Every finding on record at Parma Care Center

Based on record review, interview, and facility policy review, the facility failed to ensure a resident's bowel protocol was timely implemented as ordered. This affected one Resident (#76) of three residents reviewed for bowel management. The facility census was 76.Findings include: Review of the medical record for Resident #76 revealed an admission date of 11/06/25. Diagnoses included cerebral infarction, a stroke, malnutrition, hemiparesis, epilepsy, type II diabetes, schizoaffective disorder, bipolar disorder, and post-traumatic stress disorder (PTSD). Continued review of Resident #76's record revealed the resident was dependent on staff for toileting, showering, and transfers. The resident was incontinent of bowel and bladder.Review of the plan of care for Resident #76 dated 11/18/25 revealed the resident had constipation. Interventions included recording bowel movement pattern and administering medications as ordered.Review of Resident #76's physician orders revealed an order dated 11/25/25 for Docusate Sodium (an over-the counter stool softener which acts as a surfactant that increases water absorption into the stool, making it easier to pass) 100 milligram (mg) twice daily routine for bowel management. Resident #76 also had an order dated 11/25/25 for Polyethylene Glycol (an osmotic laxative used to treat constipation which works by retaining water in the stool which softens it, so stool is easier to pass) 17 grams twice daily routine.Continued review of Resident #76's physician orders revealed an order dated 11/25/25 for Bisacodyl rectal suppository (a fast-acting over-the-counter stimulant laxative which works by stimulating the muscles of the bowel to move stool) 10 mg daily as needed for bowel management. Resident #76 also had an order dated 12/25/25 for Milk of Magnesia (a saline laxative that softens stool and increases the frequency of bowel movements) 30 milliliters (ml) every 24 hours as needed for constipation.Review of Resident #76's bowel tracking for December 2025 revealed the resident had no documented bowel movements on 12/05/26, 12/06/25, 12/07/25, 12/08/25, 12/09/25, 12/10/25. Review of the Medication Administration Record (MAR) for December 2025 revealed no documentation of as-needed medications, such as Bisacodyl rectal suppository or Milk of Magnesia, were administered on 12/05/26, 12/06/25, 12/07/25, 12/08/25, 12/09/25, or 12/10/25 to address Resident #76's bowels. Review of an x-ray of Resident #76's abdomen results dated 12/10/25 at 11:22 A.M. revealed the resident had a large, dilated bowel loop noted in the right side of the abdomen. The report advised a computed tomography (CT) [scan] of the abdomen to rule out a bowel obstruction.Review of an emergency room (ER) summary dated 12/10/25 revealed Resident #76 was seen for concerns of bowel obstruction. The CT scan performed during the ER visit did not show an obstructed endpoint. The summary did note Resident #76 had significant constipation and stool burden. Treatment included administration of a suppository and oral laxatives. Resident #76 returned to the facility on [DATE].Review of Resident #76's bowel tracking dated December 2025 and January 2026 revealed there were no documented bowel movements on 12/30/25, 12/31/25, 01/01/26, 01/02/26, and 01/03/26.Review of the MAR for December 2025 and January 2026 revealed no documentation of as-needed medications, such as Bisacodyl rectal suppository or Milk of Magnesia, were administered on 12/30/25, 12/31/25, 01/01/26, 01/02/26, and 01/03/26 to address Resident #76's bowels. Review of a progress note dated 01/05/26 at 2:53 A.M. revealed Resident #76 was inconsolable and endorsing abdominal pain. No bowel sounds were noted to the right and left lower [abdomen] and the resident had pain when palpated near the umbilicus. Resident #76 was sent to the ER for evaluation. Resident #76's Power of Attorney (POA) was notified, and report was called to the hospital.Review of an ER summary dated 01/05/26 at 4:08 A.M. revealed Resident #76 was seen at the ER due to reports of abdominal pain. The ER summary noted the patient had a bowel movement at the ER and did not vomit while at the ER. The report indicated there was not concern for a bowel obstruction. Review of a progress note dated 01/05/26 at 7:57 A.M. revealed Resident #76 returned from the ER at 4:45 A.M. Per report, the resident had a large BM, and they sent her back with no imaging or testing done. Review of Resident #76's bowel tracking dated January 2026 revealed there were no documented bowel movements on 01/16/26, 01/17/26 and 01/18/26.Review of the MAR for January 2026 revealed no documentation of as-needed medications, such as Bisacodyl rectal suppository or Milk of Magnesia, were administered on 01/16/26, 01/17/26 and 01/18/26 to address Resident #76's bowels. Review of an ER summary dated 01/18/26 revealed Resident #76 was sent to the ER concerning a possible bowel obstruction. A CT scan was performed which indicated there was no definitive transition point that would suggest a bowel obstruction. Resident #76 received a soap suds enema (a large volume enema consisting of water and mild [NAME] soap used to treat severe constipation. This type of enema works by irritating the rectal mucosa to stimulate peristalsis and defecation). Resident #76's medication regimen was adjusted with new orders for additional laxative medications and a referral to a gastroenterology specialist. Resident #76 returned to the facility. Interview on 03/05/26 at 2:45 P.M. with the Director of Nursing (DON) stated if a resident does not have bowel movement in three days, the bowel protocol is started. The DON verified Resident #76 had no documented bowel movements on 12/05/26, 12/06/25, 12/07/25, 12/08/25, 12/09/25, 12/10/25 and on 12/30/25, 12/31/25, 01/01/26, 01/02/26, 01/03/26. The DON verified that the bowel protocol was not initiated on 12/08/25, 01/02/26 or 01/18/26.Review of the policy titled Bowel Management and Treatment dated January 2023 revealed that residents at risk for constipation should be placed on a bowel regimen. Each shift, nursing will document the resident's bowel movement in the medical record. Residents who have not had a bowel movement for three consecutive days will have a specified bowel protocol initiated, unless resident has individual orders specific to bowel management, or where the orders would be contradicted for the resident.This deficiency represents non-compliance investigated under Master Complaint Number 2723617.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility investigation, hospital documentation review, resident and staff interview, review of a mechanical lift manufacturer instructions document, policy review, and review of facility corrective action documentation, the facility failed to ensure residents who required staff assistance and use of a mechanical lift for transfers were safely transferred without injuries. Actual harm occurred to Resident #53 on 09/03/25 when two staff members were transferring the resident from the bed to a wheelchair; during the transfer, one of the mechanical (Hoyer) lift pad straps was not properly secured to the lift by the staff members which caused the resident to slip out of the sling and fall to the floor. Subsequently, Resident #53 complained of pain and was transported to the hospital where imaging revealed the resident sustained a fractured pelvis. Following the incident, Resident #53 voiced apprehension to be transferred in the mechanical (Hoyer) lift. This affected one (#53) of four residents reviewed for falls. The facility census was 76. Findings include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, post-traumatic stress disorder, and hemiplegia with hemiparesis following an unspecified cerebrovascular event affecting the left non-dominant side (resulting in weakness or paralysis on the left side of the body). Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 was dependent on staff for all activities of daily living (ADLs). Review of physician's orders dated 07/01/24 revealed Resident #53 required a mechanical (Hoyer) lift for all transfers. Review of the most recent fall risk assessment dated [DATE], as well as the seven prior fall risk assessments completed by the facility since the resident's admission, revealed Resident #53 was consistently identified as at high risk for falls. Review of the medical record revealed on 09/03/25 at approximately 10:30 A.M., a loud noise was heard by the charge nurse while seated at the nurse's station. Upon entering Resident #53's room, the nurse observed the resident lying on the floor adjacent to the bed. Two certified nurse aides (CNAs) were present. A wheelchair and Hoyer lift were nearby. Immediate assessment revealed no visible injuries to Resident #53; however, the resident verbalized slipping from the Hoyer lift sling and reported pain to the left elbow and left side of the face. The note revealed Resident #53 was maintained on the floor for safety until further evaluation. Emergency medical services (EMS), the facility Nurse Practitioner (NP), and the resident's family were notified. EMS subsequently transferred Resident #53 to a local hospital for evaluation. Review of hospital documentation dated 09/03/25 revealed Resident #53 was transferred to the hospital from the facility after a mechanical fall. The resident reported pain to the left side of the head, left elbow, and left hip. Further review of pelvis radiographs revealed Resident #53 had acute fractures of the superior and inferior rami (an arm or branch of a bone) on the left. Review of facility's investigation documents dated 09/03/25 revealed CNA #407 and CNA #408 were transferring Resident #53 from the bed to a wheelchair. During the transfer, one of the Hoyer lift pad straps was not secured to the spreader bar. The unsecured strap caused the resident to slip from the sling and fall. Both CNAs provided written statements verifying the failure to secure the strap, which directly resulted in the fall and subsequent pelvic fracture. The Director of Nursing (DON) confirmed in an interview on 09/15/25 at 4:45 P.M. that the injury suffered by Resident #53 was caused by the improper securing of the Hoyer lift sling during a transfer on 09/03/25. Interview with Resident #53 on 09/16/25 at 1:33 P.M. verified the events of the fall and subsequent pelvic fracture. Resident #53 further expressed apprehension to be transferred in the Hoyer lift after the incident. Review of the manufacturer's instructions for the Hoyer lift utilized by the facility, copyright 2022, revealed to not move the patient if the sling was not properly connected to the hooks of the hanger bar. When the sling was elevated a few inches off of the stationary surface and before moving the patient, check again to make sure the sling was properly connected to the hooks of the hanger bar. If any attachments were not properly in place, lower the patient back onto the stationary surface and correct this problem; otherwise, injury or damage may occur. Review of the policy titled, Hoyer lift, dated 07/01/22, revealed the facility would utilize a Hoyer lift to assist a resident to move with increased independence and transfer with greater comfort, to feel physically more secure while preventing accidents, maintaining safety, and body alignment, promoting, supplementing, and/or enhancing the resident's function and/or safety. The deficient practice was corrected on 09/04/25 when the facility implemented the following corrective actions: On 09/03/25 at 10:32 A.M., Resident #53's family and nurse practitioner were called to notify of incident. On 09/03/25 at 10:34 A.M., the Hoyer lift and sling used in the incident with Resident #53 were removed from service. On 09/03/25 at 10:45 A.M., Resident #53 was transported to a local hospital for evaluation. On 09/03/25 at 10:47 A.M., the Director of Nursing (DON) provided immediate education and competency check with CNA #407 and CNA #408. Both staff members passed their competency checks. On 09/03/25 at 11:00 A.M., the Hoyer lift utilized in the incident was inspected by Maintenance Manager (MM) #315 and found to be in good working order. The Hoyer pad used in the transfer was also inspected and showed no signs of wear. On 09/03/25 at 11:00 A.M., the DON and designees began education for all direct care staff regarding use of mechanical lifts with special focus on checking straps prior to beginning to lift a resident. Competencies were performed with all CNAs employed at the facility. All education and competencies were completed by 11:00 A.M. on 09/04/25. On 09/03/25, MM #315 conducted an emergency audit of all Hoyer lifts and Hoyer pads in the facility for functionality and safety with no negative findings. On 09/03/25, the facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to discuss the incident. The facility implemented a policy beginning on 09/08/25 newly hired employees would be educated regarding mechanical lift use and must pass a mechanical lift competency prior to working with residents. The Administrator and the DON would continue to monitor compliance directly in the monthly Quality Assurance and Performance Improvement (QAPI) meetings for three months and then as needed for one year. Review of the incident and accident report from July, August, and September 2025 revealed no additional instances of resident accidents or injuries involving transfers with mechanical (Hoyer) lift devices. Interviews on 09/15/25 between 10:30 A.M. and 4:00 P.M. with Licensed Practical Nurse (LPN) #348, LPN #349, CNA #383, CNA #390, CNA #393 and CNA #397 all verified being provided education regarding use of a mechanical lift for resident transfers and were able to demonstrate knowledge from the training. Observation of a Hoyer lift transfer on 09/15/25 at 3:00 P.M. for Resident #67, performed by CNA #383 and CNA #390, revealed the staff members correctly and safely completed the transfer without incident. This deficiency represents non-compliance investigated under Master Complaint Number 2616144 and Complaint Number 2574416.

Based on observation, interview, and facility policy review, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 84 residents receiving meals from the kitchen. The facility identified one resident (#6) as receiving nothing by mouth (NPO). The facility census was 85. Findings include:Observations of the facility kitchen on 07/21/25 from 8:32 A.M. to 9:00 A.M. with Dietary Manager (DM) #245 revealed the following concerns:a. There was a prep table for juice and coffee machines which included a sink built into the table. The plumbing under the sink was leaking into a plastic container on the floor.b. Observation in the dry storage room revealed various debris under racks including a pen and a package of instant coffee.c. The floors throughout the kitchen area were sticky and had various debris and crumbs. d. Spilled thickener powder was observed on a prep table holding the mixer.e. Additional prep tables had food debris and crumbs on the bottom shelves that held various supplies.f. Dried food splatter was noted on the kitchen equipment including the convection oven, steamer, two range tops, and a sink under kitchen hood. g. The sink faucet under the kitchen hood was dripping down its side.h. The dish machine area revealed there was scale build up on the outside of the dish machine.i. The three dish machine cycle revealed the dish machine did not reach required temperatures for sanitation. The wash cycle temperature was 150 degrees F and the rinse cycle was 176 degrees F.j. Multiple dead bugs were noted in the light fixtures on ceiling. k. The floors were sticky with various food debris and there was steel wool on floor under dish machine. l. Leftover food debris was noted in the dirty side of the dish machine, which included tomato sauce, corn, and elbow noodles. m. The plastic cart holding the breakfast dishes had dried food splatter and various debris on the three levels of the cart. n. There was a plastic cart of dishes left over from the previous night with food including carrots, biscuits, and fried chicken. o. There was a plastic bin with sugar and artificial sweetener packets sitting on a table with chemicals including floor cleaner. Interview on 07/21/25 at 9:00 A.M. with DM #245 confirmed the above findings. DM #245 indicated he had only been employed at the facility for a month and a half. DM #245 indicated there were no written cleaning schedules and he would make a list for the staff when things needed done. DM #245 indicated the kitchen sanitation was unacceptable, and he would address his staff. Review of the undated facility policy General Sanitation of the Kitchen revealed staff would maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Review of the undated facility policy titled Dishwashing revealed the final rinse temperature for a high temperature machine was 180.0 degrees Fahrenheit (F) to 194.0 F.Review of the facility policy Food Storage dated 2023 revealed foods would be stored in an area that is clean, dry, and free of contamination. Chemicals were required to be clearly labeled and stored away from food. The racks and storage surfaces should be clean and protected from splashes.

