Every finding on record at Phoenix of Fairlawn

Based on observation, staff interview, and policy review, the facility failed to ensure smoking safety was followed on facility grounds per facility policy. This had the potential to affect all 55 residents of the facility. The census was 55. Findings Include: Observation on 04/28/25 at 9:57 A.M. of the facility parking lot with Maintenance Director (MD) #511 revealed cigarette butts disposed of in mulch beds. The mulch bed nearest the facility dumpsters contained 17 cigarette butts. The mulch bed nearest the wooden [NAME]-cochere (a covered porch where vehicles can pick up and drop off people) at the main entrance contained 10 cigarette butts. The trash can under the [NAME]-cochere was observed to have ash marks on the sides of it from cigarettes being extinguished and the inside of the trash can was observed to contain flammable materials. The mulch bed nearest the 300 Hall entrance contained three cigarette butts. Interview on 04/28/25 at 10:08 A.M. with MD #511 confirmed the presence of cigarette butts disposed of in the facility mulch beds and ash marks on the sides of the trash can. Review of the facility smoking policy dated 02/26/25 revealed smoking was only allowed in designated smoking areas. Review of the smoking area information provided by the facility confirmed the designated smoking location was the 100/200 Hall dining room patio.

Based on observation, resident and staff interview, and review of a bid quote for work from a local construction company, the facility failed to provide a safe and homelike environment. This affected 18 (#4, #6, #8, #10, #15, #17, #18, #19, #22, #23, #25, #36, #37, #38, #39, #42, #46, and #50) of 55 residents reviewed for environment. The facility census was 55. Findings Include: 1. Interview with Resident #19 in the facility's outdoor smoking area on 04/22/25 at 9:50 A.M. revealed the resident did not feel safe in the smoking area and felt it was only a matter of time before the wooden [NAME] structure surrounding the smoking area was going collapse around the residents. Observation of the smoking area on 04/22/25 at 10:00 A.M. revealed the area was covered by a wooden [NAME]. The wood on the structure beams were noted to be visibly rotting to various degrees all throughout the area. The center beam of the [NAME] had an over five and one-half feet long hole in the wood that had been made by a large termite infestation and subsequent damage. A plastic roof was visualized to cover half the [NAME] with an active substance growth on it. A number of vertical support beams throughout the [NAME] had pieces of wood that were actively separating from the support beam. Interview with Maintenance Director (MD) #511 on 04/22/25 at 10:15 A.M. verified the condition of the wooden [NAME] in the smoking area and the damage to the main center beam had been caused by a termite infestation. MD #511 also noted the facility received a bid on replacing the [NAME] structure a while ago and the facility chose to purchase replacement air conditioners instead. Review of the bid quote from a local construction company revealed the facility received a bid for replacement of [NAME] structure on 04/20/23 with multiple options of replacement of the structure. No further action was noted to have been taken on the quote received on 04/20/23 and no other quotes from other companies regarding replacement of the structure were received. The facility identified Resident #4, Resident #8, Resident #15, Resident #17, Resident #19, Resident #23, Resident #25, Resident #36, Resident #37, Resident #39, Resident #46, and Resident #50 as active smokers residing in the facility. 2. Observation on 04/28/25 beginning at at 9:29 A.M. of hot water temperatures from the bathroom faucets in resident rooms and room conditions with MD #511 revealed the water temperature exceeded 120 degrees Fahrenheit ( F) in resident rooms and there were also other environmental issues noted. Observation of Resident #22 and Resident #8's hot water revealed it was 123 F and there were gouges on the bathroom wall and near the window. Resident #10's hot water was 124 F and had gouges on the wall and paint separating from the ceiling in the bathroom. Resident #38's room had large gouges on the walls of the room. Resident #42 and Resident #6's hot water was 124 F and had gouges in the wall by the door. Resident #18's hot water was 124 F. Interview with MD #511 on 04/28/25 between 9:29 A.M. and 9:55 A.M. verified each temperature reading and environmental concern at the time of discovery. This deficiency represents non-compliance investigated under Complaint Number OH00163638.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents were transported in the facility in a dignified and respectful manner. This affected one (#37) of one residents reviewed for respect and dignity. The facility census was 55. Findings Include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses that included cocaine abuse, sepsis, and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was severely cognitively impaired and required assistance of one staff person for completing his activities of daily living including bathing. Observation of Resident #37 on 04/21/25 at 11:44 A.M. revealed Resident #37 was sitting on a shower chair being pulled by Certified Nurse Aide (CNA) #608 to his room. Resident #37 was observed to be wearing no clothing except for a thin hospital gown with a package of deodorant and an adult incontinence brief sitting in his lap. The gown was not tied around the resident's waist and his buttocks was exposed to the air. Interview with Registered Nurse (RN) #579 verified Resident #37's gown was not tied and his buttocks was easily visible to anyone walking down the hall and an adult incontinence brief and package of deodorant was sitting in his lap while being transported down the hall in his shower chair. Review of the undated policy titled, Residents Rights and Facility Responsibilities, revealed it is the facility's policy to abide by all residents, and to communicate these rights and to residents and their designated representatives in a language that they can understand. This deficiency represents non-compliance investigated under Complaint Number OH00163638 and Complaint Number OH00159640.

Based on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interviews, the facility failed to provide the resident or resident representatives with the name and telephone number of the appeal agency. This affected two (#5 and #8) of three residents reviewed for beneficiary notices. The facility census was 55. Findings include: 1. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Review of a NOMNC letter revealed skilled services ended on 04/14/25. The letter did not contain the name or the telephone number of the Quality Improvement Organization (QIO) for appeal purposes. 2. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Review of a NOMNC letter revealed skilled services ended on 03/15/25. The letter did not contain the name or the telephone number of the QIO for appeal purposes. Interview on 04/28/25 at 11:20 A.M. with Chief Clinical Officer (CCO) #509, during review of Resident #5 and Resident #8's NOMNC letters, confirmed the QIO information was not present. CCO #509 reported the Business Office Manager talked with the residents and or family and completed the forms. Interview on 04/28/25 at 1:17 P.M. with Business Office Manager (BOM) #513 revealed she received the corrected form from the Administrator.

Based on observation, review of the medical record, and staff interview, the facility failed to ensure a resident was properly assessed for use of a restraint. This affected one (#18) of three residents reviewed for restraints. The census was 55. Findings included: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included sepsis, Alzheimer's disease, dementia, diabetes, hypertension, and depression. Review of the plan of care dated 11/29/24 revealed Resident #18 had the potential for pressure ulcer development related to a skin tear to the right fifth digit. Interventions included garden gloves at all times except while sleeping with instructions to remove at night for washing and to check skin integrity dated 04/17/25. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #18 had severely impaired cognition. Review of the progress note dated 04/09/25 at 12:35 P.M. revealed the nurse discussed options with the legal representative to prevent further skin breakdown from Resident #18 from chewing on her fingers. The physician ordered the antianxiety medication Ativan 0.5 milligrams (mg) as needed every eight hours to prevent anxious chewing. Review of the April 2025 physician's orders revealed Resident #18 had an order to remove gloves, check skin integrity, wash hands with soap, wash the gloves, and hang them to dry dated 04/17/25. Further review of the physician' orders revealed Resident #18 did not have an order for the gloves to be wore to prevent her from chewing on her fingers. Further review of the medical record revealed no restraint assessment was completed for the use of gardening gloves with hook and loop fasteners (Velcro) to the hands of Resident #18 to prevent her from chewing on her fingers. Observation on 04/22/25 at 8:12 A.M. revealed Resident #18 had long gardening gloves with Velcro around the wrist area on both her hands. Her fingers were not in the finger holes of the gloves an her hands were balled up in fists inside the gloves preventing her from movement. On 04/24/25 at 11:17 A.M. an interview with the Director of Nursing (DON) revealed the gloves to the hands of Resident #18 were due to the resident having her own teeth and would chew on her fingers. The DON verified at that time Velcro was around the resident's wrists preventing the resident from removing them herself. On 04/28/25 at 8:50 A.M. a second interview with the DON revealed the facility attempted skin preparation to harden the skin around Resident #18's nails but she would still bite at them. The DON stated they could not use bandages because the resident would chew on them. The DON verified the physician was aware; however, there was not an order or restraint assessment completed for use of the gloves to prevent biting. Review of the facility policy titled, Use of Restraints, dated 11/13/23, revealed restraints would only be used for safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. Restraints would only be used to treat a resident's medical symptom and never for discipline or staff convenience,or to prevent falls. Prior to placing a restraint there would be a Restorative Enabler Assessment and review to determine the need for restraints.

Based on record review and staff interview, the facility failed to ensure resident Preadmission Screening and Resident Review (PASARR) assessments were updated and accurate. This affected one (#52) of two residents reviewed for PASARR assessments. The facility census was 55. Findings Include: Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses that include dementia, schizophrenia, high cholesterol, and retention of urine. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 was severely cognitive impaired and required extensive assistance of one staff person for completing his activities of daily living. Review of the PASARR assessment dated [DATE] revealed the facility did not indicate the resident had a diagnosis of schizophrenia for the the question on the PASARR assessment, Does the individual have a diagnosis(es) of any of the mental disorders listed below?, with a listing of significant mental health diagnoses including schizophrenia to chose from. Interview with the Director of Nursing (DON) on 04/23/25 at 1:30 P.M. verified Resident #52's PASARR did not address his documented diagnoses of schizophrenia.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as per the plan of care and failed to ensure physician orders were in place for utilization of fall interventions. This affected two (#24 and #25) of four residents reviewed for falls. The facility census was 55. Findings include: 1. Review of Resident #24's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included schizophrenia, hypertension, breast cancer, dementia, gastrointestinal hemorrhage, heart failure, chronic obstructive pulmonary disease (COPD), anxiety, major depressive disorder, and macular degeneration. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had limited cognition and displayed inattention and disorganized thinking. The resident was not known to display any behaviors nor was she known to reject care. She required limited assistance of one staff for transfers, and ambulated around her room and the facility in a manual wheelchair. The resident had one fall since her prior MDS assessment. Review of Resident #24's care plan, last revised 02/29/25, revealed she was at risk for falls. Her fall prevention interventions included non-slip pad on her wheelchair, proper footwear when out of bed, a perimeter mattress on her bed, and for Resident #24 to participate in the restorative therapy program as needed. Review of Resident #24's physician orders revealed orders for the perimeter mattress and the non-slip pad to her wheelchair. Further review of the physician orders revealed no order regarding Resident #24 wearing proper footwear when out of bed nor an order for restorative therapy as needed. Interview on 04/22/25 at 3:18 P.M. with MDS Nurse #548 reported Resident #24 was attending restorative or functional maintenance and confirmed the fall interventions in the resident's care plan were accurate. Interview on 04/23/25 at 4:02 P.M. with Licensed Practical Nurse (LPN) #523 confirmed the physician orders for Resident #24's perimeter mattress and non slip pad, but could not confirm evidence of an order for proper footwear or to attend restorative therapy. 2. Review of Resident #25's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included insomnia, gastroesophageal reflux disease (GERD), hypertension, suicidal ideations, major depressive disorder, anxiety, COPD, and ovarian cancer. Review of Resident #25's quarterly MDS assessment dated [DATE] revealed the resident was alert, oriented, and had intact cognition. She was not known to display behaviors and was not known to reject care. She was dependent on one staff for assist with care and transfers. She ambulated about the facility with a wheeled walker. This assessment indicated she had one fall with major injury since her prior MDS assessment. Review of Resident #25's fall risk care plan, revised on 09/17/24, revealed her fall prevention interventions included using the wheeled walker while in the building and the wheelchair when going outside. Also, to ensure the telephone cord was tucked behind the night stand, there was a mobility bar to the right side of the bed, a perimeter mattress on her bed, and no obstacles in the path from bed to door. Observations of Resident #25 on 04/22/25 at 12:54 P.M. revealed all fall interventions were in place except the telephone cord was not tucked behind the bedside stand. It was confirmed by LPN #568 in an interview at the time of discovery. Observations on 04/23/25 at 10:55 A.M. and 1:02 P.M. revealed, again, all fall interventions were in place except the telephone cord was not tucked behind the bedside stand. It was confirmed by interviews with LPN #523 at 10:55 A.M. and Certified Nurse Aide (CNA) #522 at 1:02 P.M. at the time of discovery. Interview on 04/23/25 at 4:02 P.M. with LPN #523 confirmed the fall interventions in the care plan were accurate and were checked on rounds by the nurses and nurse aides. Observations on 04/24/25 at 10:07 A.M. revealed all fall interventions in place except the telephone cord was not tucked behind the bedside stand. It was confirmed by CNA #517 at the time of discovery. Review of the facility policy titled, Falls-Clinical Protocol, dated 11/10/22, revealed based on assessment of the resident's history of falling the interdisciplinary team would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 35765

Based on review of the medical record, review of narcotic count sheet, and resident and staff interview, the facility failed to ensure medications were available as ordered to treat pain. This affected one (#19) of five residents reviewed for unnecessary medications. The facility census was 55. Findings included: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, angiodysplasia of the stomach and duodenum with bleeding, urinary tract infections, skin cancer, necrotizing fasciitis, polyneuropathy, mild protein calorie malnutrition, diabetes, chronic kidney, mood disorder, suicidal ideations, chronic obstructive pulmonary disease, chronic pain syndrome, cirrhosis of the liver, hypertension, congestive heart failure, depression, sleep apnea, and anxiety disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had intact cognition and had almost constant pain. Review of the April 2025 physician's orders revealed Resident #19 had an order for one tablet of the narcotic pain medication hydrocodone-acetaminophen 5-325 milligrams (mg) three times a day for chronic pain. Review of Resident #19's electronic medication administration record (eMAR) progress note dated 04/20/25 at 10:43 P.M. revealed the facility was waiting on hydrocodone-acetaminophen 5-325 milligrams from the pharmacy. Review of the narcotic count sheets revealed Resident #19 had a dose of scheduled hydrocodone-acetaminophen 3-325 milligrams on 04/20/25 at 1:03 P.M. and did not have other dose until 04/21/25 at 5:05 A.M. which was 16 hours between doses and it was scheduled every eight hours. Review of the April 2025 medication administration record revealed Resident #19 had a pain level of eight out of ten on 04/21/25 at 5:05 A.M. after not having her routine pain medication as ordered. On 04/21/25 at 1:45 P.M. an interview with Resident #19 revealed the nurses do not reorder her pain medication on time and she runs out of it. She stated on 04/18/25 when she got her 2:00 P.M. pain pill she asked the nurse if she would have enough pain pills to get through they weekend because it was Easter weekend. Resident #19 stated the nurse told her there would not be enough pills and she would reorder it, but she never reordered it. Resident #19 stated she ran out on Saturday night and was without her pain pills for almost 17 hours and stated it happened all the time. On 04/28/25 at 8:58 A.M. an interview with the Director of Nursing (DON) revealed the nurse was unable to pull the hydrocodone-acetaminophen for Resident #19 from the stock medication because they were depleted and did not have any to give her. On 04/28/25 at 1:00 P.M. a second interview with the DON revealed she was incorrect about the hydrocodone-acetaminophen stock being depleted. She stated they actually did have the medication in the stock kit, but because her pain medication had already been sent with the full prescription amount of 30 pills from the pharmacy, they were unable to pull one from stock and give Resident #19. The DON verified they could have called the physician and ordered a one-time dose of hydrocodone-acetaminophen to be pulled from the contingent supply but it had not been done. She stated her medication was not reordered until the morning of 04/20/25 and did not know why it was not ordered sooner.

