Every finding on record at Pebble Creek Healthcare Center

Based on review of the medical record, review of the concern log, review of the incident log, interview with the staff, and review of the facility policy, the facility failed to ensure the resident representative for Resident #146 was notified of a fall. This affected one resident (Resident #146) of three reviewed for falls.Findings Include: Review of the medical record revealed Resident #146 was admitted to the facility on [DATE]. Diagnoses included Parkinsonism, benign neoplasm of the cerebral meninges, hypertensive heart disease, paranoid schizophrenia, anxiety disorder, heart failure, repeated falls, insomnia, major depressive disorder, head injury, muscle weakness and unsteadiness on feet. Resident #146 had a Medical Power of Attorney (MPOA).Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #146 had moderately impaired cognition, required supervision for transfers and ambulation, and she had one fall since her prior assessment.Review of the incident accident log revealed Resident #146 had a fall without injury on 12/01/25. Review of the nurse note dated 12/01/25 at 9:47 P.M. revealed the nursing assistant found Resident #146 sitting on the floor in the bedroom near her bed. Resident #146 slid out of bed onto the floor and denied any pain or discomfort. The physician and the unit managers were notified. It noted the staff would ensure Resident #146 was wearing non-skid footwear at all times. There was no documentation the resident's representative was notified of the fall. Review of the Concern Log dated December 2025 revealed a family member of Resident #146 had a concern on 12/04/25 regarding notification. The Executive Director was the person who resolved the concern on 12/05/25 by way of education.Review of the Concern Form dated 12/04/25 revealed a family member had a concern that she was not notified of a fall which occurred on 12/01/25. The action to resolve was the Executive Director spoke to the nurse who stated the resident was listed as her own responsible party, so she spoke to the resident about the fall and interventions. The nurse was educated to still call the party responsible.On 12/17/25 at 4:30 P.M. an interview with the Director of Nursing revealed the nurse working during the fall on 12/01/25 for Resident #146 had not called the emergency contact/POA because the resident was listed as her own responsible party on the face sheet. She verified the nurse should have called the POA designated on the face sheet in the residents record.Review of the undated facility policy titled, Notification of Changes in Condition, revealed it was the policy of the facility to provide resident centered care that met the psychological, physical and emotional needs and concerns of the residents. The purpose of the policy was to provide guidance for notification made to residents, resident representatives, and authorized family members for residents change in condition. Changes may include but not limited to accidents, incidents, transfers, changes in overall health status, significant medical changes, therapy services, hospitalizations, or death. This deficiency represents non-compliance investigated under Complaint Number 2693087.

Based on record review, local police report review, interview and facility policy and procedure review, the facility failed to report an allegation of abuse. This affected one resident (#124) of three residents reviewed for abuse. The facility census was 147.Findings include:Review of the medical record for Resident #124 revealed an admission date of 02/02/25. Diagnoses included epilepsy, dementia with agitation, anxiety disorder, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #124 had intact cognition and no noted behaviors during the seven-day look back period. Further review of Resident #127's medical record revealed no documented concerns related to alleged abuse. Review of the police report dated 11/11/25 revealed the officer was called to the hospital regarding reported elder abuse that occurred at the nursing facility. The officer spoke with Resident #124 who stated to the officer that she was assaulted sometime within the last two weeks at the nursing facility. Resident #124 claimed that someone placed their hands on her wrists causing injury while she was in her wheelchair. The officer did not observe any visible injury on her wrists. Resident #124 was unable to say who assaulted her or provide any kind of suspect description. The officer went to the facility for follow-up regarding this incident. The officer spoke with Resident #124's case worker, Licensed Social Worker (LSW) #537, in her office. LSW #537 stated that she is unaware of any incidents of assault, and no staff members have any documented incidents with Resident #124. Interview on 11/24/25 at 4:33 P.M. with LSW #537 revealed she recalled speaking with the police officer regarding Resident #124's allegation of abuse, but could not recall who, and also about family trying to steal her money. LSW #537 stated she talked with Resident #124 when she returned from the hospital, and the resident told her that she could not recall anything that happened before she went to the hospital. LSW #537 stated that she told the Director of Nursing (DON) about the police officer's visit. LSW #537 stated the police officer did not leave her a report or report number. Interview on 11/24/25 at 4:51 P.M. with the DON stated she was only told Resident #124 had said something in the hospital about money and when the police came LSW #537 showed them the transactions that family did not have access to the resident's account. The DON stated she knew nothing about her allegation of abuse and this was the first she had heard of it. The DON stated she would have filed a self-reported incident (SRI), reported it, and done an investigation. Review of the undated facility policy titled Ohio Abuse, Neglect, & Misappropriation revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury. If the events that cause the allegations involve abuse and/or serious bodily injury the self-report must be made immediately, but no later than two (2) hours after the allegation is made. For alleged violations of neglect, exploitation, misappropriation of resident property, or mistreatment that do result in serious bodily injury, the facility must report the allegation no later than 24 hours. The self-report will be made by the ED to APS, and State Survey Agency and other local authorities, including but not limited to, local police, if appropriate. All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately to the Executive Director/designee of the facility.This deficiency represents non-compliance investigated under Master Complaint Number 2673186.

Based on observation, resident and staff interview, medical record review, hospital documentation review, and policy review, the facility failed to ensure a resident received appropriate care and services to monitor for neurological changes and obtain laboratory values for a resident with know history of hepatic encephalopathy. Actual harm occurred to Resident #9 when the resident's ordered medication used to prevent hepatic encephalopathy was changed from being administered on a scheduled basis to only given as needed. Additionally, the facility did not implement monitoring for altered mental status changes as care planned and did not obtain ammonia laboratory values as ordered to determine the need for administering the as needed medication or additional interventions. This resulted in Resident #9 experiencing a change in mental status and elevated ammonia levels which necessitated hospitalization for treatment of the resident's condition. This affected one (#9) of three residents reviewed for quality of care. The facility census was 148. Findings include: Review of Resident #9's medical record revealed an admitted [DATE] and diagnoses included hepatic encephalopathy, type two diabetes mellitus, dysphagia, and congestive heart failure. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderate cognitive impairment. Resident #9 was dependent for toileting hygiene, bathing, and lower body dressing. Resident #9 required partial to moderate assistance with personal hygiene. Resident #9 was always incontinent of urine and bowel. Resident #9 was at risk of developing a pressure ulcer but did not have a pressure ulcer or injury. Resident #9 did not reject care during the seven-day assessment look-back period. Review of Resident #9's physician orders dated 07/07/24 revealed the resident was ordered the laxative and ammonia reducing medication Lactulose oral solution 10 grams (g) per 15 milliliters (ml) with instructions to give 30 ml by mouth two times a day for constipation, abdominal bloating. The order was discontinued on 11/03/24. Review of Resident #9's care plan dated 07/16/24 included Resident #9 had a neurologic disorder related to encephalopathy. Resident #9 would not have increased signs and symptoms of neurological complications through the target date of 04/26/25. Interventions included to monitor for signs and symptoms of altered neurological status such as pupils not equal and reactive to light, hand grasps are not equal, inappropriate response to pain, changes in level of consciousness; monitor vital signs as needed and report abnormal findings to the medical provider, resident, and resident representative; neurological consultation as needed, per medical providers orders; observe for changes in mental status and report abnormal findings to the medical provider, resident, resident representative; and obtain and monitor laboratory, diagnostic studies as ordered and report abnormal findings to the medical provider, resident, and resident representative. Review of Resident #9's progress notes dated 11/03/24 at 12:40 P.M. included Resident #9's Telehealth (a means to provide healthcare services via electronic means) provider was notified she refused her suppository and Lactulose today. An ammonia laboratory level was ordered and the Lactulose order was changed to as needed. Review of Resident #9's physician Telehealth progress notes dated 11/03/24 at 12:44 P.M. revealed Resident #9 was refusing a suppository and Lactulose. Resident #9 reported the Lactulose and suppository were making her bowels move too often and it was recommend to change the order to as needed. Review of Resident #9's physician orders dated 11/03/24 revealed an order for Lactulose oral solution 10 g per 15 ml with instructions to give 30 ml by mouth every 12 hours as needed for encephalopathy or constipation was given. Review of Resident #9's physician orders dated 11/03/24 revealed the facility was to obtain an ammonia level, one time only for one day. Review of Resident #9's medical record including progress notes did not reveal evidence an ammonia level was drawn. The order was discontinued on 11/05/24. Review of Resident #9's medical record including progress notes, physician orders, medication administration record (MAR), and treatment administration record (TAR) did not reveal monitoring for signs and symptoms of increased ammonia level. Review of Resident #9's MAR and TAR dated 11/03/24 through 02/05/25 did not reveal evidence Lactulose 30 ml was administered. Review of Resident #9's physician and nurse practitioner notes, written by Medical Director (MD) #413 and Nurse Practitioner (NP) #414, dated 11/03/24 through 02/05/25 did not reveal documentation related to monitoring for signs and symptoms of increased ammonia levels. Review of Resident #9's progress notes dated 02/04/25 at 1:52 P.M. through 02/04/25 at 3:15 P.M. included Resident #9 was complaining of nausea. The resident received the anti-nausea medication Zofran with little relief. NP #414 was notified and gave orders for a polymerase chain reaction (PCR) test for respiratory syncytial virus (RSV), influenza, and COVID-19. All tests came back negative. A stat (immediately) laboratory draw was ordered for a comprehensive metabolic panel and complete blood count with differential and monitor for changes. Review of Resident #9's progress notes dated 02/04/25 at 6:00 P.M. revealed Resident #9's son was notified of her change of condition. Review of Resident #9's progress notes dated 02/05/25 at 1:13 A.M. revealed NP #414 was notified of Resident #9's laboratory values and altered mental status, and orders were given to transport Resident #9 to the hospital due to elevated laboratory values and mental status change. Review of Resident #9's hospital admission progress notes dated 02/05/25 through 02/10/25 included Resident #9 was admitted to the hospital on 02/05/25 for altered mental status (AMS). All information was obtained from the resident's chart as Resident #9 was a poor historian. Per paperwork from the facility, Resident #9 had a history of metabolic encephalopathy and chronic communication deficit. Resident #9 also had a known history of hepatic encephalopathy. The facility stated Resident #9 had and episode of vomiting yesterday (02/04/25) and was sent to the emergency department (ED) due to confusion and increased bilirubin (a substance produced when red blood cells break down and are processed by the liver and converted into a substance called bile) levels. In the ED Resident #9 was noted to have elevated ammonia levels and was given a Lactulose enema. Resident #9's problem list included hyperammonemia, altered mental status, urinary tract infection (UTI) and elevated bilirubin. Resident #9's altered mental status was likely due to her UTI and hepatic encephalopathy and was improved with Lactulose and Rocephin (antibiotic). Resident #9 had hyperammonemia and was on scheduled Lactulose now (Lactulose 30 gram twice a day). The elevated bilirubin was suspected to be due to UTI and cholelithiasis (gallstones) on ultrasound. Resident #9 was admitted to the hospital and the plan included to repeat her ammonia level post Lactulose enema. Review of Resident #9's ammonia level dated 02/05/25 at 3:22 A.M. revealed a normal ammonia level was 11 to 51 micromoles per liter (umol/L) and Resident #9's ammonia level was greater than 61 umol/L. Review of Resident #9's ammonia level dated 02/06/25 at 6:17 A.M., after the Lactulose enema revealed Resident #9's ammonia level was 48 umol/L. Review of Resident #9's progress notes dated 02/14/25 at 10:41 A.M. revealed new orders were given by the nurse practitioner for bi-weekly laboratory values and Lactulose 30 ml twice a day. Resident #9 and her son were aware of all new and existing orders. Interview on 03/26/25 at 10:29 A.M. with Family Member (FM) #411 revealed Resident #9 was diagnosed with liver disease in April 2024 and was ordered Lactulose because she had high ammonia levels, and the Lactulose would bring the ammonia level down. Resident #9 had diarrhea in November 2024 and the Lactulose order was changed to as needed. FM #411 stated if the Lactulose was supposed to be taken to lower Resident #9's ammonia level then it would need to be taken to keep the levels from going up. FM #411 indicated Resident #9 was in the hospital for five days in February 2025 with part of the problem being high ammonia levels and the hospital was able to stabilized the resident. FM #411 stated he was upset Resident #9's Lactulose was discontinued, and the facility staff did not listen to him when he called. Interview on 03/26/25 at 12:36 P.M. with the Director of Nursing (DON) revealed Resident #9 and her family requested her Lactulose be discontinued because she was having diarrhea. The DON confirmed she talked to Resident #9's son and he mentioned something about the resident's liver, and she told him he requested her Lactulose to be discontinued because he did not like the side effects of the medication. The DON stated she was not sure if Resident #9 received Lactulose and it should be documented in the progress notes if she did. Interview on 03/27/25 at 7:42 A.M. with the DON revealed the facility did not do ammonia levels for Resident #9 because an ammonia level was a time sensitive test and had to be at the laboratory in a certain timeframe. The DON stated MD #413 indicated to monitor Resident #9's symptoms, check for elevated liver enzymes, and change in mental status. The DON stated Resident #9 would receive Lactulose if it was ordered by the physician. The DON confirmed Resident #9 did not have an ammonia level drawn from 11/03/24 through 02/05/25. Interview on 03/27/25 at 9:25 A.M. with Laboratory Representative (LR) #415 revealed the laboratory had a contract with the local hospital and there was a 15 minute timeframe from the time the ammonia level was drawn until it was processed, and the laboratory could not meet the timeframe due to things like drive time etcetera. Interview on 03/27/25 at 8:28 A.M. with Licensed Practical Nurse (LPN) #370 revealed Resident #9 received daily scheduled Lactulose and she did not like it but she took it without a problem when she was told it was important for her health. LPN #370 stated Resident #9 was compliant and did not refuse to take the Lactulose. Observation and interview on 03/27/25 at 8:43 A.M. revealed Resident #9 was lying in bed, was pleasant, and answered questions without issues. Resident #9 was confused and did not remember what Lactulose was or if she refused to take it. Interview on 03/27/25 at 11:54 A.M. with the DON revealed NP #414 told her Resident #9 did not like her Lactulose and to make a huge difference she would need to tolerate it twice a day. NP #414 felt like her dementia was progressing and every day she was assessed for a change in condition. The DON confirmed there was no documentation in Resident #9's medical record related to monitoring for signs and symptoms of increased ammonia levels. The DON stated if Resident #9 had a change of condition and NP #414 was notified he might say to give Lactulose. The DON stated NP #414 watched liver function and that was his gauge. The DON confirmed Lactulose was not administered to Resident #9 from 11/03/25 through 02/05/25. Review of the facility policy titled, Medication Administration, revised 12/14/17, revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the residents. Further review revealed safety of residents, visitors, and employees was a top priority of care. This deficiency represents non-compliance investigated under Complaint Number OH00162412.