Based on observation, interview, review of pest control company invoices, and facility policy review, the facility failed to effectively manage pests in the kitchen area. This had the potential to affect 84 residents receiving meals from the kitchen. The facility identified one resident (#6) as receiving nothing by mouth (NPO). The facility census was 85. Findings include:Observations of the facility kitchen on 07/21/25 from 8:32 A.M. to 9:00 A.M. with Dietary Manager (DM) #245 revealed multiple flies throughout the kitchen area and dish machine areas.Interview on 07/21/25 at 9:00 A.M. with DM #245 confirmed the presence of multiple flies throughout the kitchen area.Review of the pest control company invoice dated 06/05/25 revealed the kitchen, dishwashing area, and dry goods storage area, received a general pest treatment, but it did not include house flies or fruit flies.Review of facility policy Pest Control dated March 2023 revealed pests would be controlled in and around all buildings to reduce any potential human health hazard. Common pests included flies.Review of the facility policy Food Storage dated 2023 revealed the storage areas would be free from rodent and insect infestation. The kitchen would be treated for pests and vermin on a regular schedule.

Based on observation, interview, and facility policy review, the facility failed to ensure food was served at an appetizing temperature. This had the potential to affect 84 residents receiving meals from the kitchen. The facility identified one resident (#6) as receiving nothing by mouth (NPO). The facility census was 85. Findings include:Observation of lunch meal temperatures prior to service on 07/23/25 at 11:38 A.M. with [NAME] #214 using the facility digital thermometer revealed the two trays of breaded chicken patties temperatures were 165.2 degrees Fahrenheit (F) and 167.0 F and the rice temperature was 200.0 F.Observation of lunch tray line service on 07/23/25 from 11:45 A.M. to 12:42 P.M. revealed the facility completed tray line pass. The cook was observed to run out of plates and began using divided dishes for the last three trays served. A test tray was served on the final cart. Observation of lunch test tray on 07/23/25 at 12:54 A.M. following completion of resident tray pass revealed temperatures were taken using the facility digital thermometer by Mobile Dietary Manager (DM) #299. The test tray was served on a divided dish with a heated base and dome lid. The temperatures of the breaded chicken patty on a bun was 102.8 F and the rice was 110.2 F. A taste test revealed the temperatures of the breaded chicken patty on a bun and rice were lukewarm. Interview on 07/23/25 at 12:54 A.M. with Mobile DM #299 revealed Mobile DM #299 also tasted the breaded chicken patty on a bun and rice and confirmed the temperature was not palatable and indicated she would microwave the meal. Review of the undated facility policy Food Temperatures revealed hot foods would be held at 135.0 F or greater throughout the service process.

Based on observation, interview, and policy review, the facility failed to ensure a call light was in reach for resident use to call for assistance. This affected one resident (Resident #91) of one resident sampled for call light placement. The facility census was 85.Findings include: A review of medical record for Resident #91 revealed an original admission date of 04/13/21 and a readmission date of 05/22/23. Significant diagnoses included diabetes mellitus type two, unspecified dementia, generalized anxiety, major depressive disorder, cirrhosis of the liver, chronic hepatitis C, clostridium difficile, and chronic obstructive pulmonary disease. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 13 indicating the resident was cognitively intact. The MDS also revealed Resident #91 required substantial to maximum assistance with toileting, substantial to maximum assistance with showers and partial to moderate assistance for dressing. The MDS revealed Resident #91 to be occasionally incontinent of bowel and bladder.A care plan dated 06/19/25 revealed Resident #91 had behavioral symptoms. Interventions included encourage to place the call light in reach or off the floor and place a clip on the call light and clip it to the sheets or bed.On 07/21/25 at 9:39 A.M. an observation of Resident #91 revealed her lying in bed. The call light was on the floor on the right side of the bed.On 07/21/25 at 9:39 A.M. an interview with Housekeeping Supervisor #298 verified Resident #91's the call light was on the floor.On 07/22/25 at 4:09 P.M. an observation of Resident #91 revealed her lying in bed. The call light was on the floor on the right side of the bed. On 07/22/25 at 4:09 P.M. an interview with Certified Nurse Aide #212 verified Resident #91's the call light was on the floor.The review of the policy titled; Resident Call System dated March 2023 revealed the staff will provide an environment to assist in meeting the needs of residents and to provide an environment which supports and enhances each residents quality of life, providing the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being, consistent with the residence comprehensive assessment and plan of care. The policy also revealed, in subpoint 8, when leaving the room, be sure the call light is placed within the residents reach.

Based on medical record review, observation, interview, and review of the facility policy, the facility failed to ensure a smoking assessment was completed for a resident who was smoking on the facility premises. This affected one (Resident #54) of one reviewed for smoking. The facility census was 85.Findings Include: Review of the medical record for Resident #54 revealed an admission date of 07/14/25. Diagnoses included but were not limited to hemarthrosis of the right knee, type two diabetes mellitus with chronic kidney disease, end stage renal disease and dependence upon renal dialysis.Further review of Resident #54's medical record revealed no documented evidence that a smoking assessment was completed to determine the resident's capabilities and deficits to determine whether or not supervision was required.Review of the 07/14/25 admission Minimum Data Set (MDS) 3.0 for Resident #54 revealed intact cognition. Resident #54 was noted to use a wheelchair, required supervision for mobility and moderate assistance with dressing, toileting and bathing.Review of the 07/14/25 care plan for Resident #54 revealed no care plan related to smoking.Review of the nursing progress note dated 07/15/25 timed at 2:02 P.M. for Resident #54 revealed the Social Services Designee (SSD) #203 spoke with Resident #54 about the facility being a non-smoking facility and provided education about the smoking policy. Resident #54 stated he was aware he must sign-out each time he went out to smoke and must go off the facility property to smoke.Observation and interview on 07/21/25 at 9:15 A.M. revealed Resident #54 was smoking outside on the facility bench across from the facility entrance. There was no ash tray observed and there was a sign near the entrance door that stated, 'No Smoking'. Interview at the time of the observation with the Administrator confirmed the facility was a non-smoking facility and Resident #54 was not supposed to be smoking on the facility grounds.Interview on 07/22/25 at 2:23 P.M. with Licensed Practical Nurse (LPN) #266 confirmed Resident #54 was aware prior to admission that the facility was not a smoking facility. LPN #266 confirmed a smoking plan should have been in place following the 07/15/25 smoking incident.Interview on 07/22/25 at 2:28 P.M. with the Director of Nursing (DON) and the Administrator confirmed Resident #54 was caught smoking outside on 07/15/25 and a smoking assessment was not completed following the incident.Review of the August 2024 facility policy titled, Non-Smoking and Non-Vaping revealed smoking, including the use of tobacco, was strictly prohibited on the premises, both indoors and outdoors.

Based on interview and observation, the facility failed to ensure that infection control guidelines were followed during incontinence care for Resident #6. This affected one (Resident #6) out one resident observed for incontinence care. The facility census was 85. Findings include:Review of the medical record for Resident #6 revealed an original admission date of 03/14/23 and a re-admission date of 12/20/24. Medical diagnoses included Huntington's disease, major depressive disorder, muscle weakness, and unspecified lack of coordination.Review of Resident #6's care plan dated 04/17/24 revealed the resident required enhanced barrier precautions to reduce the transmission of multidrug-resistant organisms related to the use of a feeding tube. Interventions included to ensure thorough cleaning and disinfection of surfaces and equipment, perform hand hygiene before and after glove use, regularly reinforce education to maintain compliance, use disposable gowns and gloves during high contact care activities, and remove gowns and gloves promptly after care activities and dispose of them in the proper receptacle.Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was rarely or never understood, had short- and long-term memory impairment, was dependent upon staff for all activities of daily living and was always incontinent of bowel and bladder.Review of Resident #6's physician's orders revealed an order dated 07/26/25 for enhanced barrier precautions to be used while providing care.An observation on 07/21/25 at 10:45 A.M. revealed Certified Nursing Assistant (CNA) #292 and CNA #229 preformed incontinence care for Resident #6. CNA #292 cleansed Resident #6's buttocks and groin area and did not remove her gloves after. CNA #292 then touched multiple clean items with contaminated gloves including clean bed linens, the privacy curtain and Resident #6's overbed table. CNA #229 removed the soiled linen and adult brief from under Resident #6 and put it on the floor.An interview on 07/21/25 at 11:15 A.M. with CNA #292 and CNA #229 confirmed that CNA #292 did not remove her gloves after incontinence care and that CNA #229 placed the soiled linens on the floor. The CNA's further verified that the linens should have been placed in a bag once removed from Resident #6's bed.Review of the undated facility policy titled, Bathing - Personal Care, revealed residents of the health care facility will receive personal care in the facility according to the resident's plan of care to promote dignity cleanliness and general well-being.

Based on record review, observation and interviews, the facility failed to ensure that Resident #6 received oral care and was shaved per his preference. This affected one resident (#6) out of five residents reviewed for activities of daily living (ADLs). The facility census was 85.Findings include:Review of the medical record for Resident #6 revealed an admission date of 12/20/24 with diagnosis including Huntington's disease, major depressive disorder, muscle weakness, and unspecified lack of coordination.Review of the care plan for Resident #6 dated 03/27/25 revealed a goal he would be clean, dry, dressed, groomed and free of odors. Further review of the care plan revealed Resident #6 had a preference to be clean shaven.Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #6 was rarely or never understood, had short-term and long-term memory impairment, and was dependent upon staff for all ADLs. An interview on 07/21/2025 at 3:17 P.M. with a family member of Resident #6 revealed the resident was often unshaven and his teeth not brushed. Additionally, the family member shared that prior to Resident #6 being dependent upon the facility staff for ADL completion, he was meticulous about his hygiene and was always clean shaven.An observation on 07/23/25 at 9:00 A.M. revealed Resident #6 was in bed and dressed in a hospital gown. He had a full, short beard with a full moustache.An observation on 07/23/25 at 9:51 A.M. of Resident #6 revealed that his teeth were covered with a thick film and his lips had visible dry crust. An interview with Licensed Practical Nurse (LPN) #213 at the time of observation verified Resident #6 needed oral care performed and shared that oral care was expected to be done every shift.An interview on 07/23/25 at 3:00 P.M. with Certified Nursing Assistant (CNA) #292 verified Resident #6 had a full, short beard and a full moustache. CNA #292 stated nursing staff did not shave Resident #6, and that the went to the beauty shop to be shaved.An interview on 07/23/25 at 4:00 P.M. with Beautician #302 revealed she used clippers on Resident #6's head and face to trim as close as she could, but she does not shave him. The beautician shared that it was not safe for her to shave Resident #6 because he did not sit still enough. Beautician #302 additionally shared that nursing was to shave Resident #6 after she trimmed his beard down.An interview on 07/24/25 at 9:15 A.M. with the Director of Nursing (DON) revealed it was expected that residents would be shaved per their preference. The DON shared the facility had an CNA on light duty who was assigned to shave and perform nail care for residents. The DON further shared that activity staff and CNAs could shave residents with an electric razor. The DON stated she believed Resident #6 was shaved by Beautician #302 last Wednesday and was not aware Resident #6 had not been shaved.Review of the facility policy bathing and personal care dated 08/2022 revealed oral care would be offered twice a day, after meals and as needed, with special attention given to residents receiving tube feeding or that were nothing by mouth. The policy further stated that shaving would be offered daily as part of the routine bathing process.