Based on medical record review, pharmacy recommendation review, and staff interview, the facility failed to act upon pharmacist recommendations that were agreed to by the residents physicians as required. This affected two (#51 and #54) of five residents reviewed for unnecessary medications. The facility census was 55. Findings Include: 1. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, anxiety disorder, and depression. There were no other mental health or behavioral related diagnoses present in the medical record. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was severely cognitively impaired, required extensive assistance of one staff person for completing her activities of daily living, and had no verbal, physical, or other behaviors. Review of Resident #51's admission physician's orders from October 2024 revealed an order dated 10/16/24 noting that Resident #51 was prescribed quetiapine fumarate (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) 25 milligrams (mg) once daily for anxiety/depression. Review of the pharmacist recommendation from 11/30/24 revealed documentation of, The resident (#51) is currently receiving the antipsychotic medication quetiapine and does not have an appropriate diagnosis to support therapy. Please evaluate and update their records accordingly. Further review revealed the recommendation also provided a list of acceptable diagnoses for prescribing quetiapine per the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The list of diagnoses included, schizophrenia, schizo-affective disorder, delusional disorder, mood disorder (mania, bipolar disorder, depression with psychotic features), schizophreniform disorder, psychosis, atypical psychosis, brief psychotic disorder, dementing illnesses with associated behavioral symptoms and medical illnesses or delirium with manic or psychotic symptoms and/or treatment-related psychosis or mania. Resident #51's physician reviewed the recommendation and agreed that Resident #51 did not have an appropriate diagnosis for quetiapine fumarate but did indicate a diagnosis to add to the record. Review of the current physician's orders for April 2025 revealed Resident #51 was prescribed quetiapine fumarate 25 mg one-half tablet once daily with the indication of use as, antipsychotic. Interview with the Director of Nursing (DON) on 04/22/25 at 2:45 P.M. verified the facility did not act on the pharmacist's recommendation on 11/30/24 to update Resident #51's medical record with appropriate indications for the continued use of quetiapine fumarate. 2. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses that included a fractured nose, post-traumatic stress disorder, and psychotic disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #54 was cognitively intact and was independent for completing her activities of daily living (ADLs). Review of Resident #54's admission physician's orders from December 2024 revealed Resident #54 was prescribed quetiapine fumarate 100 mg once daily at bedtime for agitation. Review of the pharmacist recommendation from 12/31/24 revealed documentation of, The resident (#54) is currently receiving the antipsychotic medication quetiapine and does not have an appropriate diagnosis to support therapy. Please evaluate and update their records accordingly. The recommendation also provided a list of acceptable diagnoses for prescribing quetiapine per the DSM-IV. The list of diagnoses included, schizophrenia, schizo-affective disorder, delusional disorder, mood disorder (mania, bipolar disorder, depression with psychotic features), schizophreniform disorder, psychosis, atypical psychosis, brief psychotic disorder, dementing illnesses with associated behavioral symptoms and medical illnesses or delirium with manic or psychotic symptoms and/or treatment-related psychosis or mania. Resident #54's physician reviewed the recommendation and agreed to add schizo-affective disorder as the appropriate diagnoses for use of quetiapine . Review of the current physicians orders for April 2025 revealed Resident #54 was prescribed quetiapine fumarate 100 mg twice daily for agitation. Further review of Resident #54's medical record did not contain a diagnoses of schizo-affective disorder. Interview with the DON on 04/22/25 at 11:45 A.M. verified the facility did not act on the pharmacist's recommendation on 12/31/24 to update Resident #54's medical record with appropriate indications for the continued use of quetiapine fumarate.

Based on medical record review, review of pharmacy recommendations, staff interview, and policy review, the facility failed to ensure appropriate indications and/or diagnoses were in place for residents receiving antipsychotic medication. This affected one (#51) of five residents reviewed for unnecessary medications. The facility census was 55. Findings Include: Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, anxiety disorder, and depression. There were no other mental health or behavioral related diagnoses present in the medical record. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was severely cognitively impaired, required extensive assistance of one staff person for completing her activities of daily living, and had no verbal, physical, or other behaviors. Review of Resident #51's admission physician's orders from October 2024 revealed an order dated 10/16/24 noting Resident #51 was prescribed quetiapine fumarate (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) 25 milligrams (mg) once daily for anxiety/depression. Review of the pharmacist recommendation from 11/30/24 revealed documentation of, The resident (#51) is currently receiving the antipsychotic medication quetiapine and does not have an appropriate diagnosis to support therapy. Please evaluate and update their records accordingly. Further review revealed the recommendation also provided a list of acceptable diagnoses for prescribing quetiapine per the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The list of diagnoses included, schizophrenia, schizo-affective disorder, delusional disorder, mood disorder (mania, bipolar disorder, depression with psychotic features), schizophreniform disorder, psychosis, atypical psychosis, brief psychotic disorder, dementing illnesses with associated behavioral symptoms and medical illnesses or delirium with manic or psychotic symptoms and/or treatment-related psychosis or mania. Resident #51's physician reviewed the recommendation and agreed that Resident #51 did not have an appropriate diagnosis for quetiapine fumarate but did indicate a diagnosis to add to the record. Review of Resident #19's current physician's orders for April 2025 revealed an order dated 12/09/24 for staff to monitor behaviors every shift. Further review of the current physician's orders for April 2025 revealed Resident #51 was prescribed quetiapine fumarate 25 mg one-half tablet once daily with the indication of use as, antipsychotic. Review of Resident #19's treatment administration records (TARs) since admission revealed no documented behaviors were noted by the facility on the TARs. Interview with the Director of Nursing (DON) on 04/22/25 at 2:45 P.M. verified there was no appropriate diagnoses or documentation of presenting features of an appropriate diagnosis for the continued use of quetiapine fumarate in Resident #51's medical record. Review of the policy titled, Chemical Restraint Use, dated 03/06/25, revealed residents will only receive psychotropic medications when necessary to treat specific diagnosis/conditions for which they are indicated and effective.

Based on review of the medical record and interview with staff, the facility failed to ensure a resident was given insulin as ordered. This affected one (#19) of five residents reviewed for unnecessary medications. The facility census was 55. Findings included: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, angiodysplasia of the stomach and duodenum with bleeding, urinary tract infections, skin cancer, necrotizing fascitis, polyneuropathy, mild protein calorie malnutrition, diabetes, chronic kidney, mood disorder, suicidal ideations, chronic obstructive pulmonary disease, chronic pain syndrome, cirrhosis of the liver, hypertension, congestive heart failure, depression, sleep apnea, and anxiety disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had intact cognition and received insulin. Review of the April 2025 physician's orders revealed Resident #19 had an order for Novolog Flexpen three units subcutaneously before meals for diabetes. Review of the electronic medication administration record (eMAR) progress notes revealed Novolog insulin for Resident #19 was held on 04/02/25 at 8:32 A.M., 04/02/25 at 5:07 P.M., 04/03/25 at 1:15 P.M., 04/12/25 at 10:17 A.M., 04/12/25 at 12:27 P.M., 04/12/25 at 5:10 P.M., and 04/17/25 at 10:22 A.M. without perimeters or physician's notification. On 04/23/25 at 10:45 A.M. an interview with the Director of Nursing (DON) revealed the nurses were to call the physician prior to holding any insulin without perimeters or if the resident refused. The DON verified the eMAR progress notes from 04/02/25, 04/03/25, 04/12/25, and 04/17/25 indicating the insulin for Resident #19 was held without perimeters or the physician being notified. This deficiency represents non-compliance investigated under Master Complaint Number OH00164429.

Based on observation, review of the medical record, and interview with the staff, the facility failed to ensure residents were provided thickened liquids as ordered. This affected one (#29) of three residents reviewed for nutrition. The census was 55. Findings included: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, hypothyroidism, hypertension, restless legs syndrome, essential tremor, collapsed vertebrae, polyneuropathy, low back pain, spondylosis, repeated falls, slurred speech, disorder of the peripheral nervous system, diabetes, dementia without behaviors, cerebral infarction, major depressive disorder, Alzheimer's disease, and anxiety disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #29 had moderately impaired cognition, required supervision with eating, received a therapeutic diet, and did not have an weight loss. Review of the April 2025 physician's orders revealed Resident #29 had an order for a regular, mechanical soft texture diet with nectar consistency liquids dated 04/16/25. Review of the undated breakfast meal ticket revealed Resident #29 was to have a regular diet with mechanical soft texture and nectar thick liquids. Observation and interview on 04/23/25 at 8:35 A.M. revealed Agency Certified Nurse Aide (CNA) #611 gave Resident #29 two glasses of thin consistency apple juice even though the meal ticket was highlighted with thicken liquid, nectar thick. At 8:36 A.M., CNA #527 verified Resident #29 was to get thickened liquids and went into the room immediately and retrieved the two glasses of thin consistency apple juice; however, Resident #29 had already drank three-fourths a four-ounce glass of apple juice.

Based on observation, medical record review, staff interview, and policy review, the facility failed to maintain proper infection control measures during wound care and bed linen changes. This affected two (#29 and #33) of two residents observed for proper infection control measures maintained during care and services. The census was 55. Findings include: 1. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, hypothyroidism, hypertension, restless legs syndrome, essential tremor, collapsed vertebrae, polyneuropathy, low back pain, spondylosis, repeated falls, slurred speech, disorder of the peripheral nervous system, diabetes, dementia without behaviors, cerebral infarction, major depressive disorder, Alzheimer's disease, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had moderately impaired cognition. Review of the April 2025 physician's orders revealed Resident #29 had an order to paint the right scapula wound with betadine and leave open to air every day for cellulitis. Observation and interview during wound care on 04/23/25 at 10:55 A.M. revealed wound care was provided to Resident #29 by Licensed Practical Nurse (LPN) #515 and Physician #613. LPN # 515 brought the wound care supplies in the room in her hand and was observed to already have gloves on when she entered the room. LPN #515 and Physician #613 positioned Resident #29 on his left side away from them. LPN #515 pulled on the bed pad to position him farther over on his left side and did this all with her gloves on and with the four inches long by four inches wide (four by four) pad dressings in her right hand so the clean dressings touched all of Resident #29's bed linens. Physician #613 removed the old dressing from the resident, dated 04/22/25, and measured the wound. There was a moderate amount of serosanguinous drainage (a fluid that contains both serum (clear, watery fluid) and blood) on the old dressing. LPN #515 stated the staff must have placed a dressing on the wound due to all the drainage because he did not have an order for the dressing. LPN #515 cleaned the wound with the four by four pad she had in her right hand and wound cleanser then with a betadine swab without changing her gloves or washing her hands. Physician #613 told her to go ahead an place another foam dressing on the wound so she went out of the room to get a dressing. LPN #515 came back into the room and placed the foam dressing onto the wound. On 04/23/25 at 1:38 P.M. an interview with LPN #6515 verified she wore her gloves into the room, she had the four by four pad dressings in her hand when she repositioned the resident in bed and then cleaned his wound with them, and did not change gloves or wash her hands during the procedure. Review of the facility policy titled, Dressing Change (Clean), dated 11/03/22, revealed the purpose was to protect the wound, prevent infection, to prevent irritation and promote healing. The procedure indicated to wash hands, create a clean field with paper towels, put on a pair of disposable gloves, remove the old dressing an discard in a plastic bag, dispose of the gloves, wash hands, put on a second pair of disposable gloves, clean the wound as ordered, dispose of the gloves, wash hands apple prescribed medication and dressing, remove the gloves and wash hands. 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included adult failure to thrive, bifascicular block, aphasia, schizoaffective disorder, malignant carcinoid tumor of the transverse colon, hypertensive heart disease, cataract, dementia, depression, anemia, atrial fibrillation, peripheral vascular disease, hypertension, dysphagia, benign prostatic hyperplasia, osteoarthritis, glaucoma, alcohol abuse, and cerebral infarction. Review of the quarterly MDS assessment dated [DATE] revealed Resident #33 had severely impaired cognition. Observation on 04/21/25 at 9:55 A.M. revealed a large pile of soiled linen on the floor in the room of Resident #33. An interview at this time with Certified Nurse Aide # 547 revealed she just changed the resident's bed because he was wet and did not did not know where else to put the soiled linens. Review of the facility policy titled, Bedmaking (Occupied), dated 11/13/23, revealed the purpose was to provide a clean, comfortable environment for the resident. Further review revealed for staff to remove the soiled linen by rolling edges toward the center with the soiled side inward and place in a linen hamper or a bag.

Based on observation of the posted survey results, review of previous survey history, and staff interview, the facility failed to ensure posted survey results were updated with the most recent survey results. This had the potential to affected all 55 residents. The facility census was 55. Findings include: Observation of the facility survey results binder on 04/28/25 at a random time found the last survey included was dated 06/10/22. Review of facility's survey history revealed, between 06/10/22 and 04/28/25, there were eleven complaint surveys, an annual survey on 10/24/22, and 15 Focused Infection Control surveys completed. Interview on 04/28/25 at 10:56 A.M. with the Administrator confirmed there were no survey results in the facility binder since 06/10/22.

Based on observation, interview, review of QSO-24-08-NH and review of facility policy, the facility failed to ensure enhanced barrier precaution (EBP) guidelines were followed for all residents that required EBP. This affected five of ten residents (Resident #1, #23, #50, #51, #57) reviewed for EBP. The facility census was 59. Findings Include: 1. Review of the medical record for Resident #23 revealed and admitted [DATE]. Diagnoses included respiratory disorders, tracheostomy, morbid obesity and acute respiratory failure with hypoxia. Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #23 had intact cognition. Resident #23 was on oxygen, required suctioning, had a tracheostomy and required a mechanical ventilator for respiratory support. Review of the physician orders for April 2024 revealed Resident #23 was on Levofloxacin (antibiotic) 500 milligram (mg) tablet for ten days for pneumonia. There were also orders for tracheostomy care, use of ventilator and suctioning when needed. Observation of Resident #23's room door on 04/26/24 at 5:20 A.M. revealed a yellow bag hanging from the door with personal protective equipment (PPE) in it with no signage on what type of precautions the resident was on. Interview on 04/26/24 at 5:28 A.M. with Registered Nurse (RN) #300 revealed she did not know if Resident #23 was on enhanced barrier precautions. RN #300 stated she did not wear a gown when connecting or reconnecting Resident #23 from the ventilator or when providing ventilator/tracheostomy care. RN #300 verified there was no enhance barrier precaution sign on Resident #23's door or wall outside of residents' room. Interview on 04/26/24 at 6:43 A.M. with Resident #23 revealed not all staff wore PPE when caring for him. 2. Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included unspecified tracheostomy complication and respiratory failure. Review of the MDS assessment dated [DATE] revealed Resident #50 was cognitively impaired, on oxygen, had a tracheostomy, and received tracheostomy care, suctioning and tube feeding. Review of the physician orders for April 2024 revealed to change split sponge to tracheostomy daily with trach care and enteral feed order. Observation of Resident #50 and interview with RN #300 on 04/26/24 at 5:40 A.M. revealed Resident #50 had a tracheostomy and a feeding tube. Further observation revealed Resident #50 was not on EBP. RN #300 verified Resident #50 should be on EBP. 3. Review of the medical record for Resident #57 revealed an admitted [DATE]. Diagnoses included gastrostomy, respiratory tract disease, acute respiratory failure with hypoxia and tracheostomy. Review of the physician orders for April 2024 revealed orders for tracheostomy care and enteral feed order. Observation of Resident #57 and interview with RN #300 on 04/26/24 at 5:40 A.M. revealed a yellow bag of PPE on Resident #57's door. RN #300 confirmed Resident #57 had a tracheostomy and was receiving tube feedings, but RN #300 did not know if Resident #57 was on EBP because there was no sign on Resident #57's door or outside the room indicating the resident was on EBP. 4. Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included acute respiratory failure with hypoxia and urinary retention. Review of the physician orders for April 2024 revealed orders for urinary catheter care and for a wound to right buttock. Observation on 04/26/24 at 9:30 A.M. of Resident #1 and his room revealed he was not on any type of isolation precautions. There was no signage and no PPE on the door or outside the room. Observation on 04/26/24 at 11:00 A.M. of Resident #1 and his room revealed Resident #1 had been placed on EBP and there was PPE and a sign on his door for EBP. Interview on 04/26/24 at 11:10 A.M. with the Director of Nursing (DON) verified Resident #1 was supposed to be on EBP on admission and had not been put on until 04/26/24. 5. Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnosis included human immunodeficiency virus. Review of Resident #51's MDS assessment dated [DATE] revealed Resident #51 had intact cognition. Review of the physician orders for April 2024 revealed Resident #51 had an order for an indwelling urinary catheter. Observation on 04/26/24 at 9:30 A.M. of Resident #51 and his room revealed he was not on any type of isolation precautions. There was no signage and no PPE on the door or outside the room. Observation on 04/26/24 at 11:00 A.M. of Resident #51 revealed he had been placed on EBP and there was PPE and a sign on his door for EBP. Interview on 04/26/24 at 11:10 A.M. with the DON verified Resident #51 was supposed to be on EBP on admission related to his urinary catheter. Review of the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group reference QSO-24-08-NH revealed EBP recommendations include use of EBP for residents with chronic wounds or indwelling medical devices during high contact resident care activities regardless of their multidrug-resistant organism status. Review of the facility policy Enhanced Barrier Precautions, dated 04/23/24 revealed the facility would identify residents with central lines, urinary catheters, feeding tubes, hemodialysis catheters and tracheotomy/ventilator status regardless of Multi drug-resistant Organisms (MDRO) colonization status. High contact resident care activities requiring gown and glove use included but were not limited to tracheotomy/ventilator care. Residents identified with MDRO, wound, and or indwelling medical devices would have an EBP sign noting the PPE needed and the high contact care activities placed on the door or wall outside of the resident room.

