Every finding on record at Piqua Manor

Based on record review, observation, interviews, and facility policy review, the facility failed to ensure staff completed hand hygiene. This affected three residents, (#02, #07, and #17) of three reviewed for infection control. The facility census was 90. Findings Include: 1. Review of medical record for Resident #02 revealed the resident was admitted to the facility on [DATE]. Diagnoses included epilepsy, neuromuscular dysfunction of bladder, atrial fibrillation, and obesity. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #02 had Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. Resident #02 was dependent on dressing her lower body and toileting hygiene. Resident #02 required substantial to maximal assistance for bathing and personal hygiene. Resident #02 used a manual wheelchair to ambulate. 2. Review of medical records for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, major depression, and mild cognitive impairment. Review of the quarterly MDS dated [DATE] revealed Resident #17 had BIMS of 15 indicating intact cognition. Resident #17 required substantial to maximal assistance for toileting hygiene, putting on and off shoes, and personal hygiene. Resident #17 required partial to moderate assistance for dressing upper body and bathing. Resident #17 used a manual wheelchair to ambulate.3. Review of medical record for Resident #07 revealed the resident was admitted to the facility on [DATE]. Diagnoses included right heart failure, Type Two Diabetes, and chronic kidney disease stage three. Review of the quarterly MDS dated [DATE] revealed Resident #07 had BIMS of 14 indicating intact cognition. Resident #07 was dependent for dressing lower body and toileting hygiene. Resident #07 required substantial to maximal assistance for dressing upper body, bathing, and personal hygiene. Resident #07 required partial to moderate assistance in eating and oral care. Observation on 06/29/26 at 3:18 P.M. through 3:21 P.M. of Certified Nursing Assistant (CNA) #239 and CNA #228 revealed the staff came to assist Resident #02 to transfer the resident to her bathroom toilet. CNA #239 and CNA #228 were observed to put on gloves and assist Resident #02 in her bathroom, pull down Resident #02's pants and placed her on the toilet with assist of the sit to stand lift. Resident #02 was educated by the CNA's to place her call light on when she was finished. CNA #239 and CNA #228 were observed to remove their gloves and exit the room. Hand hygiene was not performed by either CNA prior to putting on gloves or after removing their gloves. Observation on 06/29/26 at 3:22 P.M. revealed CNA #228 exited Resident #02's room and was observed to answered the call light in Resident #07's room. CNA #228 entered Resident #07's room and turned off the resident's call light. Then CNA #228 was observed to sit down on Resident #07's bed to talk to Resident #07. CNA #228 was observed to exit Resident #07's room. CNA #228 did not perform hand hygiene when entering or exiting Resident #07's room. Observation on 06/29/26 at 3:23 P.M. revealed CNA #239 entered Resident #17's room to provide assistance. CNA #239 was observed to talk with Resident #17 and assist Resident #17 with managing his bedside table. CNA #239 did not perform hand hygiene when she entered or exited Resident #17's room. Interview with CNA #239 on 06/29/26 at 3:25 P.M. confirmed she never performs hands hygiene after toileting Resident #02 in her room. CNA #239 verified she left Resident #02's room, and entered Resident #17's room and did not performed hand hygiene. CNA #239 additionally verified she did not perform hand hygiene after leaving Resident #17 room. Interview with CNA #228 on 06/29/26 at 3:26 P.M. confirmed she exited Resident #02's room and never performed hand hygiene after removing Resident #02's pants and placing Resident #02 on the toilet. CNA #228 confirmed she removed her gloves and left Resident #02's room. CNA #228 verified she entered Resident #07's room, and sat on the resident's bed and did not perform hand hygiene when she entered or exited the room. Review of the facility policy titled Standard Precautions Transmission-based Precautions General Principles dated 07/2003 and last revised 10/2019 revealed: Hand hygiene is performed before and after removing gloves; after touching potentially contaminated environmental surfaces or items and before caring for another resident. Review of the facility policy titled Standard Precautions Hand Hygiene dated 07/2003 and last revised 10/2019 revealed: hand hygiene was essential to reducing over-all infections. Hand hygiene was number one defense in preventing infections. When to use alcohol hand sanitizer: only when visible soil is absent, after contact with resident's intact skin (as in taking pulse, blood pressure, or repositioning a resident), after contact with inanimate objects (including medical equipment), before donning sterile gloves, before entering the resident's room, before exiting the resident's room, and have residents use prior to eating or group activities. This deficiency represents non-compliance investigated under Complaint Number 3018113.

Based on observation, staff interview, and policy review, the facility failed to store food in a safe manner. This had the potential to affect all residents who received food from the kitchen. The facility identified four (#12, #38, #85, and #98) residents who received nothing by mouth. The census was 87.Findings include: Observation of the kitchen on 03/23/26 at 7:55 A.M., during the initial tour with Nutrition Services Assistant (NSA) #48, revealed three storage refrigerators not in temperature range to prevent food-borne illnesses. Further observation revealed refrigerator #1 registered 50 degrees Fahrenheit (F) on the internal thermometer, refrigerator #2 registered 46 degrees F on the internal thermometer, and refrigerator #3 registered 50 degrees F on the internal thermometer.Observation and interview on 03/23/26 at 7:57 A.M. revealed NSA #48 obtained pudding from refrigerator #1 and revealed a temperature of 45 degrees F and the temperature of milk from refrigerator #3 was 45 degrees F. NSA #48 confirmed the refrigerator and food temperatures. Review of a policy titled, Infection Control/Food Safety Storage of Perishable Foods, dated 01/2026, revealed a reliable thermometer shall be provided in a clearly visible position placed inside each refrigerator and freezer, close to the door. Refrigerator temps should be 41 degrees or below.

Based on observation, resident interview, and staff interview, the facility failed to ensure a reasonable accommodations were made for a resident related to placement and use of a urinal in the resident's room. This affected one (#71) of one residents reviewed for accommodation of needs. The census was 87.Findings include:Observation on 03/23/26 at 9:28 A.M. revealed a urinal with 1000 milliliters (mls) of urine inside was placed on a bedside tray table in Resident #71's room, the same surface utilized for meals and personal items. Resident #71's medication and personal items were sitting on bedside tray at the time of the observation.Interview on 03/23/26 at 9:28 A.M. with Resident #71 revealed the resident did not like the urinal being placed on the bedside table, reporting there was no other place to put urinal. Observation at the time of the interview revealed no alternative storage or designated area available for the urinal within Resident #71's reach.Interview on 03/23/26 at 9:30 A.M. with Certified Nurse Aide (CNA) #75 verified Resident #71's urinal was routinely placed on the bedside tray for accessibility and acknowledged the resident had expressed concerns but no changes were made.Interview on 03/23/26 at 9:40 A.M. with Registered Nurse (RN) #15 verified Resident #71's urinal was routinely placed on the bedside tray for accessibility. RN #15 discussed with Resident #71 to place snacks in a basket on bedside tray and place urinal on bedside table with no other items.

Based on paper and electronic medical record review, staff interview, and policy review, the facility failed to ensure the resident's code status was consistent throughout the entire medical record. This affected one (#103) of one residents reviewed for advanced directives. The census was 87. Findings include: Review of Resident #103's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including urinary tract infection, hypertensive chronic kidney disease, type II diabetes, unspecified dementia, atrial fibrillation, and peripheral vascular disease. Review of Resident #103's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognitive status was assessed as moderately impaired.Review of Resident #103's physician's orders in the electronic health record (EHR) revealed an order dated [DATE] for a code status of Do Not Resuscitate Comfort Care - Arrest (DNRCC-A; the resident would be receive cardiopulmonary resuscitation (CPR) until the heart or breathing stops the comfort care measured would be implemented).Review of Resident #103's physical (paper) medical record revealed a document dated [DATE] indicating the resident was a full code (CPR is initiated for heart or respiratory arrest). There was no state DNR form found in the paper record.Review of Resident #103's plan of care dated [DATE] revealed the resident was identified with a code status of DNRCC-A.Interview with Licensed Practical Nurse (LPN) #45 on [DATE] at 3:49 P.M. confirmed Resident #103's code status order in the paper medical record did not match the code status order in the resident's EHR. LPN #45 stated she would confirm with physician and family which code status was correct.Review of the facility advanced directives policy, dated [DATE], revealed advance directives will be reviewed with the resident and/or the responsible party upon admission.