Based on observation, medical record review, resident and staff interview, review of shower sheets, and policy review, the facility failed to ensure pressure ulcer treatments were implemented as ordered and failed to ensure pressure ulcers were properly identified and addressed in a timely manner. This affected two (#9 and #108) of four residents reviewed for pressure ulcers. The facility census was 148. Findings included: 1. Review of Resident #9's medical record revealed an admitted [DATE]. Diagnoses included hepatic encephalopathy, type two diabetes mellitus, dysphagia, and congestive heart failure. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderate cognitive impairment. Resident #9 was dependent for toileting hygiene, bathing, and lower body dressing. Resident #9 required partial to moderate assistance with personal hygiene. Resident #9 was always incontinent of urine and bowel. Resident #9 was at risk of developing a pressure ulcer but did not have a pressure ulcer or injury. Resident #9 did not reject care during the seven-day assessment look-back period. Review of Resident #9's Braden scale observation tool dated 03/11/25 revealed Resident #9 was at low risk for developing a pressure ulcer. Review of Resident #9's progress notes dated 02/05/25 at 1:40 A.M. revealed Resident #9 was transported to the local hospital. Review of Resident #9's progress notes dated 02/10/25 at 4:03 P.M. revealed Resident #9 was readmitted to the facility and had three pressure ulcers with treatments ordered. Resident #9 was placed on a low air loss mattress and Resident #9's son was notified. Review of Resident #9's wound assessment report dated 02/12/25 revealed Resident #9 had a stage two pressure ulcer (partial-thickness skin loss with exposed dermis) to the sacrum present on admission with measurements of 2.0 centimeters (cm) long by 1.0 cm wide by 0.2 cm deep. Treatment initiated to cleanse the wound with normal saline, apply Triad cream (a zinc oxide-based paste used for managing wounds), and a bordered foam dressing daily and as needed. Resident #9 had a stage one pressure ulcer (non-blanchable erythema of intact skin) to the mid-back on admission with measurements of 1.0 cm long by 1.5 cm wide with no measurable depth. Treatment was initiated to cleanse the wound with wound cleanser, apply skin prep and a bordered foam dressing three times a week and as needed. Resident #9 also had a stage one pressure ulcer to the right lateral ankle present on admission with measurements of 1.0 cm long by 1.0 cm wide with no measurable depth. Treatment was initiated to cleanse the wound with normal saline, apply skin prep and a bordered foam dressing three times per week and as needed. Review of Resident #9's wound assessment report dated 02/19/25 included Resident #9's right lateral ankle stage one pressure injury was resolved. Review of Resident #9's wound assessment report dated 02/26/25 included Resident #9's sacral stage two pressure ulcer was resolved. Review of Resident #9's wound assessment report dated 03/05/25 included Resident #9's stage one pressure ulcer to the mid-back was resolved. Review of Resident #9's progress notes and assessments dated 03/05/25 through 03/25/25 did not reveal evidence Resident #9 had reddened or open areas on her back and coccyx. Review of Resident #9's medication administration record and treatment administration record dated 03/05/25 through 03/26/25 did not reveal treatment orders were provided for Resident #9's back, buttocks, or coccyx areas. Review of Resident #9's nurse aide assignment sheets dated 03/20/25, 03/21/25, and 03/25/25 revealed Certified Nurse Aide (CAN) #253 was assigned to care for Resident #9. Review of Resident #9's shower sheet revealed the documented month was March 2025, but the specific date was unable to be determined. Further review revealed there was an area of concern over Resident #9's right buttock. Review of Resident #9's shower sheet dated 03/20/25 and 03/22/25 revealed there was a mark placed over the drawing of a back on the shower sheet indicating there was an area of concern. Observation and interview during incontinence care on 03/26/25 at 8:30 A.M. with CNA #215 revealed Resident #9 had three areas of injury on the skin including one to her mid-back which was red, non-blanchable, and the size of a deck of cards; one to her coccyx which was reddened, open, approximately 0.1 cm deep, and the size of a dime; and the third area was over slightly to the right of the coccyx wound on the right buttock which was the size of a pencil eraser, and was reddened and non-blanchable. Further observation by the surveyor determined the areas identified were pressure- related. CNA #215 verified the three areas of injury on the resident's skin at the time of the observation. Interview on 03/26/25 at 1:22 P.M. with Nurse Practitioner (NP) #412 revealed she evaluated Resident #9 today on 03/26/25 and Resident #9 had two areas of MASD on her coccyx. Interview on 03/26/25 at 12:00 P.M. with CNA #253 revealed Resident #9 had red areas on her back and coccyx for a while. CNA #253 stated she told the nurse a couple days ago about Resident #9's red areas on her back and coccyx, but she did not remember what day it was or which nurse she told. CNA #253 stated the areas were reddened and were not open the last time she cared for Resident #9. 35765 2. Review of the medical record revealed Resident #108 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic pain, metabolic encephalopathy, peripheral vascular disease, adult failure to thrive, dementia, dysphagia, insomnia, hypertensive heart disease, anxiety disorder, bullous pemphigoid, protein-calorie malnutrition, vitamin D deficiency, major depressive disorder, syncope and collapse, and hyperlipidemia. Review of the March 2025 medication administration record revealed Resident #108 had an order for the nurse to use adhesive removal when changing the dressing to the sacrum every shift dated 01/27/25 and was signed off as completed twice daily. Review of the March 2025 physician orders revealed Resident #108 had an order to cleanse the sacral wound with Hibiclens, pat dry, apply iodoform, and cover with bordered foam dressings every shift and as needed dated 03/17/25 and a nurse to use adhesive removal when changing dressing to sacrum dated 01/27/25. Observation of wound care on 03/26/25 at 8:00 A.M. revealed LPN #280 provided wound care to Resident #108. LPN #280 started to remove the border foam from the sacrum of Resident #108 and the resident voiced expressions of pain numerous times while LPN #280 removed the treatment. On 03/26/25 at 12:30 P.M. an interview with the Director of Nursing (DON) stated she does not know why Resident #108 still had an order for adhesive remover because she thought it was discontinued. The DON stated at one time Resident #108 had a dressing that was irritating the skin around her sacrum so they got an order of adhesive remover so it would be easier on her. On 03/26/25 at 11:21 A.M. an interview with LPN #280 confirmed she did not use the adhesive remover prior to removing the border foam dressing from the sacrum of Resident #108. LPN #280 stated she did not know Resident #108 had an order for adhesive remover. Review of the undated facility policy titled, Skin Care and Wound Management Overview, revealed the facility strives to prevent resident skin impairment and to promote the healing of exiting wounds. The interdisciplinary team works with the resident and for family to identify and implement interventions to prevent and treat potential skin integrity issues. This deficiency represents non-compliance investigated under Complaint Number OH00162412.

Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure fall interventions were in place as care planned to prevent falls. This affected one (#111) of three residents reviewed for falls. The facility census was 148. Findings include: Review of Resident #111's medical record revealed an admitted [DATE] and diagnoses included hemiplegia affecting the right dominant side, acute respiratory failure with hypoxia, and vascular dementia. Review of Resident #111's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 did not have a Brief Interview for Mental Status (BIMS) completed due to Resident #111 being rarely or never understood. Resident #111 was dependent for toileting hygiene, bathing, personal hygiene, and lower body dressing. Resident #111 required partial to moderate assistance for the ability to roll from lying on her back to the left and right side and return to lying on her back on the bed. Resident #111 was always incontinent of urine and bowel. Review of Resident #111's fall risk observation tool dated 11/02/24 revealed Resident #111 was at risk for falls. Review of Resident #111's care plan revised 04/22/24 included Resident #111 was at risk for falls related to diagnoses with a goal Resident #111 would not sustain a major injury related to falls through the review date. Interventions included Dycem (non-slip pad) to chair as ordered; move Resident #111 closer to the nurses station when available; and an intervention initiated 11/12/24 revealed to place Dycem between Resident #111 and the Hoyer (mechanical lift) pad. Review of Resident #111's progress notes dated 02/01/25 at 12:30 P.M. revealed the nurse heard Resident #111 start yelling, when she checked on her she was found in the common area on the floor in front of her chair. A head-to-toe assessment was completed and no injuries or pain was noted. Resident #111 was assisted back to her chair using a mechanical lift with the assistance of three staff. Neurological checks were started and an intervention was documented for extra Dycem in the resident's chair to prevent future falls. Review of Resident #111's fall risk observation tool dated 02/02/25 revealed Resident #111 was at risk for falls. Interview on 03/25/25 at 2:07 P.M. with Licensed Practical Nurse (LPN) #221 revealed when Resident #111 fell on [DATE] she was sitting in her padded tilt-in-space wheelchair and had recently been checked and changed for incontinence. LPN #221 stated she did not see the fall, she heard yelling, and ran to where the yelling was. LPN #221 stated Resident #111 slid out of her chair and she did not know how it happened. LPN #221 stated she saw Resident #111 about five minutes before she experienced the fall and she was fine. LPN #221 stated she could not remember the position of Resident #111's tilt-in-space wheelchair when she had the fall. There was no evidence she had a seizure, and sometimes Resident #111 moved around a bit in the chair. Observation on 03/25/25 at 2:32 P.M. of Resident #111 with Unit Manager (UM) #230 revealed she was lying in bed with her eyes open. A fall mat was observed on the floor next to her bed and the bed was in the lowest position. Resident #111 told UM #230 she wanted to get out of bed. UM #230 instructed Certified Nurse Aide (CNA) #292 and CNA #293 to assist Resident #111 out of her bed into her padded tilt-in-space wheelchair. CNA #292 and CNA #293 assisted Resident #111 to her padded wheelchair using a mechanical lift. Observation on 03/25/25 at 4:40 P.M. of UM #230 and LPN #270 revealed they assisted Resident #111 to her bed using a mechanical lift to check her for incontinence. Observation revealed there was Dycem located on the wheelchair cushion, but there was no Dycem between Resident #111 and the mechanical lift pad. The Dycem that was supposed to be between Resident #111 and the mechanical lift pad was observed laying on Resident #111's bedside table. UM #230 and LPN #270 confirmed the Dycem was not placed between Resident #111 and the mechanical lift pad and should have been. Review of the undated facility policy titled, Fall Prevention and Management, revealed fall prevention and management was the process of identifying risk factors that could minimize the potential for falls and also a process to manage a resident's care if a fall occurred. If the resident was identified to be at risk for falls, a care plan should be initiated that included a plan to potentially diminish the risk for falls. The care plan should be reviewed and updated as needed with each change of condition.

Based on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure incontinence care was completed timely. This affected one (#15) of three residents reviewed for incontinence. The facility census was 148. Findings include: Review of Resident #15's medical record revealed an admitted [DATE] and diagnoses included congestive heart failure, type two diabetes mellitus with diabetic peripheral angiopathy without gangrene, and chronic kidney disease. Review of Resident #15's care plan revised 03/18/25 revealed Resident #15 had impaired skin integrity or was at risk for altered skin integrity. Resident #15 would have improved or maintain current skin status through the next review date. Interventions included to provide peri-care as needed to avoid skin breakdown due to incontinence. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact. Resident #15 was dependent for toileting hygiene and lower body dressing. Resident #15 was dependent for the ability to transfer to and from a bed to a chair or wheelchair. Resident #15 was always incontinent of urine and frequently incontinent of bowel. Observation and interview on 03/24/25 at 2:48 P.M. of Certified Nurse Aide (CNA) #289 and CNA #417 revealed they transferred Resident #15 back to her bed. Resident #15 stated she was put in her chair around 10:00 A.M. and she was unable to be put back to bed until now because there is no care during meals and you might as well forget it if you need something. Resident #15 stated she had to wait until the lunch meal was finished. Observation of Resident #15's incontinence care revealed her left and right buttocks had large red areas on them. Resident #15's left buttock was more reddened than her right buttock. Resident #15 stated she had a huge bowel movement that morning that was not diarrhea, and it took at least two hours for her to be changed because it happened during the breakfast meal. CNA #289 confirmed Resident #15 had reddened areas on the right and left buttocks. CNA #289 stated she was not working at the time of the lunch meal and just came to work. CNA #417 confirmed residents often had to wait for care during meal times because the staff was passing out meal trays and feeding residents. Review of the undated facility policy titled, Perineal Care Male or Female, revealed the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. It was the policy of the facility to provide resident care that met the psychosocial, physical, emotional needs and concerns of the the residents. Providing personal care services promoted a sense of well-being and met hygiene standards of care. Perineal care was performed on residents who were unable or unwilling to maintain body cleanliness and, or who were incontinent of bowel and bladder.