Based on record review, interview and facility policy review, the facility failed to timely address a resident change in condition. This affected one resident (Resident #65) of three residents reviewed for notification of changes. The facility census was 62. Findings include: Review of Resident #65's closed medical record revealed an admitted [DATE] and diagnoses including anemia, failure to thrive, type two diabetes, hypertension, chronic kidney disease, congestive heart failure, mild cognitive impairment, cardiomegaly, COVID-19, heart disease and hypokalemia. Resident #65 was his own responsible party. Resident #65 discharged to the hospital on 02/04/23 and did not return to the facility. Review of Resident #65's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 was moderately cognitively impaired and required minimal assistance to supervision with activities of daily living. Resident #65 was coded as receiving a diuretic six out of seven days in the seven-day look back period. Resident #65 admitted to the facility from the hospital. Review of Resident #65's physician's orders revealed orders to monitor vital signs every shift. Resident #65 was a full code. Review of treatment administration records (TARs) from February 2023 revealed the last set of vitals recorded was on 02/03/23 in the evening (7:00 P.M. to 7:00 A.M.). Review of a nurses' note dated 02/04/23 at 8:15 A.M. authored by Licensed Practical Nurse (LPN) #104 revealed the following information: This nurse went into Resident #65's room to give morning mediations, resident was noted to have facial, bilateral upper extremity and bilateral lower extremity edema. Vitals as follows: blood pressure 197/129 millimeters mercury (mmHg), heart rate 67 beats per minute (bpm), temperature 98.1 degrees Fahrenheit (F), pulse oximetry (SpO2) 95% on room air and respirations 20 (breaths per minute). Message left for provider [not specified], awaiting call back. Review of the next available nurses' note dated 02/04/23 at 10:30 A.M. authored by LPN #104 revealed the following information: Resident #65's daughter in facility, wants this nurse to send resident to [hospital name], 9-1-1 (emergency medical services) called and in building. Resident #65 states he goes not want to go to [hospital name] he wants to go to [different hospital name]. Resident transferred to [different hospital name] at 10:10 A.M. Review of Resident #65's assessments revealed no transfer assessment or other documentation from 02/04/23 regarding Resident #65's change in condition. Interview on 11/17/23 at 8:58 A.M. with Resident #65's daughter revealed on 02/04/23 the nurse (name not known) never called 9-1-1 after Resident #65 had a change in condition. Resident #65's daughter stated Resident #65 called her to come to the facility and once she was at the facility she made the nurse call 9-1-1. Resident #65's daughter said the nurse told her the doctor ordered labs relative to Resident #65's change in condition. Resident #65 was hospitalized from 02/04/23 onwards and did not return to this facility. Interview on 11/17/23 at 10:53 A.M. with LPN #100 revealed for high blood pressures over 190 mmHg (systolic)/100 mmHg (diastolic) she would send residents out to the hospital as she did not mess around with changes in condition. Interviews were attempted with LPN #104 on 11/17/23 at 11:32 A.M. and 1:14 P.M. but were not successful. Interview on 11/17/23 at 11:35 A.M. with Certified Nurse Practitioner (CNP) #103 revealed she was a contracted provider thus was not on-call for the facility. CNP #103 indicated she had seen Resident #65 during his stay at the facility and shared he had significant blood pressure readings. CNP #103 stated that this facility did not have a threshold for blood pressure readings to determine if residents should be kept at the facility or sent to the hospital for further evaluation. CNP #103 stated if blood pressures were out of range for the resident, nursing staff should have called the primary care provider (PCP) for further instructions. Interview on 11/17/23 at 11:54 A.M. with the Director of Nursing (DON) revealed LPN #104 had called her after Resident #65 was sent to the hospital on 02/04/23 and shared while Resident #65 had facial edema he was still breathing, talking and acting normally and she had contacted Physician #109 but did not get a response. The DON was asked if there was a protocol for staff to follow if physicians did not respond to calls timely and she confirmed there was no protocol and stated staff were to continue to try to contact the doctor. The DON did not recall Physician #109 having a nurse practitioner or other staff that covered for him in his absence. The DON could not state if Resident #65 should have been sent to the hospital prior to his family requesting him to be sent as she was not present in the facility on 02/04/23 to make that clinical judgement. The DON indicated she kept in contact with Resident #65's family after he was discharged from the facility and it was thought Resident #65 may have had an allergic reaction which caused him to be hospitalized . Interview on 11/17/23 at 12:34 P.M. with Registered Nurse (RN) #108 revealed she cared for Resident #65 during his admission to the facility and recalled his blood pressure was consistently high. At times she would have to call the doctor for new orders and elaborated this would occur if Resident #65's systolic blood pressure was in the 200 mmHg range and his diastolic blood pressure was in the 100 mmHg range. When asked who staff were to call if the physician was not available, RN #108 stated staff would call the on-call physician and if that person was not available they would send the resident to the hospital. Follow-up interview on 11/17/23 at 1:49 P.M. with the DON revealed if Physician #109 was out of the country his nurse practitioner would take calls but that person would not be on-call. The DON stated Physician #109 was not out of the country on 02/04/23 so staff would have called him and only him, there was no one else they would have called. The DON reiterated nursing staff were to use their clinical judgement and indicated Resident #65's blood pressure of 197/129 mmHg was not abnormal for him. The DON stated LPN #104 had called the physician multiple times on 02/04/23 but was made aware during the interview this was not documented in the medical record. The DON verified there was no protocol in place in the event a resident's physician could not be reached. During the interview the DON was made aware after LPN #104's progress note on 02/04/23 at 8:15 A.M. there were no additional blood pressure readings to check Resident #65's status, there were no other notes indicating that the physician was contacted additional times and the record lacked a change in condition/transfer assessment and DON did not disagree. Review of a policy, Change in a Resident's Condition, dated 12/16/20 revealed the facility would notify the resident, their physician and their sponsor of changes in the residents' medical/mental condition. Except in medical emergencies, notifications will be made timely of a change occurring in the residents' medical/mental condition or status. The nurse supervisor/charge nurse would record in the residents' medical record information relative to changes in the residents' medical/mental condition or status. The policy lacked guidance for staff to follow in the event the physician was not available. This deficiency represents non-compliance investigated under Complaint Number OH00147933.

Based on observation, record review, and interview, the facility failed to ensure care planned interventions were in place to prevent falls for Resident #11, Resident #53, Resident #37 and Resident #20. Actual harm occurred when Resident #11 and Resident #53 suffered a fall with a fracture nose and right femur respectively and were admitted to the hospital. This affected four residents (Resident #11, Resident #20, Resident #37, and Resident #53) out of six residents reviewed for falls. The facility census was 57. Findings include: 1. Resident #53 was admitted on [DATE] with diagnoses including malnutrition, [CONDITION(S)], dementia with behaviors, delusional disturbances, [CONDITION(S)] [CONDITION(S)], constipation, [CONDITION(S)], [CONDITION(S)], fracture of the right femur, asthma, unsteadiness, difficulty walking and muscle weakness. Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] revealed he needed extensive assistance of two staff members for bed mobility and transfers. Review of Resident #53's fall assessment dated [DATE] indicated he had a moderate risk for falls. Review of Resident #53's plan of care revealed he was at risk for falls related to unstable mood/medical condition, [CONDITION(S)], debilitation, weakness, dementia, impaired balance and required assistance for activities of daily living and toileting. An intervention on the plan of care was initiated on 01/22/22 to maintain a clear pathway in his room. Resident #53's nursing progress note dated 08/28/22 at 3:21 A.M. indicated the staff at the desk heard a loud noise and heard Resident #53 yell, help, I fell !. Resident #53 was found lying on the floor on his back next to his bed near the door of his room. When asked what happened Resident #53 stated, I fell getting back into the bed when returning from the bathroom, I hit my head on the door, I hit my knee. Resident #53's knee was noticeably swollen and unable to move or bend his right leg. The note indicated the staff called 9-1-1 and Resident #53 was transported to the hospital. The nursing progress note on 08/28/22 at 8:29 A.M. indicated Resident #53 was admitted to the hospital with a fracture of the right femur and was seen by an orthopedic specialist. Resident #53's fall investigation dated 08/28/22 indicated Resident #53 had sustained a fall in his room and was sent to the hospital for an evaluation. The investigation indicated Resident #53 was attempting to remove his shoes and transfer back to bed and his walker was out of reach. The investigation indicated the nurse found the room cluttered and blocking the path to the bathroom. An observation of Resident #53's room on 10/17/22 at 11:26 A.M. and 1:30 P.M. and on 10/18/22 at 4:10 P.M. revealed oxygen equipment, a wheelchair and other personal items blocking the path to the bathroom. Resident #53's room was cluttered with personal items and medical equipment and only a very small path was available to walk to the bathroom for both Resident #53 and his roommate (Resident #11). An interview with Resident #53 on 01/17/22 at 1:47 P.M. revealed he had fallen and fractured his right leg which caused him pain when attempting to participate during therapy sessions. Resident #53 indicated he was attempting to walk from the bathroom to his bed and tripped over personal items on his way from the bathroom when he fell and fractured his leg while attempting to put on his shoes. An interview with Director of Nursing (DON) on 10/19/22 at 11:00 A.M. verified the above findings. 2. Resident #11 was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses including [CONDITION(S)], convulsions, [CONDITION(S)] (stroke) with [CONDITION(S)] (weakness of one entire side of the body) and [CONDITION(S)] (complete paralysis of half of the body), homonymous field defect (a field loss deficit in the same halves of the visual field of each eye, often resulting from [CONDITION(S)] injury or tumor.), [CONDITION(S)] (brain is unable to make and deliver correct movement instructions to the body), [CONDITION(S)] (a disorder that affects how you communicate) and unsteadiness on feet. Resident #11's plan of care initiated on 08/06/21 revealed he had a risk for falls and potential injury related to stroke, weakness, impaired balance and impaired cognition. The goal of the plan of care was to minimize potential risk factors related to falls. Interventions on the plan of care included to provide an anti-rollback wheelchair for mobility with a nonskid pad on the seat of the wheelchair, remove the wheelchair from the bedside, provide a commode/urinal at the bedside and commonly used articles in reach and provide a visual reminder to use the call light and wait for assistance. Additional interventions included to use a mechanical lift for transfers and to maintain a clear pathway. Resident #11's smoking evaluation dated 08/25/21 indicated he was a smoker, had cognition loss, dexterity problems and needed supervision while smoking. Resident #11's MDS assessment dated [DATE] revealed Resident #11 was minimally verbal due to [CONDITION(S)] diagnosis and needed extensive assistance of one person for transfers and supervision while using a wheelchair for mobility. Review of Resident #11's fall assessment dated [DATE] revealed he had a high risk for falls due to Resident #11 exhibited loss of balance while standing, was confined to a chair, sometimes had memory problems and was receiving antiseizure medication. Resident #11's clinical record indicated he had sustained multiple falls from 07/01/22 to 10/18/22. Three falls occurred in Resident #11's room on 08/29/22, 08/20/22, 07/28/22 while trying to self-transfer out of bed to his wheelchair with no injury sustained from the falls. Review of Resident #11's nursing progress note dated 07/15/22 at 11:07 A.M. revealed when Resident #11 was outside smoking another resident reported he appeared to have a [CONDITION(S)] and fell out of his wheelchair. Resident #11 hit his face and was bleeding profusely. The staff called 9-1-1 and Resident #11 was sent to the hospital for evaluation of his injuries. The nursing note dated 07/15/22 at 11:59 P.M. indicated the nurse called the hospital for a report on Resident #11's condition and was informed the hospital admitted Resident #11 with breakthrough [CONDITION(S)]. Resident #11's fall investigation dated 07/15/22 revealed he was outside smoking with other residents and appeared to have a [CONDITION(S)] and fell out of his wheelchair and hit his head on the ground. There were no staff supervising Resident #11 and the eyewitness account of the fall was provided by another resident (Former Resident #58) who no longer resided in the facility. Review of Resident #11's nurse practitioner progress note dated 07/21/22 upon re-admission assessment revealed he had sustained nasal fractures following a fall after having a [CONDITION(S)]. The nurse practitioner note indicated Resident #11 had no further [CONDITION(S)] activity and to follow-up with neurology. An observation of Resident #11's room on 10/17/22 at 1:30 P.M. revealed he shared a room with another resident and both residents had multiple personal items and designated medical equipment within reach in their room. There was a very small path from the door to Resident #11's bed with his roommate's wheelchair partially blocking the path to the door. Resident #11's bed was close to the privacy curtain and was difficult to navigate the path to enter and exit his bed and travel to the bathroom or exit the room win a wheelchair. An interview with DON on 11/19/22 at 11:00 A.M. verified the above findings and indicated she was aware of the problem with the clutter in Resident #11's room. DON indicated this was an ongoing problem due to both residents in the room were at risk for falls. 3. Resident #20 was admitted on [DATE] and readmitted to the facility with diagnoses including [CONDITION(S)], sacroiliitis (an inflammation of one or both of the immovable joints formed by the bones of the pelvis), [CONDITION(S)], Todd's paralysis (a [CONDITION(S)] is followed by a brief period of temporary paralysis), [CONDITION(S)] disorder and [CONDITION(S)] and unsteady gait. Review of Resident #20's MDS assessment dated [DATE] revealed she needed assistance with transfers, ambulation, use of the toilet and bathing. Review of Resident #20's Fall assessment dated [DATE] revealed she had a moderate risk of falls due to a history of multiple falls, use of a mobility assistance device, and use of antiseizure medications. Review of Resident #20's plan of care revised on 06/12/22, revealed Resident #20 was at risk for falls/injury due to [CONDITION(S)] disorder, depression, [CONDITION(S)], activity of daily living functional status, [CONDITION(S)]/antidepressant medication use, muscle weakness, anxiety, reoccurring [MEDICATION(S)], sacroiliitis, overactive bladder, currently experiencing uncontrolled [CONDITION(S)] activity and need for glasses due to impaired vision. Interventions on the plan of care included to provide two staff members for assistance, use of a gait belt for transfers, and Resident #20 to wear tennis shoes when transferring. Review of Resident #20's clinical record revealed she sustained five falls from 09/01/22 to 10/18/22. A review of Resident #20's fall investigation dated 09/27/22 revealed Activities Assistant (AA) #400 went to the nurse and informed her they needed her in Resident #20's room. The nurse observed Resident #20 on her buttocks in front of her recliner. Resident #20 only had socks on and the call light was in reach. AA #20 entered Resident #20's room and asked if she wanted to attend an activity to play a game. AA #20 placed Resident #20's wheelchair close to Resident #20 and informed Resident #20 she was not able to assist her with transferring from the recliner to her wheelchair. Resident #20 attempted to self-transfer to the wheelchair. Resident #20's leg became weak, and she fell to the floor. An interview on 10/20/22 at 10:15 A.M. with AA #400 indicated she rounded on the residents to ensure they had an activity calendar and invited them to attend activities. AA #400 stated she assisted the residents by pushing them in a wheelchair to the activity room to participate in the activity programs. AA #400 stated she would notify the state tested nursing assistant assigned to care for residents needing assistance with transferring to a wheelchair. Once the resident was assisted to their wheelchair AA #400 would proceed to push them in their wheelchair to the activity room. AA #400 stated on 09/27/22 when she entered Resident #20's room to invite her to participate in the activity she was seated in her recliner. AA #400 thought Resident #20 was independent with transfers and informed her she could not assist her to her wheelchair. AA #400 indicated Resident #20 attempted to self-transfer to her wheelchair and her leg became weak and she fell to the floor. An interview with DON on 10/20/22 at 11:20 A.M. verified the above findings. A review of the facility policy and procedure titled, Falls Clinical Protocol, revised 07/25/21 indicated the initial assessment would attempt to identify residents at risk for falls. Staff would evaluate and document falls that occur in the facility and indicate where the fall occurred, how the fall happened and if the fall was witnessed or unwitnessed. After a fall occurred, the facility would attempt to find the root cause of the fall and initiate interventions to prevent future falls. Based on the assessments of the resident a plan of care would be initiated, revised as needed and implement pertinent interventions to attempt to prevent subsequent falls. 4. Review of the medical record for Resident #37 revealed admitted [DATE] and diagnoses included Alzheimer's disease, anxiety disorder, [CONDITION(S)], dementia with behavioral disturbance, and polyosteoarthritis. Review of Care Plan dated 06/27/22 revealed Resident #37 was at risk for falls with intervention of the bed in lowest position. Review of Nursing Post Fall Review assessment dated [DATE] revealed Resident #37 was found to have fallen out of bed and was found by staff on knees with arm and face laying on bed still. Resident #37 had noted facial bruising after fall. Interventions implemented were to move bed into lowest position when occupied. Review of Physician's Order dated 10/09/22 revealed bed in lowest position when occupied. Review of MDS quarterly assessment dated [DATE] revealed Resident #37 had impaired cognition, disorganized thinking, and behavioral concerns. Resident #37 required total two staff assistance for transfers. Observation on 10/18/22 at 3:34 P.M. revealed Resident #37 was resting comfortably in bed. Resident #37's bed was not observed to be in lowest position. Interview on 10/18/22 at 3:37 P.M. with State tested Nursing Assistant (STNA) #212 revealed she was aware Resident #37 had recent fall and was unsure what interventions were added. Follow up observation on 10/18/22 at 3:43 P.M. with STNA #212 verified Resident #37's bed was not in lowest position. STNA #212 adjusted Resident #37's bed to lowest position. Interview on 10/18/22 at 3:47 P.M. with Director of Nursing (DON) and Chief Clinical Officer (CCO) #247 confirmed Resident #37's bed should have been in lowest position as implemented from the fall on 10/08/22. Review of facility policy titled, Falls Clinical Protocol, dated 07/25/21 revealed based on falls assessment staff and physician would identify interventions to prevent falls.