Based on medical record review, staff interview, and policy review, the facility failed to notify the physician of a change in condition in a timely manner. This affected two (#106 and #96) of two residents reviewed for change in condition. The facility census was 87.Findings include:1. Review of the medical record for Resident #106 revealed an admission date of 07/19/24 with diagnoses including centrilobular emphysema, chronic obstructive pulmonary disease (COPD), and essential hypertension.Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 was cognitively intact. Resident required set-up assistance with eating, oral hygiene, bathing, personal hygiene, and required partial assistance with toileting hygiene, dressing, bed mobility, transfers, and ambulation. The resident was dependent on staff assistance with wheelchair mobility.Review of the physician order dated 07/19/24 revealed Resident #106 wore oxygen via nasal canula at three liters continuously.Review of the care plan dated 07/19/24 revealed Resident #106 used oxygen therapy relate to COPD with interventions to monitor for signs or symptoms of respiratory distress and report to the physician, such as respiration rate increase, increased heart rate, restlessness, lethargy, and accessory muscle usage.Review of the notification note dated 01/02/26 at 9:39 A.M. revealed Resident #106 was sent to hospital per family request. Further review of the medical record revealed no documentation of vital signs, assessments, or notification to the physician of a change in condition or hospitalization.Interview on 03/25/26 at 3:04 P.M. with the Director of Nursing (DON) confirmed she remembered on 01/02/26 Resident #106 was having trouble breathing in the middle of the night but refused to go to the hospital. The DON stated the resident's daughter came in to visit that morning, she convinced the resident to go to the hospital. The DON confirmed the staff nurse (Licensed Practical Nurse (LPN) #160) working the night of the change in condition did not document the resident's change in respiratory status. The DON confirmed there was no documentation of the physician being notified of the change in condition or of the physician being notified of the transfer to the hospital. The DON stated it was the expectation of the nurse to document all changes in condition, and to notify the physician and family when the change occurs. 2. Record review for Resident #96 revealed the resident was admitted to the facility on [DATE] with diagnoses including disruption of external operation surgical wound, infection following a procedure, acute and chronic combined systolic congestive and diastolic congestive heart failure, and type two diabetes mellitus with diabetic polyneuropathy.Review of the MDS assessment dated [DATE] revealed Resident #96 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 14. The resident was assessed to be taking antidepressant, hypnotic, diuretic, antiplatelet, insulin, and anticonvulsant medications, and received a therapeutic diet including low salt, diabetic, and low cholesterol.Review of the care plan dated 02/09/26 revealed Resident #96 was at risk for alteration in nutrition/hydration status related to a surgical wound, infection, respiratory failure, type two diabetes, congestive heart failure, heart disease, and chronic kidney disease. Resident #96 was on a therapeutic diet, which may impact weight and/or fluid balance. Interventions included to monitor weight per facility protocol and as needed per order; notify the physician of any significant weight change; and monitor, document, and report to the physician changes in lung sounds on auscultation, edema, shortness of breath, vital signs, and changes in weight.Review of the medical record for Resident #96 revealed a physician order dated 11/12/25 directing staff to notify the physician of a weight gain of two or more pounds in one day or five pounds in one week.Review of weight records revealed Resident #96 was noted to have a weight increase from 219.2 pounds (lbs.) on 03/20/26 to 223.2 lbs. on 03/21/26, totaling a gain of 4.0 lbs. Further review revealed Resident #96 also experienced a weight increase from 220.4 lbs. on 03/24/26 to 223.8 lbs. on 03/25/26, totaling a gain of 3.4 lbs. There was no documentation of the physician being notified of the weight gain in the medical record.Interview on 03/25/26 at 2:30 P.M. with Regional Clinical Nurse (RCN) #1 verified the physician was not notified on 03/21/26 or 03/25/26 regarding Resident #96's weight gain per physician order.Review of facility policy titled, Notification of Changes Policy, dated 11/02/16, revealed the facility will inform the resident, the attending physician, and the resident's representative or interested family member of changes which affect the resident.This deficiency represents non-compliance related to Complaint Number 2708212.

Based on observation, medical record review, staff interview, and policy review, the facility failed to investigate a resident skin condition obtained from trauma. This affected one (#38) of six residents reviewed for skin care. The census was 87.Findings include:Review of Resident #38's medical record revealed an admission date of 12/10/24. Diagnoses included malnutrition, psychotic disturbance, hearing loss, and dementia.Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had severely impaired cognition, had no pressure sores, and had open skin lesions.Review of progress notes revealed on 11/22/25 an open area to Resident #38's right hip was noted as being 1.0 centimeter (cm) long by 2.8 cm wide. On 11/25/25 Resident #38 was added to the nurse practitioner's (NP) weekly wound rounds. Further review of progress notes revealed no documentation of any incident related to Resident #38's right hip wound.Review of NP wound notes dated 11/25/25 revealed Resident #38 had a right hip full-thickness wound related to trauma measuring 0.5 cm long by 1.0 cm wide by 0.1 cm deep. The wound was documented as in-house acquired and was reportedly obtained while staff were getting Resident #38 up for a shower.Review of NP wound notes dated 03/17/26 revealed Resident #38 continued to have a right hip full-thickness wound related to trauma measuring 2.8 cm long by 1.5 wide by 0.8 cm deep. The wound was documented as in-house acquired and was reportedly obtained while staff were getting Resident #38 up for a shower.Interview with the Director of Nursing (DON) and Regional Clinical Nurse (RCN) #1 on 03/24/26 at 1:10 P.M. confirmed Resident #38's right hip wound was documented as the result of trauma. Both the DON and RCN #1 confirmed there was not an investigation completed or any documentation of the origin of Resident #38's right hip wound.Observation on 03/25/26 at 11:45 A.M. revealed Resident #38 had right hip wound.Review of the facility's policy titled, Accident and Incidents, dated revised April 2016, revealed the facility will ensure the resident's environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistive devices to reduce accidents. All accidents and/or incidents occurring on the facility premises or involving a resident and staff off the premises must be investigated and reported to the Administrator or his designee.

Based on observation, medical record review, and staff interview, the facility failed to ensure medications were maintained in a safe and secure manner. This affected one (#71) of one residents observed for medication storage. The census was 87.Findings include: Review of the medical record for Resident #71 revealed an order for chlorhexidine gluconate mouth/throat solution 0.12 percent (%), give 0.5 ounces by mouth two times a day for prophylactic with instructions to spit the medication out and do not swallow. Further review of Resident #71's medical record revealed no assessment for self-administration was completed.Observation on 03/23/26 at 9:36 A.M. revealed a medication cup with a light blue liquid substance on the bedside tray out of reach for Resident #71. The medication was not secured and was readily accessible to others.Interview on 03/23/26 at 10:06 A.M. with Resident #71 revealed medication was typically brought in and left on the bedside tray for him to take. Resident #71 stated he had already taken his pills but had not completed the mouthwash.Interview on 03/23/26 at 10:06 A.M. with Registered Nurse (RN) #15 verified the medication at Resident #71's bedside was chlorhexidine gluconate mouth/throat solution 0.12% and the medication should have been administered instead of left on table.Interview on 03/24/25 at 5:05 P.M. with Regional Clinical Nurse (RCN) #1 confirmed no self-administration assessment was completed for Resident #71 because the resident was not able to be self-administering medication. RCN #1 stated the facility completes medical self-assessments only if residents are capable to complete the task.