Based on record review, interview, and policy review the facility failed to ensure accurate documentation related to medication administration; ensure a clear and accurate reconciliation of controlled substances; ensure controlled medications were not administered without physician orders, and as needed medications were not removed from secured storage areas prior to being requested or needed by the residents. This affected seven (Residents #16, #5, #14, #40, #84, #85 and #79) of seven residents reviewed for medication administration. The facility census was 82. Findings include: 1. Medical record review revealed Resident #16 was admitted on [DATE] and readmitted on [DATE] with diagnoses including mild intellectual disability, Alzheimer's disease, cerebral infarction (stroke), convulsions, pulmonary/heart disease, peripheral vascular disease, gastritis/colitis with esophageal reflux disease, high blood pressure/cholesterol, end stage kidney disease, diabetes mellitus, psychotic disorder, depression, anxiety, and osteoarthritis. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 received high risk medications including an anticonvulsant medication. Review of a physician order dated 03/18/22 indicated to administer Resident #16 Lacosamide 100 milligrams (mg) orally at bedtime for seizures related to unspecified convulsions. Review of Resident #16's plan of care indicated Resident #16 had a seizure disorder and history of a stroke. Interventions included to administer medications as ordered, observe for effectiveness and side effects, and document the location of seizure activity, type of seizure activity, duration, level of consciousness, and post-ictal state after seizure activity. A review of Resident #16's Controlled Substance Accountability Sheet for the documentation of Lacosamide administration dated 03/18/25 indicated inaccurate documentation of the date and time the medication was dispensed, amount administered, quantity wasted/destroyed and quantity remaining. On 04/23/25 the documentation indicated one tablet of Lacosamide remained in stock. On 04/24/25 at 9:00 A.M. the documentation indicated one tablet was dispensed, one tablet administered and the quantity remaining zero. The quantity remaining should have been one. On 04/24/25 at 4:00 P.M. the documentation indicated no tablets were dispensed and one tablet was administered with one tablet remaining which was incorrect. The remaining amount should have been zero. On 04/28/25 the documentation indicated there was one tablet of Lacosamide remaining, one tablet dispensed, one tablet administered and should have one tablet remaining. The documentation indicated no tablets remained. It was not clear upon reviewing the Controlled Substance Accountability Sheet where the Lacosamide was obtained; sometimes the medication was removed from the medication cart and sometimes the medication was removed from the electronic medication dispensing system. The electronic medication dispensing system was used when the medication was available in Resident #16's stock of medication. An interview with Registered Nurse (RN) #90 on 04/28/25 at 11:30 A.M. verified she had documented Resident #16's Lacosamide removal and administration to Resident #16 on the Controlled Substance Accountability Sheet incorrectly. An interview with Director of Nursing and Administrator on 04/29/25 at 12:00 P.M. verified the above findings and they confirmed the documentation on Resident #16's Controlled Substance Accountability Sheet was incorrect. 2. Medical record review revealed Resident #5 was admitted on [DATE] and readmitted on [DATE] with diagnoses including morbid obesity, fractured right arm/right clavicle/thoracic vertebra, depression, sleep apnea, dislocation of right acromioclavicular joint, epilepsy, nervous system diseases, chronic kidney disease, peripheral vascular disease, high cholesterol, constipation, vitamin D deficiency, anxiety, and gastroesophageal reflux disease. A review of Resident #5's physician orders dated 03/01/25 to 03/31/25 indicated to administer oxycodone hydrochloride five milligram (mg) tablet orally every six hours as needed for pain. Medical record review revealed Resident #14 was admitted on [DATE] with diagnoses including surgical joint replacement, arthropathies, cataracts, eye disease, cardiac pacemaker/defibrillator, anxiety, depression, atrial-fibrillation, osteoarthritis, dilated cardiamyopathy, gastroesophageal reflux disease, fibromyalgia, heart failure, high cholesterol, high blood pressure, and migraine. A review of Resident #14's physician orders dated 03/01/25 to 03/31/25 indicated to administer Tramadol hydrochloride 50 mg orally every six hours as needed for mild pain. Medical record review revealed Resident #40 was admitted on [DATE] and readmitted on [DATE] with diagnoses including rhabdomyolosis (muscle injury where muscles break down), schizoeffective disorder, hypo-osmoality, alcohol abuse, anemia, osteoarthritis, lupus erythmatosis (body's immune system attacks tissues and organs), heart attack, low magnesium and potassium level, atrial-fibrillation, depression, Raynaud's syndrome, vascular heart disease, retinopathy, cataracts, urinary retention with neuromuscular bladder, angioneurotic edema (unpredictable frequent edematous episodes of cutaneous and mucosal tissues such as lips, eyes, oral cavity, larynx, and gastrointestinal system.), and acute respiratory/kidney failure. A review of Resident #40's physician orders dated 03/01/25 to 03/31/25 indicated to administer Ativan 0.5 mg orally every six hours as needed and to administer oxycodone 10 mg every six hours as needed for pain. A review of the Controlled Dispensing documentation for removal of controlled substances from the electronic dispensing system dated 03/31/25 revealed from 7:32 P.M. to 7:33 P.M. one oxycodone five mg tablet and one lorazepam (Ativan) 0.5 mg tablet was removed for Resident #40, one Tramadol 50 mg tablet was removed for Resident #14 and one oxycodone five mg tablet was removed for Resident #5. An interview with Registered Nurse (RN) #92 on 04/29/25 at 9:27 A.M. revealed she had been disciplined for removing Resident #5, Resident #14, and Resident #40's controlled narcotics at the same time from the electronic dispensing system in the facility. RN #92 stated she had difficulty walking and did not want to walk back and forth three times because she knew she would be administering the as needed medications to Resident #5, Resident #14 and Resident #40 some time during her 12 hour shift. A review of the facility documentation of the investigation of RN #92 dated 04/01/25 revealed Resident #5, Resident #14 and Resident #40's controlled narcotic medications were removed from the electronic dispensing system at the same time. The investigation indicated the Director of Nursing (DON) received the daily electronic dispensing system report with controlled narcotics pulled from the night before. After reviewing, the DON noted that narcotics were all pulled around the same time. Due to narcotics being as needed, the DON questioned why they were pulled simultaneously. The DON interviewed the listed residents on the report and all residents confirmed they received their medications. The DON and the Administrator spoke with RN #92 who stated, I pulled them at the same time to save myself a trip. 3. Medical record review revealed Resident #85 was admitted on [DATE] and readmitted on [DATE] with diagnoses including emphysema, malnutrition, iron deficiency anemia, atherosclerotic heart disease, cardiomyopthy, hypo-osmoality, osteoarthritis, bone density disorder, left pubis pelvic fracture, and post-traumatic headache with acute post-traumatic general pain. Review of Resident #85's physician order dated 03/28/25 indicated to administer oxycodone hydrochloride 2.5 mg every eight hours as needed for pain due to diagnosis of a fracture of left pubis. Review of Resident #85's Medication Administration Record (MAR) dated 04/01/25 to 04/30/25 indicated on 04/02/25 Resident #85 received oxycodone hydrochloride 2.5 mg orally at 1:22 A.M. Review of Resident #85's Controlled Substance Accountability Sheet dated 03/29/25 to 04/10/25 indicated on 04/02/25, Registered Nurse (RN) #92 removed oxycodone five milligram (mg) tablet to administer to Resident #85 at 1:30 and 7:30. There was no documentation to indicate if the medication was administered in the A.M. or P.M. An interview with RN #92 on 04/29/25 at 4:15 P.M. revealed she had administered Resident #85's oxycodone medication two hours early. RN #92 confirmed Resident #85's physician order for oxycodone indicated the oxycodone could be administered for pain every eight hours and she administered the oxycodone medication at 1:30 A.M. and 7:30 A.M. on 04/02/25 which was six hours between doses and should not have been administered until eight hours between doses. An interview on 04/30/25 at 12:45 P.M. with the Administrator verified there was no documentation that Resident #85 was administered the oxycodone 2.5 mg dose at 7:30 A.M. on Resident #85's Medication Administration Record (MAR) or clinical record. The Administrator confirmed the documentation on Resident #85's narcotic control sheet did not indicate if the oxycodone removed from the medication cart was removed during the morning hours, afternoon hours or evening hours at 1:30 and 7:30 on 04/02/25. The Administrator also verified RN #92 had removed Resident #85's oxycontin medication from the medication cart at 7:30 A.M. on 04/02/25 but did not document the administration of the oxycontin medication in Resident #85's clinical record and/or MAR. 4. Medical record review revealed Resident #84 was admitted on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease, heart failure, hydronephrosis, gastritis, uropathy, high blood pressure, diabetes mellitus, high cholesterol, atherosclerotic heart disease, cerebral infarction (stroke), diaphragmatic hernia, anxiety with adjustment disorder, obstructive sleep apnea, osteoporosis, urinary retention, right tibia/fibula fracture, and neuropathy. Further review of the medical record including Resident #84's physician orders revealed there was no physician order for the administration of liquid Morphine. Review of Resident #84's Medication Administration Record (MAR) dated 09/01/25 to 09/31/25 revealed no documentation Resident #84 was administered liquid Morphine. An interview with Registered Nurse (RN) #90 on 04/28/25 at 11:06 A.M. revealed RN #90 stated she had administered Resident #84 liquid Morphine without an order. RN #90 said she gave the dosage of Morphine to Resident #84 on or about 09/25/24. Resident #84 had complained of pain and RN #90 found a bottle of liquid Morphine in the locked medication drawer of the medication cart and measured five milligrams (mg) of the liquid and administered the Morphine to Resident #84. RN #90 stated she could not explain how a bottle of liquid Morphine was labeled with Resident #84's name without a physician order. A review of RN #90's statement sent to the Ohio Board of Nursing (OBN) dated 01/09/25 revealed that on or about 09/25/24, RN #90 administered Morphine to Resident #84. The statement indicated it had been said that the resident had not had an order for Morphine and also had a listed allergy to Morphine. That particular day RN #90 had shared with a co-worker (unnamed) that Resident #84 did not seem to be doing well and that RN #90 thought she may be starting the process of dying. RN #90 made the co-worker aware that Resident #84 was still lucid and if he wanted to go and say hello and visit it might be a good time. When the co-worker returned, he had stated that Resident #84 had a complaint of pain and requested pain medication. Together RN #90 and the co-worker walked back to the medication cart where RN #90 pulled the narcotic medication record, opened the narcotic drawer where Resident #84's prescribed Morphine was found. RN #90 then drew up the Morphine medication, entered Resident #84's room and made Resident #84 aware of the administration of the requested pain medication of Morphine and that the liquid Morphine would be placed under her tongue, RN #90 then administered the Morphine. After RN #90 was done both staff exited the room. RN #90 returned to the medication cart, documented the medication was given on the paper chart, and then went to the electronic chart and was unable to find the order for the Morphine medication listed. RN #90 notified the primary care Certified Nurse Practitioner (CNP) of the error. The CNP asked if there were any adverse reactions and to please continue to monitor. The resident was in the care of Hospice at that time. Having been an RN Case Manager for a hospice company in the past, RN #90 was aware that hospice treated the symptoms of a dying resident which also meant that if a resident had a said allergy to a medication with no history of anaphylactic reaction the symptoms were treated. Resident #84 had shown no signs or symptoms of adverse reaction. RN #90 reported the medication error her next shift to the Director of Nursing (DON). RN #90 received verbal disciplinary action for the error. Also, being made aware, moving forward, to report any medication error to management immediately. RN #90 indicated had the resident not had a valid written prescription the medication would not have been available or received by the facility from the pharmacy. The medication was clearly labeled with Resident #84's name. A review of the OBN letter dated 01/27/25 revealed the OBN had investigated RN #90 for administering Morphine medication to a resident without a physician order. The Nursing Board recommended RN #90 complete additional training prior to her RN license renewal within 180 days of the date of the investigation on 01/25/25. An interview with the Administrator and DON on 04/29/25 at 12:45 P.M. verified the above findings and confirmed RN #90 had administered the Morphine medication to Resident #84 without a physician order. It could not be confirmed where the Morphine bottle came from and/or if it had Resident #84's name on the label. 5. Medical record review revealed Resident #79 was admitted on [DATE] with diagnoses including traumatic subdural hemorrhage, glaucoma, high blood pressure, legal blindness, obesity, peripheral vascular disease, psychosis, mood disorder, pseudobulbar affect, arthopathies, insomnia, and ringing of the ears. A review of Resident #79's nursing progress notes dated 04/27/25 timed 9:07 A.M. revealed Resident #79 was crying loudly and not able to state why he was crying. Resident #79 denied pain and was pulling on his catheter, Redirection and repositioning were ineffective. Ativan was administered with good results noted. Further review of Resident #79's medical record revealed there was no order for the administration of Ativan to Resident #79. An interview with the Director of Nursing (DON) on 04/29/25 at 3:38 P.M. revealed she was informed by Registered Nurse (RN) #92 that she had administered Resident #21 the Ativan medication and had documented the administration of the Ativan in the nursing progress notes in Resident #79's clinical record by accident. The DON verified the documentation of the administration of the Ativan medication in Resident #79's progress note dated 04/27/25 at 9:07 A.M. was inaccurate. Resident #79 did not receive the Ativan medication. Review of the facility's policy titled Medication Administration - Preparation and General Guidelines revised August 2014 indicated medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications would do so only after they had been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The policy further indicated the facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The policy indicated the FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, were applied for each medication being administered. A triple check of these Five Rights was recommended at three steps in the process of preparation of a medication for administration: (1) when the medication was selected, (2) when the dose was removed from the container, and finally (3) just after the dose was prepared and the medication put away. a. Check #1: Select the Medication - label, container and contents checked for integrity, and compared against the medication administration record (MAR) by reviewing the Five Rights. b. Check #2: Prepare the dose - the dose was to be removed from the container and verified against the label and the MAR by reviewing the five Rights. When medications were administered from a central location, such as the medication room, medications for the immediate administration time were to be prepared not more than 60 minutes in advance for all residents, or per applicable state law or regulation. In no case should more that one dose time be prepared in advance. Documentation (including electronic) indicated the individual who administered the medication dose recorded the administration on the resident's medication administration record (MAR) directly after the medication was given. At the end of each medication pass, the person administering the medications was to review the MAR to ensure necessary doses were administered and documented. In no case was the individual who administered the medications to report off-duty without first recording the administration of any medications. This deficiency represents non-compliance investigated under Complaint Number OH00165067.