Based on observation, interview, and record review, the facility failed to ensure a clean and sanitary kitchen area and ensure appropriate glove usage. This had the potential to affect all 57 of 57 residents receiving meals from kitchen, as the facility identified no residents with nothing by mouth diet orders. Findings include: Observations on 10/17/22 from 11:30 A.M. to 12:15 P.M. of facility kitchen revealed significant dried food debris and dark grease build up on floors, under equipment, and in corners of kitchen. The floor left a sticky substance on shoes throughout kitchen. Observation of juice machine revealed dried juice spray on wall next to the machine. Observed cleaning cloths and food wrappers on ground stuck between prep table holding microwave and wall. Observation of large food preparation table in middle of kitchen revealed storage drawer handles were sticky and had crumbs within drawers, there was dried food splatter and debris on lower shelving of tables and legs, and an open undated container of liquid margarine on lower-level shelf. Observation of oven revealed dark grease buildup running down front observation windows. There was food splatter and crumbs on front and sides of oven. Observation of deep fryer revealed dark grease with food floating. The bottom of the fryer was not visible through cooking grease. There was significant dark grease build up on back and sides of fryer. The deep fryer control unit was coated with cooking grease overspray. Observation of kitchen mixer revealed to be covered however had dried food debris on base of mixer. Observation of steam table revealed food splatter was dripping down front and sides. The lower-level shelf revealed dripping water from steam table caused significant rust build up. Observation of stove range revealed rust build up on grates. Observation of dish washing area revealed significant food debris and wrappers under equipment including dish machine and sinks. Observation of storage for cleaning supplies revealed two brooms and mop with bucket on floor in front of hand washing sink and significant food debris on floor. Observation of dry food storage revealed chemical rack with large spill of unknown red substance underneath. Observation of walk-in cooler revealed food debris and liquid red substance dripped on floor below metal racks. Observation of walk-in freezer revealed French fries and other food debris on floor. Observation on 10/17/22 at 12:00 P.M. of Dietary #267 was serving lunch meal. Dietary #267 was observed wearing pair of gloves while serving. Dietary #267 pushed the door to kitchen open and gave plate to dietary aide delivering cart. Dietary #267 returned to kitchen wearing same gloves and adjusted pants with gloved hands. Dietary #267 then walked over to rack holding bread and gathered items to prepare burger for resident. Dietary #267 prepared burger using same gloved hands then continued to serve rest of tray line without changing gloves. Interview on 10/17/22 at 12:15 P.M. with Food Service Supervisor (FSS) #226 confirmed findings with cleanliness and glove use. FSS #226 indicated there has been an issue with cleanliness and there are no current formal cleaning schedules in place. FSS #226 indicated equipment is cleaned as needed. Interview on 10/20/22 at 9:39 A.M. with Dietitian #272 revealed there was a monthly sanitation audit completed. Dietitian #272 indicated there had been concerns with kitchen cleanliness and concerns were addressed with FSS #226. Review of facility policy titled, Department Cleaning Schedule, undated, revealed a schedule outlining cleaning assignments would be posted and completed to maintain sanitation of the Food and Nutrition Services Department. The Director of Food and Nutrition Services shall be responsible for assuring the cleaning schedule is maintained at all times. Review of facility policy Refrigerated Storage undated revealed refrigerated food shall be stored in a manner that optimizes food safety. Review of facility policy Floors undated revealed all kitchen floors shall be cleaned after each meal and as needed. Review of facility policy Disposable Gloves undated revealed disposable gloves shall be used for only one task and shall be discarded when damaged, soiled, or when interruptions occur in operation.

Based on observation, record review, and interview, the facility failed to ensure Resident #11 and Resident #53's room was uncluttered to maintain a safe environment. This affected two residents (Resident #11 and Resident #53) out of 57 residents reviewed for accommodation of needs. The facility census was 57. Findings include: 1. Resident #53 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] revealed he needed extensive assistance of two staff members for bed mobility and transfers. Review of Resident #53's fall assessment dated [DATE] revealed he had a moderate risk for falls. Review of Resident #53's plan of care revealed he was at risk for falls related to unstable mood/medical condition, [CONDITION(S)], debilitation, weakness, dementia, impaired balance and required assistance for activities of daily living and toileting. An intervention on the plan of care was initiated on 01/22/22 to maintain a clear pathway in his room. Review of Resident #53's nursing progress note dated 08/28/22 at 3:21 A.M. revealed the staff at the desk heard a loud noise and heard Resident #53 yell, help, I fell !. Resident #53 was found laying on the floor on his back next to his bed near the door of his room. When asked what happened Resident #53 stated, I fell getting back into the bed when returning from the bathroom, I hit my head on the door, I hit my knee. Resident #53's knee was noticeably swollen and unable to move or bend his right leg. The note indicated the staff called 9-1-1 and Resident #53 was transported to the hospital. The nursing progress note on 08/28/22 at 8:29 A.M. indicated Resident #53 was admitted to the hospital with a fracture of the right femur and was seen by an orthopedic specialist. Review of Resident #53's fall investigation dated 08/28/22 revealed Resident #53 had sustained a fall in his room and was sent to the hospital for an evaluation. The investigation indicated Resident #53 was attempting to remove his shoes and transfer back to bed and his walker was out of reach. The investigation indicated the nurse found the room cluttered and blocking the path to the bathroom. An observation of Resident #53's room on 10/17/22 at 11:26 A.M. and 1:30 P.M. and on 10/18/22 at 4:10 P.M. revealed oxygen equipment, a wheelchair and other personal items blocking the path to the bathroom. Resident #53's room was cluttered with personal items and medical equipment and only a very small path was available to walk to the bathroom for both Resident #53 and his roommate (Resident #11). An interview with Resident #53 on 01/17/22 at 1:47 P.M. indicated he had fallen and fractured his right leg which caused him pain when attempting to participate during therapy sessions. Resident #53 indicated he was attempting to walk from the bathroom to his bed and tripped over personal items on his way from the bathroom when he fell and fractured his leg while attempting to put on his shoes. An interview with Director of Nursing (DON) on 10/19/22 at 11:00 A.M. verified the above findings. 2. Resident #11 was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .), [CONDITION(S)] (disorder that affects how you communicate) and unsteadiness on feet. Review of Resident #11's plan of care initiated on 08/06/21 revealed he had a risk for falls and potential injury related to stoke, weakness, impaired balance and impaired cognition. The goal of the plan of care was to minimize potential risk factors related to falls. Interventions on the plan of care included to provide an anti-rollback wheelchair for mobility with a nonskid pad on the seat of the wheelchair, remove the wheelchair from the bedside, provide a commode/urinal at the bedside and commonly used articles in reach and provide a visual reminder to use the call light and wait for assistance Additional interventions included to use a mechanical lift for transfers and to maintain a clear pathway. Resident #11's clinical record indicated he had sustained multiple falls from 07/01/22 to 10/18/22. Three falls occurred in Resident #11's room on 08/29/22, 08/20/22, 07/28/22 while trying to self transfer out of bed to his wheelchair with no injury sustained from the falls. Review of Resident #11's MDS assessment dated [DATE] revealed Resident #11 was minimally verbal due to [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's fall assessment dated [DATE] revealed he had a high risk for falls due to Resident #11 exhibited loss of balance while standing, was confined to a chair, sometimes had memory problems and was receiving antiseizure medication. An observation of Resident #11's room on 10/17/22 at 1:30 P.M. revealed he shared a room with another resident and both residents had multiple personal items and designated medical equipment within reach in their room. There was a very small path from the door to Resident #11's bed with his roommate's wheelchair partially blocking the path to the door. Resident #11's bed was close to the privacy curtain and was difficult to navigate the path to enter and exit his bed and travel to the bathroom or exit the room with a wheelchair. An interview with DON on 11/19/22 at 11:00 A.M. verified the above findings and indicated she was aware of the problem with the clutter in Resident #11's room. DON indicated this was an ongoing problem due to both residents in the room were at risk for falls.

Based on observation, interview, and medical record review, the the facility failed to properly treat Resident #21's constipation. This affected one resident (Resident #21) out of one resident reviewed for constipation. Findings include: Review of Resident #21's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's Care Plan dated 07/01/22 revealed the resident was at risk for constipation due to decreased mobility and medications. Interventions included for the facility to follow their bowel protocol for bowel management and record bowel movement patterns each day. Review of Resident #21's October 2022 physicians orders revealed the resident had orders for [MEDICATION(S)] Packet with instructions to give 17 grams by mouth every 24 hours as needed for constipation and [MEDICATION(S)] Suppository with instructions to insert one suppository rectally every 24 hours as needed for constipation. Additionally the resident was noted to be on several medications that can cause constipation including [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Review of Resident #21's bowel record from 09/19/22 through 10/16/22 revealed the resident did not have a recorded bowel movement on 09/23/22, 09/24/22, 09/25/22, 09/26/22, 10/01/22, 10/02/22, 10/03/22, 10/04/22, 10/11/22, 10/12/22, 10/13/22, 10/14/22, 10/15/22, and 10/16/22. Review of Resident #21's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/17/22 at 12:02 P.M. with Resident #21 revealed she has frequent constipation. Interview on 10/19/22 at 10:00 A.M. with Director of Nursing confirmed the facility did not initiate their bowel protocol for Resident #21 after she went over 72 hours without a bowel movement several times. Review of the facility's policy, Bowel Program, dated 11/13/19, revealed if the resident did not have a bowel movement in 72 hours the following actions would be taken: assess bowel sounds, assess nutritional status, initiate standing orders for constipation, or notify the the physician for an order.

Based on medical record review, review of facility fall investigation, and interview the facility failed to maintain safety to prevent a fall with injury during care. This resulted in actual harm when an unsecured stabilizer bar swung open during incontinence care and Resident #1 rolled over the bar, fell out of bed to the floor, and sustained a head injury requiring hospitalization . This affected one of three residents reviewed for falls. The facility census was 64. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. Resident #1 had a discharge date of [DATE]. Diagnoses included heart failure, cerebral infarction, [CONDITION(S)], [CONDITION(S)], and incontinence. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 01/14/22, revealed the resident had intact cognition. She required extensive assistance of two staff for all activities of daily living including bed mobility and personal care. Review of the plan of care dated 01/24/22 revealed the resident was at risk for falls due to [CONDITION(S)], dizziness and impaired vision. Interventions included to keep commonly used articles within reach, a stabilizer bar to the bed, and low bed positioning. Review of physician orders dated 03/14/22 identified orders to utilize bilateral half side rails for bed mobility. Review of the fall risk assessment dated [DATE] revealed the resident was at moderate risk for falls. Review of the nurses' notes dated 04/06/22 at 3:15 A.M. revealed Licensed Practical Nurse (LPN) #101 was informed Resident #1 slid out of bed during incontinence care. There were two State tested Nurse Assistants (STNA) on each side of the bed when she rolled over and out of the bed. Review of the fall investigation dated 04/06/22 revealed interventions as listed in the plan of care dated 01/24/22 were used properly, and the care plan was updated. Staff involved in the incident provided statements. STNA #102's statement indicated Resident #1 went to grab the stabilizer bar to hold onto during care. The bed stabilizer swung open, during the turn allowing Resident #1 to roll over top of the bar and slide off the bed. Staff tried to hold onto Resident #1, but couldn't due to having lotion on her body. Resident #1 hit her head on the telephone. LPN #101's statement also indicated Resident #1 had lotion on from head to toe and was not wearing a gown at the time of fall. The resident rolled off the bed hitting her head on the telephone. Resident #1 sustained a bump above the right eye that was bleeding. STNA #100's statement indicated Resident #1's body was covered with lotion, the side rail opened, and the resident rolled off the bed hitting her head on the telephone. Interview on 04/22/22 at 9:39 A.M. revealed the Director of Nursing (DON) stated there were staff on each side of the bed. However, when Resident #1 rolled over she fell out of bed because the side rail was not secured. The DON stated that side rails/bed stabilizers and bed sizes were subsequently audited to prevent further falls. The DON stated that a bariatric bed was also ordered for Resident #1 if she returned to the facility. The DON stated all staff received education on 04/06/22 on positioning residents and ensuring bed rails/stabilizer bars were secure during care. Interview via telephone on 04/22/22 at 10:26 A.M. revealed STNA #100 stated Resident #1 received a bed bath and staff applied cream from head to toe. Resident #1 was laying in the middle of the bed before turning to the side. The resident started to roll off the bed, but staff could not prevent her from falling due to the cream on her body. STNA #100 stated Resident #1 hit her head and was bleeding. The LPN #101 was called into the room, emergency services were called, and Resident #1 was transported to the hospital. This deficiency substantiates Complaint Number OH 745.