Based on medical record review, staff interview, and policy review, the facility failed to ensure the medical record was complete and accurate related to a resident's change in condition. This affected one (#106) of two residents reviewed for change in condition. The facility census was 87.Findings include:Review of the medical record for Resident #106 revealed an admission date of 07/19/24 with diagnoses including centrilobular emphysema, chronic obstructive pulmonary disease (COPD), and essential hypertension.Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 was cognitively intact. Resident #106 required set-up assistance with eating, oral hygiene, bathing, personal hygiene, and required partial assistance with toileting hygiene, dressing, bed mobility, transfers, and ambulation. Resident #106 was dependent on staff assistance with wheelchair mobility.Review of the care plan dated 07/19/24 revealed Resident #106 used oxygen therapy relate to COPD with interventions to monitor for signs or symptoms of respiratory distress and report to the physician, such as respiration rate increase, increased heart rate, restlessness, lethargy, and accessory muscle usage.Review of the notification note dated 01/02/26 at 9:39 A.M. revealed Resident #196 was sent to the hospital per family request. Further review revealed there were no specifics about the reason for the hospitalization including no documented vital signs or resident assessments. Interview on 03/25/26 at 3:04 P.M. with the Director of Nursing (DON) confirmed she remembered on 01/02/26 Resident #106 was having trouble breathing in the middle of the night but refused to go to the hospital. The DON confirmed when the resident's daughter came in to visit that morning, she convinced the resident to go to the hospital. The DON stated the staff nurse (Licensed Practical Nurse (LPN) #160) working the night of the change in condition did not document Resident #106's change in respiratory status, including no documentation of vitals signs and assessments of the resident. The DON stated it was the expectation of the nurse to document all changes in condition, and to notify the physician and family when the change occurred. Interview on 03/25/26 at 3:18 P.M. with LPN #160 confirmed on 01/02/26 when she arrived to work on day shift at 7:00 A.M., the start of the shift, she received report from the night shift nurse that Resident #106 was struggling to breath throughout the night. LPN #160 confirmed she took Resident #106's vital signs, but did not document the resident's condition or the vital signs in the medical record. Interview on 03/25/26 at 3:22 P.M. with the DON confirmed LPN #160 should have completed a Situation, Background, Assessment, and Recommendation (SBAR) assessment for Resident #106 when there was a change in condition or when the resident was transferred to the hospital.Review of the facility documentation policy, dated 10/2005, revealed the facility will document a complete account of resident's care including signs, symptoms, response to care, and episodic charting.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure staff wore appropriate personal protective equipment during high contact care interactions with residents in enhanced barrier precautions. This affected two (#12 and #38) of 11 residents reviewed for EBP. The census was 87.Findings include: 1. Review of Resident #38's medical record revealed an admission date of 12/10/24. Diagnoses included malnutrition, psychotic disturbance, hearing loss, and dementia.Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had severely impaired cognition, had no pressure sores, and had open skin lesions.Observation on 03/25/26 at 11:48 A.M. revealed Assistant Director of Nursing (ADON) #1 did not put on a gown before performing Resident #38's right hip wound treatment. Further observation revealed a sign posted above the head of Resident #38's bed informed staff to use enhanced barrier precautions (EBP) when performing high contact activities of which wound care was listed.Interview with ADON #1 on 03/25/26 at 11:55 A.M. confirmed she did not put on a gown when performing Resident #38's right hip wound treatment and confirmed Resident #38 was in EBP.2. Review of Resident #12's medical record revealed and admission date of 02/17/26. Diagnoses included muscle weakness, chronic hepatitis, malnutrition, and mechanical ventilator dependence.Review of an admission MDS assessment dated [DATE] revealed Resident #12 had severely impaired cognition, required tracheostomy care, and an invasive mechanical ventilator.Observation on 03/25/26 at 1:52 P.M. revealed Respiratory Therapist (RT) #67 did not put on a gown before performing Resident #12's tracheostomy care. Further observation revealed a sign posted above the head of Resident #12's bed informed staff to use EBP when performing high contact activities of which tracheostomy care was listed.Interview with RT #67 on 03/25/26 at 1:59 P.M. confirmed she did not put on a gown when performing Resident #12's tracheostomy care and confirmed Resident #12 was in EBP.Review of the facility's policy titled, Enhance Barrier Precautions, dated revised August 2022, revealed it is the policy of the facility to use EBP to prevent transmission of multi-drug resistant organisms (MDROs) from an infected or colonized resident through an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. High contact areas included dressing, bathing/showering, transferring, providing hygiene, changing linens, changing attends or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care: any skin opening requiring a dressing. An impervious gown should be worn when high-contact resident care activities are being performed.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure influenza and pneumococcal vaccinations were offered and administered to residents. This affected three (#7, #38, and #70) of five residents reviewed for immunizations. The census was 87.Findings include: 1. Review of Resident #7's medical record revealed an admission date of 11/05/25. Diagnoses included multiple sclerosis, sleep apnea, diabetes mellitus type two, depression, and congestive heart failure.Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact.Further review of Resident #7's medical record revealed a date of birth of [DATE] which represented the resident's age as [AGE] years old.Review of Resident #7's immunization list revealed no documentation of a pneumococcal vaccine being offered or administered and no documentation of Resident #7 previously receiving a pneumococcal vaccine.2. Review of Resident #38's medical record revealed an admission date of 12/10/24. Diagnoses included malnutrition, psychotic disturbance, hearing loss, and dementia.Review of an annual MDS assessment dated [DATE] revealed Resident #38 had severely impaired cognition.Further review of Resident #38's medical record revealed her date of birth was 11/16/49 which represented the resident's age as [AGE] years old.Review of a pneumococcal vaccine consent document dated 12/13/24 revealed Resident #38's son signed that Resident #38 had previously had a pneumococcal vaccine. Review of Resident #38's immunization list revealed no documentation of a pneumococcal vaccine being offered or administered at the facility. There was no documentation of what date Resident #38 previously received a pneumococcal vaccine or what type of vaccine was received.3. Review of Resident #70's medical record revealed an admission date 01/07/26. Diagnoses included atrial fibrillation, liver failure, depressive disorder, anxiety disorder, and kidney failure.Review of a significant change MDS assessment dated [DATE] revealed Resident #70 was cognitively intact.Review of an influenza vaccine consent form revealed Resident #70 signed and consented to the vaccine on 01/09/26.Review of Resident #70's medication administration records (MARs) revealed on 01/13/26 the influenza vaccine was documented as being held and to see nursing notes. Review of the resident's nursing notes revealed no documentation of a reason the influenza vaccine was held.Review of Resident #70's immunization list revealed no documentation of an influenza vaccine being administered at the facility.Interview with Regional Clinical Nurse (RCN) #1 on 03/25/26 at 4:10 P.M. confirmed there was no documentation of Resident #7 being offered or receiving the pneumococcal vaccine while at the facility. RCN #1 confirmed there was no documentation of Resident #70 previously receiving a vaccine. RCN #1 confirmed Resident #38 had not been re-offered the pneumococcal vaccine since 2024. RCN #1 confirmed there was no documentation of when Resident #38 received a pneumococcal vaccine or what type was administered. RCN #1 confirmed both Resident #7 and Resident #38 were eligible to receive the pneumococcal vaccine due to age and health conditions. Review of the facility's policy titled, Resident Pneumococcal Vaccination, revised April 2022, revealed each resident's vaccination status will be determined upon admission and will be documented in the medical record. Current residents will have their medical record reviewed for immunization status yearly and as needed. All residents without documented history of immunizations or with unknown pneumococcal vaccination status will be educated on and offered the vaccine sequence.Review of the facility's policy titled, Resident Influenza (Flu) Vaccination, revised April 2022, revealed current and newly admitted resident's will be offered the influenza vaccine from October of each year through the end of March of the following year. Each resident's immunization status will be determined prior to vaccination and will be documented in the resident's medical record. A resident who received the vaccination prior to admission will not receive the vaccine.

Based on medical record review, staff interviews, review of the facility investigation information and policy review, the facility failed to report an allegation of abuse. This affected one (#85) resident out of three reviewed for abuse. The facility census was 90.Findings include:Review of the medical record for Resident #85 revealed an admission date of 08/26/22 with medical diagnoses of senile degeneration of brain, hypertension, diabetes mellitus, and unspecified psychosis. Review of an annual Minimum Data Set (MDS) assessment, dated 06/02/25, indicated Resident #85 had severe cognitive impairment and required partial/moderate staff assistance with bathing/showers, supervision with bed mobility and transfers, and set-up assistance with eating. Interviews on 08/22/25 between 9:30 A.M and 10:26 A.M. with Licensed Practical Nurse (LPN) #207 and #205 and Certified Nursing Assistant (CNA) #202, #217, and #227 all stated they were aware of an allegation that CNA #220 took a photo of Resident #85 when the resident was walking in her room topless. They all confirmed they had not been working on 06/13/25, the day of the allegation, but confirmed they received education on the facility policy for phone use at work. Interview on 08/22/25 at 11:00 A.M. with Housekeeper #231 stated on 06/13/25 she was at the nurses' station across from Resident #85's room and observed Resident #85 walking toward the closet in her room. Housekeeper #231 stated Resident #85 had pants on but was topless. Housekeeper #231 stated she observed CNA #220 state Oh, look at Resident #85. I need to take a picture and sent to Resident #85's daughter. Housekeeper #231 stated she observed STNA #220 take her phone out of her pocket, and appeared she take a picture of Resident #85. Housekeeper #231 stated she immediately reported the incident to the facility Administrator. Interview on 08/22/25 at 11:32 A.M. with Director of Nursing (DON) confirmed an allegation of abuse had been made that CNA #220 took a photo of Resident #85 while she was in her room and topless. DON stated the Administrator had been made aware of the allegation of abuse and interviewed witnesses CNA #211 and Housekeeper #231 and took their statements. DON also stated the Administrator interviewed CNA #220 who denied taking a picture of Resident #85. DON confirmed Administrator did not interview the two CNAs in training who were also present at the time of the incident per witness statements. DON confirmed the facility had not completed a Self-Reported Incident or notified Ohio Department of Health as per regulations. DON confirmed CNA #220 had been terminated on 06/13/25. Review of the facility policy titled, Abuse, Neglect, Injuries of Unknown Source, and/or Misappropriation of Resident Property, stated the facility would investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident or Misappropriation of Resident Property, including injury of unknown source, in accordance with the policy. Mistreatment was defined as inappropriate treatment or exploitation of a resident. The policy stated all allegations of abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, and all injuries of unknown source must be immediately reported to Administrator. The policy stated allegations of abuse or serious bodily injury must be reported to Ohio Department of Health (ODH) immediately, but no later than two hours after the allegation was made. The policy continued to state the Administrator, or his/her designee would notify ODH all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, and all injuries of unknown source as soon as possible but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. The policy stated the investigation protocol included interviewing the resident, the accused and any witnesses.This deficiency represents non-compliance investigated under Complaint Number 1385924.