Based on observation, record review, interview and policy and procedure review the facility failed to ensure staff performed hand hygiene during medication administration to Resident #40 and Resident #50 to prevent cross contamination of germs and failed to initiate isolation precautions for Resident #20 to prevent the spread of influenza. This affected two out of three residents observed during medication administration and one out of three residents reviewed for isolation precautions. The facility census was 82. Findings include: 1. Medical record review revealed Resident #40 was admitted on [DATE] and readmitted on [DATE] with diagnoses including rhabdomyolosis ( muscle injury where muscles break down), schizoeffective disorder, hypo-osmoality, alcohol abuse, anemia, osteoarthritis, lupus erythmatosis (body's immune system attacks tissues and organs), heart attack, low magnesium and potassium level, atrial-fibrillation, depression, Raynaud's syndrome, vascular heart disease, retinopathy, cataracts, urinary retention with neuromuscular bladder, angioneurotic edema (unpredictable frequent edematous episodes of cutaneous and mucosal tissues such as lips, eyes, oral cavity, larynx, and gastrointestinal system), and acute respiratory/kidney failure. Medical record review revealed Resident #50 was admitted on [DATE] and readmitted on [DATE] with diagnoses including right lower leg pain, acute cough, intervertebral disc degeneration of the lower back, high blood pressure, gastroesophageal reflux disease, chronic kidney disease, scoliosis, group B vitamin deficiency, encephalopathy, and anemia. An observation of Licensed Practical Nurse (LPN) #91 administer 11 medications to Resident #40 on 04/28/25 at 8:59 A.M. revealed a failure to perform hand hygiene to prevent cross contamination of germs. LPN #91 dispensed the following medications in a medication cup: - lactobacillus acidophilus two capsules - colace 100 milligram (mg) tablet - duloxetine 30 mg tablet - potassium chloroide 10 milliequivalents (mEq) tablet - Lasix 20 mg tablet - Thera M multivitamin with minerals supplement 1 tablet - ethylene glycol powder 1 gram (gm) - thiamin 100 mg tablet - sodium chloride 1 gm tablet - sertraline 50 mg tablet - sertraline 25 mg tablet LPN #91 then removed the two lactobacillus acidophilus capsules from the medication cup and opened the capsules with her bare hands to empty the capsules in the medication cup mixed with applesauce. LPN #91 proceeded to administer the above listed medications to Resident #40 and did not perform hand hygiene after administering Resident #40's medications. LPN #91 then proceeded to remove Resident #50's medications from the medication cart and administer the following seven oral medications to Resident #50: - guaifenesin 600 mg tablet - amlodipine 5 mg tablet - colace 100 mg tablet - senna 8.6 mg tablet - metoprolol 37.5 mg tablet - pantoprazole 40 mg tablet - losartan potassium 100 mg tablet After administering the above seven medications LPN #91 failed to perform hand hygiene. An interview with LPN #91 on 04/28/25 at 9:40 A.M. confirmed she opened the lactobacillus using her bare hands, did not perform hand hygiene after administering Resident #40's medications, and did not perform hand hygiene after administering medications to Resident #50. Review of the facility's policy titled Medication Administration - Preparation and General Guidelines revised August 2014 indicated medications were to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications were to do so only after they had been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The policy further indicated the facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The procedure included: Handwashing and Hand Sanitization: The person administering medications was to adhere to good hand hygiene, which included washing hands thoroughly - before beginning a medication pass, - prior to handling any medication, - after coming into direct contact with a resident, - before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations, and before and after administration of medications - via enteral tubes. - Examination gloves were to be worn when necessary Hand sanitization was to be done with an approved sanitizer - between hand washings, when returning to the medication cart or preparation area (assuming hands have not touched a resident or potentially contaminated surface). - at regular intervals during the medication pass such as after each room, again assuming handwashing was not - Sanitization was not a substitute for proper handwashing, and washing should be done if there is any question. indicated. 2. Medical record review revealed Resident #20 was readmitted on [DATE] with diagnoses including spastic paraplegia, asthma, diabetes mellitus, anemia, heart failure, kidney disease, atherosclerotic heart disease, morbid obesity, gout, edema, high blood pressure, depression, insomnia, hypothyroidism, deep vein thrombosis of right lower extremity, cognitive impairment, anxiety with restlessness/agitation, osteoarthritis, abnormal liver function, rotator cuff tear of right shoulder, disorder of kidney and ureter, vitamin D deficiency, high potassium level, gastroesophageal reflux disease, embolism of left popliteal vein, respiratory synctial virus (RSV), hearing loss, eye diseases, high cholesterol, dizziness, low blood pressure, low heart rate, urinary retention, hydronephrosis, and pulmonary embolism. Further review of the medical record revealed nursing progress notes dated 03/19/25 which indicated Resident #20 was readmitted to the facility from the hospital with a diagnosis of influenza A. The nursing progress note revealed Resident #20 had a moist cough, abnormal lung sounds on both sides and was receiving Tamiflu medication to treat the diagnosis of influenza A. Further review of Resident #20's clinical record revealed no documentation that isolation precautions were implemented. A review of Resident #20's physician orders dated 03/01/25 to 03/31/25 revealed no order to implement isolation precautions. The above was confirmed with the Director of Nursing on 04/29/25 at 12:00 P.M. Review of the the facility's undated policy and procedure titled Isolation - Categories of Transmission-Based Precautions revealed the policy statement indicated transmission-based precautions were initiated when a resident developed signs and symptoms of a transmissible infection; arrived for admission with symptoms of an infection; or had a laboratory confirmed infection; and was at risk of transmitting the infection to other residents. The indications for contact precaution isolation included : 1. Contact precautions were to be implemented for residents known or suspected to be infected with microorganisms that could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 2. Contact precautions were also used in situations when a resident was experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that could not be contained and suggested an increased potential for extensive environmental contamination and risk of transmission of a pathogen, even before a specific organism has been identified. 3. Contact precautions were to be used for residents infected or colonized with MDROs in the following situations: a. When a resident had wounds, secretions, or excretions that are unable to be covered or contained; and b. On units or in facilities where, despite attempts to control the spread of the MDRO, ongoing transmission was occurring. 4. These strategies could differ depending on the prevalence or incidence of the MDRO in the facility and region. For example, additional usage of PPE (enhanced barrier precautions) could be used for residents who did not meet criteria for contact precautions but were infected or colonized with MDROs (or have risk factors for MDRO acquisition). 5. The decision on whether contact precautions were necessary were to be evaluated on a case by case basis. 6. The individual on contact precautions was to be placed in a private room if possible. If a private room was not available, the infection preventionist was to assess various risks associated with other resident placement options (e.g., cohorting, placing with a low risk roommate). 7. Staff and visitors were to wear gloves (clean, non-sterile) when entering the room. a. While caring for a resident, staff were to change gloves after having contact with infective material (for example, fecal material and wound drainage). b. Gloves were to be removed and hand hygiene performed before leaving the room. c. Staff were to avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 8. Staff and visitors were to wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 9. When transporting individuals with skin lesions, excretions, secretions, or drainage that was difficult to contain, contact precautions were to be taken during resident transport to minimize the risk of transmission. This deficiency represents non-compliance investigated under Complaint Number OH00165067.

Based on observation, medical record review, staff interview, mechanical lift customer service technician interview, review of the facility investigation, review of hospital records, review of manufacturer's recommendations, and policy review, the facility failed to ensure mechanical lift equipment was maintained in a safe and working condition to prevent an avoidable fall for Resident #244. This resulted in Actual Harm on 06/20/23 when Resident #244 was lifted in the mechanical lift by State tested Nursing Assistant (STNA) #573 and STNA #592 who failed to ensure the integrity of the mechanical lift pad which led to mechanical failure when the lift pad ripped resulting in Resident #244 descending three to four feet to the floor. Subsequently, Resident #244 was hospitalized with five left posterolateral rib fractures and a minimal left pleural effusion with adjacent atelectasis (a complete or partial collapse of the lung or portion of the lung). This affected one resident (#244) of three residents reviewed for mechanical lift transfers. The facility census was 78. Findings Include: Review of the medical record for Resident #244 revealed an admitted [DATE]. Resident #244 was discharged to the hospital on 06/20/23 and currently remained in the hospital. Resident #244 had diagnoses including diastolic heart failure, type II diabetes mellitus, stage III chronic kidney disease, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #244 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The assessment revealed Resident #244 required total dependence of two (staff) for transfers. Review of the physician's order for Resident #244 revealed he required a Hoyer (mechanical lift) for all transfers. Review of Resident #244's care plan revealed he had a self-care deficit. Interventions included a mechanical lift and two staff assistance for transfers. Review of the current weight for Resident #244 revealed he weighed 325 pounds. Review of a facility investigation, dated 06/20/23 revealed STNA #573 and STNA #592 were attempting to transfer Resident #244 from the bed to his wheelchair in the mechanical lift. Review of the witness statement from STNA #573 revealed around 10:45 A.M. on 06/20/23 following hooking Resident #244 up to the mechanical lift with assistance from STNA #592, they began to turn the lift. The lift pad strap broke and Resident #244 fell to the floor. Review of the witness statement from STNA #592 revealed she came to assist STNA #573 with the mechanical lift transfer of Resident #244 around 10:45 A.M. When they began to turn the lift, the strap snapped, and he fell to the floor, but she was able to keep him from hitting his head. Review of the witness statement from Licensed Practical Nurse (LPN) #559 revealed on 06/20/23 she heard a loud noise and responded to Resident #244's room where she observed the resident laying on his left side with the lift pad underneath him. LPN #559 assessed Resident #244 for injuries, and he was sent out for evaluation and treatment. Review of the hospital admission record dated 06/20/23 for Resident #244 revealed he arrived at the local hospital at 11:45 A.M. Resident #244 was noted to have fallen three to four feet to the floor after a mechanical lift strap broke and dropped him to the ground. Resident #244 landed on his left side. Resident #244 complained of left lateral rib pain and left upper arm pain with movement. The physician impression for Resident #244 revealed he had several acute, minimally displaced left posterolateral rib fractures involving left ribs six through ten, associated minimal left pleural effusion presumed hemorrhagic with minimal adjacent atelectasis. Interview on 06/27/23 at 9:52 A.M., with STNA #573 revealed she was in Resident #244's room around 10:00 A.M. on 06/20/23 to give him a bed bath, get him dressed and up to his wheelchair. She requested the assistance of STNA #592 to use the mechanical lift to transfer Resident #244 from his bed to his wheelchair. STNA #573 and STNA #592 hooked up Resident #244 to the mechanical lift using the green strap on the lift pad. They proceeded to lift Resident #244 off the bed and the left side strap broke clean through and Resident #244 fell three to four feet to the ground falling on his left side on top of the metal stabilization bar of the mechanical lift. Interview on 06/27/23 at 8:52 A.M., with Licensed Practical Nurse (LPN) #559 revealed she was providing care across the hall from Resident #244's room when she heard a loud noise and Resident #244 shout. LPN #559 immediately ran to Resident #244's room and found Resident #244 in the lift sling but laying on his left side on the floor. LPN #559 yelled for help and began to assess Resident #244 for injuries. The nurse at the desk alerted the Director of Nursing (DON) and the Administrator and called for emergency medical services (EMS). Interview on 06/27/23 at 11:00 A.M., with STNA #592 revealed STNA #573 was lifting Resident #244 with the mechanical lift, and she was guiding his legs. Once they raised him off the bed they began to turn, and the lift pad strap ripped and Resident #244 fell to the floor falling on his left side onto the metal frame of the mechanical lift. Resident #244 expressed pain on his left side. LPN #559 came to assess Resident #244, and EMS was called. Interview on 06/27/23 at 10:14 A.M., with the Laundry Staff #548 revealed the mechanical lift slings in the laundry were undated and the staff member was unsure how long they had been in service. Laundry Staff #548 revealed some of the lift slings were faded and had bleach discoloration spots on them. Interview on 06/27/23 at 10:48 A.M., with Medical Supply Staff #502 revealed prior to the incident on 06/20/23 involving Resident #244, the facility was going by visible fraying or strings of the lift slings to indicate the need to replace them and was unsure how long the lift slings had been in use. Observation following the interview of Resident #212's lift sling revealed it appeared faded. Observation in Resident #265's room of her lift sling revealed it appeared to be faded. Observation in Resident #215's room of his lift sling revealed it was faded and appeared to have some bleach spots on it. Medical Supply #502 verified the above observations. The facility was unable to provide the most current order date of mechanical lift slings/pads. Observation on 06/27/23 at 12:06 P.M. with the Director of Nursing (DON) and the Administrator of the lift sling used in the 06/20/23 incident involving Resident #244 revealed the left green hook broke and severed the black strap attached to it. The strap on the other side had visible fraying up near the top above the purple loop. The DON and Administrator verified they were unsure how long the blue mechanical lift sling had been in service, the green hook appeared worn, and the actual pad had discolored pink spots on it that appeared to have been from use of bleach. The weight limit of the pad was not able to be visualized as the tag was worn off. Telephone interview on 06/27/23 at 1:32 P.M., with Customer Services Technician #800 at Invacare (the mechanical lift company) revealed after each laundering of a Hoyer sling, they should be inspected for wear, tears, loose stitching, discoloration, or bleach stains which could weaken the integrity of the fabric. A follow-up interview on 06/28/23 at 11:01 A.M., with the Administrator revealed the staff would visualize the mechanical lift sling to check for any signs of wear and remove items if they appeared to be worn and notify administration for them to be replaced. Review of the Invacare Reliant 600 RPL600-1 user manual revealed under Using the Sling section; after each laundering (in accordance with instructions on the sling), inspect sling(s) for wear, tears, and loose stitching, bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately. Review of the Emerald Supply Slings Manual for the Hoyer sling revealed do not use padded standing slings as a transport device. Its intended purpose is to transfer a resident from one seated or resting position to another. The anticipated usable product life was six months. Bleached, torn, cut, frayed or broken slings are unsafe and could result in injury. Destroy and discard. Do not wash slings with bleach. Bleach will damage the material. Slings can suffer damage during washing and drying. Review of the policy titled Hoyer Lift, dated July 2022 revealed the procedure involved ensure the mechanical lift if appropriate with respect to weight restrictions, examine sling and attachment areas for tears, holes, and frayed seams. Do not use sling with any signs of wear. Sling with any sign of wear should be removed from service and discarded immediately. Notify administrator of need for replacement. This deficiency represents noncompliance discovered in Complaint Number OH00143999.

Based on observation, staff interview, review of the facility policy, review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) when the county community transmission levels were high. This had the potential to affect 31 residents (#5, #6, #7, #10, #11, #12, #14, #15, #17, #20, #21, #26, #28, #29, #32, #33, #34, #38, #42, #46, #48, #51, #58, #62, #68, #71, #72, #74, #76, #80, and #81) who resided on the 2 East Hall. The facility census was 79. Findings include: Review of the CDC COVID Data Tracker website on 03/07/23 revealed the community transmission levels for the county in which the facility was located was high and in the red. Observation during tour of the facility on 03/07/23 at approximately 8:55 A.M. revealed State tested Nurse Aide (STNA) #475 passing breakfast trays on the 2 East hall. STNA #475 was not wearing a facemask. Interview with STNA #475 at the time of observation revealed wearing a facemask was optional. Sometimes STNA #475 wore a facemask and other times she did not. Today STNA #475 decided not to wear a facemask. STNA #475 stated information regarding community transmission levels and what PPE staff needed to wear was posted by the time clock. Interview on 03/07/23 at 9:07 A.M. and 10:42 A.M. with the Director of Nursing (DON) revealed based on the information obtained from a website (not the CDC community transmission levels) indicating the county levels were medium and in the yellow the facility was allowing staff to have the option of wearing a facemask. Review of the CDC website with the DON revealed the county transmission level was high and in the red. The DON stated the accurate community transmission level would be posted and staff would be notified of the appropriate PPE to wear. Observation on 03/07/23 at 3:42 P.M. revealed STNA #473 on the 2 East Hall without wearing a facemask. Interview with STNA #473, at the time of the observation, verified she was not wearing a facemask in an area where residents could be encountered. STNA #473 stated facemask were available at the nurses station and also by the time clock. STNA #473 stated notes were left to let staff know what PPE they should be wearing and she did not check to see what PPE was required prior to coming onto the 2 East Hall. Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 09/27/23 revealed, under recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic, when SARS-CoV-2 community transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. Source control options for healthcare personnel include A NIOSH-approved particulate respirator with N95 filters or higher; a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators; a barrier face covering that meets ASTM F3502-21 requirements including Workplace Performance and Workplace Performance Plus masks; or a well-fitting facemask. Review of facility policy titled COVID-19; SARS-CoV-2, dated 09/28/22 revealed when SARS-CoV-2 community transmission levels were high (red), source control was recommended for everyone in a healthcare setting when in areas that could encounter residents. Source control was defined as the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they were breathing, talking, sneezing, or coughing. This deficiency represents non-compliance investigated under Complaint Number OH00140441.