Based on record review and interview, the facility failed to ensure Resident #69 received appropriate and timely incontinence care. This finding affected one (Resident #69) of three residents reviewed for incontinence care. Findings include: Review of Resident #69's medical record revealed the resident was admitted on [DATE] with diagnoses including paraplegia complete, neuromuscular dysfunction of the bladder and colostomy status. Review of Resident #69's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #69's physician orders revealed an order dated 06/21/24 for colostomy care every shift, monitor for stoma changes; and an order dated 06/21/24 to change the suprapubic catheter as needed for occlusion/dysfunction every shift. Review of Resident #69's care plans indicated a consult was obtained with palliative care and would go outside or common areas without pants but covered his lower body with towels. Was admitted with impaired skin integrity and was non-compliant with preventative and protective interventions related to skin despite education. Had behaviors of making false statements related to not getting meals, then found hoarding food items in his room. admitted for skilled care and refused to allow adjustments to personalized wheelchair for skin protection and prevention. Would grab onto another resident's motorized wheelchair for a ride despite education related to safety. Refused to wear clothing on his lower body and covered himself with sheets and towels. Review of Resident #69's progress note dated 07/08/24 at 3:24 A.M. authored by Physician #701 revealed the resident had a history of chronic pain and opioid abuse and spends long periods of time outside. Patient now essentially unresponsive and barely upright. He had been in and out of the building. The blood pressure was 178/83, heart rate 77 beats per minute (BPM), respirations 17 and pulse oximetry 97% (percent). The resident was slumped over, breathing and arousable but barely. No Narcan was available in the building. The telehealth physician was concerned for an overdose and emergency medical services (EMS) were called immediately. Review of Resident #69's telehealth notification progress note dated 07/08/24 at 3:59 A.M. authored by Licensed Practical Nurse (LPN) #989 indicated the resident was unable to stay awake while talking to him and unable to sit up straight. He refused to be put in bed after the intravenous antibiotic was administered and stated he was going outside to smoke. He never made it outside and was found in his chair at his door slumped over in his chair. Telehealth was called and notified of the resident's condition. An order was obtained to administer Narcan, but it was unavailable. An order was obtained to call 911 immediately and they were notified when they arrived of the resident's condition. They were also notified that the resident's ostomy was just changed prior to shift change and he refused all other care including to be placed in bed. The rapid response team was rude during the transport of the resident. The resident was transferred to the gurney and his seat was filled with urine and stool all over the floor. Resident #69 had a habit of taking off his ostomy and never putting it back on. Review of Resident #69's progress note dated 07/08/24 at 1:41 P.M. authored by Registered Nurse (RN) Clinical Manager #981 indicated the resident was admitted to the hospital with a diagnosis of decubitus ulcer. Review of Resident #69's hospital Emergency Department (ED) Provider Note form authored by Physician #702 dated 07/08/24 indicated the resident presented with an altered level of consciousness and arrived via EMS from the skilled nursing facility (SNF). Per report, the resident was found in his room in a wheelchair covered in feces with a urine puddle under his chair after the facility called for a suspected overdose. The EMS stated the resident had been in the facility for a few weeks and was alert and oriented times one. The [AGE] year-old male present to the ER via EMS for altered mental status and had a past medical history of paraplegia, neurogenic bladder, decubitus ulcers, suprapubic catheter and colostomy placement. The resident was recently admitted to the hospital for decubitus ulcers and left lower extremity osteomyelitis. He was placed on Vancomycin antibiotic and declined a recommended left above the knee amputation (AKA). He was discharged to the SNF for intravenous (IV) Vancomycin and wound management. The EMS described a traumatic scene of neglect including large amounts of feces to be strewn across the resident and urine that began to puddle on the floor out of the resident's catheter bag. A colostomy bag was not attached, and the resident had altered mentation for no obvious reason. The resident was placed on oxygen by EMS. Resident #69 presented to the ED covered in feces and urine, the ostomy was uncovered/unbagged, the peripherally inserted central catheter (PICC) line was covered in feces and the resident was oriented to self. The resident had obvious multiple decubitus wounds that do not look obviously infected on the resident's sacrum and right thigh. The Disposition/Plan indicated the resident was present to the ER via EMS for altered mental status. Once the resident arrived to the ER, the resident was cleaned including but not limited to the PICC line, suprapubic catheter, and the ostomy with no bag attached. The resident's decubitus ulcers were examined and redressed. A urinalysis was ordered, but due to the complexity of the suprapubic catheter and the amount of feces that was found on the resident, an inpatient urologist would need to be consulted for management and replacement. Based on the resident's presentation and lab work, the resident was not believed to be suffering from an acute stroke, hypoglycemia, anemia or sepsis. The resident was believed to be suffering from failure to thrive secondary to neglect and was admitted for further management in addition to IV antibiotics and wound management. Interview on 07/10/24 at 10:56 A.M. with Nurse Practitioner (NP) #703 indicated Resident #69 had expressed to her that he wanted to care for his own colostomy and Suprapubic catheter. NP #703 confirmed the resident had a habit of lying his suprapubic catheter on the ground and was educated multiple times. She stated he had refused her to assess him and on a specific incident, she had refused to allow her to assess his colostomy bag. She had never noticed urine or stool on the resident's floor and the staff cleaned the room multiple times. NP #703 confirmed the resident went out to smoke. Telephone interview on 07/10/24 at 12:03 P.M. with Resident #69 indicated the facility provided good care to him and he changed his own catheter and ostomy bags. He stated on 07/07/24 during the dayshift, his suprapubic catheter bag was leaking, and the nurse changed the bag. Resident #69 confirmed it solved the issue until later during the night on 07/07/24 when the resident's bag started leaking again. He stated he did not tell the nursing staff and just cleaned it up with a towel. Resident #69 stated the facility did not do anything wrong and the colostomy bag came off on its own during the nightshift. He denied concerns with his care while in the facility. Telephone interview on 07/10/24 at 12:36 P.M. with LPN #989 indicated she went in to Resident #69's room around 10:00 P.M. on 07/07/24 and the resident was in his room. LPN #989 denied any urine or feces on the resident or floor at that time. She stated she went in the resident's room shortly before 2:00 A.M. during a wellness check and the resident was in his wheelchair in his room sleeping. She denied the resident had urine or feces on his person or stool. When questioned, she stated the resident refused to allow staff to put him in bed. She stated at 2:00 A.M., she went in Resident #69's room and administered his scheduled pain medications. She stated at that point, the resident was groggy but arousable. LPN #989 indicated the resident told her he wanted to go outside to smoke. LPN #989 denied the resident had urine or feces on his person at this point. She stated she was at the desk charting around 2:45 A.M. when she realized Resident #69 did not go outside to smoke so she went to check on the resident and found him slumped over in his wheelchair in the doorway of the resident's room. She stated she tried to arouse the resident, immediately took vitals and called the physician. She stated at this point, she had noticed the urine on the floor of the resident's room underneath of his chair but did not see any feces on the resident. LPN #989 stated she was more concerned with determining the cause of the change in condition and the telehealth physician told her to administer Narcan for a suspected drug overdose. LPN #989 indicated she went to the Omnicell medication distribution center to obtain the Narcan and determined the medication was not loaded for the resident's use. She confirmed she sent the resident out by 911 and when they arrived, it was discovered the resident was sitting in feces and was set with urine. Email interview on 07/11/24 at 10:55 A.M. with EMS #705 indicated their department received a call from the SNF on 07/08/24 at 3:33 A.M. and they arrived on the scene at 3:42 A.M. Telephone interview on 07/11/24 at 11:03 A.M. with EMS #704 indicated when their squad arrived at the facility on 07/08/24, there was a horrendous smell coming from down the hallway. EMS #704 stated when they arrived, it was clear the smell was coming from Resident #69's room. The resident was sitting just inside the doorway with his head slumped over to his knees and his airway was not protected. Three staff members were standing outside the room in the hallway looking in and not providing care to the resident. Resident #69 was adjusted to sit upright by EMS #704 and that was when the resident was observed to having caked on stool on his person and lap. The resident was moved to the gurney by the squad and more caked on stool was located on the wheelchair seat. EMS #704 indicated it appeared to be a large amount of stool on the wheelchair seat and resident which appeared to be more than one instance of incontinence. EMS #704 confirmed the resident's colostomy bag was not in place at the time of the observation. Telephone interview on 07/11/24 at 12:48 P.M. with EMS #711 stated he had responded to a call from the facility because of a suspected overdose and change in mental status. EMS #711 indicated when they arrived on the scene, a bunch of staff members were outside of Resident #69's room looking in. He stated the resident had his eyes open and was mumbling. EMS#711 confirmed the resident had a large amount of fecal matter on his genitals and caked on his body and clothing. He also stated urine was puddled underneath of the wheelchair with a trail across the room and towards the window. EMS #711 stated the resident appeared extremely disheveled and he did not believe the caked on fecal matter and urine on the floor and on the resident was a recent occurrence. Telehealth interview on 07/11/24 at 12:59 P.M. with Physician #701 revealed she had assessed Resident #69 on 07/08/24 for a change in mental status. She stated she did observe something on his shirt and thought it was vomit. She stated he was seated in his wheelchair and was sitting upright with his head slumped over and looking downward. She stated she suspected the resident had overdosed on something and she ordered Narcan for the resident. Physician #701 stated the facility could not get the Narcan out of their system and she ordered the resident to go to the hospital. She denied the resident was neglected when questioned. Review of the undated Routine Resident Care policy revealed it was the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs and honor lifestyle and preferences while in the facility. Review of the undated Male and Female Perineal Care policy indicated the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents' skin conditions. This deficiency represents non-compliance investigated under Complaint Numbers OH00155493 and OH00154792.

Based on observation, interview, and record review, the facility failed to ensure Resident #69 was free from significant medication error. This finding affected one (Resident #69) of three residents reviewed for medication administration. Findings include: Review of Resident #69's medical record revealed the resident was admitted on [DATE] with diagnoses including paraplegia complete, neuromuscular dysfunction of the bladder and colostomy status. Review of Resident #69's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #69's progress note dated 07/08/24 at 3:24 A.M. authored by Physician #701 revealed the resident had a history of chronic pain and opioid abuse and spends long periods of time outside. Patient now essentially unresponsive and barely upright. He had been in and out of the building. The blood pressure was 178/83, heart rate 77 beats per minute (BPM), respirations 17 and pulse oximetry 97% (percent). The resident was slumped over, breathing and arousable but barely. No Narcan (medication to treat narcotic overdose in an emergency) was available in the building. The telehealth physician was concerned for an overdose and emergency medical services (EMS) were called immediately. Review of Resident #69's telehealth notification progress note dated 07/08/24 at 3:59 A.M. authored by Licensed Practical Nurse (LPN) #989 indicated the resident was unable to stay awake while talking to him and unable to sit up straight. He refused to be put in bed after the intravenous antibiotic was administered and stated he was going outside to smoke. He never made it outside and was found in his chair at his door slumped over in his chair. Telehealth was called and notified of the resident's condition. An order was obtained to administer Narcan, but it was unavailable. An order was obtained to call 911 immediately and they were notified when they arrived of the resident's condition. They were also notified that the resident's ostomy was just changed prior to shift change and he refused all other care including to be placed in bed. The rapid response team was rude during the transport of the resident. The resident was transferred to the gurney and his seat was filled with urine and stool all over the floor. Resident #69 had a habit of taking off his ostomy and never putting it back on. Review of Resident #69's progress note dated 07/08/24 at 1:41 P.M. authored by Registered Nurse (RN) Clinical Manager #981 indicated the resident was admitted to the hospital with a diagnosis of decubitus ulcer. Interview on 07/10/24 at 12:36 P.M. with LPN #989 indicated she went in to Resident #69's room around 10:00 P.M. on 07/07/24 and the resident was in his room. LPN #989 denied any urine or feces on the resident or floor at that time. She stated she went in the resident's room shortly before 2:00 A.M. during a wellness check and the resident was in his wheelchair in his room sleeping. She denied the resident had urine or feces on his person or stool. When questioned, she stated the resident refused to allow staff to put him in bed. She indicated at approximately 2:00 A.M., she went in Resident #69's room and administered his scheduled pain medications. She stated at that point, the resident was groggy but arousable. LPN #989 indicated the resident told her he wanted to go outside to smoke. LPN #989 denied the resident had urine or feces on his person at this point. She stated she was at the desk charting around 2:45 A.M. when she realized Resident #69 did not go outside to smoke so she went to check on the resident and found him slumped over in his wheelchair in the doorway of the resident's room. She stated she tried to arouse the resident, immediately took vitals and called the physician. She stated at this point, she had noticed the urine on the floor of the resident's room underneath his chair but did not see any feces on the resident. LPN 989 stated she was more concerned with determining the cause of the change in condition and the telehealth physician told her to administer Narcan for a suspected drug overdose. LPN #989 indicated she went to the Omnicell medication distribution center to obtain the Narcan and determined the medication was not loaded for the resident's use. She confirmed she sent the resident out by 911 and when they arrived, it was discovered the resident was sitting in feces and was set with urine. Interview on 07/10/24 at 1:32 P.M. with the Director of Nursing (DON) indicated the Narcan was loaded in the Omnicell but LPN #989 was attempting to remove the medication by the brand name of Narcan instead of the generic name of Naloxone. The DON confirmed the facility had both nasal spray and injectable forms of the medication. Observation on 07/10/24 at 1:35 P.M. with RN Clinical Manager #981 of the Omnicell medication distribution center revealed the Narcan, under the name Naloxone, was available in both nasal spray and injectable forms. RN Clinical Manager #981 confirmed she educated LPN #989 on how to remove Narcan from the machine since she was a new nurse.

Based on record review and staff interview the facility failed to ensure residents admitted with pressure ulcer wounds had appropriate wound care orders and treatments in place when admitted to the facility. This affected one (Resident #137) of six residents reviewed for wound care. The facility census was 136. Findings include: Review of the Resident #137's medical record revealed an admitted [DATE] with admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission nursing skin assessment completed on 05/11/22 identified an unstageable pressure ulcer (depth of wound is unknown due to obstruction by slough and/or eschar) to the sacrum. An admission progress note entered on 05/12/22 also identified the unstageable pressure ulcer to the sacrum. The admission skin assessment and admission progress note did not contain any descriptive information or assessment of the wound including wound bed, peri wound, drainage, pain and/or odor. The admission skin assessment and admission progress note only indicated the stage of the wound and measurement. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record including the Treatment Administration Record (TAR) found no evidence of wound care or treatment to the sacrum pressure ulcer until 05/13/22 when Resident #137 was initiated on wound care. Resident #137's hospital discharge orders found no evidence of wounds or orders for wound care. Review of the facility On-Boarding Evaluation assessment completed prior to admission to the facility identified an unstageable pressure ulcer to the sacrum with wound care to be completed daily and as needed. Interview with the Director of Nursing on 05/31/22 at 11:40 A.M. verified Resident #137 was admitted to the facility with an unstageable pressure ulcer to the sacrum, had no orders for wound care in place until two days after admission and staff failed to notify the physician of the need for wound care for the wound. This deficiency substantiates Complaint Number OH 749.