Based on medical record review, staff interviews, review of the facility investigation information and facility policy review, the facility failed to thoroughly investigate an allegation of abuse. This affected one resident (#85) out of three reviewed for abuse. The facility census was 90.Findings include:Review of the medical record for Resident #85 revealed an admission date of 08/26/22 with medical diagnoses of senile degeneration of brain, hypertension, diabetes mellitus, and unspecified psychosis. Review of an annual Minimum Data Set (MDS) assessment, dated 06/02/25, indicated Resident #85 had severe cognitive impairment and required partial/moderate staff assistance with bathing/showers, supervision with bed mobility and transfers, and set-up assistance with eating. Interviews on 08/22/25 between 9:30 A.M and 10:26 A.M. with Licensed Practical Nurse (LPN) #207 and #205 and Certified Nursing Assistant (CNA) #202, #217, and #227 all stated they were aware of an allegation that CNA #220 took a photo of Resident #85 when the resident was walking in her room topless. They all confirmed that they had not been working on 06/13/25, the day of the allegation, but confirmed they received education on the facility policy for phone use at work. Interview on 08/22/25 at 11:00 A.M. with Housekeeper #231 stated on 06/13/25 she was at the nurses' station across from Resident #85's room and observed Resident #85 walking toward the closet in her room. Housekeeper #231 stated Resident #85 had pants on but was topless. Housekeeper #231 stated she observed CNA #220 state Oh, look at Resident #85. I need to take a picture and sent to Resident #85's daughter. Housekeeper #231 stated she observed CNA #220 take her phone out of her pocket, and appeared she take a picture of Resident #85. Housekeeper #231 stated she immediately reported the incident to the facility Administrator. Interview on 08/22/25 at 11:32 A.M. with Director of Nursing (DON) confirmed an allegation of abuse had been made that CNA #220 took a photo of Resident #85 while she was in her room and topless. DON stated the Administrator had been made aware of the allegation of abuse and interviewed witnesses CNA #211 and Housekeeper #231 and took their statements. DON also stated the Administrator interviewed CNA #220 who denied taking a picture of Resident #85. DON confirmed Administrator did not interview the two CNAs in training who were also present at the time of the incident per witness statements. DON confirmed the facility had not completed a Self-Reported Incident or notified Ohio Department of Health as per regulations. DON confirmed CNA #220 had been terminated on 06/13/25. Review of the facility investigation documentation revealed on 06/13/25 Administrator obtained witness statements from Housekeeper #231, CNA #211 and CNA #220. Review of witness statement from CNA #211 revealed documentation to support two CNAs in training were also present at the time of the incident. Review of the facility investigation information did not contain documentation to support the two CNAs in training were interviewed. Further review of the investigation revealed no documentation to support any residents on the hall were interviewed for concerns of abuse. Review of the facility policy titled, Abuse, Neglect, Injuries of Unknown Source, and/or Misappropriation of Resident Property, stated the facility would investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident or Misappropriation of Resident Property, including injury of unknown source, in accordance with the policy. Mistreatment was defined as inappropriate treatment or exploitation of a resident. The policy stated all allegations of abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, and all injuries of unknown source must be immediately reported to Administrator. The policy stated allegations of abuse or serious bodily injury must be reported to Ohio Department of Health (ODH) immediately, but no later than two hours after the allegation was made. The policy continued to state the Administrator, or his/her designee would notify ODH all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, and all injuries of unknown source as soon as possible but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. The policy stated the investigation protocol included interviewing the resident, the accused and any witnesses.This deficiency represents non-compliance investigated under Complaint Number 1385924.

Based on medical record review, observations, interviews, and policy review, the facility failed to ensure showers were provided as scheduled. This affected three (Residents #89, #72 #85) of three residents reviewed for bathing. The facility census was 94. Findings include: 1. Medical record review for Resident #89 revealed an admitted [DATE] with diagnoses including but not limited to stroke, diabetes mellitus type two, carpel tunnel bilateral upper extremities, hypertension and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the assessment was not completed at the time of the survey. Review of the plan of care for Resident #89 dated 02/23/24 revealed Resident #89 had an activities of daily living (ADL) self care performance deficit related to hypertension, stroke, diabetes, and cognitive impairment. Interventions included resident requires one staff participation with bathing, supervision with transfers and encouragement to use call bell for assistance. Observation and interview on 02/22/24 at 4:14 P.M. of Resident #89 stated he could not remember when his last shower was provided. Further stated unable to recall what day his showers were scheduled. Review of the response history documentation for Resident #89 dated 02/12/24 through 02/26/24 revealed no showers were documented as given for Resident #89. Interview on 02/27/24 at 2:19 P.M. with Corporate Registered Nurse (RN) #350 verified the facility did not have any additional documentation to indicate showers were provided for Resident #89. Further verified showers should have been completed two times a week. 2. Medical record review for Resident #72 revealed an admitted [DATE] with diagnoses including but not limited to iron deficiency anemia, arteriovenous malformation of cerebral vessels, hypertension, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the assessment was not completed at the time of the survey. Review of the plan of care for Resident #72 dated 2/12/24 revealed the resident had an ADL care performance deficit related to hemiplegia, limited mobility, pain, weakness, arteriovenous malformation of cerebral vessels. Interventions included physical therapy evaluation, occupational therapy evaluation, transfers with one or two staff members, use call bell for assistance and encourage resident to participate with each interaction. Review of the response history documentation for Resident #72 dated 01/26/24 through 02/26/24 revealed two showers were documented as given for Resident #72. Interview on 02/26/24 at 10:15 A.M. with Resident #72 revealed he was unsure of what days he received showers. Interview on 02/27/24 at 2:19 P.M. with Corporate (RN) #350 verified the facility documentation did not reflect any showers had been provided as scheduled and the facility did not have any additional documentation to indicate showers were provided for Resident #85. Further verified showers should have been completed two times a week. 3. Medical record review for Resident #85 revealed an admitted [DATE] with diagnoses including but not limited to maxillary fracture, protein calorie malnutrition, dementia, urinary retention, and heart failure. Review of the MDS assessment dated [DATE] for Resident #85 revealed impaired cognition. Resident #85 was not coded with refusal for care during the assessment period. The resident required extensive assistance for bed mobility, transfers, bathing and toileting. Review of the plan of care for Resident #85 dated 12/26/23 revealed the resident had an ADL self-care performance deficit related to impaired balance, limited mobility and weakness. Interventions included physical therapy evaluation, occupational therapy evaluation, transfers with one or two staff members, use call bell for assistance and encourage resident to participate with each interaction. Review of the response history documentation for Resident #85 dated 01/26/24 through 02/26/24 revealed no showers were documented as given for Resident #85. Interview on 02/27/24 at 2:19 P.M. with Corporate (RN) #350 verified the documentation did not reflect any showers had been provided as scheduled and the facility did not have any additional documentation to indicate showers were provided for Resident #85. Further verified showers should have been completed two times a week. Review of the facility policy titled, Quality of Care Policy/Activities of Daily Living, dated 04/29/16 revealed a resident who is unable to carryout activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00149959.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, facility investigation review, observations, staff and resident interviews, and facility policy review, the facility failed to administer medications according to the physician orders. This affected one (Resident #95) of three residents reviewed for medication errors. The census was 94. Findings include: Review of Resident #95's medical record revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included bacterial pneumonia, kidney disease, spinal enthesopathy, viral hepatitis C, wedge compression fracture, gout, non-Hodgkin lymphoma, irritable bowel syndrome, bipolar disorder, depression, diabetes, and high blood pressure. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #95 had no cognitive impairments. Resident #95 required limited assistance with bed mobility, transfers, toileting, and supervision for eating. Review of the physician orders for Resident #95 revealed an order dated 01/09/24 for Pregabalin Oral Capsule 25 milligrams (mg) one tablet daily for pain. Review of the facility medication incident report dated 01/10/24 revealed on 01/10/24 Resident #95 received Pregabalin Oral Capsule 25 mg two tablets instead of one tablet as ordered. Further review of the incident report revealed the licensed practical nurse failed to verify the order against the medication administration record before administering the incorrect dosage. Review of the pharmacy label for Resident #95 revealed the medication was filled on 01/08/24. Further review of the pharmacy label for Resident #95 revealed Pregabalin Oral Capsule 25 mg two tablets to equal 50 gm by mouth daily. Interview on 02/22/24 at 10:19 A.M. with Physician #140 verified Resident #95 had no long lasting effects from the medication error. Interview on 02/22/24 at 4:39 P.M. with Pharmacist #99 verified the label on the Pregabalin medication was not correct and should have been only one tablet. A prior prescription was used in error. Interview with the Administrator on 02/22/24 at 4:50 P.M. verified Resident #95 was given medication in error due to the nurse following the medication label and not checking it against the medication administration record first. Review of the facility policy titled, Medication Errors Policy, dated 04/29/26 revealed an error is considered when the administration of medications are given which are not in accordance with the physician orders. As a result of the incident, the facility took the following actions to correct the deficient practice by 01/19/24: On 01/10/24, the facility notified the physician and the family of the medication error. The medication was removed from the med cart. On 01/10/24, Resident #95 was fully assessed by facility nursing and deemed to be in good health; there were no injuries or health declines noted. On 01/10/24, the pharmacy was notified of the wrong prescription directions written on the label of the medication for Resident #95 On 01/10/24, the nurse administering the medication was educated and disciplined. On 01/19/24, the Director of Nursing audited 100 percent of all medication cards and verified no other medications differed from the MAR. On 01/19/24, all licensed nurses were provided education regarding medication. On 02/22/24, the facility completed follow-up cart audits with no additional problems noted. This deficiency represents non-compliance investigated under Complaint Number OH00150851.

