staffing information posted in the Cornerstone Cottage. Interview on 04/16/25 at 10:17 A.M. with the Administrator verified there was no daily nurse staffing information posted in the Cornerstone Cottage.

Based on observation and staff interview, the facility failed to ensure all required postings were displayed in the facility in a manner which was accessible to all residents. This affected all 10 (#1, #2, #5, #6, #8, #9, #10, #11, #171, and #172) residents who resided in the Cornerstone Cottage. The facility census was 17. Findings include: Observation upon arrival at the facility on 04/14/25 at approximately 7:30 A.M. revealed the facility was comprised of two houses, one being the Cornerstone Cottage and the other being the [NAME] House. Observation on 04/16/25 at approximately 10:12 A.M. of all facility common areas and hallways revealed there was no posted contact information for pertinent state agencies and advocacy groups, and no statement the residents may file a complaint with the State Survey Agency concerning suspected violations. Interview on 04/16/25 at 10:17 A.M. with the Administrator verified the Cornerstone Cottage did not have all required postings.

Based on the review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report, staffing schedule, staff time sheets, and staff interview, the facility failed to submit accurate information in the PBJ in the first quarter of 2024. This had the potential to affect all residents. The facility census was 17. Findings include: Review of the PBJ Staffing Data Report revealed the facility triggered for not having licensed nursing coverage 24 hours a day in the first quarter of 2024. The specific days identified were Monday 01/01/24, Friday 01/05/24, Saturday 01/06/24, Sunday 01/07/24, Sunday 01/19/24, Sunday 01/21/24, Monday 01/29/24, Saturday 02/03/24, Sunday 02/04/24, Friday 02/09/24, Saturday 02/10/24, Sunday 02/11/24, Saturday 02/17/24, Sunday 02/18/24, Friday 02/23/24, Saturday 03/02/24, and Sunday 03/17/24. Review of the staffing schedule for the 17 days noted in the PBJ as having insufficient nursing coverage revealed the staff on the floor did not match the information entered into the PBJ. For the days identified as deficient in the PBJ the actual nurse coverage ranged from 24 hours of nurse coverage a day to 32 hours of nurse coverage. There was sufficient nurse staffing for 24 hours on each of the days identified as deficient in the PBJ. Reconciliation of the staffing time sheets for Monday 01/01/24, Friday 01/05/24, Saturday 01/06/24, Sunday 01/07/24, Sunday 01/19/24, Sunday 01/21/24, Monday 01/29/24, Saturday 02/03/24, Sunday 02/04/24, Friday 02/09/24, Saturday 02/10/24, Sunday 02/11/24, Saturday 02/17/24, Sunday 02/18/24, Friday 02/23/24, Saturday 03/02/24, and Sunday 03/17/24 revealed the staffing schedule matched the staffing times worked. Interview on 06/17/24 at 10:54 A.M. with the Administrator verified the data entered into the PBJ for the first quarter of 2024 was not entered accurately. The Administrator reported the corporate agency had taken over entering data into the PBJ and appears to have missed the data when agency nursing staff was used. Follow up interview on 06/17/24 at 2:37 P.M. with the Administrator reiterated the data entered into the PBJ was not correct and audit of all the facilities was being completed to ensure the issue was corrected.