Based on medical record review, review of hospital records, interview with staff and Physician #211, observation, review of the facility [MEDICATION(S)]/[MEDICATION(S)] monitoring policy, and review of the Medscape Guidelines 2020, the facility failed to ensure adequate monitoring was completed for one resident (Resident #70) who received the oral anticoagulant (blood thinning) medication, [MEDICATION(S)]. The failure to monitor the anticoagulant therapy resulted in Immediate Jeopardy and potential serious-life threatening harm for Resident #70 who did not receive ordered prothrombin time (PT) and International Normalized Ratio (INR) testing after starting antibiotics on 01/04/22. This affected one (Resident #70) of two residents who received [MEDICATION(S)] therapy (Resident #69 and Resident #70). The facility census was 66 residents. On 01/24/22 at 2:58 P.M., Chief Clinical Officer (CCO) #206, Assistant Director of Nursing (ADON) #203, and the Administrator were notified Immediate Jeopardy began on 01/04/22 when the facility failed to obtain a physician ordered PT/INR test to monitor Resident #70's [MEDICATION(S)] level. A level was obtained on 01/06/22 which was elevated. Physician #211 ordered a STAT level for 01/07/22 which was not obtained until 01/10/22. At that time the level was greater than 8 and Certified Nurse Practitioner (CNP) #210 ordered the resident to be transported to the hospital via emergency transport. The Immediate Jeopardy was removed on 01/24/22 when the facility implemented the following corrective actions: · On 01/24/22 at 3:17 P.M. the Medical Director was notified of Immediate Jeopardy by the Chief Clinical Officer #206. · On 01/24/22 at 3:35 P.M. Resident #69, who was on [MEDICATION(S)], PT/INR orders, labs, and [MEDICATION(S)] orders were reviewed to ensure compliance. · On 01/24/22 Assistant Director of Nursing #203 and Administrator were educated on policy for monitoring [MEDICATION(S)] to include orders, labs, critical INR and treatment, monitoring and [MEDICATION(S)] log by the Chief Clinical Officer #206. · On 01/24/22 all nurses were educated on orders for [MEDICATION(S)], labs, critical INR and treatment, monitoring and [MEDICATION(S)] log by the Chief Clinical Officer #206 or/designee in person or via phone. · On 01/24/22 all nurses were educated on notification of the physician when plan of care, such as transportation via 911, or non-urgent transportation does not arrive in the parameters given by Chief Clinical Officer #206/designee in person or via phone. · On 01/24/22 at 4:00 P.M. all Nurses were educated on proper treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . · On 01/24/22 a [MEDICATION(S)] log was initiated for Resident #69 by Chief Clinical Officer #206/designee. · On 01/24/22 the Chief Clinical Officer #206 updated [MEDICATION(S)] orders to include a place to record the current INR prior to administering the medication. · On 01/24/22 the [MEDICATION(S)] monitoring policy was updated to include recording INR by the Chief Clinical Officer #206. · Beginning 01/25/22 audits of [MEDICATION(S)] logs will be completed in morning meeting by the Director of Nursing/designee five times a week for one month, then three times week for two months. · Beginning 01/25/22 audits of nursing notes for notification of the physician when transportation, etc. does not occur will be completed five times a week for one month, then two times a week for two months by the Director of Nursing/designee. · Beginning 01/25/22 audits of INR values and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . · Beginning 02/03/22, review in Quality Assurance and Performance Improvement (QAPI) monthly with Interdisciplinary Team for three months. Negative findings will be corrected immediately, and the plan updated to reflect changes. Although the Immediate Jeopardy was removed on 01/24/22, the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring for effectiveness and on-going compliance. Findings include: Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 70's hospital admission record, from 12/22/21 through 12/31/21, revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #70's plan of care, revealed Resident #70 did not have a care plan identifying his use of anticoagulants, the need to monitor for abnormal bleeding, the need to obtain labs as ordered, or the need to report abnormal findings to the physician. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 received an anticoagulant medication for five out of seven days during the assessment period. Further review revealed Resident #70 was cognitively intact with a brief interview for mental status of 14 out of 15. Resident #70 required extensive assistance of two plus staff for bed mobility and total assistance with two plus staff for transfers. Review of the January 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 01/04/22 for [MEDICATION(S)] (antibiotic) 500 mg by mouth two times a day for infection until 01/12/22 and an order dated 12/31/21 to start 01/01/22 for [MEDICATION(S)] (antibiotic) use 1.5 grams intravenously every 24 hours until 01/15/22. Review of Resident #70's physician order, dated 01/01/22, revealed orders to check Resident #70's PT/INR levels daily while on antibiotic therapy starting on 01/03/21. Review of lab reports for Resident #70 revealed the facility did not obtain a PT/INR level on 01/04/22, 01/05/22, 01/07/22, 01/08/22, and 01/09/22. On 01/06/22 Resident #70's lab reports revealed an elevated PT of 51.0 and elevated INR 5.2. Normal range with anticoagulant therapy is 2-4. The physician was notified and ordered the resident's [MEDICATION(S)] be discontinued and ordered a STAT (immediate) PT/INR on 01/07/22 and a repeat PT/INR again on 01/08/22. Review of Resident #70's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #70's lab reports revealed the labs were not obtained until 01/10/22. The 01/10/22 results revealed a PT level of 79.1 and an INR level greater than 8. CNP #210 was notified of the critical level on 01/10/22 at 3:54 P.M. and ordered Resident #70 transfer via 911 to hospital. Review of Resident #70's nurse progress note, dated 01/10/22 at 3:54 P.M., revealed Registered Nurse (RN) #205 updated CNP #210 of Resident #70's critically high lab results of INR greater than 8 and PT of 79.1. CNP #210 stated the resident either goes hospice on this day or needed to go out via 911 to the hospital. This nurse presented Resident #70 with the options and the resident chose to go to the hospital. RN #205 called 911. Review of Resident #70's nurse progress note, dated 01/10/22 at 4:17 P.M., revealed Emergency Medical Services (EMS) arrived at the facility and assessed the resident. Resident #70's vital signs were stable and due to the local fire department's protocol, they were unable to transport the resident. CNP # 210 was made aware and RN #205 would call and schedule transport for Resident #70 to be transferred to the hospital non-emergently. Review of Resident #70's nurse progress note, dated 01/10/22 at 4:49 P.M., revealed RN #205 called and scheduled transportation with a local ambulance service to the hospital emergency department and the estimated time of arrival would be four to five hours. Review of Resident #70's nurse progress note, dated 01/10/22 at 8:00 P.M., revealed Licensed Practical Nurse (LPN) #209 administered the Resident #70's Ciproflaxin 500 mg tablet, assessed the resident's temperature (98.2), and indicated the resident did not have any signs or symptoms of an adverse reaction to antibiotic therapy. The resident was also given fluids. Review of Resident #70's nurse progress notes revealed the next nurse progress note was not until 01/11/22 at 4:00 A.M. The 01/11/22, 4:00 A.M. nurse progress note revealed while LPN #209 was doing visual rounds she heard wet breath sounds coming from Resident #70. LPN #209 called the resident's name and raised the head of bed up immediately. Resident #70 tried to respond but was going in and out of consciousness. Vitals were obtained and revealed Resident #70's blood pressure was 103/42, pulse 55, respirations 26, and oxygen saturation level at 88 percent. LPN #209 increased the resident's oxygen up to four liters and called 911. EMS arrived and transported Resident #70 to the local hospital. Review of Resident #70's medical record revealed no evidence Resident #70's physician or CNP were made aware the transport for Resident #70 did not arrive within the four to five hours. In addition, there was no evidence of an assessment of Resident #70's condition from 8:00 P.M. on 01/10/22 through 4:00 A.M. on 01/11/22. Interview on 01/24/22 at 9:43 A.M. with ADON #203 confirmed Resident #70 was to receive daily PT/INR's from 01/03/21 through 01/15/22 while on antibiotic therapy. She confirmed the PT INR was not not obtained on 01/07/21 after the physician had ordered a STAT level due to an Increased INR of 5.2 on 01/06/22. She confirmed the facility did not complete any assessments of Resident #70 after 8:00 P.M. on 01/10/22 until 01/11/22 at 4:00 A.M. when the resident's blood pressure and oxygen saturation dropped, and the resident was sent out via 911. She confirmed the facility did not notify the physician Resident #70 was not sent to the hospital as ordered. ADON #203 revealed it would be her expectation for the nurse to notify the physician that the resident was not picked up by the scheduled transportation and to complete frequent monitoring on Resident #70 until he was safely transported to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 01/22/22 at 4:00 P.M. with CNP #210 revealed on 01/10/22 she was in the building and tried to send Resident #70 out via 911 due to an INR of greater than eight and a risk for bleeding. She stated she liked to see Resident #70's INR stay between two and three. She reported she was aware the squad did not take the resident initially and the nurse called for other transportation that would arrive around 9:00 P.M. or 10:00 P.M. on 01/10/22. She was never made aware the backup transportation did not come, and that he was never sent to the hospital. She was made aware the next day that Resident #70's oxygen level declined, and staff had to call 911. CNP #210 reported had she known transport did not come and take Resident #70 to the hospital she would have treated him with Vitamin K (assists with blood clotting) at the facility. Interview on 01/22/22 at 4:13 P.M. with RN #205 revealed on 01/10/22 the facility called 911 due to Resident #70's INR coming back at a level greater than eight. She stated she called 911 and they refused to take the residents due to his vitals being stable at that time. She then called for alternative non-emergent ambulance transport and was told it would be a four to five hour wait. RN #205 indicated she notified the CNP of the EMS refusal to transport and wait time for the backup transportation taking four to five hours. She stated Resident #70 was a little lethargic when she called 911 initially, but was he was able to hold a conversation with EMS. RN #205 reported she was unaware Resident #70 was never sent out until her next shift. Interview on 01/22/22 at 3:50 P.M. with LPN #209 revealed she worked 7:00 P.M. to 7:00 A.M. on 01/10/22 through 01/11/22. She reported Resident #70 had orders to be sent to the hospital for an increased INR. She stated when she arrived to work, he had not been sent out. She stated the previous nurse, RN #205, stated EMS came and did not take him since he was stable at that time. RN #205 told her she called for other transportation and they were supposed to be at the facility around 9:00 P.M. to 10:00 P.M. LPN #209 indicated around 3:00 to 4:00 A.M. she heard wet breath sounds coming from Resident #70's room and went to check on him. LPN #209 attempted to call transportation and they said they would not be there before 6:00 A.M. so she called 911. LPN #209 stated EMS came and took Resident #70 to the hospital. LPN #209 reported she did not update the physician or CNP that the transportation did not come when scheduled. Interview on 01/22/22 at 4:29 P.M. with Physician #211 revealed he was never notified Resident #70 was not sent to the hospital on 01/10/21 or of his increased INR on 01/10/22. Physician #211 revealed had he been notified he would have sent him immediately to the hospital due to risk of spontaneous bleeding. He stated if he could not have been treated at the hospital, he would have treated the resident with Vitamin K at the facility. Review of the facility's policy titled, [MEDICATION(S)]/[MEDICATION(S)] Monitoring, dated 01/05/22, revealed that the facility should obtain orders for [MEDICATION(S)] as desired by the physician or nurse practitioner. Review of the medication information titled, Medscape Guidelines 2020, revealed [MEDICATION(S)] was an anticoagulant and was indicated for indefinite duration of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Normal values include the following, the reference range for prothrombin time is 11.0-12.5 seconds. The reference range for the international normalized ratio (INR) is 0.8-1.1 with possible critical values of an INR: >5.5. Under the black box warning it indicated [MEDICATION(S)] could cause major or fatal bleeding and risk factors for bleeding included high intensity of anticoagulation (INR greater than 4), and a patient age of sixty-five years or older. Regular INR monitoring of INR should be performed on all treated patients; those at high risk for bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR and a shorter duration of therapy is recommended if possible.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memoranda, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID-19 line list, review of facility policies, observations, staff and resident interviews and record review the facility failed to ensure staff members self-screened for COVID-19 prior to working in the facility and failed to ensure staff donned appropriate personal protective equipment (PPE) including gowns, gloves, N95 respirator masks and face shields or goggles when providing care to residents who were confirmed COVID-19 positive. The facility also failed to ensure residents who tested positive for COVID-19 were not cohorted in the same room with residents who were negative for COVID-19, failed to ensure COVID-19 positive residents remained in isolation and redirected back to their rooms to prevent the spread of COVID-19 and failed to ensure staff members who tested COVID-19 positive were not permitted to return to work earlier than five days for contingency staffing, 10 days since symptom onset or seven days with a negative test, if asymptomatic or mildly symptomatic (with improving symptoms). This resulted in Immediate Jeopardy on 01/03/22 when Resident #23, who tested positive for COVID-19 was cohorted with Resident #2, who tested negative for COVID-19 on 01/06/22 and they remained in the same room. Resident #40 tested positive for COVID-19 on 12/27/21 and received a roommate on 01/05/22, Resident #67, who tested negative for COVID-19 on 01/06/22. Additionally, Resident #66, who had no evidence of receiving any COVID-19 vaccines, tested positive for COVID-19 on 01/06/22 and remained in the room with her roommate, Resident #19, who tested negative for COVID-19 on 01/06/22. Interviews and observations on 01/10/22 confirmed State tested Nursing Assistant (STNA) #802 provided care to Resident #66, who was COVID-19 positive, without the proper personal protective equipment (PPE) including an N95 respirator mask. Observations and interview with Licensed Practical Nurse (LPN) #806 revealed she administered medications on the 300 unit to Residents #2 (COVID-19 negative) and Resident #23 (COVID-19 positive), who resided in the same room, without wearing an isolation gown or a surgical mask covering her N95 respirator mask to prevent possible cross contamination. LPN #806 also administered medications to Residents #40 (COVID-19 positive) and Resident #67 (COVID-19 negative), who resided in the same room, without the utilizing all proper PPE including an isolation gown and a surgical mask covering her N95 respirator mask. Interviews on 01/10/21 with STNA #802, Registered Nurse (RN) #803, LPN #804, LPN #805, LPN #806 and STNA #812 revealed they did not self-screen for COVID-19 prior to working their shifts on 01/09/22 and 01/10/22 including an assessment of COVID-19 signs and symptoms and obtaining their temperatures to prevent the spread of COVID-19. RN #803 tested positive on 01/05/22 (day 0) and returned to work on 01/10/22. She should have not returned to work until 01/11/22 per updated CDC guidance revised 12/23/21. Observations revealed Resident #23 and Resident #66, who were both COVID-19 positive, were moving about the facility halls and smoking area wearing surgical masks. Staff were not observed redirecting these residents to return to their rooms and remain in isolation for COVID-19. The lack of effective infection control practices placed all residents at the facility at risk for serious life-threatening harm, complications and/or death. The current facility census was 70 residents, which included 15 COVID-19 positive residents, 11 residents in quarantine precautions (new admissions or readmissions) and an additional 44 residents who were COVID-19 negative. Review of undated facility Timeline COVID Out Break form revealed 15 residents and 11 staff members tested positive for COVID-19 using rapid tests from 12/23/21 to 01/06/22. On 01/10/22 at 2:45 P.M., the Administrator, Director of Nursing (DON) and RN Infection Preventionist #809 were notified Immediate Jeopardy began on 01/03/22 when staff permitted COVID-19 positive residents to remain in their rooms with COVID-19 negative residents, allowed COVID-19 positive residents to move freely about the facility and smoking areas, staff failed to self-screen prior to the start of their shifts, and staff were not utilizing and/or properly cleaning PPE to prevent the spread of COVID-19. The Immediate Jeopardy was removed on 01/12/22 when the facility implemented the following corrective actions: · The Medical Director was notified of the Immediate Jeopardy by the DON on 01/10/22. A Quality Assurance (QA) meeting will be held on 01/13/22 to review the findings. · The employee screening procedure was updated on 01/10/22 to reflect using paper screening and manual thermometer if the electronic self-screening kiosk machine was not working correctly. · On 01/10/22, the DON and Administrator were educated on transmission-based precautions related to cohorting COVID-19 positive and COVID-19 negative residents, COVID-19 positive and quarantine residents to remain in their rooms, PPE usage and appropriately cleaning PPE when providing care for COVID-19 positive residents/quarantine residents and self-screening protocols by Chief Clinical Officer/Infection Preventionist #809. · Facilities Manager #823, LPN Assistant Director of Nursing (ADON) #824, Activity Director #826, Business Office Manager (BOM) #827, Admissions/Marketing Director #828, Medical Records #829, Dietary Manager #830, Licensed Social Worker (LSW) #831 and Director of Rehab #832 were educated on transmission-based precautions to include cohorting and residents to remain in their room, PPE usage and cleaning for COVID positive residents, and self-screening protocols on 01/10/22 by Chief Clinical Officer/Infection Preventionist #809. · All Staff were educated on transmission-based precautions to include cohorting and residents to remain in their room, PPE usage and cleaning for COVID positive residents, and self-screening protocols on 01/10/22 via OnShift (a phone messaging system to send text messages to staff) and every employee was contacted by phone to complete the infection control education completed by the managers. · All staff not contacted would be educated prior to working their next shift by the Administrator, DON or LPN, ADON #824 in person as they arrive for their shift. Telephone interview on 01/12/22 at 10:00 A.M. with the Administrator revealed the infection prevention education, including all updates, was sent to all staff using the OnShift system. · Signage was placed on the kiosk on 01/10/22 reminding staff to use paper questionnaires and the manual thermometer if the electronic self-screening kiosk machine was not working. · By 01/10/22, paper forms would be available on the entry table if staff were unable to use the self-screening kiosk machine. A note stating extra forms were available at the nursing stations. Audits of staff self-screening would be completed by the Administrator/designee five days a week for two weeks, then two times a week for two weeks, then weekly for two months. · On 01/10/22, transmission-based droplet precautions signage was updated to include PPE to be worn by staff, including use of a surgical mask over the N95 respirator mask as needed and disinfecting goggles/face shields when leaving quarantine/COVID-19 resident rooms. The new signage was placed on all COVID-19 positive/quarantine resident rooms. · Residents on transmission-based precautions would be audited by the DON/designee. On 01/10/22, Resident #66 and Resident #23, who were COVID positive and cohorted with COVID-19 negative residents, were reassessed for COVID-19 symptoms and retested . Test results revealed they were negative for COVID-19. These residents will be tested again on 01/11/22, 01/17/22, 01/20/22, 01/24/22, 01/27/22, 01/31/22 and biweekly testing will continue until no additional positive COVID-19 residents were identified for 14 days. Resident #40's was removed from transmission-based precautions on 01/11/21. · On 01/10/22, all residents on transmission-based precautions were educated on remaining in their rooms with the door closed by the DON/designee. · Audits of residents on transmission-based precautions would be completed by the DON/designee for compliance of isolation protocols beginning on 01/11/22 and continue five days a week for two weeks, then two times a week for two weeks, then weekly for two months. · Audits of proper PPE usage would be completed by the DON/designee on 01/11/22 and continue five days a week for two weeks, then two times a week for two weeks, then weekly for two months. · Audits of staff COVID-19 sign in screening would be reviewed daily beginning on 01/11/22 by the Administrator/designee and would continue daily for two weeks, then three times a week for two weeks, then two times a week for two months. · All findings would be reviewed in or by the Quality Assurance and Performance Improvement (QAPI) committee monthly with the interdisciplinary team for three months. Negative findings would be corrected immediately, and the plan updated to reflect changes. · On 01/12/22, the Administrator and Infection Preventionist #809 educated the DON and Scheduler #823 on the CDC guidelines for scheduling staff members who tested COVID-19 positive and their accurate return to work date. Audits to ensure no staff returned to work earlier than the CDC guidelines for contingency staffing would be completed daily for two weeks beginning on 01/11/22, three times a week for two weeks then two times a week for two months. · Interviews on 01/12/22 from 6:17 A.M. to 7:45 A.M. with STNA #819, LPN #820, RN #821, STNA #822, Facilities Manager #823, LPN ADON #824 and LPN #825 confirmed the staff members were educated on proper PPE, cleaning PPE, cohorting of residents, COVID-19 self-screening guidelines and infection control. Although the Immediate Jeopardy was removed on 01/12/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #2's medical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 received the first dose of COVID-19 vaccination on 12/21/21 and he was COVID-19 negative on 01/06/22. Resident #2 received a roommate, Resident #23, on 12/30/21 (new admission). Review of Resident #23's medical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited moderate cognitive impairment. Resident #23 was fully vaccinated but had not received the booster vaccine. Resident #23 tested positive for COVID-19 on 01/03/22 and the facility left him in the same room with Resident #2. Review of Resident #40's medical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #40 was vaccinated for COVID-19 on 03/17/21 and 04/27/21. Resident #40 tested positive for COVID-19 on 12/27/21. Resident #40 received a roommate, Resident #67, on 01/05/22 (new admission). Resident #67 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He received the first COVID-19 vaccination on 03/17/21 and the second dose on 04/07/21 and he was not administered the booster. Resident #67 was COVID-19 negative on 01/06/22. Both residents remained in the same room from 01/05/22 to the present. Resident #40's last day of droplet isolation precautions was 01/10/22. Review of Resident #19's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19's COVID-19 Vaccination Record Card indicated she received the first dose on 03/22/21, the second dose on 04/12/21 and the third dose on 10/12/21 and she tested COVID-19 negative 01/06/22. Resident #19 received a roommate, Resident #66, on 12/14/21 (transferred from another room). Review of Resident #66's medical record revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #66's MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Resident #66 was not vaccinated for COVID-19 and she tested positive for COVID-19 on 01/06/22. The facility allowed Resident #19 and Resident #66 to remain together as roommates after Resident #66 tested positive for COVID-19. On 01/10/22 at 6:11 A.M., STNA #801, who worked 6:30 P.M. to 6:30 A.M., was observed with her surgical mask on her chin instead of covering her mouth and nose while seated at the nursing station. STNA #801 said she could not breathe so she put her mask on her chin. She indicated she was screened at the door upon entry into the facility. Review of the Screening Sign-In forms from 01/08/22 to 01/10/22 revealed STNA #801 last signed in and screened for COVID-19 on 01/08/22 at 6:32 P.M. There was no evidence STNA #801 completed the required COVID-19 self-screening on 01/09/22 prior to starting her night shift. Interview on 01/10/22 at 6:15 A.M. with STNA #802, who worked 6:30 P.M. to 6:30 A.M., revealed she self-screened for COVID-19 on the kiosk upon entry into the building before her shift. STNA #802 was observed wearing a surgical mask at the time of the interview. STNA #802 said she used a face shield, surgical mask, and isolation gown when she assisted Resident #66 out of bed that morning following provision of morning care. STNA #802 confirmed she was aware Resident #66 was COVID-19 positive, but stated she was not aware she was required to wear an N95 respirator mask when providing care to COVID-19 positive residents. Observation of the resident's door revealed signage on her door for droplet isolation precautions. Review of the Screening Sign-In forms from 01/09/22 to 01/10/22 revealed STNA #802 did not sign in and self-screen using the kiosk prior to starting her night shift on 01/09/22. There was no documented self-screen for COVID-19 including a temperature check upon entering the building on 01/09/22. On 01/10/22 at 6:17 A.M., Resident #66, who was COVID-19 positive and cognitively impaired, was observed in the hall in her wheelchair wearing a surgical mask. An interview was attempted with Resident #66 and she indicated she had her COVID-19 vaccines (she had not) and was allowed out of her room. None of the staff were observed to attempt to re-direct Resident #66 back to her room. Resident #66 was observed grabbing the handrails to help guide her wheelchair while she was rolling about the halls. Interview on 01/10/22 at 6:24 A.M. with RN #803, who worked 6:30 A.M. to 7:00 P.M., indicated she was not screened for COVID-19 and had not had her temperature taken upon entry into the building that morning. RN #803 indicated she was recently COVID-19 positive and today was her first day back to work. RN #803 indicated the facility staff had no issues with having proper PPE available as needed, including gowns and N95 respirator masks. RN #803 was observed wearing an N95 respirator mask and face shield at the time of the interview. Review of the Sign-In sheets from 01/09/22 to 01/10/22 revealed RN #803 did not self-screen for COVID-19 including signs and symptoms as well as taking her temperature upon entering the building. RN #803 tested positive on 01/05/22 (day 0) and she should have not returned to work until 01/11/22 per the updated CDC guidelines revised 12/23/21. Interview on 01/10/22 at 6:29 A.M. with LPN #804, who worked from 6:30 P.M. to 7:00 A.M., indicated she was an agency staff nurse and she signed into the kiosk and completed the COVID-19 screening questions as well as completing her temperature check prior to starting her shift. LPN #804 was observed wearing an N95 respirator mask and goggles. Review of the Sign-In Sheets from 01/09/22 to 01/10/22 revealed LPN #804 did not sign in at the kiosk upon entry to the front of the building and did not self-screen for COVID-19, including signs and symptoms and a temperature check before entering the building and working her shift. Observation on 01/10/22 at 6:40 A.M. revealed Resident #23, who was positive for COVID-19, walked out of his room, without any face mask, and obtained juice from the juice cart located against the opposite wall across from his room. Resident #23 returned to his room with the juice. Signage on the resident's door revealed he was in droplet isolation precautions. On 01/10/22 at 6:42 A.M., Residents #67 (COVID-19 positive) and Resident #40 (COVID-19 negative) were observed in their beds sleeping in the same room. The room door was open and signage on the door indicated these residents were in droplet isolation precautions. Interview on 01/10/22 at 6:45 A.M. with LPN #805, who worked from 6:30 A.M. to 7:00 P.M., confirmed she did not sign in on the kiosk by the front door and complete the self-screening questions for COVID-19 sign/symptoms or obtain her temperature when she entered the building. She indicated she was an agency staff nurse and had not worked at this facility in several weeks. Review of the Sign-In sheets from 01/09/22 to 01/10/22 revealed LPN #805 did not self-screen for COVID-19 including signs or symptoms or obtaining her temperature upon entering the building. Interview on 01/10/22 at 6:53 A.M. with LPN #806, who worked from 6:30 A.M. to 7:00 P.M., indicated she self-screened at the kiosk prior to the start of her shift and said she was an agency staff nurse. LPN #806 indicated she worked in this facility several times a week but was unaware she needed to clean her goggles when leaving the rooms of residents who were COVID-19 positive. Review of the Sign-In Sheets from 01/09/22 to 01/10/22 revealed LPN #806 did not self-screen for COVID-19 signs and symptoms or obtain her temperature upon entering the building. Interview on 01/10/22 at 7:00 A.M. with STNA #807, who worked from 6:30 A.M. to 6:30 P.M., indicated she did not self-screen for COVID-19 signs and symptoms prior to beginning her shift. STNA #807 said she was positive for COVID-19 on 12/23/21 and was off work for 10 days. She indicated the facility did not have enough gowns and gloves. She was observed to have a face shield and N95 respirator mask in place at the time of the interview. Review of the Sign-In Sheets from 01/09/22 to 01/10/22 revealed STNA #807 did not self-screen for COVID-19 signs and symptoms or obtain her temperature upon entering the building. Observation on 01/10/22 at 7:23 A.M. revealed LPN #806 was in Resident #2's (COVID-19 negative) room and assisting him to sit up and then obtained the resident's blood pressure. LPN #806 was observed wearing an N95 respirator mask and goggles, but no isolation gown to protect her clothing from cross contamination. LPN #806 passed by the roommate, Resident #23 (COVID-19 positive), who was in the bathroom so she could wash her hands. LPN #806 was observed to leave this room, walk to the medication administration cart and disinfectant the blood pressure cuff. LPN #806 did not disinfect her face shield when she left the resident's room. The signage on the door for these residents revealed they were in droplet isolation precautions. Observation on 01/10/22 at 7:26 A.M. revealed Resident #23, who was COVID-19 positive, was observed coming out of his room in a wheelchair. He had a surgical mask in place, and he wheeled himself to the smoking area on another unit. Staff were not observed attempting to redirect the resident back to his room to remain on isolation at any point. On 01/10/22 at 7:30 A.M., RN #803 indicated she was told by the Administrator it was Resident #23's home and he could come and go as he pleased even though he was COVID-19 positive. Observation on 01/10/22 at 7:40 A.M. revealed LPN #806 entered Resident #67's (COVID-19 negative) room to administer his medications. LPN #806 wore an N95 respirator mask and goggles but did not wear an isolation gown and she did not place a surgical mask over her N95 respirator mask to prevent cross contamination of her respirator mask. LPN #806 was observed leaving the room and then re-entered the room at 7:42 A.M. for medication administration for the other resident, Resident #40 (COVID-19 positive). LPN #806 did not don an isolation gown at any point or disinfect her goggles upon exiting the room. LPN #806 did not remove the contaminated N95 respirator mask when leaving the room after medication administration for Resident #40 and for Resident #67. The signage on the door of the residents' rooms revealed the residents were in droplet isolation precautions. Resident #40 was confirmed COVID-19 positive, and Resident #67 was a new admission. An additional interview on 01/10/22 at 10:27 A.M. with LPN #806 indicated she did not use an isolation gown when administering Resident #23 or Resident #40's medications because she could not readily find an isolation gown. Observation with LPN #806 revealed small plastic carts in the hall by the resident rooms with PPE available, including gowns. LPN #806 confirmed she did not sanitize or disinfect her goggles when exiting the droplet isolation rooms because disinfectant was not readily available and she confirmed she did not cover or change her N95 respirator mask between medication administrations for Residents #2, #23, #40 and #67 to prevent possible cross contamination. Tour of the facility on 01/10/22 from 11:10 A.M. to 11:23 A.M. with the Administrator revealed the facility had ample supply of isolation gowns, a half box of N95 respirator masks (approximately 100 masks) and ample supply of face shields/goggles. Email interview on 01/10/22 at 12:37 P.M. with the Administrator revealed he did not believe there were any open rooms on the 200 unit where Residents #19 and #66 resided and no open rooms on the 300 unit where Residents #2, #23, #40 and #67 resided to separate COVID-19 positive and COVID-19 negative residents. Tour of the facility on 01/10/22 at 12:57 P.M. with the Administrator revealed the 200 unit did not have any empty rooms however the 300 unit had one empty room, which had been available since 01/06/22. While on the tour with the Administrator, Resident #66 (COVID-19 positive) was observed in her wheelchair in the hallway wearing a surgical mask. The Administrator indicated facility staff kept trying to redirect Resident #66, but she had cognitive impairment and would continue to come out of her isolation room. The Administrator, nor any other staff members, attempted to redirect Resident #66 to her room during this observation. Interview via email on 01/12/22 at 11:05 A.M. and via telephone interview at 11:40 A.M. with the Administrator indicated the facility was in contingency staffing and he was unsure why RN #803 returned to work one day earlier than the five days required for contingency staffing. Review of the facility undated Timeline COVID Out Break form revealed 15 residents and 11 staff members tested positive for COVID-19 using rapid testing from 12/23/21 to 01/06/22. Resident #27 and Resident #72 and STNA #810, STNA #811 and STNA #812 tested positive for COVID-19 on 12/23/21. STNA #813 tested positive on 12/25/21 and Residents #40, #46, #48, #73 as well as Housekeeper #808 tested positive on 12/27/21. Resident #74 tested positive on 12/28/21. RN #814 and STNA #815 tested positive on 12/29/21. Resident #10, Resident #52, and Dietary Aide #816 tested positive on 12/30/21 and Resident #23 and Resident #41 tested positive on 01/03/22. RN #803 and STNA #817 tested positive on 01/05/22 and Resident #6, Resident #22, Resident #36, Resident #66 and STNA #818 tested positive on 01/06/22. Review of the CDC Infection Control for Nursing Homes updated 09/10/21, under Managing Residents with Suspected or Confirmed COVID-19 Infection, stated health care providers caring for residents with suspected or confirmed COVID-19 infection should use full PPE (gowns, gloves, eye protection, and an approved N95 respirator mask or equivalent or higher-level respirator). Review of the Testing and Documentation Requirements policy, revised 12/16/21, indicated all staff and residents would be tested in outbreak testing, regardless of vaccination status. No staff or residents would be tested who had tested positive for COVID-19 in the last 90 days. Review of the Entrance Quick Guide with Accushield Kiosk policy revised 12/16/21 indicated upon entry into the facility, but before entry into patient care areas, screening at the kiosk or on paper screening forms was to be completed by everyone. Screening should be completed for fever greater than 100.0 degrees Fahrenheit. The kiosk also required a questionnaire be completed regarding signs and symptoms of COVID-19. Review of the COVID-19 Outbreak policy, revised 12/16/21, indicated exposed fully vaccinated, asymptomatic residents should wear source control and did not need to be quarantined, restricted to their room, or cared for with full PPE unless they develop symptoms of COVID-19, were diagnosed with COVID-19, or were directed to do so by the public health authority. Review of the Resident diagnosed with Positive COVID-19 policy, revised 12/16/21, indicated PPE would be worn by all staff in resident areas including an N95 respirator mask which was to be replaced when wet or soiled. The face shield or goggles would be cleaned between residents or upon exiting a room using 60% alcohol hand sanitizer and a paper towel. Gown should be disposed of after each use. Review of the CDC Potential Exposure at Work Summary of Recent Changes, updated 12/23/21, indicated health care personnel (HCP) were considered vaccinated or unvaccinated if they have not received all COVID-19 vaccine doses, including a booster dose, as recommended by CDC. Boosted, vaccinated or unvaccinated HCP with confirmed COVID-19 infections may return to work as a contingency in five days with/without a negative test, if asymptomatic or mildly asymptomatic (with improving systems). For calculating day of test for those with infection, consider first positive test if asymptomatic as day 0. Review of the COVID-19 Transmission Based Precautions - Droplet Precautions policy, revised 12/28/21 indicated residents were to be instructed to stay in the facility designated area/room with the door closed if able, and to post signage for transmission-based precautions-droplet precautions and staff to utilize PPE when providing care for residents suspected or diagnosed with COVID-19 including N95 masks, eye protection, gowns, and gloves. The policy was revised on 01/10/22 to include new information requiring surgical masks to be worn over N95 respirator masks when entering and providing care for residents in COVID-19 precautions and quarantine precautions. This deficiency substantiates Complaint Number OH 022.