Based on observations, medical record review, and staff interview, the facility failed to provide privacy for residents receiving enteral feedings/flushes via gastrostomy tube (g-tube). This affected two residents (#71 and #72) of three residents reviewed for dignity and respect. The facility census was 79. Findings include: 1. Medical record review for Resident #71 revealed an admitted on 05/19/23 with diagnoses including, but not limited to, acute respiratory failure, anxiety, overactive bladder, epilepsy, hypertension, and lupus. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #71, revealed the resident had severely impaired cognition. Resident #71 required total dependence for eating and received all nutritional intake via a feeding tube. Review of the plan of care for Resident #71, revealed the resident was at risk for alteration in nutrition/hydration needs and the resident was dependent on staff for all nutritional and hydration needs via an enteral feeding tube. Review of the physician's orders dated 06/18/23 or Resident #71, revealed an order for Diabetisource AC (enteral liquid nutrition administered through an artificial opening in the abdomen) per g-tube at 55 milliliter/hour (mL/hr.) from 6:00 A.M. to 10:00 P.M. Orders revealed to flush the g-tube every six hours with 200 mL of water. Observation of Resident #71 on 06/28/23 at 05:30 P.M., revealed the resident was positioned in a Geri-chair in the hallway in front of the nursing station with Licensed Practical Nurse (LPN) #113 administering a water flush via the resident's g-tube. Resident #71 was observed to have an exposed abdominal area allowing visualization of the g-tube insertion site. At the same time, visitors for other residents were observed walking past Resident #71. Interview on 06/28/23 at 05:42 P.M. with LPN #105, verified all enteral feedings should occur in the resident's room or in a private area. Interview on 06/28/23 at 05:49 P.M. with LPN #113 verified she administered a water flush to Resident #71 via a g-tube in the hallway and did not provide the resident with any privacy during procedure. LPN #113 verified visitors were in the immediate area and could have observed the resident during the procedure. 2. Medical record review for Resident #72 revealed an admitted [DATE] with diagnoses including, but not limited to, cerebral infarction, urinary tract infection, neurofunction of bladder, hypertension, hyperlipidemia, and hemiplegia and hemiparesis. Review of the comprehensive MDS assessment dated [DATE] for Resident #72, revealed the resident had severely impaired cognition. Resident #72 was dependent on staff for enteral feeding. Review of the plan of care for Resident #72, revealed the resident had a feeding tube related to dysphagia and was dependent on staff for tube feedings and flushes. Review of the physician's orders dated 06/06/23 for Resident #72, revealed an order for nothing by mouth (NPO) and enteral feeds every four to six hours for hydration and nutritional needs via the resident's g-tube. Observation of Resident #72's room on 06/28/23 at 5:39 P.M. with LPN #105, revealed the resident positioned in the bed with the room door open and LPN #113 was standing at the bedside administering a liquid nutrition supplement via the resident's g-tube. Observation also revealed the resident's abdominal region was uncovered allowing visualization of his g-tube insertion site. Interview on 06/28/23 at 05:42 P.M. with LPN #105 indicated all enteral feedings should occur in the resident's room and/or in a private area. LPN #105 verified the door to Resident #72's room was open as LPN #113 provided the enteral feeding via G-tube. LPN #105 indicated Resident #72's door should have been closed, or a curtain pulled to provide the resident with privacy. Interview on 06/28/23 at 05:49 P.M. with LPN #113 verified she was administered the nutritional supplement to Resident #72 via G-tube and did not provide the resident with privacy during the procedure.

Based on medical record review, staff interview, observations and review of facility policy, the facility failed to ensure pharmaceutical medications were stored properly. This affected three residents (#17, #42 and #62) reviewed for medication storage. Facility census was 79. Findings include: 1. Medical record for Resident #17 revealed an admitted [DATE] with diagnoses including, but not limited to, depression, low back pain, hypertension, right artificial hip joint and history of falling. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 revealed a mildly impaired cognition. Review of the active physician's orders dated 10/05/22 for Resident #17, revealed an order for Bengay greaseless external cream (over the counter topical pain cream) 15 percent apply to affected areas as needed and Norco (narcotic pain reliever) tablet 5-325 milligrams (mg) one tablet every six hours. Observation on 06/26/23 at 12:24 P.M. of Resident #17's bedside table revealed a tube of Bengay pain relieving cream at bedside. Interview with Resident #42 at the same time, revealed she asked the nurses to apply the medication when she could not reach it. Interview on 06/26/23 at 1:10 P.M. with Licensed Practical Nurse (LPN) #01 verified the tube of Bengay was in Resident #17's room and should not have been as the resident does not have an order for medication self-administration. Observation of Resident #17's room on 06/29/23 at 2:17 P.M with Corporate Registered Nurse (RN) #300 and Director of Nursing (DON) #117, revealed a white tablet in a clear medication administration cup on bedside table. Interview on 06/29/23 at 2:20 P.M. with Corporate RN #300 verified the observation of the white tablet in the medication cup and further verified medication should not have been left in the room unsupervised. Interview on 06/29/29 at 2:25 P.M. with LPN #18 verified she left a Norco 5-325 mg tablet in Resident #17's room without observation of the medication administration. 2. Medical record review for Resident #42 revealed an admitted [DATE] with diagnoses including, but not limited to, cardiomyopathy, intervertebral disc degeneration, hypothyroidism stage three chronic kidney disease, and congestive heart failure. Review of the quarterly MDS assessment dated [DATE] for Resident #42 revealed an impaired cognition. Observation on 06/26/23 at 11:53 A.M. of Resident #42's bathroom, revealed a partially empty bottle of chlorhexidine gluconate 0.12 percent mouthwash dated 11/05/22 with a prescription pharmacy label affixed. Interview on 06/26/23 at 11:59 A.M. with LPN #113 verified Resident #42 does not have a current order for the chlorhexidine mouthwash. LPN #113 verified the medication mouth should not be in the resident's bathroom. Review of June 2023 physician orders for Resident #42 revealed no active orders for chlorhexidine gluconate 0.12 percent mouthwash. 3. Medical record review for Resident #62 revealed an admitted [DATE] with diagnoses including, but not limited to, irritable bowel syndrome, unspecified psychosis, and Alzheimer's disease. Review of the quarterly MDS assessment dated [DATE] for Resident #62, revealed an intact cognition. Observation of Resident #62's room on 06/26/23 at 2:25 P.M. revealed a bottle of nystatin powder on the resident bathroom sink a prescription pharmacy label affixed. Interview on 06/26/23 at 2:31 P.M. with LPN #113 stated the medication should not be left in the resident's room. Review of the June 2023 physician's order for Resident #62 revealed an order to cleanse under bilateral breasts with soap and water and pat dry and apply antifungal powder (nystatin) two times a day and as needed. Review of 03/30/22 facility policy titled Medication Storage in the Facility revealed medications and biologicals will be stored safely, securely, and properly and medications are accessible only to licensed nursing personnel or staff member lawfully authorized to administer medications.