Based on observation, interview, facility policy review, review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of Covid-19, and review of the CDC Covid Tracker website, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This had the potential to affect all residents residing in the facility. Facility census was 130. Finding include: Observation of the 700 unit on 11/29/21 at 5:10 A.M. revealed Licensed Practical Nurse (LPN) #138 was not wearing eye protection. Interview with LPN #138 at time of observation revealed she was aware she was required to wear eye protection while in the facility. Observation on the 700 unit on 11/29/21 at 5:13 A.M. revealed LPN #139 was not wearing eye protection. Interview with LPN #139 at time of observation revealed she was aware she was required to wear eye protection while in the facility. Observation of the 600 unit, on 11/29/21 at 5:14 A.M. revealed State tested Nursing Assistants (STNAs) #140 and #141 were exiting a resident's room and neither were wearing eye protection. STNAs #140 and #141 stated they were aware eye protection was required. Observation of the 600 hall on 11/29/21 at 5:16 A.M. revealed STNA #142 providing activities of daily living (ADL) care for Resident #109 and not wearing eye protection. Interview with STNA #142 revealed she was not aware she was required to wear eye protection because she was not on the Covid unit. Observation of the 200 hall on 11/29/21 at 5:24 A.M. revealed STNA #143's surgical mask was pulled down below her chin. Interview with STNA #143 revealed she was aware her mask was supposed to cover her nose and mouth. Observation of the 800 unit on 11/29/21 at 5:28 A.M. revealed STNAs #144 and #145 exiting Resident #12's room and STNA #144's surgical masks was pulled down below her chin. STNA #144 confirmed her mask should be covering her nose and mouth. Observation of the facility Covid unit on 11/29/21 at 5:42 A.M. revealed STNA #147 and LPN #148 were at a nurses' station and both were not wearing a mask or eye protection. Interview at time of observation revealed STNA #147 recently used the bathroom and had not put her mask or eye protection back on and LPN #148 stated the strap of her face shield just broke, and she had not gotten a new one yet. Further observation revealed there was a box of surgical masks, N95's and face shields at the nurses' station desk. STNA #147 and LPN #148 confirmed the supplies were in close proximity of where they had been seated. STNA #147 and LPN #148 stated they were aware they were required to wear a face mask and eye protection while in the facility. Observation on 11/29/21 at 7:31 A.M. revealed a sign posted outside of Resident #71's room indicating Resident #71 was on droplet precautions and a mask, eye protection and gown was required prior to entering. Further observation revealed STNAs #154 and #155 entering Resident #71's room and assisting Resident #71 out of bed into a wheelchair for breakfast. STNA #154 removed Resident #71's bed linen. Neither STNA #154 or #155 were wearing a gown during care. At time of observation Unit Manager #153 was present on the floor and confirmed the observation and stated staff should have been wearing a gown prior to providing care. Unit Manager #153 confirmed Resident #71 was on quarantine. Interview on 11/29/21 at 8:10 A.M. with Infection Preventionist #156 confirmed staff was required to wear eye protection and masks while in the facility. Further interview with Infection Preventionist #156 revealed the facility was in a Covid 19 outbreak status and had 10 positive cases. Observation on 11/29/21 at 10:32 A.M. revealed LPN #150 delivering charts and medications to the facility's Covid unit. Further observation revealed LPN #157, who was present on the Covid unit, open the protective barrier to receive the charts and medications and she was not wearing eye protection. This observation was confirmed with LPN #150 who stated LPN #157 should have been wearing eye protection. Review of facility policy titled Use of PPE While in the facility updated 10/29/21 revealed all direct care staff must wear a surgical mask and eye protection at all times. The policy further stated staff on the Covid unit were required to wear an N95 mask and eye protection on the general area of the unit. Review of the CDC Covid Tracker website, seven day county metric, revealed the facility was located in a county with a high (red) transmission rate and a positivity rate on 17.44 percent. Review of the CDC guidance updated 09/10/21 titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes revealed Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as [CONDITION(S)]-CoV-2. A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Even as nursing homes resume normal practices, they must sustain core IPC practices and remain vigilant for SARSCoV- 2 infection among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death. In general, healthcare facilities should continue to follow the IPC recommendations for unvaccinated individuals (e.g.,use of Transmission-Based Precautions for those that have had close contact to someone with [CONDITION(S)]-CoV-2 infection) when caring for fully vaccinated individuals with moderate to severe immunocompromise due to a medical condition or receipt of immunosuppressive medications or treatments. Manage Residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection HCP caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have: · Not been fully vaccinated; or · Suspected or confirmed [CONDITION(S)]-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or · Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with [CONDITION(S)]-CoV-2 infection for 14 days after their exposure, including those residing or working in areas of a healthcare facility experiencing [CONDITION(S)]-CoV-2 transmission (i.e., outbreak); or · Moderate to severe immunocompromise; or · Otherwise had source control and physical distancing recommended by public health authorities · should still consider continuing to practice physical distancing and use of source control. Implement Universal Use of Personal Protective Equipment for HCP If [CONDITION(S)]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: NIOSH-approved N95 or equivalent or higher-level respirators should be used for: · All aerosol-generating procedures (refer to Which procedures are considered aerosol generating procedures in healthcare settings? ) · All surgical procedures that might pose higher risk for transmission if the patient has COVID-19 (e.g., that generate potentially infectious aerosols or involving anatomic regions where [CONDITION(S)] loads might be higher, such as the nose and throat, oropharynx, respiratory tract) · Facilities could consider use of NIOSH-approved N95 or equivalent or higher-level respirators for HCP working in other situations where multiple risk factors for transmission are present. One example might be if the patient is unvaccinated, unable to use source control, and the area is poorly ventilated. · Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. This deficiency substantiates Complaint Number OH 710.

Based on observation, record review and interview the facility failed to ensure personal protective equipment (PPE) was utilized appropriately to prevent the spread of Covid 19. This had the potential to affect all residents residing in the facility. The facility census was 144. Findings include: Interview with Registered Nurse (RN) #204 on 03/17/21 at 4:04 A.M. revealed she was caring for a Covid positive resident and non Covid positive residents. RN #204 stated she wore an N95 mask, face shield, gown and gloves during care and disposed of the PPE prior to leaving the Covid positive resident's room. She further stated after she doffed the PPE she performed hand hygiene. At time of interview RN #204 was wearing a surgical mask and no eye protection. RN #204 was unable to state if eye protection was to be worn while in the facility unless it was with a Covid positive resident. Observation of State tested Nurse Assistant (STNA) #307 on 03/17/21 at 4:27 A.M. revealed the surgical mask she was wearing was pulled down below her chin and she was not wearing eye protection. Interview with STNA #307 at the time of the observation confirmed she was to have her mask pulled up over her nose and eye protection was required. Observation of STNA #308 on 03/17/21 at 4:39 A.M. revealed she was not wearing eye protection. Interview with STNA #308 at the time of the observation confirmed she was required to wear eye protection. Observation of Resident #20's door revealed signs indicating the resident was on isolation precautions and PPE was required prior to entering. Further observation upon entering the resident's room revealed STNA #312 was providing incontinence care for the resident. STNA #312 was not wearing a gown while providing care. Interview with STNA #20, at time of observation, revealed he was aware the resident was on precautions however he was unable to state the reason for the precautions. STNA #312 confirmed he was required to wear a gown during care and had confirmed he did not don a gown prior to entering the resident's room to provide care. Interview with the Infection Preventionist on 03/17/21 at 7:16 A.M. revealed staff were required to wear eye protection while in direct contact with a resident or within six feet of a resident. She stated the facility had two cases of Covid. The residents were discovered as Covid positive during a weekly testing of the residents. She stated the two residents were being quarantined in their room for the required amount of time and remained on precautions. She further stated residents on isolation would require the staff to don proper PPE prior to entering their rooms which included, face masks, eye protection, gown and gloves. Review of Resident #20's medical records revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 03/11/21 revealed the resident was on antibiotic therapy related to pneumonia, and was at risk for Covid due to recent hospitalization . Review of facility policy titled Updated PPE Policy dated 02/15/21 revealed staff was to wear eye protection when within six feet of a resident. This deficiency substantiates Complaint Number OH 532.

Based on observation, record review and interview the facility failed to provide privacy during incontinence care. This affected two residents (Resident #12 and Resident #19) observed for incontinence care. The facility census was 144. Findings include: Observation of incontinence care for Resident #12 on 03/12/21 at 8:45 A.M. with State tested Nurse Assistants (STNAs) #304 and #305 revealed they did not close the door prior to beginning care and the room did not have a privacy curtain. The STNAs proceeded to remove the resident's brief while the door remained more than half way open. The STNAs were cued to close the door as to not expose the resident during incontinence care. The STNAs confirmed the door was not closed and indicated they were aware the door should be closed prior to performing care. As the STNAs continued to provide incontinence care a staff member knocked on the door. The STNAs stated they were performing resident care. The staff member proceeded to open the door and stand in the doorway. The staff informed the STNAs another resident had been incontinent of stool. The staff member left the resident's room leaving the door open. The resident was positioned on his left side and his buttocks was exposed while the door was open. The STNAs returned the resident to a supine position and one STNA closed the door and then the STNAs resumed provision of incontinence care. The STNAs said the staff member should not have entered the room while resident care was being performed and further stated the staff member should have closed the door prior to exiting. Observation on 03/17/21 at 4:15 A.M. revealed STNA #306 providing incontinence care to Resident #19. The privacy curtain was not drawn. Resident #19's buttock was exposed and visible upon entrance to the room. Resident #19 had a roommate who was sleeping in bed at the time of the observation. Interview with STNA #306 at the time of the observation confirmed the resident had a roommate and the privacy curtain should have been drawn prior to care. Resident #19 was not interviewable. Review of Resident #12's medical records revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and required extensive assistance with bed mobility, personal hygiene and dressing and was totally dependant for transfers. Review of care plan dated 02/02/21 revealed Resident #12 was incontinent of bowel and bladder. Review of Resident #19's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident had impaired cognition and required extensive assistance with toileting, personal hygiene and bed mobility and was totally dependant for transfers. Review of care plan dated 03/10/21 revealed Resident #19 was incontinent of bladder. Review of the facility policy titled Routine Resident Care revised 05/29/19 revealed staff was to provide an environment that preserved dignity and promoted respect. This deficiency substantiates Complaint Number OH 532.