Based on review of the Self-Reported Incident (SRI), medical record review, staff interview and review of the facility policy, the facility failed to implement their policy and ensure staff accused of physical abuse were removed from the facility and put on leave during the investigation. This affected one (#10) of four residents reviewed for abuse. The facility census was 17. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included symbolic disfunctions, edema, anxiety disorder, restlessness and agitation. Review of Resident #10's Minimum Data Set (MDS) assessment, dated 05/11/24, revealed Resident #10 was severely cognitively impaired. Resident #10 required maximum assistance with toilet use and parts of dressing. Resident #10 required moderate assistance with bathing. Resident #10 had delusions during the review period and displayed wandering behaviors one to three days during the review period. Review of Resident #10's care plan revised 05/29/24 revealed supports and interventions for self-care deficit, risk for falls, plan to discharge to prior level of care, impaired cognitive function, chronic pain, and anxiety. Review of Resident #10's progress notes revealed on 05/24/24 while Resident #10 was waiting to be toileted she reported the aid was mean to her and slapped her. The nurse was notified of Resident #10's accusation, who notified the nurse on duty to do a complete skin assessment. An assessment was completed, and no marks were found. The nurse asked Resident #10 the name of the aid and Resident #10 accused someone who she said was a family friend and could not give a specific date. On 05/28/24 an interview was held with Resident #10's daughter regarding the comment Resident #10 made to the nurse regarding a family friend potentially slapping her. Resident #10's daughter reported no knowledge of any visitors and was not aware of anything like this happening in the past. Review of the Self-Reported Incident (SRI) dated 05/24/24 and completed 05/28/24 revealed On 05/24/2024 Resident #10 verbally alleged to a nurse she was slapped. Resident #10 was unable to initially say who slapped her or when this occurred. Resident #10 then pointed to State tested Nursing Assistant (STNA) #204 who was walking through unit and said Her. The nurse further reported moments later Resident #10 stated It was a family friend who slapped her. The nurse completed a head-to-toe skin assessment of Resident #10 with no adventitious findings noted. Resident #10's family and physician were notified. Resident #10's daughter reported it was likely Resident #10's anxiety was high. Anxiety medication was administered. All other residents were interviewed by the nurse with no complaints found. All residents interviewed report feeling safe and secure. STNA #204 was removed from providing care during the investigation. Staff present on shift interviewed and no family friends of Resident #10 were known to have visited. No family or friend visitors were able to be identified. Resident #10 had a diagnosis of anxiety and brief interview for mental status (BIMS) assessment for cognitive impairment score of six indicating Resident #10 was severely impaired. All staff were immediately educated on the facility policy related to abuse, neglect, misappropriation, and exploitation. Monitoring was to occur by additional resident interviews and additional interviews with Resident #10. The allegation was found to be unsubstantiated. Evidence revealed abuse, neglect or misappropriation did not occur. In addition, residents were re-interviewed, including Resident #10, and allowed time to express concerns. No findings were noted. All staff was educated on the facility's policy related to abuse and identifying abuse. Review of the facility's investigation revealed there was no indication STNA #204 was removed from the facility and put on leave during the investigation. Review of the Staffing Schedule for the time the SRI investigation was taking place 05/24/24 through 05/28/24 revealed the STNA #204 worked on 05/25/24 from 6:30 P.M. to 6:30 A.M., 05/26/27 from 6:30 P.M. to 6:30 A.M., 05/27/24 from 6:30 P.M. to 6:30 A.M., and 05/28/24 from 6:30 P.M. to 6:30 A.M. Interview on 06/17/24 at 12:15 P.M. with the Director of Nursing (DON) verified the Specified Perpetrator (STNA #204) in the self-reported incident was not removed from the facility nor taken off the schedule after the allegation of physical abuse. The DON reported STNA #204 was moved to the other building and worked under the nurse after the allegation of slapping. The DON stated Resident #10 accused STNA #204 and quickly changed her story stating a family member had slapped her. The DON reported had Resident #10 specifically identified STNA #204 she would have been removed from the facility and put on administrative leave. However, they did not feel Resident #10 had done so. Interview on 06/17/24 at 3:22 P.M. with the Administrator revealed STNA #204 was moved to another home during the investigation and the interview portion of the investigation was completed within a couple hours at which time they determined there was not an abuse concern. The 05/28/24 date was the date the facility completed all portions of the investigation and submitted the final report. Review of the facility policy title, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, revised 10/25/22, revealed the facility if a partner was accused or suspected of abuse the facility should immediately remove the partner from the facility and the schedule pending the outcome of the investigation. This non-compliance was indentified during the investigation of Complaint Number OH00153669.