Based on observation, staff interview and policy review, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBPs) during personal care. This affected three residents (#69, #71, and #72) of the five residents reviewed for infection control. Facility identified 39 residents who were on EBPs. The facility census was 79. Findings include: 1. Medical record review for Resident #71 revealed an admitted on 05/19/23 with diagnoses that included, but not limited to, acute respiratory failure, anxiety, overactive bladder, epilepsy, hypertension, and lupus. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #71, revealed the resident had severely impaired cognition. Resident #71 required extensive assistance from two staff members for bed mobility, transfers, and toileting. Resident #71 required total dependence for eating. Resident #71 received all nutritional intake via feeding tube. Review of the plan of care dated 05/23/23 for Resident #71, revealed the resident had a gastrostomy tube (g-tube) and was in EBPs. Interventions include educate family/resident and staff on EBPs, monitor for psychosocial effects, encourage participating in activities, and go to the dining room for meals and report any concerns. Review of the physician's orders dated 06/18/23 or Resident #71, revealed an order for Diabetisource AC (enteral liquid nutrition administered through an artificial opening in the abdomen) per g-tube at 55 milliliter/hour (mL/hr.) from 6:00 A.M. to 10:00 P.M. Orders revealed to flush the g-tube every six hours with 200 mL of water. Observation on 06/26/23 at 10:20 A.M. of Resident #71's room entrance, revealed a posted sign which indicated providers and staff must wear gloves and a gown for high contact care activities including central line, urinary catheter, feeding tube, and tracheostomy. Observation of Resident #71 on 06/28/23 at 05:30 P.M., revealed the resident was positioned in a Geri-chair in the hallway in front of the nursing station with Licensed Practical Nurse (LPN) #113 administering a water flush via the resident's g-tube. Observation revealed LPN #113 did not have a gown on per EBPs. Interview on 06/28/23 at 05:42 P.M. with LPN #105, verified all staff should be wearing a protective gown when completing any g-tube procedures on Resident #71 due to the resident being on EBPs. Interview on 06/28/23 at 05:49 P.M. with LPN #113, verified she administered a water flush through Resident #71's g-tube who was on EBPs and she was not wearing a protective gown during the procedure and should have been. 2. Medical record review for Resident #72 revealed an admitted [DATE] with diagnoses including, but not limited to, cerebral infarction, urinary tract infection, neurofunction of bladder, hypertension, hyperlipidemia, and hemiplegia and hemiparesis. Review of the comprehensive MDS assessment dated [DATE] for Resident #72, revealed a severe cognitive impairment. Resident #72 required extensive assistance from two staff for bed mobility, and total dependence for toileting, and transfers from two staff members. Resident #72 received abdominal tube feeding. Review of the plan of care for Resident #72 revised on 06/28/23, revealed the resident had g-tube and was on EBPs. Interventions include educate family/resident and staff on EBPs, monitor for psychosocial effects, encourage the resident to participate in activities, and go to the dining room for meals and report any concerns. Review of the physician's orders dated 06/06/23 for Resident #72, revealed an order for nothing by mouth (NPO), 225 milliliters (ml) water flush every four hours via g-tube for hydration, and an enteral feed of 360 milliliter liquid bolus every six hours via g-tube. Observation on 06/26/23 at 11.31 A.M. of Resident #72's room entrance revealed a posted sign which indicated providers and staff must wear gloves and a gown for high contact care activities including central line, urinary catheter, feeding tube, and tracheostomy. Observation of Resident #72's room on 06/28/23 at 5:39 P.M. with LPN #105, revealed the resident was resting in bed with the door to the room open and LPN #113 was standing at the bedside administering a liquid nutritional supplement to the resident via the resident's g-tube and without wearing a protective gown. Interview on 06/28/23 at 05:42 P.M. with LPN #105 verified Resident #72 was on EBPs and LPN #113 should have been wearing a protective gown during the g-tube feeding. Interview on 06/28/23 at 05:49 P.M. with LPN #113 verified that she was administering nutritional supplement to Resident #72 via a g-tube and did not have a protective gown on and should have according to the EBPs. 44076 3. Review of medical record for Resident #69 revealed admitted [DATE]. The resident was admitted with diagnoses including non-traumatic subarachnoid hemorrhage, anxiety, and chronic obstructive pulmonary disease. The admission MDS assessment dated [DATE] for Resident #69 revealed the resident had a Brief Interview Mental Status (BIMS) score of 06 indicating impaired cognition. She required extensive two-person assistance for bed mobility, transfers, toileting, and total dependence for eating. Observation of the medication administration on 06/28/23 at 8:19 A.M., revealed LPN #115 entered Resident #69's room with gloves on and no other Personal Protective Equipment (PPE) to administer the resident's morning medication. Observation revealed a posted sign on the exterior of the resident's door frame, which indicated the resident was on EBP. The sign indicated providers and staff must wear gloves and a gown for high contact care activities including central line, urinary catheter, feeding tube, and tracheostomy. Continued observation revealed Resident #69 was positioned in the bed and LPN #115 pulled up the resident's gown to expose a jejunostomy tube (j-tube). LPN #115 was observed to administer the resident's medications through the residents j-tube with no protective gown in place. Interview on 06/28/23 at 8:29 A.M., with LPN #115, verified he did not wear a protective gown as he administered medications to Resident #69 via his j-tube. Review of the facility's policy titled Enhance Barrier Precautions dated August 2022 revealed it is the intent of the facility to use EBP in addition to standard precautions for residents to prevent transmission of multi-drug resistant organisms (MDROs) in their care community. All personnel must wear gloves when high-contact resident care activities are being performed. Shared resident care equipment should be clean and disinfected. High contact resident care activities listed were dressing, bathing/showering, transferring, providing hygiene, changing linens, changing attends, or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing.