Based on observation, review of physician orders, review of the bowel movement (BM) log, review of the hospital discharge instructions, review of the medical records, review of the facility policy Bowel Management and Treatment and interviews with the Director of Nursing, Regional Nurse #625 and Certified Nurse Practitioner (CNP) #626 the facility failed to provide appropriate care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Immediate Jeopardy on 03/02/22 when Resident #53, who had not had a bowel movement for four days, was not assessed for constipation and no treatment was provided by the facility. On 03/05/22 Licensed Practical Nurse (LPN) #503 identified the lack of bowel movement, administered milk of magnesia (MOM), charted the MOM was ineffective but implemented no further bowel interventions. Resident #53 continued to have no bowel movement, except for a small amount on 03/06/22. On 03/09/22 Resident #53 had a medium bowel movement followed by no bowel movement on 03/10/22, 03/11/22, 03/12/22, 03/13/22 and 03/14/22. No action was taken by the facility to assess the lack of BMs or intervene on the lack of BMs during this time frame. Resident #53 was sent out to the hospital on 03/20/22 with a firm distended abdomen and sluggish bowel sounds. A fecal impaction was diagnosed at the hospital. This affected one (Resident #53) of four residents reviewed for abuse and neglect. The facility census was 73. On 08/03/22 at 11:46 A.M., the Administrator, DON, Regional Nurse #625, and Corporate Director of Clinical Services (CDOCS) #621 were notified Immediate Jeopardy began on 03/02/22 when Resident #53 had three consecutive days, 02/27/22, 02/28/22 and 03/01/22 with no bowel movement and was not assessed for constipation and no effective treatment was provided by the facility. The Immediate Jeopardy was removed on 08/04/22 when the facility implemented the following corrective actions: Resident #53 was reassessed on 08/03/22 at 1:00 P.M. by RN #804 to find no changes in baseline. All 80 residents were assessed on 08/03/22 between 12:30 P.M. and 4:00 P.M. by RN #804, RN #803 and RN #805 for bowel issues. Changes in condition were being addressed timely and appropriate care and services were being provided. There were no negative outcomes to any resident because of the findings. The facility bowel and bladder policy and procedure were reviewed on 08/03/22 to ensure licensed staff can identify and manage bowel treatment. This treatment will be timely so appropriate care and services can be provided so no residents experience a bowel condition that is likely to cause serious life-threatening harm or injuries and/or adverse negative health outcomes. The policy and procedure are as follows: A bowel condition is a clinical change in the resident's bowel pattern that would result in the lack of a bowel movement for a period of 72 hours. The licensed nurse will initiate a bowel toileting review for all residents upon admission, quarterly, and with significant change. The appropriate level of care and treatment will be delivered as required to best manage a resident's bowel condition. This will include residents who have not had a bowel movement for three consecutive days will have the following protocol initiated, unless a resident has individual orders specific to bowel management, or where the orders below would be contraindicated for the resident. The initial nurse receiving the alert, and identifying the lack of BM for three days, will begin the following bowel protocol for the residents on the list: assess bowel sounds, administer 30cc of MOM. If the resident refuses the MOM, the nurse will notify the attending physician and document such on the MAR and in the nurse's notes. Document on the MAR and in the nurse's notes when the resident has a bowel movement and then the resident will be placed on the modified promotional bowel regimen as listed above. The medication nurse on the next shift will check the list upon beginning her shift and the following will be performed: assess for bowel sounds and if the resident does not have a bowel movement within eight hours of the MOM, the licensed nurse will administer a suppository (type and amount to be determined by the physician or the Medical Director) to be given at HS per physician's order. If the resident refuses the suppository, the nurse will notify the attending physician and document such on the MAR and in the nurse's notes. Document on the MAR and in the nurse's notes when the resident has a bowel movement and then the resident will be placed on the promotional bowel regimen. The medication nurse for the 3rd consecutive/next shift, will check the list at the start of her shift and the following will be performed: assess bowel sounds. If the resident does not have a bowel movement within eight hours of receiving the suppository, the nurse will administer an enema. If the resident refuses the enema, the nurse will notify the attending physician and document such on the MAR and in the nurse's notes. Document on the MAR and in the nurse's notes when the resident has a bowel movement and then place the resident on the promotional bowel regimen. If the resident does not have a bowel movement within one hour of receiving the enema, notify the attending physician for further instructions and document such in the MAR and in the nurses notes. The Corporate Director of Clinical Services (CDOCS) #621 re- educated the Director of Nursing on 08/03/22 on ensuring staff provide appropriate bowel monitoring and treatment as per the facility Bladder and Bowel/Urinary Assessment policy and the facility Bowel Management and Treatment policy. The Director of Nursing educated the licensed nursing staff ( 13 LPNs by phone, 2 LPNs in person, 3 RNs by phone and 7 RNs in person) on 08/03/22 and 08/04/22 on ensuring staff provide timely and appropriate bowel care. This education was completed by review of the facility Bladder and Bowel/Urinary Assessment policy and the facility Bowel Management and Treatment policy. Education of 100% of total licensed staff will be completed by 08/04/2022. An audit tool was implemented for the Director of Nursing and/or designee (RN #805) to monitor for the compliance of providing timely and appropriate care and services when residents experience a change in condition that has or is likely to cause serious life-threatening harm or injuries and/or adverse negative health outcomes. The audit will monitor for resident's bowel frequency and management. The DON or designee (RN #805) will conduct an audit on four residents on each unit, at random each week for four weeks, then bi-weekly for two weeks, and then monthly for one week. All findings of concern will be immediately addressed and reported to the QAPI committee monthly for further review and prompt response and resolution. The Administrator and/or designee (DON) will monitor this area for ongoing compliance. Although the Immediate Jeopardy was removed on 08/04/22, the deficiency remained at a Severity Level of 2 (No actual harm with the potential of more than minimal harm) as the facility was continuing to monitor for compliance with care and treatment when a resident experienced a change in condition. Findings included: Record review for Resident #53 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had severe cognitive impairment scoring five out of 15 points on the Brief Interview for Mental Status (BIMS). Resident #53 required extensive physical assistance of one-person for bed mobility, transfers, locomotion on the unit, assistance on and off the toilet and for personal hygiene.Resident #53 had an indwelling catheter and was always continent of bowel. Record review of the care plan dated 08/20/18 revealed Resident #53 had potential for constipation related to decreased mobility and a history of constipation. Resident #53's care plan goal was the resident will pass soft, formed stool at a minimum of every three days. The intervention included to follow the facility bowel protocol for bowel management. Record review of the physician orders for Resident #53 for the month of March 2022 revealed on 02/16/21 Resident #53 received the following orders: 1. Milk of magnesia 400 milligrams (mg) per five milliliters (ml), give 30 ml by mouth as needed for constipation once daily per bowel protocol administer once daily if no bm (bowel movement) in three consecutive days. 2. [MEDICATION(S)] [MEDICATION(S)] suppository 10 mg insert one rectally as needed for constipation once daily at night if no bm eight hours after MOM. 3. Enema mineral oil insert 118 ml rectally as needed for constipation once daily if no bm eight hours after receiving suppository. If no bm within one hour after receiving enema notify the physician. Record review for Resident #53 of the facility document titled BM log and the MAR for 02/27/22 through 03/20/22 revealed Resident #53 had no BM for three days (02/27/22, 02/28/22 and 03/01/22), and on the fourth day 03/02/22 Resident #53 should have received the physician ordered bowel protocol but did not. Resident #53 continued to have no bowel movement on 03/03/22 and 03/04/22. On 03/05/22 the nurse gave Resident #53 MOM and charted the MOM was ineffective on the MAR. No further bowel interventions or abdominal assessment was evidenced in the chart as completed by the nurse. Resident #53 continued to have no bowel movement from 03/2/22 to 03/9/22 when he had a medium bowel movement on 03/09/22. During the period 03/02/09 to 03/09/22, no bowel assessment was documented, and the physician had not been notified. Resident #53 again had no bowel movement on 03/10/22, 03/11/22, 03/12/22, 03/13/22 or 03/14/22. No assessment was completed, the bowel protocol again was not initiated on 03/13/22 or 03/14/22. Resident #53 had a large bowel movement documented 03/15/22. Resident had none on 03/16/22, had two mediums 03/17/22, one medium on 03/18/22 and one medium on 03/19/22. Resident #53 was sent to the hospital on 03/20/22 due to sluggish bowel sounds and a firm, distended abdomen and diagnosed with a bowel impaction. Record review of the Nursing Progress Note dated 03/20/22 at 10:48 A.M. completed by Licensed Practical Nurse (LPN) #503 revealed Resident #53's super pubic (s/p) catheter was leaking large amounts of urine. The catheter was changed. Upon insertion it was noted Resident #53's abdomen was distended and firm with sluggish bowel sounds. The record review included the physician was notified and the nurse received a new order to send Resident #53 to Hospital #624. Record review of the Nursing Progress Note dated 03/20/22 at 9:55 P.M. completed by LPN #540 revealed Resident #53 was returning from Hospital #624 with the hospital reporting he was impacted, and they gave him a [MEDICATION(S)] and disimpacted him. Resident #53 also had a urinary tract infection ([CONDITION(S)]) and was given a dose of [MEDICATION(S)] antibiotic. He would return to the facility with orders for the antibiotic. Record review of Hospital #624 discharge instructions for Resident #53 dated 03/20/22 under additional notes and instructions completed by Emergency Physician #905 revealed Resident #53 had been treated with a fecal disimpaction done in the emergency department and his urine appeared infected. The hospital discharge instructions included instructions for the prescribed antibiotic and instructions for constipation. Interview on 08/02/22 at 8:09 A.M. with the DON confirmed Resident #53's BM log was where the bowel movements were documented by staff for Resident #53. The DON verified Resident #53's medical record did not contain evidence of the Bowel Management and Treatment protocol being implemented or evidence Resident #53's physician orders for the bowel protocol had been followed for the period 03/01/22 through 03/19/22. Interview and record review on 08/02/22 at 10:15 A.M. with the DON and Regional Nurse #625 revealed they located a progress note for Resident #53 completed by Certified Nurse Practitioner (CNP) #626 dated 03/18/22. Review of the document provided by the DON and Regional Nurse #625 revealed it was titled Medical Rounding Note, dated 03/18/22 and authored by CNP #626. The note indicated it was Resident #53's monthly progress note. Resident #53 was found sitting up in a wheelchair in the dining room, he was mildly confused with impaired short-term memory and denied pain, nausea, vomiting, constipation, diarrhea, or cough. Resident #53's bowel sounds were circled as both positive and negative and the abdomen was noted as soft and round. Interview on 08/02/22 at 12:37 P.M. with CNP #626 revealed Resident #53 was not a good historian so she would talk to the nursing staff to obtain information. CNP #626 revealed on her visit, she did look at Resident #53's abdomen revealing he always had a pot belly. Resident #53 had a super pubic catheter and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNP #626 revealed on this occasion (03/18/22) the nursing staff told her Resident #53 had no constipation concerns. Interview and observation on 08/03/22 at 11:09 A.M. with Resident #53 revealed Resident #53 was sitting in the television lounge watching television. Resident #53 was alert but could not verbalize his location, date, or the time. When asked if he ever had constipation, resident stated, I am not sure. Record review of the facility policy titled, Bowel Management and Treatment, dated October 2017, revealed residents who have not had a bowel movement (BM) for three consecutive days will have the following protocol initiated, unless resident has individual orders specific to bowel management or where the orders would be contraindicated for the resident: 1. The Initial nurse receiving the alert and identifying the lack of bm for three days, will begin the following bowel protocol: assess bowel sounds, administer 30 milliliters (ml) milk of magnesium (MOM). If the resident refuses the MOM the nurse will notify the physician and document such on the MAR and in the nurses note. The nurse will document on the Medication Administration Record (MAR) and in the nurses note when the resident has a bowel movement and then the resident will be placed on a modified promotional bowel regimen as is listed above. (Review medications, obtain physician orders, daily administration of natural laxatives or prune fiber mixture, increase fluid intake, assess bowel sounds each shift and document, the licensed nurse will document on the MAR or Treatment Administration Record (TAR) when the resident has had a BM. 2. The medication nurse on the next shift will check the list on beginning of her shift and the following will be performed: assess for bowel sounds. If the resident has not had a bowel movement within eight hours of MOM, the licensed nurse will administer a suppository given at bedtime (HS) per the physician's order. If the resident refuses the suppository the nurse will notify the physician and document such on the MAR and in the nurses note. The nurse will document on the MAR and in the nurses note when the resident has a bowel movement and then the resident will be placed on a modified promotional bowel regimen as is listed above. 3. The medication nurse for the consecutive/next shift will check the list at the start of the shift and the following will be performed: assess for bowel sounds. If the resident has not had a bowel movement within eight hours of receiving the suppository, the licensed nurse will administer an enema. If the resident refuses the enema the nurse will notify the physician and document such on the MAR and in the nurses note. The nurse will document on the MAR and in the nurses note when the resident has a bowel movement and then the resident will be placed on a modified promotional bowel regimen as is listed above. If the resident does not have a bowel movement within one hour of receiving the enema, notify the physician for further instruction and document such on the MAR and in the nurses note.