Based on closed medical record review, policy review, observations, staff interview, and review of fire department records, the facility failed to provide adequate supervision during meals and failed to provide the correct texture to prevent Resident #24 from choking. This resulted in Immediate Jeopardy for one Resident (Resident #24) of three residents identified to require supervision during meals. The facility also failed to implement safety interventions for one resident (Resident #65) with exit-seeking behaviors of four residents reviewed for elopements. On [DATE] at 2:39 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 5:45 P.M. when Resident #24 was served, in her room, two hot dogs chopped in three-fourth inch pieces on whole buns and was left unsupervised while eating the incorrect texture of food. As a result of being served the wrong diet texture and not being supervised, Resident #24 began to choke on the hot dogs. Resident #24 initiated the call light at which time State-tested Nurse Aide (STNA) #100 found the resident with food on her clothes and choking. The resident became unconscious, 911 was activated and Cardio-Pulmonary Resuscitation (CPR) was provided by the facility. After arrival at the facility, the paramedics removed two large pieces of hot dog from Resident #24 ' s airway. Resident #24 then began to have agonal breaths (irregular and gasping breathing) and required intubation by the paramedics. Resident #24 was transferred to the hospital where she was admitted with a [DIAGNOSES REDACTED]. The Immediate Jeopardy was removed on [DATE] at 11:00 A.M.; when the facility implemented the following corrective actions: · On [DATE], in-service records revealed seven of nine dietary staff employed at the facility were educated by Dietary Manager #127 on serving hot dogs and Polish sausage. The education included the food must be split down the middle crisscross. The in-service included no mechanical soft food was to be served whole; it must be ground. Pureed food must be pudding like texture. The staff was educated on reading meal tickets. The in-service included no food or fluids were to be served without a meal ticket and/or checking the diet sheet. · On [DATE], an in-service was completed by the DON for 10 of 21 STNAs employed at the facility and three of 11 Licensed Practical Nurses (LPNs) employed at the facility on emergency response, following diet orders, reviewing textures, meal tickets and mechanical soft diets. All 79 staff members were in-serviced by [DATE]. · On [DATE], STNA #107 was educated by the DON regarding ensuring resident meal tickets matched the food on the tray prior to serving the meal to the resident. STNA #107 was educated not to serve a resident a different diet or diet texture than what was ordered and that mechanical soft diet textures included ground/chopped meats. STNA #107 was given the education due to serving the actual incorrect diet. · On [DATE], Cook #110 was given a written warning by Dietary Manager (DM) #127 for giving Resident #24 a hot dog when Resident #24 had a diet order for a mechanical soft diet and the resident choked on the meat. Cook #110 was further educated on all dietary policies being implemented at all times including foods not to be given without a diet ticket or verifying the diet. · On [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] all meals were audited by the DON, Registered Nurse (RN) #130, and Assistant Director of Nursing (ADON) #111, LPN #121, and Therapy Director #131. All meals were audited on the above dates to assure the meal tickets matched the proper consistency for the food. · On [DATE], RN #132 compared all current residents ' diet orders with their meal tickets to ensure they matched. · On [DATE], an in-service was completed by the DON for two of four RNs and one of 11 LPNs regarding diet textures, physician notification, emergency response, and elopement. All nursing staff were provided in-service training by [DATE]. · On [DATE], random staff interviews related to compliance and supervision of diets revealed 13 facility staff were interviewed related to noncompliance and supervision. These interviews were conducted by ADON #111 and Therapy Director #131 in order to determine which residents were noncompliant with their diets and which residents required more supervision. · On [DATE], the facility ' s service at meal time supervision policy was revised to include education by the DON or designee, of all managers and licensed nurses regarding residents who become non-compliant with their dietary needs and the need for supervision while eating. Employees who are serving meals must ensure they are comparing resident meal ticket to tray contents. If the meal is not accurate, staff must correct immediately. · On [DATE] at 11:00 A.M., the DON educated 16 of 16 facility managers on service at meal times including the supervision of meals and the new policy and procedure for managers and nurses. · On [DATE] each meal, beginning with breakfast that day, was assigned a staff member to monitor and the meal audit tool was to be completed by the assigned staff. The meal tray audit tools were reviewed and verified the monitoring was initiated on [DATE] and continued on [DATE]. The monitoring was conducted by Dietician #104, ADON #111, RN#130, LPN #121, Business Office Manager (BOM) #133, the DON, Therapy Director #131, Regional Vice President #134 and the Administrator. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity Level 2, (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as not all staff had received the in-service training on meal service and supervision. Findings Include: 1. Review of Resident #24's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #24 ' s barium swallow report dated [DATE] revealed evaluation of the swallowing mechanism was performed by the speech pathology service utilizing barium and barium-coated foods of varying consistencies. The study was performed to evaluate dysphagia. Mild abnormalities were identified involving the oral and pharyngeal phases without evidence of laryngeal penetration or frank aspiration. Review of the speech pathology report revealed recommendations and treatment plan including mechanical soft diet, thin liquids, and to continue speech therapy as planned emphasizing general safe swallowing strategies and indicated an example of slow pace of eating and small bites and/or sips. Review of the nurse ' s note written by LPN #135 dated [DATE] revealed Resident #24 trialed a regular diet with speech therapy and was not able to tolerate the diet. The resident had difficulty swallowing chicken. Resident #24 has dysphagia and tolerated a modified barium swallow. The note indicated Resident #24 attempted to try ' take out ' (Food ordered from outside the facility) with speech therapy. The chicken lodged in Resident #24 ' s esophagus and was difficult to clear. Review of the physician orders [REDACTED].#24 ' s diet texture to mechanical soft/thin liquids due to resident request following a modified barium swallow (MBS) at the hospital. Review of Resident #24 ' s dysphagia education dated [DATE] revealed evidence Resident #24 was educated related to the pulmonary complications of aspiration including pneumonia, abscess, airway obstruction, fibrosis, and adult [DIAGNOSES REDACTED] (ARDS). The education form indicated the resident requested mechanical soft and thin liquids against the direction of the facility ' s speech pathologist; and the hospital modified barium swallow indicated a mechanical soft diet with thin liquids. Review of the physician progress notes [REDACTED]. Speech therapy at the facility was not in agreement so informed consent was obtained. The note indicated the resident would like diet advanced in spite of differing opinions. Risk of aspiration, respiratory failure and ARDS has been explained to Resident #24. Resident #24 understands all information. Review of Resident #24 ' s speech therapy discharge recommendations dated [DATE] revealed recommendations for supervision indicating close supervision during meals. Review of the episodic behavior note by LPN #137 on [DATE] at 6:05 P.M. revealed Resident #24 was swearing and cursing at staff because she had to eat dinner in the dining room. STNA #100 asked Resident #24 what was wrong and the resident continued cursing at the STNA, name unknown. The STNAs stated come on so we can take you to your room . There was no evidence that Resident #24 ' s plan of care was updated to reflect interventions for safety related to dining or the preference of Resident #24 eating in the her room. LPN #137 was no longer employed by the facility and could not be interviewed to confirm identities of the STNAs involved. Review of the plan of care initiated on [DATE] revealed Resident #24 displayed noncompliance with the diet. Interventions included encouraging the resident to eat in dining room for all meals for safety due to noncompliance with diet texture. Another intervention included to encourage slow pace of eating and small bites/sips. The plan of care identified the resident was to be monitored for signs and symptoms of aspiration and choking. The plan of care also indicated to review as needed risks and benefits of following ordered diet type and texture with Resident #24. Review of Resident #24 ' s Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #24 with a Brief Interview of Mental Status (BIMS) score of 13 indicating Resident #24 was cognitively intact. Review of the MDS revealed Resident #24 required supervision, oversight, encouragement and cueing and set up help only for eating. Review of the physician orders [REDACTED].#24 was a full code status. Review of the nurse ' s note written by LPN #101 on [DATE] at 6:50 P.M. revealed LPN #101 was sitting at the nurse ' s station in report with LPN #109 when STNA #100 came out of Resident #24 ' s room yelling for both nurses. STNA #100 stated Resident #24 was choking and couldn ' t breathe. When LPN #101 entered Resident #24 ' s room, Resident #24 was sitting up in the wheelchair and was slobbering at the mouth with food stuck in her throat. Resident #24 could not respond at this time. LPN #101 and STNA #100 tried sweeping the food out of the resident ' s mouth and the Heimlich maneuver was attempted. The note indicated Resident #24 was still choking on the food. LPN #101 then ran to get RN #102 and RN #103 on the 300 hall and LPN #101 called 911. The note indicated LPNs #101, #109 and STNAs (unidentified) went to the room where the resident was placed on the bed. Resident #24 was still unresponsive and not breathing at that point. The note indicated CPR was started; emergency medical services (EMS) arrived at 7:00 P.M. and took over care of Resident #24. The note indicated Resident #24 was transferred to the hospital at that time with a blood pressure of ,[DATE] and the oxygen saturation level at 89%. Review of the nurse ' s note by LPN #101 dated [DATE] at 7:59 P.M., revealed a late entry indicating when the EMS team arrived at the facility and took over from the facility staff. The note stated Resident #24 was still unresponsive but vital signs present. The EMS team was able to pull a piece of a hot dog and bread from Resident #24 ' s throat. Resident #24 was then suctioned by the paramedic allowing more little particles of food to come out. Resident #24 was still unresponsive at that time. The note indicated the resident was then transferred to the hospital. Review of the nurse ' s note by LPN #101 dated [DATE] at 11:57 P.M. revealed LPN #101 called the hospital to check on Resident #24 and get an update. The resident was admitted with acute respiratory failure and was in the intensive care unit on a ventilator. Review of Resident #24 ' s nurse ' s note dated [DATE] at 10:12 P.M. revealed LPN #136 spoke to the hospital RN for a status update on Resident #24. The note indicated the resident was currently on a ventilator, sedated, receiving tube feedings via a nasogastric tube and receiving antibiotics. The note indicated on this date Resident #24 had angioedema of the face and oral cavity. The attempt to wean the resident from the ventilator was unsuccessful due to the angioedema (the rapid swelling of the dermis, subcutaneous tissue, mucosa and submucosal tissues). Review of Resident #24 ' s undated diet card revealed Resident #24 was on a mechanical soft textured diet. Review of the EMS report revealed per staff, Resident #24 was found supine and unresponsive apparently choking. Upon EMS arrival Resident #24 was found in respiratory arrest with unknown time frame. EMS was able to remove two large pieces of hot dog with Magill ' s (a type of forceps). Resident airway was patent with agonal respiration and no gag reflex. Resident did not improve in route to the emergency department. Resident #24 had a strong pulse entire code. Review of the call report revealed on [DATE] at 18:54 P.M. that a female resident is choking, Heimlich being performed . The [DATE] call report noted that Resident #24 was in full arrest. Review of the witness statement dated [DATE] by Cook #110 regarding the incident on [DATE] revealed the menu for [DATE] was steamed rice, sweet and sour chicken, with steamed veggies. The beef hot dogs were the alternate. At approximately 4:55 P.M. to 5:00 P.M. Cook #110 prepared the food for a mechanical soft diet plate for Resident #24. STNA #107 came to the kitchen stating Resident #24 was refusing the meal and wanted two hot dogs with ketchup, mustard and onions. I took the first meal and replaced it with chopped hot dogs sliced in the middle and chopped up and sent the meal to the proper hall . Review of the witness statement dated [DATE], a phone interview conducted by the DON with STNA #100, revealed STNA #100 saw Resident #24 up in the wheelchair in the hallway earlier in the shift. STNA #100 indicated she did not see Resident #24 at dinner time and indicated Resident #24 ate in her room. STNA #100 indicated that she did not pass trays on the hall where Resident #24 resides. The statement indicated that STNA #100 went to answer Resident #24 ' s call and observed Resident #24 had food on her shirt and was trying to say something. STNA #100 indicated she asked if the resident was choking and Resident #24 shook head yes. STNA #100 indicated that she yelled for the nurse who came to the room right away and tried to help Resident #24 by doing the Heimlich maneuver. The statement indicated the nurses did CPR and the paramedics took the resident to the hospital. Review of the witness statement dated [DATE] revealed a telephone interview was conducted on [DATE] by the DON with LPN #101. The statement revealed LPN #101 ' s shift did not start until 6:30 P.M. LPN #101 indicated that she did not interact with Resident #24 during dinner time. The statement revealed that LPN #101 heard STNA #100 calls for help; LPN #101 ran to Resident #24 ' s room. When LPN #101 entered Resident #24 ' s room the resident was sitting in the wheelchair. LPN #101 questioned Resident #24 if she was choking and the resident nodded her head yes. LPN #101 performed a mouth sweep and then did back blows and initiated the Heimlich maneuver. When LPN #109 entered the room LPN #109 took over the Heimlich. LPN #101 indicated she called 911, paged Resident #24 ' s physician, and returned to the resident room to continue attempting to dislodge the food. EMS arrived and was able to remove food obstructing the resident ' s airway with forceps and the resident was transferred to the hospital. LPN #101 indicated that she called the resident ' s family and physician and informed them of the incident. The statement indicated CPR was initiated by staff prior to the EMS arriving to the facility. Review of the statement dated [DATE], identified the DON conducted a phone interview with RN #103 which revealed RN #103 worked the 300 hall from 6:30 A.M. to 6:30 P.M. The statement revealed RN #103 did not have any interaction with Resident #24 during her shift. The statement revealed RN #103 was giving report to RN #102 when LPN #101 called for help. RN #103 and RN #102 went to the resident ' s room. RN #103 retrieved the crash cart, hooked up the suction machine and suctioned Resident #24 ' s mouth between t Heimlich maneuvers. EMS arrived, removed food from the resident ' s throat and took the resident to the hospital. The statement indicated that RN #102 started CPR and RN #103 assisted prior to EMS arriving at the facility. Review of a statement dated [DATE], reflected the DON conducted a phone interview with RN #102. RN #102 started work at 6:30 P.M. on the 300 hall and had no interaction with Resident #24 at dinner time. The statement revealed RN #102 was getting report and counting medications with RN #103. LPN #101 called for help. RN #102 and RN #103 went to Resident #24 ' s room and assisted with the Heimlich maneuver; EMS arrived and removed the lodged food. LPN #101 assisted EMS to transfer the resident to the stretcher. The note indicated CPR was initiated prior to the paramedics arriving and they took over once they arrived. Review of a statement dated [DATE] indicated the DON conducted a telephone interview with LPN #109 which revealed LPN #109 gave Resident #24 ' s 4:00 P.M. medications. LPN #109 did not see Resident #24 at dinner time and indicated that Resident #24 ate in her room. LPN #109 indicated he was at the desk with LPN #101 when STNA #100 called for help from the resident ' s room. LPN #101 immediately went to Resident #24 ' s room. The statement indicated LPN #109 followed LPN #101. LPN #101 indicated Resident #24 was choking and LPN #101 was doing the Heimlich maneuver. The statement revealed LPN #109 assisted LPN #101 and then took over. While LPN #101 went to call 911 and the physician, LPN #109 stayed with Resident #24 and continued to do the Heimlich maneuver. LPN #101 returned to the room and assisted with Resident #24. RN #102 and RN #103 came to the room. RN #102 took over doing the Heimlich maneuver. RN #103 did oral suctioning. EMS arrived and used forceps to remove the food and transfer the resident to the hospital. Review of the Witness Statement, dated [DATE], revealed the Administrator conducted an interview with STNA #107. STNA #107 answered Resident #24 ' s call light and Resident #24 requested a substitute for the meal. STNA #107 set up the food tray and gave it to Resident #24. STNA #107 stated Resident #24 refused to have the meat cut up. The statement revealed STNA #107 last saw Resident #24 when the tray was passed at 5:45 P.M. STNA #107 indicated she did not see Resident #24 again until 7:00 P.M. Resident #24 was not on STNA #107 ' s assignment list. Review of the Witness statement dated [DATE], identified the Administrator conducted an interview with STNA #108. Resident #24 was on this employee ' s assignment. STNA #108 indicated she last saw Resident #24 around 4:00 P.M. at which time the resident was given orange juice per LPN #109 ' s instruction for [DIAGNOSES REDACTED]. The statement revealed STNA #108 saw the resident again when she answered another resident ' s call light around 6:00 P.M. STNA #108 stopped in the resident ' s room to check on her and offered to pick up the resident ' s tray. Resident #24 stated she was not done at that time. STNA #108 indicated she did not see the resident again until the incident around 7:00 P.M. Interview on [DATE] at 10:51 A.M. with Dietician #104 revealed when a resident was ordered a mechanical soft diet the meat should be ground. Dietician #104 indicated that hot dogs should be ground when given to residents on mechanical soft diets. Interview on [DATE] at 11:09 A.M. with LPN #105 revealed that during report she was told to make sure the resident gets the appropriate diet but denied any further in-servicing. LPN #105 indicated that a mechanical soft hot dog or sausage would be cut once down the middle and then cut in smaller pieces. Interview on [DATE] at 11:12 A.M. with STNA #106 revealed there was an in-service completed related to checking the diet slips prior to taking the tray into the resident. STNA #106 indicated that she could not remember when it was but it was since the [DATE] incident. Interview on [DATE] at 11:53 A.M. with the Administrator revealed the facility conducted an investigation on Resident #24 ' s choking incident. The Administrator confirmed the statements that were obtained by STNA #100, STNA #107, STNA #108, LPN #101, LPN #109, RN #102, and RN #103. The Administrator reviewed the information in the fire department EMS report and call log. The Administrator indicated that the resident had a history of [REDACTED]. The Administrator stated during that incident the resident was able to clear the food on her own after coughing. The Administrator stated consent was signed related to dysphagia education of advancing the resident to the mechanical soft diet. The Administrator indicated on [DATE] STNA #100 was passing out the trays to the residents in the hall. The Administrator indicated there was something being served as the main dish that was presented for the resident who was on the mechanical soft diet without altering the meal. The Administrator indicated this was soft steamed rice, sweet and sour chicken, and vegetables which would have been appropriate for a resident on a mechanical soft diet without altering the food. Resident #24 did not want the main meal. Resident #24 requested beef hot dogs with ketchup, mustard and onions. The Administrator indicated Cook #110 gave the hot dogs sliced in the middle and sent it down the hall on the tray. The Administrator stated the STNA #107 passed the trays down the hall and gave Resident #24 the tray as the cook prepared it. The Administrator indicated STNA #107 asked Resident #24 at that time if she wanted her to cut her meat up some more and the resident refused. The Administrator confirmed the resident was left alone and was not seen again per the interviews until STNA #100 responded to the resident ' s call light when the resident was choking. The Administrator indicated STNA #100 yelled down the hall for the nurse and the nurse came to the room right away and started to do the Heimlich maneuver. Interview on [DATE] at 1:05 P.M. with STNA #107 revealed that she passed Resident #24 ' s tray on [DATE]. STNA #107 stated that Resident #24 requested to have STNA #107 get her some food from a restaurant outside the facility. STNA #107 stated she told Resident #24 she could not do that because STNA #107 did not have a car. STNA #107 stated Resident #24 then stated she did not want the main meal served and wanted a hot dog instead. STNA #107 confirmed that she notified dietary that the resident was requesting a hot dog. STNA #107 stated that the resident did not specify anything else just that the resident wanted two hot dogs with ketchup, mustard, and onion. STNA #107 stated the trays were passed late that evening at approximately 5:45 P.M. STNA #107 indicated that the cook was new and she thought that was why the trays may have been late. STNA #107 stated Resident #24 ' s tray consisted of two hot dogs that were sliced down the middle and chopped up. STNA #107 stated the pieces of the hot dog were approximately three fourths an inch and symmetrical on whole buns. STNA #107 indicated that the kitchen determines who can have bread and who cannot. STNA #107 stated that I would of thought the kitchen knew what they were to provide to the resident related to the mechanical soft diet. STNA #107 stated that she thought the meat should have been ground as sometimes it was but confirmed that she did not return the tray to the kitchen to verify the texture. STNA #107 stated that she did ask the resident if she wanted the food cut up more after providing the meal to her and the resident stated no . STNA #107 revealed that she did not know whether Resident #24 required any supervision or dining assistance. STNA #107 indicated that she was not Resident #24 ' s aide at the time. STNA #107 indicated that Resident #24 started eating after everything was set up for the resident and then STNA #107 left the resident ' s room and continued passing trays to the other residents. STNA #107 stated that the resident used to go to the dining room for meals but for an unknown reason, started to refuse going to the dining room. STNA #107 stated that when Resident #24 would eat in the dining room there was a lot of slobber and drool while she was eating and STNA #107 thought the resident might be uncomfortable around the other residents because of this. STNA #107 stated that she did not see Resident #24 until LPN #101 came over to the unit to get RN #102 and RN #103. STNA #107 stated she went to Resident #24 ' s room. STNA #107 stated that she entered the resident ' s room and LPN #109 was on the resident ' s right side trying to talk to the resident and calling the resident ' s name. LPN #109 stated Resident #24 was unconscious. Resident #24 was slouched over to the right side in the wheelchair at that time. STNA #100 was on the left side of the resident holding her left arm up and patting the resident on the back. STNA #109 stated that she immediately went behind the resident and started to do the Heimlich maneuver while the resident was seated in the wheelchair. STNA #109 stated that she could not get the right positioning due to the resident ' s size. STNA #100 stated that the resident was over 300 pounds. STNA #107 stated she asked LPN #109 and STNA #100 to hold the resident ' s arms out in front of her to help with the positioning. STNA #107 stated this was also ineffective. STNA #107 denied any direction coming from LPN #109 on what to do. STNA #107 stated RN #103 and RN #102 arrived in the room. STNA #107 stated at this time someone else took over for me but was unable to indicate who did that and stated that this was also unsuccessful. STNA #109 indicated that by this time the resident ' s color was changing and the resident was turning black. STNA #109 stated that this was when we decided to put the resident in bed and perform CPR STNA #19 indicated the resident was transferred to the bed by herself, RN #102, STNA #108, STNA #100 and LPN #101. STNA #107 stated she did not remember anything different being done to the bed when the resident was placed on it. STNA #107 stated RN #102 started CPR on Resident #24 by doing compressions after the resident was in bed. STNA #107 stated RN #102 and STNA #100 rotated doing compressions. STNA #107 stated LPN #101 put oxygen over Resident #24 ' s nose and stated that she tried to do a mouth sweep. STNA #107 stated that she could see the food stuck in Resident #24 ' s throat but could not get it out and did not want to push the food further back. STNA #107 stated LPN #101 was doing the mask . STNA #107 indicated it was a mask that was squeezed on the side and they were rotating that to but could not remember who all was involved. STNA #107 stated she remained in the room until the paramedics arrived and then left the room. Interview on [DATE] at 2:22 P.M. with Speech Therapist (ST) #126 revealed Resident #24 was admitted from the hospital in [DATE]. ST #126 indicated that prior to admission the hospital identified that Resident #24 needed honey thick liquids and a pureed diet. ST #126 indicated the resident was started on speech therapy on admission, and therapy completed oral motor exercises with Resident #24. ST #126 stated Resident #24 had a lot of leakage of saliva and a large tongue. ST #126 stated Resident #24 had aspiration and respiratory issues consistently. ST #126 indicated Resident #24 was noncompliant with therapy recommendations including eating the appropriate texture of foods. ST #126 indicated that when she was present with Resident #24, the resident would be compliant including with the oral motor exercises, however would not do the recommended exercises that the resident was able to do independently. ST #126 indicated Resident #24 was honest about not completing the exercises and continuing to eat regular food against recommendations. ST #126 stated Resident #24 wanted her diet advanced. The physician ordered a modified barium swallow (MBS) in March of 2015. ST #126 stated Resident #24 came back from the hospital and stated that she passed her MBS. The results of Resident #24 ' s MBS were not back. ST #126 stated that she was not here but another speech therapist (unidentified) was and was asked by nursing to sit in with the resident while eating. ST #126 indicated Resident #24 ordered food from outside the facility and was going to eat the food. ST #126 stated that the other ST sat with the resident while the resident ate the meal. ST #126 stated the resident had a choking episode while eating the regular textured chicken that was ordered. ST #126 stated that the chicken was cleared with direction from the nursing staff that was with Resident #24. ST #126 indicated that the ST that was with the resident that day recommended to have the chicken cut up more but the resident stated it would lose flavor. ST #126 stated that at that point it was safer for staff being with Resident #24 at the time since the resident was not being compliant with the texture recommended. ST #126 indicated Resident #24 was educated that ST #126 did not recommend the mechanical soft diet that the hospital MBS recommended. ST #126 stated she recommended Resident #24 stay on the pureed diet and advance slowly. ST #126 indicated since the resident wanted to have the diet advanced as per the recommendations of the swallow study that was completed on [DATE] education was provided regarding dysphagia and pulmonary risks involved. ST #126 indicated the resident still wanted to have the diet advanced to mechanical soft. ST #126 stated the resident was not making progress in her opinion and was discharged from therapy on [DATE]. ST #126 confirmed when the resident was discharged from therapy on [DATE] she recommended the resident be supervised closely for meals. Interview on [DATE] at 3:50 P.M. with Cook #110 revealed Cook #110 had been employed for about three weeks and confirmed part of her responsibilities was to cook and plate the food for the residents. Cook #110 indicated that she received training including following meal spread sheets, plating trays, and what a mechanical soft diet was. Cook #110 indicated mechanical soft meat was ground up with gravy or served moist. Cook #110 indicated the meal on [DATE] was already appropriate for a mechanical soft diet. Cook #110 indicated it was steamed rice, sweet and sour chicken (the chicken came diced already) and vegetables. Cook #110 indicated she prepared the meal for Resident #24 and placed it on the cart. STNA #107 came to the kitchen and stated that Resident #24 wanted an alternate meal and requested two beef hot dogs. Cook #110 indicated that the resident requested relish, ketchup, mustard, and onions. The onions were diced and placed on the hot dog while the other condiments were in packets sent on the tray. Cook #110 stated there were no problems with any of the kitchen equipment including the equipment used to grind the meat. Cook #110 stated

