Every finding on record at Residence at Huntington Court

Based on observation, interview, record review and policy review, the facility failed to ensure proper cleaning of reusable equipment between residents and failed to maintain clean linen storage. This affected Residents #37 and #38 and had the potential to affect the 13 residents residing on the F Hallway. The facility census was 89.Findings include:Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included sepsis and sarcoid myocarditis. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was cognitively intact. Review of the physician orders for Resident #37 dated 03/11/26 revealed an order for enhanced barrier precautions (EBP) due to an indwelling urinary catheter and maintain contact precautions due to Klebsiella Pneumoniae.Review of the medical record revealed Resident #38 was admitted to the facility on [DATE]. Diagnoses included onychogryphosis. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 had moderately impaired cognition.Review of the physician orders for Resident #38 dated 03/01/26 revealed an order for EBP due to suprapubic catheter.Observation and interview on 03/18/26 from 10:26 A.M. to 10:46 A.M. revealed Licensed Practical Nurse (LPN) #10 was in Resident #37 and Resident #38's room, LPN #10 obtained vital signs, including pulse oximetry, thermometer and blood pressure cuff from Resident #38 and obtained vital signs from Resident #39 without cleaning the reusable equipment between residents. LPN #10 removed her gown and gloves, attempted to place the PPE in red biohazard bin in the bathroom. LPN #10 stated the bag had fallen down in the red biohazard bin. LPN #10 reached down with ungloved hands and was attempting to find the bag, and there were multiple dirty gowns were in the red biohazard bin. LPN #10 confirmed no gloves were worn when reaching in red biohazard bin and should have been worn. LPN #10 also confirmed she did not clean the reusable equipment between Resident #37 and Resident #38 while obtaining vital signs and should have cleaned them.Observation on the F Hallway and interview on 03/18/26 at 12:04 P.M. with Certified Nursing Assistant (CNA) #11 revealed the three tier linen cart front cover was uncovered with all of the linen open to air. CNA #11 confirmed the front flap should always be down covering all towels and gowns.Observation on the F Hallway and interview on 03/18/26 at 1:29 P.M. with Housekeeping Supervisor #12 revealed he three tier linen cart had a dirty white towel with brown spots sitting on top of the clean linen cart and a dirty bag directly next to the linen cart on floor with gloves and gown inside. Housekeeping Supervisor #12 confirmed the dirty towel on top of the linen cart and the bag of dirty items on the floor directly next to the linen cart. Interview on 03/24/26 at 8:35 A.M. with the Director of Nursing (DON) confirmed the staff should be cleaning all reusable equipment between residents.Review of the policy titled Infection Control dated 11/28/17 revealed gloves are worn if potential contact with blood or body fluid, mucous membranes, or non-intact skin. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.Review of the policy titled Infection Control Standard Precautions dated 05/05/17 revealed ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed. This deficiency represents non-compliance investigated under Complaint Number 2719210.

Based on staff interviews, record review, and policy review, the facility failed to implement a comprehensive person-centered care plan for hearing aids and hearing loss for a resident. This affected one (Resident #50) of six residents reviewed for care plans. The facility census was 89.Findings include:Review of the medical record revealed Resident #50 was admitted to the facility on [DATE]. Diagnoses included paroxysmal atrial fibrillation and encephalopathy Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had minimal difficulty hearing and hearing aids. The MDS 3.0 assessment dated [DATE] revealed Resident #50 had severely impaired cognition, had moderate difficulty with hearing, and did wear hearing aids.Review of Resident #50's care plan with last revision date of 03/13/26 revealed there was no focus of area of the resident being hard of hearing or wearing a hearing aid. There were no interventions in place for the care and storage of the hearing aid.Interview on 03/23/26 at 10:45 A.M. with the MDS Coordinator #15 confirmed there was no care plan in place for Resident #50's hearing loss with a hearing aid.Interview on 03/24/26 at 11:12 A.M. with the Administrator revealed Resident #50's hearing aids were reported lost on 02/25/26, reordered by facility on 03/02/26 and arrived to the facility for Resident #50 on 03/23/26.Review of the policy titled Care Conference dated 03/20/24 revealed the facility's interdisciplinary team shall periodically review the resident's care plan and make revisions based on the goals, preferences and needs of the resident.This deficiency represents non-compliance investigated under Complaint Number 2802107.