Based on medical record review, staff interview, review of the fall investigation, and policy review, the facility failed to ensure care was provided in a manner to prevent an avoidable fall with injury and was not initially thoroughly investigated to determine the root cause analysis to identify potential hazards to reduce and/or eliminate falls with major injury. This resulted in Actual Harm when State tested Nurse Aide (STNA) #114 stepped away from the bedside while providing care for Resident #78. Subsequently, Resident #78 slid or rolled from the bed and landed on her knees complaining of right knee pain. Resident #78 was sent to the hospital where it was determined both femurs had been fractured resulting in surgical intervention. This affected one resident (#78) out of three residents reviewed for falls. The facility census was 77. Findings include: Review of the medical record for Resident #78 revealed she was admitted [DATE] and discharged [DATE]. Her diagnoses included hypertensive, osteoporosis, disorders of bone density and structure, benign neoplasm of meninges, glaucoma, obstructive sleep apnea, personal history of transient ischemic attack and cerebral infraction, and gastro-esophageal reflux disease. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #78 was cognitively intact. She required supervision with eating and extensive assistance with activities of daily living (ADL's). No falls since admission. Review of her Discharge MDS dated [DATE] revealed two or more falls with major injury. Review of the Care Plan for Resident #78 dated 01/03/23 revealed she was at risk for falls related to unsteady gait and balance and with a diagnosis of benign paroxysmal vertigo. Interventions included ensuring call light was within reach and encouraging use, encouraged to sit in beside chair or wheelchair and not the side of the bed, encourage appropriate footwear, monitor for dizziness and side effects of medication, therapy evaluation and treatment as needed, review past falls to determine cause and provide education and remove cause if possible to avoid further falls, keep environment clutter free and answer call light promptly due to urgency to use the restroom. Review of the Progress Notes for Resident #78 revealed a note dated 01/24/23 at 10:25 P.M. documenting she was sitting on the side of the bed and slid off onto her knees which was witnessed by the nurse aide. The Nurse Practitioner was notified of the fall and complaint of pain in the right knee and an order was obtained for an x-ray with a portable unit called for a stat x-ray. Review of the physician orders revealed 01/24/23 for an immediate (STAT) portable x-ray of the right knee due to being unable to stand. Review of a progress note dated 01/25/23 at 10:19 A.M. revealed the team met to discuss the fall of Resident #78 with staff reporting she sat on the edge of the bed often, but her knees did not straighten due to pain and the mass on her spine. Resident #78 was in therapy who reported she was having increased weakness and pain related to the mass on her spine making transfers more difficult. The team intervention was to encourage Resident #78 to sit in a bedside chair or her wheelchair rather than the side of the bed. Review of a progress note for Resident #78 on 01/25/23 at 2:03 P.M. revealed her x-ray results revealed a fracture of the distal femur with displacement and osteoporosis and osteoarthritis and she was sent to the hospital for additional evaluation and treatment. Review of the Fall Incident Report dated 01/24/23 revealed Resident #78 was sitting on the side of the bed and slid off onto her knees. She was assessed for injury or pain with pain medication given and an x-ray ordered following notification of the Nurse Practitioner due to voiced complaint of right knee pain. During an interview on 02/27/23 at 9:26 A.M., with the Medical Doctor (MD) #250 she reported she was told Resident #78's accident happened during care while Resident #78 was sitting on the edge of the bed and accidentally fell . She stated the residents center of gravity was off due to having a larger trunk and her diagnosis of osteoporosis was also a likely factor contributing to the injury. MD #250 reported there was no concern about the proper protocol of care as it was just an unfortunate, unavoidable accident from the information she was provided. During an interview on 02/27/23 at 3:00 P.M., with a Registered Nurse (RN) #115 she reported she had not witnessed the fall but was told by the aide who was in the room they were doing nightly care for Resident #78 when she slid from the bed landing on her knees. The Nurse Practitioner was notified of complaints of pain in her right knee and ordered an x-ray. RN #115 stated they saw no need to send her out based on the report she was given and a portable x-ray was ordered. During an additional interview at 5:17 P.M. with RN #115 she stated she assumed Resident #78 had been sitting on the side of the bed when she slid out as she had a history of sitting on the side of the bed but acknowledged she had not questioned the aide to clarify the exact details of how Resident #78 fell . During an interview on 02/27/23 at 3:12 P.M., with a Certified Nurse Aide (CAN) #110 she reported she was in training the day of the incident with Resident #78. She stated they were changing Resident #78's linens while she was in bed. The other STNA #114 was on her left side and CNA #110 was on her right. CNA #110 reported STNA #114 went to get a incontinence pad and Resident #78 slid and went to the floor falling on her knees. During an interview on 02/27/23 at 3:38 P.M., STNA #114 reported they had put Resident #78 in bed to change her and were providing incontinence care and changing her bedding. STNA #114 reported she rolled Resident #78 toward her and CNA #110 who was in training was on the other side of the bed. STNA #114 stated she moved for a second to grab a incontinence pad and Resident #78's legs slipped off the bed, she tried to catch her but just caught her top half trying to keep her from hitting her head and Resident #78 landed on the floor on her knees. During an additional interview with STNA #114 at 5:05 P.M. she reported the Incontinence pad she went to retrieve was in the bathroom, she saw Resident #78 starting to fall as she was returning from the bathroom with the supplies and ran to grab her to attempt to stop her fall. She verified she had been retrained and a skills check completed before working again following this incident. During an interview on 02/27/23 at 3:48 P.M., the Nurse Practitioner (NP) #225 stated she was on call on 01/24/23 and had been contacted around 10:00 P.M. to 10:30 P.M. regarding Resident #78. She stated it was reported to her Resident #78 fell to her knees during care and was complaining of right knee pain only. Based on the information provided she had not felt the need to send Resident #78 out and ordered a portable x-ray. During an interview on 02/27/23 at 4:12 P.M., with the Administrator and the Director of Nursing (DON) they reported they initially were told by the nurse Resident #78 slid off the side of the bed, so they utilized that information for their investigation. During morning meeting it was verified Resident #78 had a history of sitting on the side of the bed and the therapists reported that due to the mass on her back her legs contracted so it was unsafe for her to sit on the edge of the bed. The intervention put in place was for Resident #78 to sit in a bed side chair or in her wheelchair rather than the edge of the bed. The Administrator and the DON then reported Resident #78's family called on Friday 01/27/23 and stated Resident #78 reported to them she rolled out of bed during care. They stated they then began a second investigation based on this information. The Administrator and the DON reported they had not spoken to the aide during the first investigation as they assumed the nurse had interviewed her prior to relaying the information about the incidents and they did not talk to the aide if there was a clear-cut picture of what had occurred. As Resident #78 had also stated she slid from the bed they assumed it was from her common behavior of sitting on the side of the bed as reported by the nurse and no one investigation further. When they interviewed the STNA #114 she reported Resident #78 slide from the bed during care. The Administrator reported STNA #114 had turned to grab supplies and tried to catch Resident #78 when she saw her begin to fall. The Administrator and the DON reported STNA #114 was provided with education and skills competency on 01/28/23 before working again after this incident. They reported there had been no ongoing or follow up monitoring since that time and no other resident who STNA #114 had provided care for or who were at risk of falls had been assessed at the time of the incident for Resident #78. During a call received by the Administrator on 03/01/23 at 10:30 A.M. she reported they reinterviewed the RN, the STNA and the CNA on 02/28/23 between the hours of 3:30 P.M. and 4:00 P.M. She stated RN #115 did not change her story, STNA #114 reported she was still at bedside and had just turned to get supplies off the night stand and CNA #110 had her hands on Resident #78 at all times and CNA #110 reported she had both hands on Resident #78 at all times but was not able to catch her when she began to slide off the bed as she was on the opposite side. When notified this was not the interview obtained by the surveyor the Administrator stated every time they talked with STNA #114 she reported new or different information. Review of the policy titled Fall -Care of Fallen Resident, revised April 2001 revealed the objective was to assess any resultant injuries sustained in a fall and provide necessary treatment. Review of the procedure revealed the resident should not be left alone while staff called for help, the resident should not be moved until examined by the nurse who should check vitals and check for injuries. Notify the doctor for any orders and the family regarding the incident. Return resident to bed or chair, leaving them comfortable and with assess to their call light. Complete documentation on an incident report and submit to the Director of Nursing. Chart on the condition of the resident following the fall and every shift for 72 hours or until resident was stable. Review of the policy titled Fall Investigation - Post-Fall Protocol, revised September 2001 revealed all falls would be investigated and appropriate interventions instituted. After each fall an incident report should be completed, a post-fall investigation should be initiated by the nurse with fall risk protocol completed within 24-72 hours after the fall and interventions noted on their care plan. This deficiency represents noncompliance in Complaint Number OH00140001.