Based on observation of Resident #04, review of the medical records for Resident #04, Review of the current, online Medscape application titled Medscape Report of the Expert Committee on the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #574, the facility failed to provide timely care and services for the monitoring and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Immediate Jeopardy on 03/26/22 at approximately 10:51 A.M. when Resident #04, who was not previously diagnosed with diabetes, was noted to have excessive urination with incontinence (loss of urine control), high ketones (chemical derived from fat in the body when the body is unable to use glucose for energy and is an indicator of a life threatening condition known as diabetic ketoacidosis) with a blood glucose of 531 mg/dl and did not receive medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one, Resident #04, of three residents reviewed for hospitalization . The facility census was 73. On 07/28/22 at 12:45 P.M., the Administrator, DON, and Corporate Director of Clinical Services (CDOCS) #621 were notified Immediate Jeopardy began on 03/26/22 at 10:51 A.M. when Resident #04 did not receive care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was removed on 07/29/22 when the facility implemented the following corrective actions: o Resident #04 was assessed on 07/29/22 by LPN #800 and there were no changes found from Resident #04's baseline. o All 80 residents were assessed for change of condition beginning 07/28/22 at 6:00 P.M. through 07/29/22 at 11:29 A.M. by LPN #800, #801, #802, RN #803 and #804. No changes in baseline were identified since the findings of the immediate Jeopardy citation. o The facility updated the Resident Change in Condition policy and procedure on 07/28/22 to ensure licensed staff can identify and direct timely and appropriate care and services when residents experience a change in condition that has or is likely to cause serious life-threatening harm or injuries and/or adverse negative health outcomes. o The Corporate Director of Clinical Services (CDCS) #621 educated the Director of Nursing (DON) on 07/28/22 on ensuring staff provide timely and appropriate care and services when residents experience a change in condition that has or is likely to cause serious life-threatening harm or injuries and/or adverse negative health outcomes. The contents of the education consisted of the following: - The facility Resident Change in Condition policy and procedure - Identifying changes in physical, psychosocial and/or mental changes - Ensuring staff provide timely and appropriate care and services when residents experience a change in condition that has or is likely to cause serious life-threatening harm or injuries and/or adverse negative health outcomes. - Interventions if a change in condition is identified as stated in policy - Definitions of acute and significant change of condition - Monitoring of elevated blood sugar levels while awaiting physician return call - Process of notifying condition and interventions to take if unable to contact physician including confirming transport and wait time. - Utilizing the audit tool to validate resident status and appropriateness of care match and contain all pertinent information and actions needed to provide and meet a residents medical, nursing, and mental and psychosocial needs if a change of condition is identified. o The DON on 07/29/22 educated nine of nine RNs and 11 of 11 LPNs in person or by telephone on ensuring staff provide timely and appropriate care and services when residents experience a change in condition that has or is likely to cause serious life-threatening harm or injuries and/or adverse negative health outcomes. Education of 100% of total licensed nursing staff would be completed on 7/29/2022. o An audit tool was implemented for the DON and designee (RN #805) to monitor for the compliance of providing timely and appropriate care and services when residents experience a change in condition (physical, non-physical and/or mental status change) that has or is likely to cause serious life-threatening harm or injuries and/or adverse negative health outcomes. The DON and/or RN # 805 will conduct an audit on four residents on each unit, at random weekly for four weeks, then bi-weekly for two weeks, and then monthly for one week. o All findings of concern will be immediately addressed and reported to the QAPI committee monthly for further review and prompt response and resolution. o The Administrator and/or designee (DON) will monitor this area for ongoing compliance. Although the Immediate Jeopardy was removed on 07/29/22, the deficiency remained at a Severity Level of 2 (No actual harm with the potential of more than minimal harm) as the facility was continuing to monitor for compliance with care and treatment when a resident experienced a change in condition. Findings included: Review of Resident #04's medical record revealed he was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly Minimum Data Set 3.0 (MDS) assessment for Resident #04 dated 01/07/22 revealed Resident #04 had severe cognitive impairment scoring six out of 15 points on the Brief Interview for Mental Status (BIMS). Resident #04 required supervision and/or assistance with all activities of daily living. Resident #04 was always continent of urine. Resident #04 had no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the nursing note for Resident #04 dated 03/26/22 at 10:51 A.M. completed by Licensed Practical Nurse (LPN) #574 revealed Resident #04 was noted having excessive urination with episodes of incontinence. His urine was checked with a chem-strip to rule out a urinary tract infection and was noted with a large amount of ketones (high [MEDICATION(S)] levels may indicate diabetic ketoacidosis (DKA) a complication of diabetes that can lead to coma or even death). Documentation included LPN #574 assessed Resident #04's blood sugar with a result of 568 mg/dL. LPN #574 rechecked Resident #04's blood sugar with another glucometer and was noted 531 mg/dL. Primary Physician (PP) #901 was called, and LPN #574 was awaiting a call back. Record review of the Nurses Note for Resident #04 dated 03/26/22 at 1:26 P.M. completed by LPN #574 revealed PP#901 was called again and LPN #574 continued to await a call back. Record review of the nurses note for Resident #04 dated 03/26/22 at 3:57 P.M. completed by LPN #574 revealed Physician #900, who was the on-call physician, called back for PP#901 and gave a new order to send Resident #04 to the emergency room of Hospital #624 for an evaluation. Record review of the nurses note for Resident #04 dated 03/26/22 at 9:32 P.M. completed by LPN #540 revealed LPN #540 spoke with community transport service (CTS) #806 and CTS #806 stated pick up would be within 15-20 minutes. Record review of the nurses note for Resident #04 dated O3/26/22 at 9:47 P.M. completed by LPN #540 revealed Resident #04 continued to be incontinent of bladder. Record review of the nurses note for Resident #04 dated O3/26/22 at 9:54 P.M. completed by LPN #540 revealed Resident #04's blood sugar was 521 mg/dL and was still awaiting transport to the emergency room by CTS #806. Record review of the nurses note for Resident #04 dated O3/26/22 at 10:50 P.M. completed by LPN #540 revealed CTS #806 arrived to take Resident #04 to the hospital. Record review of the meal intake records for 03/26/22 revealed the facility served breakfast and lunch to Resident #04 of which he ate 50 percent of both meals. There was no record to reflect if he had been served dinner on 03/26/22 and no additional blood glucose monitoring had been done before or after the meal service. Record review of the nurses note for Resident #04 dated O3/27/22 at 6:30 A.M. completed by LPN #540 revealed Resident #04 was admitted to Hospital #624 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview were conducted on 07/27/22 of Resident #04 who was found watching television in room. The resident presented as alert with confusion, and unable to carry on a factual, reciprocal conversation with the surveyor. When asked simple questions he provided unrelated, off topic answers illustrative of his cognitive impairment. Record review and interview on 07/27/22 at 3:47 P.M. of Resident #04's medical record for 03/26/22 with the DON confirmed Resident #04 should have been sent to the hospital for emergency medical services on 03/26/22 at 10:41 A.M. via 911 when he was noted to have excessive urination with episodes of incontinence, high ketones and a blood glucose of 531 mg/dlL The DON verified Resident #04 should have been sent to the hospital emergency room (ER) via 911 as a nursing measure responding to an emergent situation requiring immediate medical attention. The DON verified a nurse should send a resident to the ER via 911 emergency when the nurse was unable to contact the physician, then the nurse would update the physician when the physician returned the call. The DON confirmed 03/26/22 was a Saturday and she was not made aware at that time of this situation by any nurse. Review of the hospital record dated 03/27/22 completed by Hospital Physician #903 revealed Resident #04 had no history of diagnosed diabetes mellitus, was not on insulin or oral hypoglycemics (medication taken by mouth to decrease blood glucose levels). Resident #04 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In the emergency room the vital signs were stable, slightly tachypneic (rapid heart rate) and the data was significant for [CONDITION(S)] and blood glucose above 500 mg/dL Resident #04 was ordered to receive intravenous fluids and insulin (medication used to decrease elevated blood glucose levels) in the emergency department. Physician #903's assessment of Resident #04 stated newly diagnosed with diabetes mellitus likely type two, with diabetic ketoacidosis and hypercalcemia (high calcium level). The plan was to start an intravenous (IV) insulin drip and adjust it as needed, give IV fluids, monitor kidney function panel, monitor anion gap and replace electrolytes as needed. Interview on 07/28/22 at 8:30 A.M. with LPN #574 revealed when she first called PP #901, there was no answer. LPN #574 explained Resident #04 was not diabetic, he was just urinating a lot and incontinent. LPN #574 confirmed when she finally got ahold of the physician on call, Physician #900 (03/26/22 at 3:57 P.M.), Physician #900 stated to send Resident #04 to the emergency room . LPN #574 said Physician #900 did not say how to send Resident #04 to the ER, so she decided to send Resident #04 to the ER via CTS #806. LPN #574 stated, So we just monitored him, and he seemed fine. Interview on 07/28/22 at 9:15 A.M. with Physician #900 revealed when she gave orders to send a resident to the emergency room , she expected them to be sent 911. If 911 could not come immediately, the least she would expect was a call back to let her know 911 could not come immediately. Physician #900 repeated her expectations where residents were to be sent 911 when orders were given to send a resident to ER. Physician #900 expressed sending a resident any other way, when she gave orders to send the resident to the ER, would have been unacceptable and at the least, she would have expected to be called back to let her know 911 would not be coming immediately. Interview on 07/28/22 at 10:31 A.M. with Supervisor #807 at CTS #806 revealed CTS #806 was a private ambulance company. Supervisor #807 revealed 911 service stayed in the city and CTS #806 covered 13 counties. Supervisor #807 revealed if someone was at a nursing home and needed immediate service, the facility should call 911 because it was quicker because CTS #806 provided service all over Ohio for transports and it could take much longer before a resident was picked up. Review of the online, current Medscape application titled Medscape Report of the Expert Committee on the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility policy titled, Status Change in Resident Condition - Notification dated October 2017, revealed the facility will promptly notify the resident, his/her attending physician and responsible party of changes in the residents' condition and or status. The licensed nurse will notify the residents attending physician for directive when there is a significant change the residents physical, mental or psychosocial status.

Based on observation, interview and record review the facility failed to ensure the high temperature dish machine was in good repair and functioning properly, and failed to ensure the kitchen's food processor used to make pureed foods was in good repair. This had the potential to affect all residents residing in the facility except for one resident (#226) who did not eat by mouth. The facility census was 73. Findings include: 1. Observation on 07/25/22 at 10:40 A.M. with Dietary Aide (DA) #545 and Dietary Manager (DM) #576 of the dish machine wash and rinse cycle revealed the wash cycle gauge was not functioning and did not display the wash cycle water temperature. DA #545 confirmed the wash cycle gauge was broken and had been broken for awhile. DM #576 confirmed the gauge was broken and the representative from the company was called about it two weeks ago. Review of the facility document titled Extra Service Request, dated 07/25/22 and timed 12:07 P.M., from the dish machine company representative included temperature gauges were bad and both the rinse and wash temperature gauges were replaced. Observation on 07/28/22 at 10:45 A.M. with DA #545 and DM #576 of the dish machine completing washing and rinse cycles revealed the rinse temperature did not reach 180 degrees Fahrenheit (F). Observation of the dish machine complete five cycles revealed the rinse temperature only reached 176 F. DM #576 stated sometimes the dish machine lost heat as the day progressed and the representative from the dish machine company was called about the issue. DM #576 stated when the temperature did not reach 180 F the dishes were washed two to three times. DM #576 stated the dishwashing temperature was double checked with thermolabels ( paper thermometers) as a back-up to ensure dishes were sanitized appropriately. DM #576 confirmed the thermolabels were accurate to 160 F (not the required 180 F). Review of the document Service Detail Report, dated 07/28/22 at 2:04 P.M., from the dish machine company included the dishwasher was not hitting the rinse temperature and the thermostat was turned up a bit to hit 184 F after a few tests. Review of the Extra Service Request,, dated 07/29/22 at 1:16 P.M., from the dish machine company representative included the dishwasher was not hitting the rinse temperature so burnt wires and the thermostat were replaced. 2. An observation was conducted on 07/28/22 at 10:35 A.M. of Cook #513 preparing pureed food for the resident meal. Cook #513 placed approximately six pickle spears into the food processor and turned the food processor on. Cook #513 stopped and started the food processor three times then placed the pickle puree in a metal container. Upon taste test of the pickle puree by the surveyor it was revealed the pureed pickle did not have a smooth texture but instead had chunks of pickle skin in it. Cook #513 verified the finding and stated she would puree the pickles a fourth time to create a smooth consistency. An observation was conducted on 07/28/22 at 12:03 P.M. with Dietary Manager (DM) #576 and Cook #513 who revealed the pureed pickles were not going to be served to the residents for the lunch meal due to the inability to puree the pickles to remove the chunks of skin. Cook #513 stated she ran the pickles two more times through the food processor but the chunks of pickle skin were still present. Cook #513 informed the surveyor the food processor was on it's last leg and the kitchen staff had to run it several times just to get it to work. Cook #513 explained if it ran too long it would just stop working. DM #576 stated peas had been pureed to use as a substitute for the pureed pickles. The pureed peas were already in a metal, steam table pan to be used for meal service. The taste test by the surveyor of the pureed peas revealed the pea puree had pieces of intact pea skin in it and was not a smooth consistency of puree. DM #576 confirmed the presence of pea skins in the puree and stated the pea puree would not be served to the residents. DM #576 stated the peas were processed three times through the food processor but the skins were still present.

Based on record review and interview with the Administrator, the facility failed to provide a Facility Assessment identifying what resources would be needed to provide competent care to the residents during both day-to-day operations and emergencies. This had the potential to affect all 73 residents residing in the facility. The facility census was 73. Findings included: Interview on 07/25/22 at 9:12 A.M., during the entrance conference, the Administrator was asked to make the Facility Assessment available to the survey team. Record review was conducted of the facility document titled IFC Self-Assessment Guide for Health Care Organization, dated 01/09/22. and provided by the Administrator to the survey team as the Facility Assessment requested at the entrance conference. The document consisted of 13 pages of self-assessment elements for the facility. The document was completed by the Administrator and the Director of Nursing as indicated on the first page. There were no members of the governing body or other facility staff listed as participants in this assessment. It did not contain both the number of residents and the facility capacity, the care required by the resident population to meet the acuity needs of the residents, the staff competencies necessary to provide the level and types of care needed for the resident population, the physical environment, equipment, services and other physical plant considerations needed to care for the residents, any ethnic, cultural or religious factors for the residents nor did it contain information on the facility resources ( all physical structures, medical and non-medical equipment), medical services, staffing plans including management and non-management positions, information on technology resources and resources needed in case of an emergency. On page three there was a typed line reading see detailed facility assessment. An interview was conducted on 07/28/22 at 3:40 P.M., 08/01/22 at 4:56 P.M. and 08/02/22 at 2:50 P.M. with the Administrator regarding the contents of the ICF Self-Assessment Guide for Health Care Organizations, dated 01/09/22, compared to the federal regulation requirements for content of the Facility Assessment. The Administrator verified the document was provided by him as the current Facility Assessment requested by the survey team and he had provided said document to two of the three surveyors on the survey team. The Administrator provided no additional information to reflect a detailed Facility Assessment had been completed for the facility.