The following deficiency represents an incident of past noncompliance that was subsequently corrected prior to this survey. Based on closed medical record review, staff interviews, review of witness statements, review of the Emergency Medical Service (EMS) care record, review of the facility policies related to Cardiopulmonary Resuscitation (CPR) and choking, the facility failed to ensure the correct code status was verified for former Resident #2. This resulted in Immediate Jeopardy that was actual harm when Resident #2 had cessation of vital signs, and CPR was not initiated as ordered. The resident subsequently expired at the facility. This affected one of one resident reviewed for full code and death. The facility identified 54 residents residing in the facility designated with Full Code Status. The facility census was 123. On [DATE] at 8:40 A.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 3:58 A.M. when the incorrect code status of Do Not Resuscitate Comfort Care Arrest (DNR-CCA) was communicated to EMS on arrival to the facility then was later found that Resident #2's code status was Full Code, which was then communicated to EMS. Facility staff failed to initiate CPR, CPR was not completed by EMS, and Resident #2 was beyond resuscitation attempts once EMS arrived. The resident expired at the facility. The Immediate Jeopardy was removed and corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 10:30 A.M., Regional Director of Operations #22 completed a whole house code status audit. · On [DATE] at 10:30 A.M., Licensed Practical Nurse (LPN) #23 implemented a red dot system on any resident with like names on the same unit to assure the appropriate code status was double checked. · On [DATE] at 12:00 P.M., an Ad Hoc Quality Assurance meeting with the interdisciplinary team regarding the code status plan was completed. · On [DATE] at 3:00 P.M., the Director of Nursing and LPN #15 had educated all nurses regarding the Initiate CPR policy and that a nurse was to verify code status. · On [DATE] at 7:00 A.M., all nurses had completed a CPR quiz. · On [DATE] at 7:00 P.M., [DATE] at 7:00 A.M., [DATE] at 6:30 A.M., [DATE] at 7:30 A.M., [DATE] at 12:00 P.M., [DATE] at 7:30 A.M., [DATE] at 7:00 P.M., [DATE] at 2:30 P.M., [DATE] at 6:00 A.M., CPR drills were completed and supervised by the DON and/or LPN #23 to ensure accuracy. · Nurse's completed quarterly CPR attestations training during different months since [DATE]. · On [DATE] at 11:15 A.M., the DON completed a second whole house code status audit. Findings include: Review of the closed medical record for former Resident #2 indicated an admission date of [DATE], discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the code status care plan initiated [DATE] indicated Resident #2 had end of life choices related to code status, living will with an intervention to obtain physician order [REDACTED].#2's decision for full measures. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] indicated Resident #2 was severely cognitively impaired, was usually able to make herself understood about ideas or wants, required total dependence of two-people with transferring, toilet use and personal hygiene and utilized a wheelchair for mobility. Review of the [DATE] physician order [REDACTED].#2, and the resident had a pacemaker present. The verbal order was given on [DATE]. Review of the nurse practitioner progress note dated [DATE], authored by Nurse Practitioner #20, indicated Resident #2's code status was currently full code, discussed with Power of Attorney/daughter multiple times in past that due to multiple comorbidities patient statistically very unlikely to survive CPR/intubation and recommended change code status to DNR. Patient/daughter wanted no change in code status - wished to remain full code. Review of the nurse's note dated [DATE] at 3:42 A.M. authored by LPN #12 indicated this nurse was alerted by State tested Nurse Aide (STNA) that help was needed in Resident #2's room. Upon entering the room, the residents' lips were noted to be blue, and the resident was nonresponsive. The resident had a faint radial pulse, and oxygen was increased to five liters via nasal cannula. The resident was pulled higher into the bed and was sat to more of an upright position. Back blows were started by this nurse. LPN #12 told another nurse to get the crash cart and the suction machine. The resident was suctioned with clear particle free fluids coming out. The [MEDICATION NAME] maneuver was started by another nurse with only clear liquids coming from Resident #2's mouth. A faint pulse was felt to right carotid artery via auscultation. A non-rebreather mask was applied. When 911 arrived, the nurse left the room to allow them to take over care. Review of the nurse's notes dated [DATE] at 3:45 A.M. authored by Registered Nurse (RN) #8, indicated at 3:45 A.M., she was alerted by the STNA that the resident was unresponsive. Upon entering the room, two nurses and two STNAs were assisting the resident. The floor nurse stated medications were administered approximately ten minutes prior. When entering the room, she noted the resident was unresponsive. EMS was called. The resident had a palpable carotid pulse. Back blows were administered by the other nurse but were ineffective. Suction was attempted with small amounts of fluid with no change in the resident's condition. The [MEDICATION NAME] maneuver was administered three times with small amounts of clear fluid coming from the resident's mouth. A carotid pulse was no longer palpable by RN #8, but the other nurse stated she was able to auscultate a pulse with the stethoscope. A non-rebreather mask was applied with oxygen on highest setting. EMS arrived and took over. Review of the nurse's note dated [DATE] at 4:00 A.M., authored by RN #8, indicated EMS applied an automated external defibrillator (AED, a portable electronic device that automatically detects life-threatening cardiac arrhythmias). EMS stated the resident was in V tach ([MEDICAL CONDITION]), and V tach was not a sustainable rhythm. EMS stated they would not initiate CPR due to no heart rate or respirations. Review of the nurse's note dated [DATE] at 4:45 A.M., authored by LPN #9, indicated this nurse entered Resident #2's room at approximately 3:30 A.M. and obtained a respiratory assessment and vital signs. After assessment, she left the room and returned with appropriate medications and eight ounces of water. Resident #2 took the medications in pudding and took two sips of water and began to cough. At this time, LPN #9 elevated the head of bed even more and asked if the resident was okay and she responded yes and coughing subsided. LPN #9 then offered the resident more water, and she accepted approximately four ounces and began to cough again. LPN #9 asked the resident again if she was okay, and she stated, yes. The resident's coughing subsided again, and LPN #9 left the room. Approximately ten minutes later, LPN #9 was alerted by the assigned STNA that she was needed in (Resident #2's room number). Upon entering, the resident was noted to be unresponsive with a pulse present. LPN #12 was performing back blows, and the crash cart was obtained. The resident was suctioned, and a small amount of clear fluid was obtained. LPN #9 was informed that a pulse was present by LPN #12. LPN #9 then left the room and called 911. When she returned to the room, RN #8 gave abdominal thrusts while LPN #9 assisted with positioning. Resident #2 was suctioned again, and clear fluid was obtained. A non-rebreather mask was applied with oxygen. Paramedics arrived and LPN #9 was informed they would not be taking the resident to the emergency department, and the resident had expired. Telephone calls were made for notification to the daughter and the physician. Review of the nurse's note dated [DATE] at 8:00 A.M., authored by LPN #15, indicated she spoke with the coroner, and the coroner recommended to release the resident's body to the funeral home. Review of the witness statement dated [DATE], signed by STNA #13 indicated .LPN #9 was on the way to get the crash cart and asked me to check (Resident #2's name) code status. I saw the chart that indicated (the resident's last name), looked up the code status and told LPN #9 that it said DNRCC-A. It wasn't until later when the nurses went to pull the chart for the squad that I realized I had looked at (Resident #5's name) not (Resident #2's name). Review of the witness statement dated [DATE], signed by LPN #9 stated while walking towards the (crash) cart, I saw STNA #13 at the nurses station, and I asked her to look at (Resident #2's name) code status. She got the chart and stated, she is a DNRCC-A. When I returned to (Resident #2's room number), I informed LPN #12 and RN #8 of the code status. At that time, we removed the red locking tag off of the crash cart and retrieved supplies. LPN #12 began suctioning while I assisted with positioning the resident. After a short time, other staff took over this task while I left the room to call 911 regarding the changes to the resident's condition. I printed off a face sheet and medication list for the transfer to the hospital. I then returned to the room and saw that abdominal thrusts were being performed by RN #8. I again assisted with holding the resident up. I could feel what felt like fluid coming up from her abdomen. The resident was again suctioned with a small amount of clear fluids coming out. LPN #12 was auscultating the carotid and stated a faint pulse was heard. A non-rebreather mask was applied; the squad arrived, and I left to gather the paperwork for transfer from the printer. RN #8 asked for a copy of the DNR form and at that time I noted the chart that had been pulled by the STNA was for a different resident and Resident #2 was in fact a full code. I notified the paramedics at that time. I placed a call to the resident's daughter and told her 911 had been called and originally stated that her mom would be going to the hospital but during the conversation, RN #8 informed me that the squad would not be transferring and that she had expired. Review of the witness statement dated [DATE], signed by RN #8 indicated .at 4:00 A.M., unable to palpate pulse. LPN #12 able to auscultate pulse with stethoscope and EMS enters room. LPN #12 and I removed ourselves from the bedside to allow EMS to assist patient. Review of the undated witness statement, signed by LPN #12 revealed I was in the supply room walking out with STNA #13 was asking STNA #21 if she could help with Resident #2 because she thought she was choking. I followed STNA's #13 and #21 to the room where I noticed the patient's lips were blue, and the patient was nonresponsive. Pulse checked and it was faint. A sternal rub was started, and oxygen increased to five liters via nasal cannula. STNA #13 stated she had just received her morning medications and was given a drink of water by LPN #9 and started choking stating, she's going to need a speech evaluation. STNA #13 went to get another nurse while STNA #21 and I pulled patient higher in bed and in more upright position and started back blows. I told LPN #9 to get crash cart and suction machine. I started suction machine and suctioned patient several times with clear liquids coming out with no particles with fluids. RN #8 started [MEDICATION NAME] maneuver while STNA #21 and I help patient to sitting position. Nonrebreather applied and faint pulse heard via auscultation on right carotid. When 911 (arrived), left room. Review of the EMS Care record for Resident #2 dated [DATE] timed 3:58 A.M. indicated (EMS) dispatched for an unresponsive patient. On arrival, patient was found sitting upright, not breathing with no pulse. Patient head was being held by staff on scene. Staff on scene had no resuscitation efforts, stating patient was a DNRCC-A. Staff stated to EMS she was not breathing and had no pulse. EMS found the same on assessment with mottled skin and fixed and dilated pupils. Pacemaker was creating electrical impulses. EMS asked and confirmed multiple times with nursing home staff that patient was a DNR and staff stated yes. Down time on the patient is greater than 20 minutes as the supervising nurse proceeded to run down the hallway and stated she was a full code. Nurse was visibly frustrated stating that the patient's nurse had a wrong chart up. EMS and supervising nurse concluded and did not attempt resuscitations efforts due to length of time with no treatment and comorbid factors. Patient was left at the nursing home and transfer of care back to the facility. The initial EMS assessment found the skin was cold, mottled and pale with a body temperature of 94 degrees Fahrenheit, and the eyes were dilated and non-reactive. There were two paramedics (Paramedic #18 and Paramedic #19) involved in emergency medical service of Resident #2. Review of the procedure in the event of death form dated [DATE], authored by LPN #16, indicated Resident #2 expired on [DATE] at 4:00 A.M. and Physician #17 was going to sign the death certificate with the [DIAGNOSES REDACTED]. Interview on [DATE] at 11:15 A.M. with the Director of Nursing revealed LPN #9 resigned immediately after Resident #2's death because the nurse was so shaken up. Interview on [DATE] at 2:20 P.M. with LPN #12 revealed one of the STNAs had notified her as she was passing through the unit that one of the resident's was choking. LPN #12 entered Resident #2's room, and the resident was low in bed, lips slightly blue, not responding like her normal self. The STNA pulled her up in bed to a sitting position, moved her forward to start patting her back. RN #8 got the crash cart and suction machine and started suctioning and doing the [MEDICATION NAME] maneuver. Resident #2 had a very faint pulse. LPN #12 stepped out once 911 arrived. LPN #12 stated she couldn't remember details about the code status; however, she did remember someone else looked at the chart. Interview on [DATE] at 8:45 A.M. with RN #8 revealed a code was called and she responded. Resident #2 had choked, and LPN #12 was suctioning the resident. RN #8 ran for supplies and LPN #9 called 911. RN #8 helped to do the [MEDICATION NAME] maneuver and small bits of water came out of the resident's mouth. The resident did have a mask on for oxygen, but she did not remember if the resident had a pulse oxygen reading. The mask was applied to the resident as the squad arrived. Resident #2 did have a pulse when the squad arrived, and the nurses removed themselves from the room. The squad was asking for the DNR form, and someone ran down and got the form from the front of the chart. There was a big X on the DNR form indicating to do CPR. RN #8 stated Resident #2 was a full code. Interview on [DATE] at 1:40 P.M. with STNA #13 revealed LPN #9 went into Resident #2's room, administered medication and left the room. STNA #13 entered the room to complete her final rounds on the resident to find Resident #2 having trouble swallowing. Resident #2 stated, I'm choking however the resident could still speak so STNA #13 knew she wasn't choking; it sounded like the resident had water in her throat. STNA #13 left the room, went to find a nurse, and found LPN #12 and STNA #21. LPN #9 found STNA #13 and asked her to go grab Resident #2's chart (which happened to be the wrong chart), and the chart stated DNR. STNA #13 slid the opened chart to LPN #9 to look at the resident's code status; however, LPN #9 didn't look at the chart. EMS was still at the facility when RN #8 quickly realized that Resident #2 was a full code. Interview on [DATE] at 2:10 P.M. with the Director of Nursing, with Regional Director of Operations #22 present, verified that EMS had originally been told Resident #2 was a DNRCC-A and then EMS was notified Resident #2 was in fact a full code. Review of the facility Initiate CPR policy, revised on [DATE], indicated the facility will maintain and train staff on a communication method that will quickly alert staff as to the code status of a resident in the event heart or respirations cease. Residents found unresponsive, not breathing or without a pulse, will have staff immediately locate the Code Status and communicate this to the team. If CPR is indicated, staff will begin CPR and call 911 with these exceptions: there is a valid DNR order in place, there is obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition) are present, initiating CPR could cause injury or peril to the rescuer. Review of the facility foreign body airway obstruction or choking policy, implemented on [DATE] indicated it is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of this facility to honor the wishes and rights of the resident/representative to make the determination of what, if any, resuscitative measures will be implemented in the event the resident's respirations and/or pulse cease either by natural or unnatural causes. In the event the resident's airways cannot be cleared or the resident will eventually lose consciousness and should be eased to the floor. Begin CPR per AHA (American Heath Association) guidelines expect when a valid DNR status is in place and it is determined that respirations and pulse have ceased and CPR would be the next logical step for resuscitative measures if the DNR code status were not in place. DNR documentation will be readily available for EMS upon arrival. This deficiency substantiates Complaint Number OH 654.