Based on observation, staff interview, and review of the facility policy review, the facility failed to ensure hairnets worn by dietary staff in the kitchen restrained all of their hair to ensure food was served in a sanitary manner for the 90 residents who received food from the kitchen. The census was 90. Findings included: During an observation on 06/18/25 at 9:57 A.M., [NAME] #1 was noted to prepare pureed foods. [NAME] #1 wore a hairnet that covered the top part of her hair. [NAME] #1's hair hung down her back and approximately 12 inches of her hair was outside of the hairnet. During an observation on 06/18/25 at 11:10 A.M., [NAME] #1 prepared the lunch meal and the back of her hair remained outside the hairnet. During an observation on 06/18/25 at 11:34 A.M., [NAME] #1 served residents their lunch meal from the steam table and the back of her hair remained outside the hairnet. During an interview on 06/18/25 at 12:30 P.M., [NAME] #1 stated the hairnet should cover her whole head. [NAME] #1 stated she was in a hurry and forgot to properly put on the hairnet. During an interview on 06/18/25 at 3:29 P.M., Regional Registered Dietitian #40 stated her expectation was that hairnets and beard covers should be worn at all times while staff were in the kitchen. During an interview on 06/18/25 at 3:31 P.M., the Dietary Manager (DM) #50 stated her expectation was that staff should always wear a hairnet, and the hairnet should cover all their hair. DM #50 stated it was important to wear a hairnet so that they did not get hair in the residents' food. During an interview on 06/20/25 at 9:37 A.M., the Director of Nursing (DON) stated her expectation was that kitchen staff wore hairnets that covered their hair. During an interview on 06/20/25 at 9:43 A.M., the Administrator stated her expectation was that staff always wore hairnets in the kitchen. The Administrator stated everyone who went into the kitchen should wear a hairnet, and the hairnet should cover all their hair. Review of a facility policy titled, Infection Control - Dietary/Food Handling, revised 05/2015, indicated hairnets or caps must be worn to effectively keep hair from contacting exposed food, clean equipment, utensils and linens.

Based on medical record review, staff interview, and facility policy review, the facility failed to hold blood pressure medications when the blood pressure was out of physician prescribed parameters which resulted in a significant medication error. This affected one (#29) of five sampled residents reviewed for unnecessary medications. The census was 90. Findings included: Review of an admission record indicated the facility admitted Resident #29 on 07/26/18. Diagnoses included acute combined systolic and diastolic (congestive) heart failure. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/21/25, revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident had moderate cognitive impairment. Review of Resident #29's care plan report included a focus area initiated 06/29/23 that indicated the resident had cardiac symptoms. Interventions directed staff to administer medications as ordered, monitor for side effects related to anti-hypertensive medication, and monitor the effectiveness of the interventions. Review of Resident #29's order summary report for active orders as of 06/20/25, included an order dated 02/16/24, for Isosorbide Mononitrate (decreases blood pressure) extended release (ER) 60 milligrams (mg), give one tablet by mouth one time daily at 9:00 A.M. for hypertension, with instructions to hold if systolic blood pressure (SBP) was less than 120 millimeters of mercury (mmHg) or heart rate was less than 60 beats per minute (BPM); and an order dated 08/28/24, for Lisinopril (decreases blood pressure)10 mg, give one tablet by mouth two times a day at 9:00 A.M. and 9:00 P.M. for hypertension, with instructions to hold for SBP less than 120 mmHg, heart rate less than 60 BPM. Review of Resident #29's medication administration record (MAR) for the timeframe 04/01/25 through 04/30/25, revealed at 9:00 A.M. on 04/02/25, 04/03/25, 04/10/25, and 04/11/25 Isosorbide Mononitrate ER 60 mg and Lisinopril 10 mg were administered to the resident when their SBP was less than 120 mmHg. Review of Resident #29's MAR for the timeframe 04/01/25 through 04/30/25, revealed Lisinopril 10 mg was administered to the resident at 9:00 P.M. on 04/03/25, 04/05/25, 04/06/25, 04/08/25, 04/10/25, 04/12/25, 04/13/25, 04/15/25, 04/17/25, 04/28/25, and 04/30/25 when the resident's SBP was less than 120 mmHg. Review of Resident #29's MAR for the timeframe 05/01/25 through 05/31/25, revealed at 9:00 A.M. on 05/17/25 and 05/18/25 Isosorbide Mononitrate ER 60 mg and Lisinopril 10 mg were administered to the resident when their SBP was less than 120 mmHg. Review of Resident #29's MAR for the timeframe 05/01/25 through 05/31/25, revealed Lisinopril 10 mg was administered to the resident at 9:00 P.M. on 05/03/25, 05/04/25, 05/05/25, 05/06/25, 05/08/25, 05/09/25, 05/11/25, 05/13/25, 05/14/25, 05/18/25, 05/19/25, 05/28/25, and 05/31/25 when the resident's SBP was less than 120 mmHg Review of Resident #29's MAR for the timeframe 06/01/25 through 06/30/25, revealed Lisinopril 10 mg was administered to the resident at 9:00 P.M. on 06/05/25 and 06/09/25 when