Based on observation, interview, and record review the facility failed to ensure cold foods were stored and served at proper temperatures, and failed to ensure the high temperature dish machine was consistently hitting 180 degrees Fahrenheit to properly sanitize the dishes and cookware. This had the potential to affect all residents receiving meals from the kitchen except for one resident (#226) who did not eat by mouth. The census was 73. Findings included: 1. Observation on 07/25/22 at 8:15 A.M. of the kitchen with Dietary Manager (DM) #576 revealed there was a power outage starting on 07/25/22 at 1:30 A.M. and the walk-in cooler and walk-in freezer in the kitchen were not hooked up to the emergency back-up generator leaving that equipment without power to maintain proper cold storage temperatures. DM #576 stated they were opening the cooler and freezer as little as possible to conserve the cool temperatures. DM #576 stated she had been trying to get back-up power to the kitchen for three years but had not been successful. Observation of the tray line revealed Cook #513 and Dietary Aides (DA)'s #545 and #592 placing eggs, hot cereal and yogurt into disposable styrofoam containers with disposable utensils to be served to the residents. DM #576 stated they were able to cook eggs and hot cereal because the flat top stove was supplied by natural gas and not electricity. Observation of tray line food temperatures on 07/25/22 at 8:20 A.M. completed by DM #576 revealed the yogurt was 62 degrees Fahrenheit (F) and the yogurt was in a metal container with no ice under the container to keep it cold. DM #576 stated the yogurt should be under 35 F. DM #576 stated they were about half done serving breakfast and she was worried about the food temperatures in the cooler and freezer. DM #576 revealed she arrived at the facility around 8:10 A.M. and did not have a chance to get ice before starting to serve the breakfast tray line so the yogurt had been sitting at room temperature as it was being dished into the disposable styrofoam containers for meal service. Review of the food temperature log on 07/25/22 at 8:20 A.M. with DM #576 revealed there were no temperatures logged for any of the foods being served for the breakfast meal. Interview on 07/25/22 at 8:20 A.M. with Cook #815 revealed she took the temperature of the breakfast food before tray line, but did not document it on the food temperature log because she wanted to get started with breakfast. Cook #815 was unable to report the temperatures of the food. Observation of the walk-in-coolers on 07/25/22 at 8:25 A.M. with DM #576 revealed there were no thermometers visible through the window of the cooler. DM #576 confirmed there were no thermometers visible inside the cooler and the temperature was unable to be determined. DM #576 stated there was a thermometer in the back of the cooler, but it could not be seen and she did not know the temperature of the food in the cooler because she was trying to limit the number of times the door was opened to the cooler. Interview on 07/25/22 at 8:25 A.M. with Cook #513 revealed she noted the temperature of the cooler when she arrived at the facility but did not document it anywhere because she wanted to get started with breakfast. Cook #513 stated she arrived around 5:30 A.M. and the cooler temperature was 45 F, but the walk-in-freezer thermometer was hard to read and she did not check the temperature. Interview on 07/25/22 at 9:41 A.M. with Maintenance Supervisor (MS) #555 revealed he received a text at 1:12 A.M. from Licensed Practical Nurse (LPN) #574 regarding the power outage and arrived at the facility between 6:00 A.M. and 6:30 A.M. MS #555 confirmed the kitchen was not on a back-up emergency generator and he did not know why. Interview on 07/25/22 at 9:41 A.M. with DM #576 revealed she was notified at 5:38 A.M. by Cook #513 of the power outage. DM #576 stated dietary staff did not work night shift and she did not know about the power outage until Cook #513 notified her at 5:38 A.M. so there had been no temperature monitoring of the food inside the coolers or freezer throughout the night. Observation on 07/25/22 at 9:42 A.M. of the walk-in-cooler with DM #576 and MS #555 revealed a thermometer hanging in the cooler revealed the temperature was 50 F. DM #576 brought a digital thermometer with her into the cooler, stating the thermometer had been calibrated that morning. DM #576 checked food temperatures and found lactose-free milk in a cup with a lid had a temperature of 48.7 F, nectar thick consistency juice had a temperature of 50 F, chocolate milk in a single serving carton had a temperature of 42.2 F, two open gallons of milk had temperatures of 45.2 F and 46.9 F, a metal container with chicken salad had a temperature of 46.4 F, turkey lunch meat had a temperature of 43.3 F, a raw egg was 45.2 F, a hard-boiled cooked egg had a temperature of 50.3 F, a pitcher of milk had a temperature of 48.4 F. DM #576 stated she needed to go through the cooler and discard food. Interview on 07/25/22 at 9:50 A.M. with LPN #574 revealed on 07/25/22 at around 1:00 A.M. to 1:30 A.M. she heard a loud boom, a short time later the power went out and after about 10 seconds the generator kicked on and some of the facility power was restored. LPN #574 stated she notified the Director of Nursing (DON), the Administrator, the on-call supervisor and the Maintenance Supervisor #555 of the power outage. LPN #574 stated she was busy making sure the residents were taken care of and extension cords were used for important resident equipment like air mattresses, oxygen, tube feedings, and so LPN #574 did not enter the kitchen all night. LPN #574 stated the other nurses working night shift did not enter the kitchen or check the cooler and freezer. Observation on 07/25/22 at 3:12 P.M. of the walk-in-cooler with DA #589 revealed the chicken salad was still in the cooler and had not been discarded. Review of the menu changes on 07/25/22 at 3:15 P.M. due to the power outage for the lunch meal revealed deli sandwiches, potato chips, pickles and watermelon were served to the residents. Interview on 07/25/22 at 3:21 P.M. with DM #576 confirmed the chicken salad was still in the cooler and had not been discarded. DM #576 stated she was very busy and still needed to go through the cooler. DM #576 stated she used the turkey lunch meat for the lunch meal because it was in sealed, unopened packages and she thought it was alright to use even though the temperature was 43.3 F earlier. DM #576 stated she would not have had anything to serve for the lunch meal if she did not use the turkey. Review of the Food Temperature Log on 07/25/22 at 3:21 P.M. for the lunch meal with DM #576 revealed the deli-sandwiches temperature was 42 F. The food temperature log stated cold foods temperature should be served at 41 F or lower. DM #576 confirmed the sandwiches should have had a temperature of 41 F or lower at the point of service. Interview on 07/25/22 at 3:32 P.M. with Registered Dietician (RD) #627 revealed she was notified regarding the power outage around 6:30 A.M. RD #627 stated temperatures in the walk-in-cooler and walk-in-freezer should be monitored because there was a four hour window after the power outage for safe food storage and the food should not be in the danger zone. RD #627 was not sure how often the food temperatures should be monitored. RD #627 stated a temperature of 62 F for yogurt was in the danger zone. Interview on 07/25/22 at 3:43 P.M. with the Administrator revealed the power was back on in the facility at 10:30 A.M. Interview on 07/25/22 at 4:17 P.M. with the Administrator revealed even though the chicken salad was not removed from the walk-in-cooler there was no chance it could be served to the residents and the kitchen staff were in the kitchen the entire time. The Administrator stated no residents had been sent out for food borne illness in the past month. Interview on 07/25/22 at 3:45 P.M. with DM #576 revealed the food temperatures were checked at 8:15 A.M., 9:41 A.M. and 2:00 P.M. DM #576 stated she did not have the food temperatures documented on a disaster log because she had been so busy today. Review of the facility policy titled Food Safety and Sanitation, undated, included stored food was handled to prevent contamination and growth of pathogenic organisms. Refrigerated foods were stored at or below 41 degrees Fahrenheit. Review of the facility policy titled Food Safety Requirements, undated, included holding temperature (ready for service) should be 135 F or above for hot foods and 41 F or below for cold foods. 2. Observation on 07/25/22 at 10:40 A.M. with Dietary Aide (DA) #545 and Dietary Manager (DM) #576 of the dish machine wash and rinse cycle revealed the wash cycle gauge was not functioning and did not display the wash cycle water temperature. DA #545 confirmed the wash cycle gauge was broken and had been broken for awhile. DM #576 confirmed the gauge was broken and the representative from the service company was called about it two weeks ago. Record review on 07/25/22 at 10:40 A.M. with DM #576 of the Dish Machine Temperature Log revealed on 07/16/22 and 07/17/22 temperatures for the wash and final rinse cycles were not documented for the breakfast and lunch meals, 07/22/22 did not have temperatures for the wash and final rinse cycles documented for the breakfast, lunch and dinner meal, on 07/23/22 there were no temperatures documented for the breakfast and lunch meals, on 07/24/22 there were no temperatures documented for the breakfast, lunch, and dinner meals, and on 07/25/22 there were no temperatures documented for the breakfast meal. DM #576 confirmed the temperatures were not documented. Observation on 07/28/22 at 10:45 A.M. with DA #545 and DM #576 of the dishwashing machine completing washing and rinse cycles revealed the rinse temperature did not reach 180 degrees F. Observation of the dishwashing machine complete five cycles revealed the rinse temperature only reached 176 F. DM #576 stated sometimes the dishwashing machine lost heat as the day progressed and the representative from the dishwashing machine company was called about the issue. DM #576 stated when the temperature did not reach 180 F the dishes were washed two to three times. DM #576 stated the dishwashing temperature was double checked with a paper thermometer as a back-up to ensure dishes were sanitized appropriately. DM #576 revealed the paper thermometers were accurate to 160 F so were not able to measure up to the required 180 F for the final rinse. Review of the Service Detail Report dated 07/28/22 at 2:04 P.M. from the dishwasher company included documentation the dishwasher was not hitting the rinse temperature and the thermostat was turned up a bit to hit 184 F after a few tests. Review of the manufacturer information for the paper thermometers titled Paper Thermometer revealed the paper thermometer was a temperature sensitive tape device that read up to 160 degrees F. Review of the facility policy titled Dish Machine Temperature Log, undated, included staff would record dish machine temperatures for the wash and rinse cycles at each meal. The director of food and nutrition services would spot check the log to assure temperatures were appropriate and staff was correctly monitoring dish machine temperatures. Review of the facility policy titled Dishwashing, undated, included dishes, pots and pans would be washed using procedures, chemicals and equipment that resulted in clean, sanitized dishes, pans flatware and utensils. Dish machine temperatures were logged at each meal on the Dish Machine Temperature Log and minimum temperatures, as required by the manufacturer were wash 150 to 160 F and Final Rinse 180 to 195.

Based on observation, interview, and review of the facility policy, the facility failed to ensure expired medications and expired medical supplies were removed from the medical supply rooms and the medication cart, after the expiration date. This had the potential to affect all 73 residents residing at the facility. Findings include: Interview on 07/27/22 at 8:03 A.M. with Assistant Director of Nursing/Registered Nurse (ADON/RN) #805 revealed the main medication room, of the five located in the facility, used by all nurses for all residents had an Alixa dispensing machine, intravenous (IV) supplies including IV solutions, IV starter kits, IV tubing, over the counter stock medications, and additional medical supplies. Observation on 07/27/22 at 8:05 A.M. with ADON/RN #805 of the main medication storage room revealed there were two carts next to the Alixa machine filled with IV bags of solution. The room also had multiple cabinets filled with supplies and over the counter medications. Observation revealed two expired IV administration sets (IV tubing). The first set had an expiration date of 09/19/20 and the second set had an expiration date of 02/19/21. In the same room was a container of insyte needles, (needle used to start an IV) in the container was insyte 24 gauge with an expiration date of 12/31/19 and three insyte 20 gauge with an expiration date of 06/30/20. In one cabinet, a partially used isopropyl rubbing alcohol bottle had an expiration date 07/2016, a container of bleach wipes had an expiration date of 2019 (unable to read the month), in addition seven IV kits were located in a different storage area with one expiration date of 09/30/19 and six had expiration dates of 01/07/20. In the cart next to the Alixa machine were multiple bags of IV solution. Two IV bags labeled [MEDICATION(S)] 400 milligrams (mg) read discard after 01/28/22. ADON/RN #805 verified all findings. Observation on 07/27/22 at 8:20 A.M. with ADON/RN #805 of the East Medication Storage room revealed six individual influenza vaccine syringes, located in the medication storage refrigerator, with an expiration date of 06/30/22. ADON/RN #805 verified all findings. Observation on 07/27/22 at 8:27 A.M. with ADON/RN #805 of the 200 hall medication cart revealed a partially used container of clorox wipes with an expiration date of 06/22 and a container of purell hand sanitizing wipes with an expiration date of 04/22. ADON/RN #805 verified all findings. Interview on 08/03/22 at 8:15 A.M. with the DON revealed there was no specific policy for disposal of medical supplies. The DON verified expired medications and medical supplies should have been removed from the medication rooms and medication carts at the time of expiration. The DON revealed this was the pharmacy technician who would come to the facility two times a month and check the expiration dates of the medications and medical supplies to assure all expired medications and supplies were removed from the supply room and disposed of. Record review of the facility policy titled, Medication Storage in the facility revised August 2014, revealed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secured closures are immediately removed from inventory, disposed of according to procedures for medication disposal.