Based on observation, record review and interview the facility failed to ensure the appropriate amount and appropriate serving size equipment was used to serve food. This had the potential to affect all 134 of 134 residents who received meal trays from the kitchen. The facility identified five residents (Resident #1, Resident #149, Resident #139, Resident #390, and Resident #393 who received nothing by mouth). The facility census was 139. Findings include: Observation on 10/04/17 at 9:59 A.M. revealed Cook #2 was preparing pureed meatballs. Cook #2 placed seven servings of three, one-ounce meatballs into the blender. Interview, during the observation, with Cook #2 verified the serving was three, one-ounce meatballs and there were seven residents who were ordered a pureed diet. Review of the meatball recipe revealed the serving was four, one-ounce meatballs and for puree preparation. The recipe revealed to measure out the desired number of servings into the food processor and blend until smooth. Interview on 10/04/17 at 11:30 A.M. with Regional Dietary Manager (RDM) #4 and District Dietary Manager (DDM) #5 verified Cook #2 should have placed four meatballs per serving in to the blender instead of only three meatballs. Additionally, review of the meatball recipe revealed the serving size was four, one-ounce meatballs. Review of the Wednesday lunch menu spreadsheet revealed a four-ounce scoop was to be used to serve the ground meatballs and a #10 scoop was to be used to serve the pureed Capri vegetable blend. Observation on 10/04/17 at 11:32 A.M. revealed Cook #6 was serving three meatballs per plate for the residents who were ordered a regular diet until the surveyor intervened. Interview, during the observation, with Cook #6 verified she was giving three meatballs on the plate instead of four meatballs (which the serving size called for). Observation on 10/04/17 at 11:45 A.M. revealed Cook #2 was using a #16 (two ounce) scoop to serve ground meatballs. Interview, during the observation, with Cook #2 revealed DDM #5 directed her to use the #16 ounce scoop to the serve the ground meatballs. Another interview, during the observation, with Dietary Manager #1 verified a #8 (four ounce) scoop was supposed to be used to serve the ground meatballs instead of a #16 scoop. Observation on 10/04/17 at 11:58 A.M. revealed Cook #2 was using a #12 scoop (2.67 ounces) to serve pureed Capri vegetable blend. Interview, during the observation, with Cook #2 verified the findings. Another interview, during the observation, with Registered Dietitian #3 verified a #10 scoop (3.20 ounces) was supposed to be used to serving the pureed Capri vegetable blend instead of a #12 scoop. Review the 10/05/17 resident diet order list revealed Resident #1, Resident #149, Resident #139, Resident #390, and Resident #393 received nothing by mouth (NPO) and did not receive meals from the kitchen.

Based on observation and interview the facility failed to ensure dietary staff washed their hands, changed gloves and served food under sanitary conditions to prevent contamination and food borne illness. This had the potential to affect 134 of 134 residents who received meal trays from the kitchen. The facility identified five residents (Resident #1, Resident #149, Resident #139, Resident #390, and Resident #393) who received nothing by mouth. The facility census was 139. Findings include: 1. A tour of the kitchen was conducted on 10/02/17 at 8:48 A.M. with Certified Dietary Manager #8 and at 11:15 A.M. with Registered Dietitian/Licensed Dietitian (RD/LD) #3 and Regional Dietitian (RD) #4. During the tour a large wall mounted fan was observed with a large amount of dust on it. The dusty fan was turned on and blowing on the clean area where the dishwasher clean dishes were located. Regional RD #4 reach up and pulled the plug on the fan. Regional RD #4 stated the facility had new staff and the current certified dietary manager just returned from leave. 2. An observation of the lunch meal was conducted on 10/02/17 at 11:30 A.M. with Registered Dietician/Licensed Dietitian (RD/LD) #3 and Regional Dietician (RD) #4. Dietary Aide (DA) #9 was observed standing at the tray line with gloves on. DA #9 crossed his arms across his chest, placing his gloved hands under his armpits. When the food was plated and it was his turn to finish the tray of food, he removed his gloved hands from under his armpits and placed milk and the plated food on the tray without changing his gloves and washing his hands. The observation was verified via interview with RD/LD #3 and Regional RD #4 on 10/02/17 at 11:33 A.M. The facility identified Resident's #1, Resident #139, Resident #149, Resident #390, Resident #393 who received nothing by mouth and did not receive meals from the kitchen. 3. On 10/02/17 at 11:38 A.M., DA #9 was observed wearing black pants which were below DA #9's waist line. Exposing four inches of his black underwear. At 11:40 A.M., DA #9 was observed by the surveyor, RD/LD #3 and Regional RD #4 to lean back and rest his buttocks on the opening door of the ice machine. DA #9's top portion of his underwear and his regular pants were observed resting on the lower portion of the ice machine door where dietary staff had to open the door to obtain ice for the meal service. Interview with Regional RD #4 on 10/02/17 at 11:43 A.M. verified DA #9 was not to lean his buttocks up against the door of the ice machine.

Based on observation, record review and interview the facility failed to ensure fall safety interventions were in place as care planned for Resident #47 to prevent falls. This affected one resident (Resident #47) of four residents reviewed for accidents. Findings include: Record review revealed Resident #47 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #47's annual Minimum Data Set (MDS) 3.0 assessment, dated 09/22/17 revealed the resident had short and long term memory problems, her cognition was moderately impaired for decision making, and she required extensive one person assistance for bed mobility, transfers, and toileting. Review of Resident #47's comprehensive care plan initiated on 01/24/16 revealed the resident was at risk of falls. Interventions included the use of reminder signs which should be placed in the resident's room to encourage use of the call light and staff assistance. On 04/16/17 an intervention was added for a reacher to be given to resident to use for items on floors after Resident #47 fell on [DATE] reaching forward from her wheelchair to get a pair of shoes that were underneath a chair. Observation on 10/03/17 at 12:36 P.M. revealed Resident #47 was lying in bed in her room. Observation revealed the resident did not have a reacher or signs to call for assistance in her room. Interview on 10/03/17 at 2:33 P.M. with Licensed Practical Nurse (LPN) #10 verified Resident #47 should have a reacher and signs to call for assistance in her room to help prevent the resident from falling. LPN #10 and the surveyor entered Resident #47's room at this time and LPN #10 confirmed the reacher and sign to call for assistance were not in the room.