Based on medical record review, staff interview, and facility policy review, the facility failed to timely implement interventions for a resident with severe weight loss. This affected one (Resident #75) out of three residents reviewed for nutrition. The census was 73. Findings include: Review of the medical record for Resident #75 revealed an admitted [DATE] and discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had significant cognitive impairment and required setup assistance with eating. The MDS revealed Resident #75 was on a mechanically altered diet and had no natural teeth. Review of the plan of care dated 05/12/22 revealed Resident #75 was an elderly resident with cognitive issues, liver [CONDITION(S)], abnormal laboratory (labs) results, wrist fracture, and diuretic usage with interventions including provide diet as ordered, encourage fluids, administer medications, labs and weights as ordered, and monitor appetite/intakes and adjust supplements as needed. Review of Resident #75's physician orders revealed an order, with a start date of date of 05/08/22 and a discontinue date of 06/13/22, for weekly weights for four weeks then monthly and PRN (as needed). Review of the progress note dated 05/13/22 revealed Resident #75's appetite was poor and he drank his milk and orange juice at breakfast. Review of Resident #75's physician orders revealed an order, with a start date of 05/16/22 and a discontinue date of 05/18/22, for a regular diet with regular texture and regular consistency. Review of the progress note dated 05/16/22 by Dietary Technician (DT) #60 revealed Resident #75's weight history was unknown and Resident #75 had no teeth. The note revealed Resident #75 had been eating 50-75% of estimated needs and was meeting 50% of estimated fluid needs. The note revealed Resident #75 had no significant weight changes with a plan to update the Registered Dietitian as needed. Review of Resident #75's physician orders revealed an order, with a start date of 05/19/22 and a discontinue date of 06/22/22, for a regular diet with mechanical soft texture and regular consistency, and a magic cup (high calorie/protein ice cream) supplement with lunch and dinner. Review of the progress note dated 06/04/22 revealed Resident #75 had a poor appetite. Review of the progress note dated 06/05/22 revealed the physician gave a verbal order for magic cup with lunch and dinner (this was previously ordered on 05/19/22 and was already implemented). Review of the progress note dated 06/07/22 from Social Services Director #75 revealed she spoke with Resident #75's family regarding concerns of weight loss. Resident #75's daughter requested magic cup be offered and was informed it had already been ordered. Resident #75's daughter revealed Resident #75 drank Ensure at home and Resident #75's daughter asked about adding Ensure for Resident #75. Resident #75's daughter reported he had severe visual impairment and increased confusion which may be contributing to lower nutritional intakes. Resident #75's family revealed Resident #75 does not like some of the served foods and was educated on the substitute menu. Resident #75's family provided several items Resident #75 enjoyed eating to social services. Resident #75's family also revealed they were informed Resident #75 would be having daily weights but the order had not changed from weekly weights. Social services revealed she would discuss the concerns with the interdisciplinary team. Review of the progress note dated 06/10/22 by DT #60 revealed Resident #75's current supplements included [MEDICATION(S)]-M and [MEDICATION(S)] (Vitamin B1 supplement). The note revealed Resident #75 triggered for weight loss on 06/09/22 due to a 26% weight loss in 29 days. Resident #75 had a 49% meal intake. Resident #75 may benefit from facility nourishment and may also benefit from a divided plate and advanced supervision while feeding himself. The note revealed staff was to offer an alternative if less than 75% of the meal was consumed and also noted Resident #75 had a magic cup with lunch and dinner. Review of the progress note dated 06/11/22 revealed Resident #75 refused dinner with no mention of an alternative having been offered. Review of Resident #75's physician orders revealed an order, with a start date of 06/13/22 and a discontinue date of 06/22/22, for weekly weights for four weeks then monthly and PRN. Review of the progress note dated 06/16/22 revealed Resident #75's weight was 132.4 pounds with a continued trend downwards. Review of Resident #75's weight records revealed the following weights: On 05/12/22, Resident #75 weighed 195.8 pounds (lbs). On 05/19/22, Resident #75 weighed 186.04 lbs. On 06/03/22, Resident #75 weighed 148.04 lbs. A reweigh was completed on 06/03/22 and was 148.12 lbs. On 06/09/22, Resident #75 weighed 144.96 lbs. On 06/14/22, Resident #75 weighed 132.4 lbs. A reweigh was completed on 06/14/22 and was 132.4 lbs. There was no evidence of a weight having been obtained for Resident #75 from 05/23/22 to 05/27/22 and there was no evidence reweighs were obtained on 05/19/22 and 06/09/22 as per the facility policy. Further review of the weight records revealed Resident #75 experienced a clinically significant 24.4% weight loss from 05/12/22 to 06/03/22 and an additional 2.08% weight loss from 06/03/22 to 06/09/22. Review of Resident #75's medical record revealed there was no evidence a risk occurrence form was completed for Resident #75's weight loss. Interview on 06/30/22 at 1:18 P.M. with DT #60 revealed she started at the facility in early June 2022. DT #60 revealed the facility had a COVID-19 outbreak shortly after she started and stated she did not go on the COVID-19 unit to assess the residents for nutritional concerns while they were in quarantine. DT #60 revealed she was not sure if extra weights were being completed in order to monitor the residents that had contracted COVID-19 at the facility. DT #60 revealed Resident #75 was on hospice (admitted to hospice on 06/22/22 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #75 was admitted to hospice, the hospice team will address nutritional concerns instead of the dietary technician and/or dietitian. DT #60 revealed she got daily weight alerts from the system and followed up for interventions. DT #60 revealed she was not familiar with what interventions were put in place for Resident #75. DT #60 revealed she could make recommendations to obtain extra weights and changes in diet/supplements; however, the physician would need to place the official order for these changes. DT #60 revealed she was first alerted to a weight loss after the 06/09/22 weight and entered a note in the system on 06/10/22 with her recommendations. DT #60 revealed she was not sure why she had not become involved after the weight loss on 06/03/22 when Resident #75 was found to have lost 38 lbs. Interview on 07/05/22 at 12:00 P.M. with the Director of Nursing (DON) and Administrator revealed they were unaware that staff were not obtaining re-weighs but would review resident records to verify if they may have been documented elsewhere. The DON and Administrator revealed they were unaware of the involvement with the previous dietary technician and revealed the dietitian had recently resigned. The Administrator revealed the facility had a corporate staff member filling in but were unable to say whether she was involved with Resident #75. They revealed a northern dietitian was helping out and was overseeing but revealed she did not come onsite to the facility. The DON and Administrator revealed the nursing staff had spoken with the physician about adding supplements for Resident #75 after his large percentage of weight loss. The DON and Administrator were unaware of the dietary technician and dietitians lack of involvement with Resident #75. Interview on 07/05/22 at 1:35 P.M. with the Administrator revealed a risk occurrence form was not completed per facility policy for Resident #75. The Administrator revealed this form was only completed if resident weight loss was unexplained. Interview on 07/05/22 at 1:55 P.M. with Assistant Director of Nursing (ADON) #62 revealed if a reweigh had similar or the same results then it would not be documented in the medical record. If the reweigh was different, it would be documented in the medical record under recorded weights. ADON #62 revealed if the resident had a significant change, then the physician would be updated. ADON #62 revealed it was unknown why the dietary technician and dietitian had not had much involvement with Resident #75. ADON #62 revealed Resident #75's weight loss was not explained and the weight loss was unintentional. ADON #62 confirmed Resident #75's weight was not obtained around 05/26/22 and also revealed no reweighs were documented after the weight losses on 05/19/22 and 06/09/22. Interview on 07/05/22 at 2:58 P.M. with Corporate Dietitian (CD) #58 revealed she had been covering the building as of 07/05/22 at the request of the Administrator. CD #58 revealed the facility had been using other Corporate Dietitians for a while and revealed those involved were not available for interview. CD #58 revealed the dietary technicians work under the dietitian's license and should involve the dietitian for difficult cases or large weight losses. CD #58 revealed all reweighs should be documented in the resident's medical record. CD #58 revealed after reviewing the medical record of Resident #75, the physician should have been notified after the initial weight loss. The dietary technician should have discussed the likely weight loss due to diuretic use and confirmed this with the physician and included the information in the medical record. CD #58 revealed Resident #75 should have had reweighs documented after the weight losses according to the facility policy. CD #58 revealed Resident #75 was weighed with different scales which could account for some of the variety in his weights. CD #58 revealed after the first week when Resident #75 lost 4.98% weight, an investigation or further review should have been done. CD #58 revealed weight alerts in the electronic medical record must be checked off and cleared by the dietary technician or dietitian, and was not sure how the 38 lb. weight loss could have been missed. CD #58 revealed the care plan should have been updated to reflect weight loss and any supplements Resident #75 had ordered and CD #58 would expect all supplements to have been ordered by the physician. CD #58 confirmed the facilities lack of follow up regarding Resident #75's weight loss. Interview on 07/08/22 at 11:18 A.M. with Social Services Director (SSD) #75 revealed she spoke with Resident #75's family regarding concerns related to Resident #75's weight loss. SSD #75 revealed she spoke with the interdisciplinary team including the DON, ADON #62, and DT #60 regarding Resident #75's family concerns about Resident #75 not being on a daily weight. SSD #75 confirmed Resident #75's family indicated Resident #75 drank ensure daily and identified certain foods Resident #75 liked; however, SSD #75 revealed no memory of whether these were discussed with the interdisciplinary medical team. SSD #75 revealed the staff would need a physician order to provide supplements to a resident and confirmed Resident #75 only had orders for a magic cup at lunch and dinner during his admission. Interview on 07/08/22 at 11:20 A.M. with the Administrator confirmed the only supplement ordered for Resident #75 was a magic cup with lunch and dinner. Review of the facility policy titled Nutritional Assessment - Weight and Scales policy, dated 03/2017, revealed weights will be monitored monthly or more frequently when indicated and the data will be used to identify residents with significant weight variances as an indicator of nutritional risk. Weights will be obtained by a staff member trained in the weight policy. Residents will be reweighed for significant weight changes of three or five pounds depending on total weight. Weights would be monitored on a weekly/monthly weight changes form that may be used to refer to the dining skills committee. A weight loss of 5% in 30 days, 7.5% in three months and 10% in six months will be calculated by the dietitian and the dietitian should determine if further review was needed. If more than 15% of weight loss from admission, the Administrator would be notified and fill out a risk occurrence form to be sent to the corporate office. The nutrition services supervisor, nursing designee and dietary technician will assess the resident for potential causes of weight loss. This deficiency substantiates Complaint Number OH 453.

Based on medical record review and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) 3.0 Assessment for a residents discharge. This affected one (#1) out of one resident reviewed for accuracy of assessments. The facility's census was 84. Findings included: Medical record review for Resident #1 revealed an admitted d of 01/27/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 Minimum Data Set (MDS) 3.0 Assessments history, revealed a Discharge Return Anticipated assessment was completed on 01/28/21. Review of Resident #1 progress notes revealed Resident #1 went to the hospital on 01/28/21. There was no evidence the Discharge Return Anticipated assessment was modified to reflect Resident #1 did not return to the facility. Interview on 06/17/21 8:41 A.M. MDS Nurse #12 verified the Resident #1 discharged to the hospital, the resident did not return and there is no plan for the resident to return to the facility. MDS Nurse #12 verified Resident #1's MDS Discharge Return Anticipated assessment was not modified to reflect Resident #1 did not return from the hospital.