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident who was on contact isolation had proper signage posted and personal protective equipment available. This affected one (Resident #117) of one resident reviewed for transmission based precautions and had the potential to affect the other seven residents (#2, #12, #14, #118, #119, #120, and #121) who resided in the home. The facility census was 18. Findings include: Review of Resident #117's medical record revealed an admitted [DATE]. Diagnoses included esophageal cancer and clostridium difficile (C-Diff). Review of Resident #117's care plan revised 03/15/23 revealed supports and interventions for Resident #117 having a microbial infection related to being admitted with C-Diff. Interventions included isolation as ordered, educate on disease management, educate on infection control precautions, and on contact precautions with required hand washing, gloves, mask, and eye protection. Review of Resident #117's physician orders revealed an order dated 03/15/23 for Resident #117 to be on contact isolation for a diagnosis of C-Diff. Resident #117 was to receive all meals, medication, nursing care, activities of daily living and therapy in his room while on isolation. Two times a day/every shift staff were to wear appropriate PPE for Resident #117's direct care. Observation on 03/20/23 at 10:11 A.M. of Resident #117's room revealed no signage and no available personal protective equipment (PPE) or PPE cart indicating Resident #117 was on isolation in or around Resident #117's room entrance. Subsequent observation on 03/20/23 at 2:03 P.M. revealed there continued to be no signage indicating Resident #117 was on isolation and no personal protective equipment cart was available. Interview on 03/20/23 at 2:04 P.M. with State tested Nursing Assistant (STNA) #414 verified there was no signs or PPE cart available for Resident #117. STNA #414 was not aware Resident #117 was on isolation. STNA #414 reported there should be signs posted to see the nurse before entering the room along with PPE in a cart and red barrels inside the room for disposal of used items. Interview on 03/20/23 at 2:22 P.M. with the Director of Nursing (DON) verified Resident #117 was admitted to the facility last week and was on contact isolation for C-Diff. The DON reported the nurse over the weekend mistakenly thought it was colonized and removed the signs and PPE. The DON verified the PPE and signage should not have been taken down and there was still an active order in place. Interview on 03/21/23 at 9:58 A.M. with Registered Nurse (RN) #406 verified she had been the nurse who completed Resident #117's intake and did not put up signs or put out PPE. RN #406 stated she was under the impression Resident #117's C-Diff was colonized but verified she should have posted the signs and put the PPE cart out because there was still an active order for contact isolation. Review of the facility policy titled Isolation Precautions Process, revised 08/01/22, revealed contact precautions were required when the possibility of the spread of infection was by person to person. The use of personal protective equipment (PPE) including a gown and gloves upon entering the resident's room is required. Prior to leaving the room, the PPE was to be removed and hand washing was to occur.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident's tube feeding was administered at the rate ordered by the physician. This affected one (Resident #117) of one reviewed for tube feeding. The facility identified one resident who received tube feeding. The facility census was 18. Findings include: Review of Resident #117's medical record revealed an admitted [DATE]. Diagnoses included esophageal cancer, clostridium difficile (C-Diff), and anxiety disorder. Review of Resident #117's care plan revised 03/15/23 revealed supports and interventions for Resident #117 altered mental status, self-care deficit, and enteral feeding. Interventions for tube feeding included checking for residual, flush the gastric-tube with 30 cubic centimeters of water before and after each medication and keep the head of the bed at least 30 degrees. Review of Resident #117's physician orders dated 03/15/23 revealed an order for Isosource 1.5 at 80 milliliters (ml) per hour per day through the feeding tube. Start the tube feed running at 2:00 P.M. and turn off at 8:00 A.M. Observation on 03/21/23 at 1:55 P.M. of Registered Nurse (RN) #406 revealed RN #406 preparing to administer/connect Resident #117 continuous feed tube feeding. RN #406 reviewed the order in the electronic medical record. The order read Resident #117 was to be connected to his continuous tube feed for 18 hours, from 2:00 P.M. to 8:00 A.M., running at a rate of 80 ml per hour. Coinciding interview with RN #406 revealed due to Resident #117 having excessive residual over the weekend, the rate was reduced to 65 ml per hour. RN #406 verified that was not the active order in the electronic medical record. Observation on 03/21/23 at 2:04 P.M. revealed RN #406 programmed the tube feeding flow, primed the continuous tube feed machine and connected the device to Resident #117 feeding tube. RN #406 verified Resident #117's tube feeding was set and running at 65 ml per hour with a 60 ml flush every eight hours. Interview on 03/21/23 at 3:10 P.M. with the Administrator verified there was no order for the flow rate of Resident #117's tube feeding to be changed. The Administrator stated Resident #117's tube feed rate should not have been changed without an updated order. Interview on 03/22/23 at 9:26 A.M. with the Director of Nursing (DON) verified Resident #117's tube feeding was to be running at 80 ml per hour and not the 65 ml per hour it was set at yesterday. The DON stated Resident #117 had some excess residual over the weekend and verified RN #406 reduced the feeding amount without an order. Review of the facility policy titled External Tube Medication Administration, revised 06/21/17, revealed the staff was to check medication administration record for order.