Based on record review and interview the facility failed to ensure Resident #55 was treated with respect and dignity during personal care and staff interaction. This affected one resident (Resident #55) of two residents reviewed for dignity and respect. Findings include: Record review revealed Resident #55 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident #55's admission Minimum Data Set (MDS) 3.0 assessment, dated 04/28/17 revealed the resident's cognition was intact. The resident was assessed to be always continent of bowel and bladder, and required two staff extensive assistance for bed mobility and toileting. Review of an investigation of an allegation of verbal abuse from a Self Reported Incident submitted by the facility on 05/24/17, revealed on 05/24/17 at 7:00 P.M. Resident #55 made a statement that State tested Nursing Assistant (STNA) #11 made a derogatory statement to him. The Director of Nursing (DON) witness statement revealed on 05/24/17 she spoke to Resident #55 about his concerns with STNA #11. Resident #55 explained he was on a bed pan and while waiting for STNA #11 to come back to take him off the bed pan he came more and more frustrated and began to curse and yell at the STNA when STNA #11 returned. Resident #55 stated when STNA #11 was walking out of the room, she stated, you (explicit), I am not your wife. Review of STNA #11's witness statement taken 05/25/17, revealed as she was leaving Resident #55's room she did say under her breath, I am not your wife and thought she did say a curse word, but did not remember for sure. STNA #11 did not think Resident #55 heard what she said. Interview on 10/04/17 at 8:47 A.M. with DON revealed STNA #11 admitted she cursed while walking out of the resident's room, but was unsure what word or in what context the word was used. DON revealed STNA #11's statement while walking out of Resident #55's room on 05/24/17 was not intended to harm or be to be verbally abusive but was inappropriate and was a customer service issue.

Based on observation, record review and interview the facility failed to ensure Resident #391 was provided adequate and timely personal care following an episode of incontinence and failed to ensure the resident had access to her call light to obtain timely staff assistance. This affected one resident (Resident #391) of three residents reviewed for incontinence care. The facility identified 94 residents who required incontinence care. The census was 139. Finding include: Review of Resident #391's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 10/06/17 revealed the resident had intact cognition. The resident required extensive assistance of two staff for transferring and toileting. The resident was identified to be occasionally incontinent of bowel and bladder. Review of the plan of care, dated 10/01/17 revealed the resident was incontinent of bladder and at risk for falls due to weakness. Interventions included to change clothing as needed after incontinence episodes, ensure call light was within reach and encourage to use call light for assistance. Observation revealed upon entering Resident #391's room on 10/03/17 at 8:27 A.M. a strong urine odor was noted. Resident #391 was observed sitting at a table the in room with a wet urine soaked gown. Interview on 10/03/17 at 8:30 A.M. with Resident #391 revealed the nurse assisted her with changing her urine soaked incontinence pull up this morning but did not change her wet gown after providing care. Resident #391 revealed she was cold due to her gown being wet and she could not reach her call light that was hanging on her bed. Interview on 10/03/17 at 8:35 A.M. with State tested nursing assistant (STNA) #800 revealed Licensed practical nurse (LPN) #801 told her a half hour ago, she changed Resident #391's pull up and that Resident #391 needed a clean dry gown because the one she had on was wet. STNA #800 verified Resident #391's gown was urine soaked and the call light was still attached to the bed rail. STNA #800 verified Resident #391 call light was not within reach. Interview on 10/03/17 at 8:39 A.M. with LPN #801 revealed she had gone into Resident #391's room and assisted Resident #391 with changing her urine soaked pull up. LPN #801 stated she forgot to place the call light within reach for Resident #391. Interview on 10/03/17 at 3:10 P.M. with the Director of Nursing (DON) revealed all nursing staff should change all soiled clothing when providing resident incontinence care. Review of facility policy, Resident Rights dated 08/11/17 revealed call light or bell access will be within reach of the resident.

Based on record review and interview the facility failed to offer the appropriate pneumoccocal vaccinations for Resident #74 and Resident #47. This affected two residents (Resident #74 and #47) of five residents reviewed for immunizations. Findings include: 1. Record review revealed Resident #74 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#74's date of birth was 04/15/44. Resident #74's facility immunization record revealed the resident received a pneumococcal vaccination on 10/20/08. It was unclear if the vaccination was the [MEDICATION NAME] 23 or Prevnar 13. Interview on 10/05/17 at 12:28 P.M. with the Director of Nursing (DON) revealed Resident #74 most likely received the [MEDICATION NAME] 23. The DON revealed the facility had not offered Resident #74 the Prevnar 13 vaccination. Review of the facility undated Resident Pneumococcal Vaccine policy revealed adults age 65 or over who had not received Prevnar 13 but had received a dose of [MEDICATION NAME] 23 at age [AGE] years or older should be offered the Prevnar 13 at least one year after the dose of [MEDICATION NAME] received at age [AGE] years or older. 2. Record review revealed Resident #47 was admitted initially to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Record review revealed Resident #47's date of birth was 04/21/47. Resident #47's facility immunization record revealed the resident declined the pneumococcal immunization because she had it October 2015. It was unclear if the vaccination was the [MEDICATION NAME] 23 or Prevnar 13. Interview on 10/05/17 at 12:28 P.M. with the Director of Nursing (DON) revealed Resident #47 most likely received the [MEDICATION NAME] 23. The DON revealed the facility had not offered Resident #47 the Prevnar 13 vaccination. Review of the facility undated Resident Pneumococcal Vaccine policy revealed adults age 65 or over who had not received Prevnar 13 but had received a dose of [MEDICATION NAME] 23 at age [AGE] years or older should be offered the Prevnar 13 at least one year after the dose of [MEDICATION NAME] received at age [AGE] years or older.

Based on observation, record review and interview the facility failed to ensure all medication was stored properly. This affected two residents (Resident #367 and Resident #387) of 44 residents who received medication from the 700 and 800 unit medication carts. The facility census was 139. Findings include: 1. Review of Resident #367's physician's orders [REDACTED]. An observation of the 800 south medication cart on 10/0/417 at 9:40 A.M. with Unit Manager Registered Nurse (RN) #7 revealed Resident #367's Atorastatin 10 milligrams was setting unsecured, out of the blister pack and on the in the surface of the medication storage bin. An unidentified Zofran 4 milligram tablet was also found setting on the bottom of the medication storage area out of the blister pack. The observation was verified with RN #7 on 10//04/17 at 9:43 A.M. An interview with conducted with Unit Manager, RN #7 on 10/04/17 at 10:00 A.M. RN #7 verified the medication was found out of the blister packs setting on the bottom surface of the middle bin of the medication cart. RN #7 was unable to identify when the medication was dropped/not administered out of the blister packs of for Resident #367. RN #7 verified nurse who passed medication was to ensure all medication was completed removed from the blister packs before placing the blister packs back into the medication cart. 2. Review of Resident #387 physician's orders [REDACTED]. An observation of the 700 medication cart was conducted on 10/04/17 at 9:58 A.M. with Unit Manager Register Nurse (RN) #7. RN #7 identified and verified Resident #387's Hydralazine 100 mg was setting unsecured, out of the blister pack on the in the bottom surface of the medication cart storage bin. An interview with conducted with Unit Manager, RN #7 on 10/04/17 at 10:00 A.M. RN #7 verified the medication was found out of the blister packs setting on the bottom surface of the middle bin of the medication cart. RN #7 was unable to identify when the medication was dropped/not administered out of the blister packs of for Resident #387. RN #7 verified nurse who passed medication was to ensure all medication was completed removed from the blister packs before placing the blister packs back into the medication cart.

Based on record review and interview, the facility failed to prevent and promptly identify the development of three pressure ulcers for Resident #165. Actual harm occurred when Resident #165 developed two unstageable pressure ulcers to her left and right buttocks and one Stage Two pressure ulcer to her coccyx on 11/28/13. This affected one of three residents reviewed for pressure ulcers of six residents identified with pressure ulcers. The facility's census was 141. Findings include: Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3.0 Minimum Data Set (MDS) admission assessment indicated Resident #165 was severely impaired for cognition. The MDS assessment revealed Resident #165 required extensive assistance for care including bed mobility. Resident #165 had an indwelling urinary catheter and was frequently incontinent of bowel. The MDS assessment indicated Resident #165 was admitted to the facility with intact skin. The MDS assessment identified Resident #165 at risk for the development of pressure ulcers. The skin integrity plan of care was initiated on 11/01/13. The plan of care included no intervention to turn and reposition Resident #165 while in bed. Resident #165 was discharged from the facility on 12/03/13. Therefore, no observations of Resident #165's wounds were made. Review of the facility Pressure Ulcer Skin Grid dated 11/29/13 revealed an unstageable left inner buttock pressure ulcer (measuring 1.0 centimeter (cm) by 1.0 cm by 0.1 cm.), was discovered on 11/28/13 for Resident #165. The wound bed was described as red slough. Slough is necrotic/vascular tissue in the process of separating from the viable portions of the body. The wound was described as unstageable since the wound bed was not completely visible, and therefore the depth of the entire wound bed could not be measured. Review of the facility Pressure Ulcer Skin Grid dated 11/29/13 revealed an unstageable right inner buttock pressure ulcer (measuring 2.0 cm by 0.6 cm by 0.1 cm) was discovered on 11/28/13 for resident #165. The wound bed was described as red slough. Review of the facility Pressure Ulcer Skin Grid dated 11/29/13 revealed a Stage Two coccyx pressure ulcer (measuring 0.3 cm by 0.5 cm by 0.1 cm deep) discovered on 11/28/13. A stage two pressure ulcer presents as a partial thickness skin loss involving the epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. The wound was described with a red wound bed and thin drainage. An interview was conducted on 12/19/13 at 10:47 A.M. with the Director of Nursing (DON) and the Wound Nurse/Registered Nurse (RN) #12. The DON verified that the skin care plan initiated for Resident #165 included no intervention to turn and reposition the resident. However, the DON reported that an intervention to turn and reposition the resident was included on the "Resident's Summary," which was used by the State tested Nurses Aides. The DON verified that Resident #165 required extensive assistance for bed mobility and all care. The DON verified Resident #165 was provided incontinence care by the staff. The DON acknowledged that two unstageable pressure ulcers to Resident #165's left and right buttocks were not identified until they had advanced to unstageable. The DON verified a stage two pressure ulcer to Resident #165's coccyx was also identified on that same date.