Based on observations, interviews, and record review, the facility failed to implement appropriate infection control practices regarding the proper use of personal protective equipment (PPE) by all direct care staff providing care and services to residents on transmission based precautions for COVID-19 and COVID-19 quarantine precautions. This had the potential to affect all 73 residents residing in the facility. The facility also failed to ensure reusable medical equipment (glucometer) was appropriately sanitized in between residents affecting Resident #29, #51 and #324. The facility census was 73. Findings included: 1. Record review revealed Resident #48 had an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #48 resided in the memory care unit. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had severe cognitive impairment. Resident #48 required limited assistance and supervision with activities of daily living. Record review of the care plan dated 07/18/22 revealed Resident #48 was on droplet isolation precautions due to positive COVID-19. Interventions included to adhere to infection control precautions at all times by all staff, and wear appropriate personal protective equipment per policy. Record review of the physician order dated 07/18/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 07/25/22 at 9:26 A.M. revealed Wound Care Consultant Certified Nurse Practitioner (CNP) #906 entered Resident #48's room without putting on an isolation gown. Resident #48 was lying in bed and began sitting up. Wound Care Consultant CNP #906 went over to Resident #48 and began assisting Resident #48. Wound Care Consultant CNP #906 then closed Resident #48's door for privacy. Resident #48 had a sign on the door to please see the nurse before entering and an isolation cart next to the entrance of the door. Wound Care Nurse Registered Nurse (RN) #803 was at the treatment cart next to Resident #48's doorway and verified Resident #48 was diagnosed with COVID-19 requiring isolation. Wound Care Nurse RN #803 opened Resident #48's door and instructed Wound Care Consultant CNP #906 Resident #48 was diagnosed with COVID -19 and she would need to leave his room to put on the appropriate PPE. Interview on 07/25/22 at 9:30 A.M. with Wound Care Consultant CNP #906 revealed she was unaware Resident #48 was on isolation and was not notified by the facility it was in COVID-19 outbreak status. Wound Care Consultant CNP #906 revealed she did not read the sign posted on Resident #48's door and needed to be directed by staff before entering a room if the resident was on isolation. Wound Care Consultant CNP #906 confirmed she did not wear an isolation gown prior to assisting Resident #48 with care. Wound Care Consultant CNP #906 then left the unit without washing her hands, changing her mask or cleaning her goggles. Interview on 07/25/22 at 9:33 A.M. with Wound Care Nurse RN #803 confirmed Wound Care Consultant CNP #906 was in Resident #48's room with the door closed assisting Resident #48 to prepare for wound care. Wound Care Nurse RN #803 confirmed Wound Care Consultant CNP #906 did not have the appropriate PPE on, did not clean her goggles, change her mask, or wash her hands prior to exiting the unit onto another residential area. Observation on 07/25/22 at 9:39 A.M. revealed Hospice STNA #907 entering the memory care unit where three Residents (Resident #48, #27, and #53) were positive for COVID-19. Hospice STNA #907 verified she was not wearing goggles nor a face shield for eye protection. Interview on 07/25/22 at 9:40 A.M. with LPN #521 confirmed Hospice STNA #907 was not wearing goggles nor a face shield when she entered the unit. LPN #521 revealed Hospice STNA #907 was there to assist Hospice Resident #21 who also resided in the memory care unit and staff should be wearing eye protection on the unit. Interview on 07/25/22 at 9:53 A.M. with the DON revealed contract staff such as Hospice staff would be expected to wear appropriate PPE when entering the facility and entering a residents room requiring isolation precautions. The DON revealed she did not know how the contract staff were notified of the facility outbreak status. Observation on 07/25/22 at 3:02 P.M. revealed STNA #550 entered the memory care unit and was not wearing goggles nor a face shield. STNA #550 verified she was not wearing goggles or a face shield when she entered the unit. Observation on 07/27/22 at 1:13 P.M. revealed RN #602 entered Resident #48's room with the bottom strap of the N-95 mask dangling under his chin. After exiting Resident #48's room, RN #602 did not clean his goggles and placed the new N-95 mask on with the bottom strap dangling under his chin. Interview on 07/27/22 at 1:18 P.M. with RN #602 confirmed he entered Resident #48's room with the bottom strap of the N-95 mask dangling under his chin. After exiting Resident #48's room, RN #602 verified he did not clean his goggles and placed the new N-95 mask on with the bottom strap dangling under his chin. 2. Record review for Resident #27 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission MDS 3.0 assessment dated [DATE] revealed Resident #27 had moderately impaired cognition. Resident #27 required extensive assistance for bed mobility, transfers, dressing, grooming, and toilet use. Record review of the care plan dated 07/18/22 revealed Resident #27 was on droplet precautions due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 07/25/22 at 12:33 P.M. revealed State tested Nursing Assistant (STNA) #504 was assisting Resident #27 in her room with setting up the lunch tray sitting in front of Resident #27. STNA #504's isolation gown was not tied at the top or at the waist. The top of the isolation gown was dangling at STNA's elbows as she was setting up the lunch tray. STNA #504 continued assisting Resident # 27 with positioning and the lunch tray. Interview on 07/25/22 at 12:37 P.M. with STNA #504 confirmed the isolation gown was not tied and was dangling at the elbows while providing care for Resident #27. STNA #504 confirmed she did not change her mask, clean her goggles or wash her hands prior to leaving Resident #504's room. Observation on 07/25/27 at 12:38 P.M. revealed STNA #504 then walked up the hall, retrieved a lunch tray for Resident #18 (not on isolation precautions), she did not change her mask, clean her goggles or wash her hands and delivered the lunch tray to Resident #18. Interview on 07/25/27 at 12:41 P.M. with STNA #504 verified she delivered the lunch tray to Resident #18 and did not wash her hands, clean goggles or change her mask after assisting Resident #27 and before assisting Resident #18. Observation on 07/27/22 at 4:09 P.M. revealed Radiology Technician #908 was in Resident #27's room performing a procedure. Radiology Technician #908 was wearing his N-95 mask below his mouth exposing his mouth and nose and was not wearing goggles. Interview on 07/27/22 at 4:17 P.M. with Radiology Technician #908 verified his face mask was below his mouth while in Resident #27's room and he had no goggles on. Radiology Technician #908 left the unit and did not change his mask. 3. Record review for Resident #326 revealed an admitted [DATE]. Resident #326 was discharged to the hospital on 07/14/22 and returned 07/19/22. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] revealed Resident #326 had intact cognition. Resident #326 required limited assistance of one for bed mobility, extensive assistance of one for transfers and limited assistance of one for toilet use and personal hygiene. Record review of the care plan dated 07/25/22 for Resident #326 revealed resident was on droplet isolation precautions related to guidelines for quarantine related to recent hospitalization . Interventions included to adhere to standard infection control precautions at all times by all staff. Record review of the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 07/26/22 at 11:47 A.M. of RN #544 assisting Resident #326 with medication administration revealed RN #544 donned her isolation gown and did not tie the top of the gown. RN #326 did not place a surgical mask over the N-95 mask. The top of the gown fell to RN #544's elbows while providing care to Resident #326. RN #544 exited Resident #544's room then did not change the N-95 mask or clean her goggles. Interview on 07/26/22 at 11:57 A.M. with RN #544 while she was walking up the hall confirmed she did not tie the top of the gown causing it to fall to the top of her elbows while providing care to Resident #326. RN #544 also verified she did not change her mask prior to exiting the room and she did not clean her goggles. Interview on 08/01/22 at 9:31 A.M. with Infection Preventionist Assistant Director of Nursing RN #805 revealed all staff including contract staff were expected to donn and doff appropriate PPE prior to entering rooms positive for COVID-19 or on quarantine including an N-95 mask and goggles or face shield while in the residential areas of the facility. 4. Record review for Resident #29 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician orders for Resident #29 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was to inject as per sliding scale after checking the resident's blood sugar level. Observation on 07/26/22 at 8:20 A.M. with RN #544 who was assessing Resident #29's blood sugar level using a glucometer. After RN #544 assessed Resident #29's blood sugar, RN #544 then wiped the glucometer off with a hand sanitizer wipe for less than five seconds and sat the glucometer directly on top the medication cart. Interview on 07/26/22 at 8:24 A.M. with RN #544 confirmed she briefly wiped the glucometer off with a hand sanitizer wipe and revealed she would normally use a bleach wipe for 30 seconds but she did not have bleach wipes. RN #544 verified she used the same glucometer for all of her residents who required a blood sugar assessment. 5. Record review for Resident #324 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the physician orders for Resident #324 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was to inject as per sliding scale after checking the residents blood sugar level. Observation on 07/26/22 at 08:35 A.M. with RN #544 who was assessing Resident #324's blood sugar using a glucometer. After using the glucometer, RN #544 wiped the glucometer off with a bleach wipe for less than six seconds, then assessed Resident #29's blood sugar. RN #544 then wiped the glucometer off again with a bleach wipe for approximately six seconds after assessing the blood sugar for Resident #29 then sat the glucometer on top the medication cart which RN #544 verified at the time of the finding. 6. Record review for Resident #51 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the physician orders for Resident #51 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 07/26/22 at 8:44 A.M. of RN #544 assessing Resident #51's blood sugar using a glucometer revealed after RN #544 assessed Resident #51's blood sugar, she placed the glucometer in the top drawer of the medication cart without cleaning the glucometer. Interview on 07/26/22 at 8:56 A.M. with RN #544 confirmed she did not clean the glucometer after assessing Resident #51's blood sugar, and she placed the glucometer in the top drawer of the medication cart. RN #544 confirmed she used the same glucometer for Resident #29, #324, and #51. Interview on 07/26/22 at 9:10 A.M. with the DON revealed the medication cart should have had three glucometers on it and each glucometer should have been cleaned a minimum of two minutes before the next use because that is what was indicated in the manufacturer instructions so that is what the nurse should follow to clean the glucometer. The DON provided the manufactures instructions titled, Cleaning and disinfecting the On Call Pro Blood Glucose Monitoring System. Record review of the facility policy titled, Cleaning and Disinfecting of Equipment, dated October 2017, included the manufacturers guidance titled, Cleaning and disinfecting the On Call Pro Blood Glucose Monitoring System. The instructions included a cautionary statement to not disinfect the meter with any product containing bleach. The meter should be disinfected using Super Sani cloth germicidal disposable wipes with a contact time of two minutes. Record review of the Community Risk Level for Cuyahoga County for COVID-19, updated 07/28/22, revealed the community risk level was high. Record review of the policy titled, Covid-19, Coronovirus, revised 06/28/22, revealed after receipt of confirmed COVID 19 test results the resident would remain in droplet precautions per guidelines. Any new admissions would be placed in a 14 day quarantine if not updated. The facility would provide cumulative updates to their residents, their representatives, families and staff at least weekly during an outbreak or by 5:00 P.M. the next calender day following the subsequent occurrence of either: each time a COVID 19 infection was identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. Record review of the facility policy titled, Covid 19 Donning and Doffing, revised 01/05/22, revealed if the facility was in outbreak status for COVID-19 eye protection must be donned by all staff in all zones. Instructions included, while donning the gown, fully cover the torso from neck to knees, arms to end of wrist, and wrap around the back, fasten in back of neck and waist. The donning of the mask instructions indicated staff should secure ties or plastic bands at the middle of head and neck. For residents on a 14 day quarantine, a surgical mask would be worn over the N-95 mask and disposed of after exiting quarantined rooms and before entering another residents room. Wash hands or use alcohol based hand sanitizer immediately after removing all PPE.

Based on observation, interview, and record review, the facility failed to ensure interventions were in place to prevent the development of Stage II pressure ulcers on the right and left buttocks of Resident #68. This affected one of four residents reviewed with wounds. The facility census was 98 residents. Findings include: Review of the "Skin Assessment/Audit" policy and procedure, dated August of 2009, revealed the purpose of the skin assessment was to promote healthy skin integrity and to assist in wound identification and wound healing. A complete "head to toe" skin assessment would be completed on the admission of each new resident, and if an area was identified, a care plan for skin integrity would be implemented on admission and treatments would be administered according to the physician's orders [REDACTED]. Review of the medical record for Resident #68 revealed [DIAGNOSES REDACTED]. Resident #68 was admitted to the facility on [DATE], sent to the hospital for an evaluation related to a change in mental status on 09/28/10, and returned to the facility for a re-admission on 10/01/10. Review of the pressure sore risk assessments dated 09/27/10 and 10/02/10 revealed Resident #68 was at risk for pressure sore development. Review of the Minimum Data Set (MDS)-Version 3.0 assessment, dated 01/07/11, revealed Resident #68 had no current or recently healed pressure ulcers. Review of the resident's care plans revealed a pressure ulcer care plan was first initiated on 11/30/10. Review of the admission nursing skin assessment dated [DATE] at 9:36 P.M. revealed Resident #68 arrived at the facility with "no open areas." Review of the hospital transfer sheet, dated 10/01/10, revealed no indication Resident #68 had a pressure area or wound to his buttocks. Review of the admission skin assessment, dated 10/02/10 at 3:07 A.M., revealed the resident returned from the hospital with a "2 centimeter by 5 centimeter purple, non-opened area to coccyx." Review of the physician's orders [REDACTED]. Review of a nurse's progress note dated 10/02/10 at 2:09 A.M. revealed Resident #68 arrived at the facility on 10/01/10 at 7:20 P.M. with a 7.0 centimeter (cm) by 5.0 cm dark purple area to his coccyx. The nurse documented she cleansed the area and covered it with a dressing for protection. Review of the progress notes from 10/02/10 at 9:58 A.M. through 10/05/10 at 6:43 A.M. revealed no documentation or assessment of the resident's buttocks. Review of a nurse's progress note dated 10/05/10 at 10:49 A.M. revealed Resident #68's left upper buttocks had an open area described as 1.1 cm by 1.0 cm by 0.1 cm deep, moist and "yellowish red" in color. The left lower buttocks had an open area described as 2.0 cm by 0.8 cm by 0.1 cm with a yellowish red color. The right buttocks had an "8.0 cm by 4.0 cm dark area" with a 7.0 cm by 0.8 cm by 0.1 cm "red/yellowish opened area." Review of the "Resident Care Flow Sheet" for October of 2010 revealed the nursing assistants did not document Resident #68 was turned and repositioned every two hours as ordered on admission. Review of the October of 2010 treatment administration sheets (TAR) revealed the order to "turn side to side every two hours while in bed" was added on 10/05/10. The TAR did not provide evidence to indicate the resident was turned every two hours from 10/01/10 through 10/05/10. The TAR also revealed Resident #68's buttock was not cleansed and Remedy cream was not applied as ordered on [DATE], 10/04/10, and 10/05/10. Observation of wound care on 01/26/11 at 1:55 P.M. revealed Resident #68's right and left buttock was red and denuded (loss of the [MEDICATION NAME] layer of skin) in appearance. The resident had a small, approximately 2.0 cm long, linear scabbed area on the coccyx which was covered with a [MEDICATION NAME] dressing (an opaque dressing used in medicine to protect wounds from contamination, and provide a moist wound-healing environment). Interview with the wound nurse at this time revealed Resident #68's wound was currently "a stage two" pressure ulcer. On 01/26/11 at 11:27 A.M., an interview with the director of nursing (DON) indicated Resident #68's wound was not a pressure ulcer. The DON revealed she classified the wound as "a deep tissue injury" caused by the resident's [MEDICAL CONDITION] (an infection that causes frequent diarrhea). Review of Resident #68's medical record revealed the resident did not contact the [MEDICAL CONDITION] infection until 10/13/10. On 01/26/11 at 3:15 P.M., an interview with the wound care nurse and the DON verified the ordered interventions to turn and reposition the resident every two hours and to cleanse and apply Remedy cream to Resident #68's buttocks was not documented in the medical record from 10/01/10 through 10/05/10. The DON verified the nurses and nursing assistants were to initial the TAR's and the Resident Care Flow Sheets when the ordered interventions were completed. The wound nurse verified the condition of Resident #68's buttocks worsened from the admission assessment on 10/01/10 to the skin assessment on 10/05/10 and the resident currently had a Stage II pressure ulcer. This deficiency substantiates allegations contained in Complaint Number OH 343.