the resident's SBP was less than 120 mmHg. During a telephone interview on 06/20/25 at 5:35 A.M., Licensed Practical Nurse (LPN) #3 stated if a resident had parameters for their medications she would check the resident's vital signs prior to preparing the medications and if the vital signs were out of the established parameters, she would hold the medication and make a note. LPN #3 stated Resident #29's blood pressure medications had an order to hold if the resident's SBP was less than 110 mmHg or their pulse was less than 60 BPM. LPN #3 then checked Resident #29's physician orders and stated the parameters were for 120 mmHg and not 110 mmHg. LPN #3 confirmed she had given the medication when the resident's SBP was out of the parameters on multiple occasions because she thought the parameter was 110 mmHg. LPN #3 stated she should have read the order completely to ensure she was following the physician orders. During a telephone interview on 06/19/25 at 3:49 P.M., Registered Nurse (RN) #2 stated if a resident had parameters for when to hold their medications then she would hold the medication if needed and document on a progress note or put it in the drop-down box on the MAR. RN #2 reviewed the resident's MAR for April 2025 and May 2025 and stated the resident's blood pressure medications should not have been given, but she was typically good about holding the medication and may have signed off that she gave the medication but really held it. RN #2 stated at times she would forget what the parameters were and would need to double check. RN #2 stated she would not have given the medication if Resident #29's blood pressure was 98/53 mmHg (on 04/03/25 at 9:00 P.M.), that it had to be a documentation error, but she was not sure about the other times she documented that she had given it. During an interview on 06/19/25 at 3:25 P.M., LPN #4 stated if the resident's blood pressure was within parameters she would give the blood pressure medication and if not, then she would hold the medication, make a note, notify the physician, then waste the medication. LPN #4 verified that she gave Resident #29 their blood pressure medications when they should have been held on 04/03/25, 05/17/25, and 05/18/25. LPN #4 stated she should have double checked the order to ensure she was giving the medication according to the physician order. During an interview on 06/19/25 at 3:44 P.M., LPN #6 stated if a resident's order had parameters when to hold their blood pressure medications, she would hold the medication until vital signs were obtained and then hold if needed. After review of Resident #29's blood pressures on 04/02/25 and 04/10/25, LPN #6 stated the medication should have been held. LPN #6 stated she was not sure why she did not hold the medication except that most of the resident's hold orders were for 110 mmHg. LPN #6 stated she should have checked and rechecked the order to ensure what the parameters were for that resident. During an interview on 06/20/25 at 9:58 A.M., the Director of Nursing (DON) stated the nurse should be aware of the parameters prior to administering the medications, and if the resident's blood pressure or pulse did not meet the parameters, they should not administer the medication. The DON stated if the medications were held it should be documented on the MAR, but a progress note would not necessarily be written. Per the DON, there were no medication error reports completed for Resident #29. The DON reviewed Resident #29's MARs for April, May, and June 2025 and stated the nurses should not have given the medication on those days the resident's SBP was out of the prescribed parameters. During an interview on 06/20/25 at 10:17 A.M., the Administrator stated the nurses should read the orders completely, verify and double check everything. The Administrator stated medication should not be given if the resident's vital signs were not in the parameters. After review of Resident #29's MARs, the Administrator stated it was not okay that the nurses administered the medication when the resident's blood pressure was out of the parameters. The Administrator stated that even if they had not given the medication, they still documented that they did, and that was not okay either. During an interview on 06/20/25 at 12:32 P.M., the Medical Director (MD) #30 stated parameters were used for blood pressure medications to keep a resident's blood pressures from going too low, and medications should be held to avoid complications of hypotension, dizziness, and increased risk for falls. MD #30 stated the parameters depended on the resident and the medication. MD #30 stated he was notified on 06/20/25 that the resident's blood pressure medications were not being held according to the parameters. MD #30 stated his expectation was that staff held the medication if it was out of the set parameters, and if the resident was symptomatic, he should be notified. Review of a facility policy titled, Medication Administration, dated 06/11/17, indicated medications will be administered by legally-authorized and trained persons in accordance to applicable State, Local, and Federal laws and consistent with accepted standards of practice. The policy specified to obtain and record any vital signs as necessary prior to medication administration.