Based on medical record review, staff interview, review of personnel records, and review of facility self-reported incident reports, the facility failed to prevent physical abuse to one resident (Resident #27). This resulted in Immediate Jeopardy for one resident (Resident #27) when a staff member held her arm down and spit in her face during care. Resident #27 sustained a five inch by two inch bruise to the left wrist and forearm. This affected one of two residents reviewed in self-reported incidents for abuse and injury of unknown origin. On 06/01/15 at 3:23 P.M. the Administrator, Director of Nursing (DON), and Regional Nurse #12 were notified that Immediate Jeopardy began on 04/22/15 at 8:30 P.M. when State-tested Nurse Aide (STNA) #3 held down Resident #27's arm during care and spit in the resident's face. This was witnessed by STNA #1 and STNA #2. The incident was not reported until 04/23/15 at 9:25 P.M., when STNA #1 informed Licensed Practical Nurse (LPN) #4 of the incident. LPN #4 notified the DON on 04/23/15 at 9:26 P.M. and was instructed to immediately send STNA #3 home. Resident #27 was assessed from head to toe and a 5.2 inch by 2 inch area of ecchymosis (bruise) that was pale blue in color was noted on the left wrist and forearm. The Immediate Jeopardy was removed on 04/24/15 when the facility implemented the following corrective actions: . On 04/23/15 at 9:26 P.M., STNA #3 was sent home from work and did not return to work at the facility. · On 04/23/15, 04/24/15 and 04/25/15, the DON, Registered Nurse (RN) #5, RN #11, RN #18, LPN #4, LPN #19, LPN #20, LPN #21, and LPN #22, completed skin checks on all 53 residents and found no new or unexplained injuries. The skin checks were reviewed by the DON. · On 04/24/15, Therapy Director #13, Social Service Director #14, Business Office Manager #15 and Maintenance Director #16 interviewed the 41 interviewable residents specifically in regard to STNA #1, STNA #2 and STNA #3, and the care provided by them. All of these residents were also interviewed in regard to abuse or neglect since they resided in the facility and what they would do if they were abused. · On 04/23/15, and 04/24/15, the DON and the Administrator conducted inservice training on abuse reporting, intervention, and dealing with residents with behaviors for 14 STNAs, 5 LPNs, 5 RNs, 7 Dietary Staff, 8 Housekeeping Staff, 13 Therapy Staff, 2 Activities Staff and 1 Social Service Staff. · On 04/24/15, the DON and the Administrator interviewed 13 STNAs, 3 RNs and 4 LPNs in person or by phone in regard to witnessed abuse or neglect involving STNA #1, STNA #2 and STNA #3 and whether they ever witnessed any employee of the facility abuse or neglect any resident. They were also interviewed in regard to knowledge of abuse and/or neglect reporting. · On 05/01/15, 3 STNAs, 2 RNs, 1 Therapy Staff, 1 Dietary Staff, the Business Office Manager #15 and Director of Maintenance #16, attended the Crisis Prevention Institute - Maintaining Safety in the Nonviolent Crisis Intervention Training Program. · On 05/01/15, STNA #1, STNA#2 and STNA#3 were terminated from employment by the facility. · On 05/07/15, 3 STNAs, 1 RN, 7 Therapy Staff, 1 Housekeeping Staff attended the Crisis Prevention Institute - Maintaining Safety in the Nonviolent Crisis Intervention Training Program. A third training session was scheduled for 06/02/15 for 12 STNAs, 1 RN and 4 LPNs. · On 05/29/15, the DON and Administrator conducted another inservice training on abuse reporting, intervention, and dealing with residents with behaviors for 1 Housekeeping Staff, 1 Dietary staff and two Therapy staff. · On 06/02/15, from 9:10 A.M. until 10:00 A.M. the surveyor interviewed STNA #7, STNA #8, STNA #9, LPN #10 and RN #1 regarding abuse, neglect, misappropriation, reporting, and protection of residents. All answered the abuse questions correctly and stated they would report any suspected abuse, neglect and misappropriation immediately to a supervisor. All stated they were recently in-serviced at the end of April or early May for abuse, neglect, reporting and dealing with residents with behaviors. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as training on abuse reporting, intervention, and dealing with residents with behaviors has not been completed for all staff including 5 STNAs, 1 RN and 1 Housekeeping staff. Findings include: Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility self-reported incident (SRI) dated 04/23/15, revealed an incident of witnessed abuse that the facility substantiated. The report indicated STNA #1 reported to LPN #4 on 04/23/15 at 9:25 P.M., that on 04/22/15 at approximately 8:30 P.M., STNA #1 was assisting STNA #2 in providing care for Resident #27. Resident #27 was resistive to care and combative with staff. STNA #3 entered the room to provide further assistance. STNA #1 and STNA #2 witnessed STNA #3 hold Resident #27's arms down and then spit in the resident's face. LPN #4 reported this to the DON on 04/23/15. Review of STNA #1's written statement dated 04/23/15, revealed STNA #3 grabbed Resident #27's arms by the wrist and held her arms back. STNA #3 then told the resident, You better not bite me. You already bit me once and I had to go to the hospital. I promise you'll never bite me again. Resident #27 then blew her lips and spit at STNA #3. STNA #3 then spit on Resident #27's face and it landed on her cheek. STNA #3 let go of the resident's arms and said, Now wipe it off. Review of the facility's investigation report revealed the allegation of physical abuse was substantiated when the facility determined that STNA #3 held down Resident #27's arms and spit in her face in retaliation for the resident spitting in STNA #3's face. Review of a nursing progress note dated 04/23/15 at 9:26 P.M., and written by the DON, indicated the DON received a call from LPN #4 who stated STNA#1 told her that on 04/22/15 at approximately 8:30 P.M., she and STNA#2 were assisting Resident #27 to bed. The resident was agitated, yelling and swinging her arms around. RN #5 entered the room and attempted to calm and reassure Resident #27. The STNAs were able to transfer the resident to bed. Once in bed, Resident #27 became agitated again. STNA#3 entered the room and held on to the resident's arm. Resident #27 started spitting and STNA#3 told the resident not to spit, and then STNA#3 spit at the resident. The DON instructed LPN #4 to send STNA#3 home. Resident#27 was assessed from head to toe. An area of ecchymosis (bruising) was observed on her left anterior wrist and forearm, 5.2 inches by 2 inches and pale blue in color. Review of the undated, written statement provided by RN #5 referenced the incident on 04/22/15 and revealed that after Resident #27 was in bed, RN #5 asked STNA #1, STNA #2 and STNA #3 if they required more assistance and they expressed they did not. RN #5 left the room. At that time, RN #5 did not observe a bruise on Resident #27's arm. On the morning of 04/23/15 (no time provided), STNA #6 showed RN #5 the bruise on Resident #27's left arm. Review of a nursing progress note for Resident #27 dated 04/24/15 at 7:51 A.M. and written by the DON, documented there was an ecchymotic area on the left anterior wrist and forearm that was purple with red edges and measured 5.2 inches by 2 inches. The above information was verified with the DON on 05/27/15 at 3:19 P.M. The DON stated that the facility substantiated the abuse occurred and that STNA #3 was terminated from the facility. Review of the facility investigation report documented that upon notification of the 04/22/15 incident; the facility initiated an investigation and notified the State agency. STNA #3 was sent home from the facility. Review of STNA #3's time card/punch detail revealed the STNA clocked out on 04/23/15 at 9:25 P.M. STNA #3 did not punch in to work again after that. Review of STNA #3's personnel file revealed STNA #3 was terminated from the facility via phone on 05/01/15. Review of STNA #1's time card/punch detail revealed STNA #1 last punched out of the facility on 04/24/15 at 6:36 A.M. and did not punch in to work again after that. Review of STNA #1's personnel file revealed STNA #1 was terminated from employment at the facility on 05/01/15. Review of STNA #2's time card/punch detail revealed STNA #2 punched out of the facility on 04/22/15 at 10:33 P.M. STNA #2 did not punch in to work again after that. Review of STNA's personnel file revealed STNA #2 was terminated from employment at the facility on 05/01/15. During an interview on 06/01/15 at 11:21 A.M., the facility Administrator stated that on 04/23/15, LPN #4 notified the DON of the incident of abuse that occurred on 04/22/15. On 04/23/15 STNA #3 was sent home. The facility initiated an investigation of the incident. The facility also initiated an investigation into the bruise on Resident #27's left arm and wrist. The Administrator stated that STNA #1, STNA #2 and STNA #3 came to the facility in the morning (unable to provide exact time) of 04/24/15 as part of the investigation and re-enacted the incident of 04/22/15. The Administrator stated they were not able to determine if the bruise was caused by STNA #1 or STNA #3. STNA #2 was at the foot of the bed. The facility determined that STNA #3 did spit in Resident #27's face, and terminated STNA #3 on 05/01/15. The facility terminated STNA #1 and STNA #2 on 05/01/15 for failure to immediately report the incident of abuse. On 06/02/15 at 8:30 A.M. the surveyor observed Resident #27. There were no visible bruises. The surveyor attempted to interview Resident #27. Resident #27 was not interviewable; she was very pleasant, very confused and did not answer questions appropriately.

Based on record review, interview and observation, the facility failed to ensure the air- mattress on Resident #70's bed functioned properly. Resident #70 was found on a partially deflated air-matress with blisters and abrasions to his forehead, right temporal area and his right upper extremity. This affected one of 11 residents who had air mattresses on their beds. Facility census was 75. Findings include: Review of Resident #70's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment dated [DATE] revealed Resident #70 had total dependence on two persons for bed mobility and functional limitation in range of motion to both sides of his upper and lower extremities. A care plan dated 11/30/11 revealed due to impaired cognitive function staff needed to anticipate his needs, keep him clean, dry, odor free and comfortable. The care plan also indicated, under the area of activities of daily living, the resident required two persons to transfer and staff needed to reposition and turn him in bed. Nurse's notes dated 01/18/13 at 7:00 A.M. revealed blisters were noted on the right arm and forehead of Resident #70. The blisters to the right arm were open. The nurse medicated Resident #70 with Vicodin (a narcotic pain medication). Nurse's notes dated 01/18/13 at 9:30 A.M. revealed the physician was contacted regarding the blisters and increased pain. At 2:00 P.M. Resident #70 was transported to the hospital for evaluation of the blisters, abrasions and to ensure there were no other injuries which were not visible. Review of the facility's investigation related to the injuries revealed a statement dated 01/18/13 written by Licensed Practical Nurse (LPN) #1. The statement indicated on 01/17/13 at 9:30 P.M. she was notified Resident #70 was in his bed positioned on his right side with some deflation noted on the right side of the air-mattress, the left side of the air-mattress was fully inflated. LPN #1 and State tested Nurse Aide (STNA) #2 turned the air- mattress off then back on and switched the settings. LPN #1 told STNA #2 to keep checking on the resident. A statement dated 01/18/13 written by STNA #2 revealed on 01/17/13 at 10:00 P.M. the side of Resident #70's bed closest to the door looked over inflated and the side by the window had less air. STNA #3 entered the room. STNA's #2 and #3 could not hear the air- mattress working, so they turned it off and then back on. They thought the bed would reset itself. STNA #2 wrote that she asked the two night shift aides to keep an eye on Resident #70 "because of the bed." A statement dated 01/18/13 written by STNA #4 revealed on 01/18/13 she entered Resident #70's room and found Resident #70 laying on the edge of the right side of the bed, she notified LPN #5. The statement did not indicate a time. LPN #5's statement, dated 01/18/13, revealed when she entered Resident #70's room the air-mattress was not working properly. The statement did not indicate a time. LPN #5 instructed STNA #4 to get the resident out of the bed. Interview with LPN #5 on 02/01/13 at 10:38 A.M. revealed she observed Resident #70 on 01/18/13 between 6:45 A.M. and 7:00 A.M. The air- mattress was "pretty much deflated." Resident #70 was on his right side with his body lying against the metal frame of the bed and his head was resting on the storage closet next to the bed. The air-matress was not alarming. At this time LPN #5 noted blisters to Resident #70's forehead, right temporal area and his right upper arm. The blisters on his right upper arm were open. Interview with STNA #4 on 02/01/13 at 10:42 A.M. revealed on 01/18/13 she entered Resident #70's room about 6:35 A.M. The air-matress was not alarming. Resident #70 was on the edge of the bed, "kind of on his side." STNA #4 said she was not sure what was holding him in bed, the bed did not have siderails. Only 1/2 of the air- mattress was inflated. Resident #70 was awake and alert. She reported her findings to LPN #5 and with the assistance of two other STNAs Resident #70 was transferred to a chair. STNA #4 said the night shift normally washed and dressed Resident #70 but on 01/18/13 Resident #70 had not been washed or dressed. He was wet with urine. Review of wound evaluation flow sheets dated 01/18/13 revealed the following wounds: 1. Blister to the proximal right upper extremity measuring 12.5 centimeters (cm) x 2.5 cm 2. Blister to distal right upper extremity measuring 0.5 cm x 7.5 cm. 3. Abrasion to forehead measuring 6.0 cm x 4.0 cm. Observation of Resident #70 on 02/01/13 at 2:20 P.M. revealed he was awake and alert. His speech was difficult to understand. The skin on his forehead and temporal area was healed, all pigmentation had returned. His right upper arm had two pink healing areas with spotty areas of pigmentation returning. The larger of the two areas measured 12 cm x 2.5 cm. Review of the Owner's Operator and Maintenance Manual revealed the air-matress had an alarm silence feature. Staff were able to press the alarm silence button to acknoweldge and silence the alarm when there was a low air pressure detected or when power to the pump failed. The operator manual indicated if the mattress stayed soft on one side for more than two hours the supplier should be contacted. This is an example of continued non-compliance from the annual survey of 01/04/13.