Based on observation, staff interview, and medical record review, the facility failed to ensure adequate nail care was provided for one (#24) of 18 sampled residents. The census was 90. Findings included: Review of an admission record revealed the facility admitted Resident #24 on 01/10/25 with diagnoses including cerebral infarction due to thrombosis of the right posterior cerebral artery, dementia with agitation, need for assistance with personal care, type II diabetes mellitus, and contracture of the muscle of the left upper arm. Review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/19/25, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident had severe cognitive impairment. The MDS assessment indicated the resident was dependent on staff for bathing and required partial to moderate assistance with personal hygiene. Review of Resident #24's care plan report, included a focus area initiated 01/29/25, that indicated the resident's needs for activities of daily living (ADLs) care ranged from requiring partial assistance to being totally dependent on staff. Interventions directed staff to provide bathing assistance, diabetic nail care, and grooming (including nails) assistance as needed, and to monitor for a decline in care and report to clinical staff as needed. The care plan report also included a focus area initiated 01/29/25, that indicated the resident refused personal care at times. Interventions directed staff to document educational attempts made with the resident. Review of Resident #24's ADL-Bathing record revealed staff documented nail care was provided on 06/14/25 and 06/18/25. The report revealed no documented evidence the resident refused nail care on 06/14/25 or 06/18/25. Review of Resident #25's shower day skin inspection sheet dated 06/14/25, revealed Certified Nurse Aide (CNA) #12 documented Resident #24's fingernails were cleaned. Review of Resident #24's shower day skin inspection sheet, dated 06/18/25, revealed CNA #13 documented Resident #24's fingernails were cleaned. Review of Resident #24's progress notes, dated 06/13/25 through 06/18/25, revealed no evidence to indicate Resident #24 refused nail care on 06/14/25 or 06/18/25. During an observation on 06/17/25 at 11:23 A.M., Resident #24 was observed in bed and the resident's fingernails on the right hand were approximately one-half an inch beyond the nail bed and there was brown matter under each nail. During an observation on 06/19/25 at 8:41 A.M., Resident #24 was in bed and the resident's fingernails on the right hand had brown matter underneath the nail. During a telephone interview on 06/20/25 at 8:28 A.M, CNA #12 stated she provided a bed bath for Resident #24 on 06/14/25. She stated Resident #24 became combative while cleaning the resident's nails and she was only able to clean two nails on the left hand and one nail on the right hand. She stated she notified Licensed Practical Nurse (LPN) #7 that the resident refused nail care but did not document on the shower day skin inspection sheet that she was unable to finish cleaning the resident's fingernails. During a telephone interview on 06/20/25 at 9:39 A.M., LPN #7 stated she remembered CNA #12 told her that she was not able to clean all of Resident #24's nails on 06/14/25; however, she forgot to document the refusal. LPN #7 stated Resident #24 did not like their hands to be touched and would not allow staff to clean their nails on 06/14/2025. During an interview on 06/19/25 at 11:46 A.M., CNA #13 stated on 06/18/25, Resident #24 allowed her to start cleaning their nails but became combative and she was not able to finish cleaning the resident's nails on their right hand. CNA #13 stated she meant to go back to finish the resident's nail care but forgot. During an interview on 06/19/25 at 12:03 P.M., Unit Manager (UM) #9 stated Resident #24 could be very resistant to care. During a concurrent interview and observation on 06/19/25 at 12:09 P.M., UM #9 entered Resident #24's room, picked up the resident's right hand, and stated the resident's nails were long and had some type of substance underneath the nails. UM #9 stated the resident's fingernails definitely needed to be cleaned and trimmed. UM #9 then opened the clenched fingers on Resident #24's left hand and stated the nails could be trimmed. During an interview on 06/19/25 at 11:18 A.M., the Director of Nursing (DON) stated the CNAs needed to clean the residents' fingernails when they were soiled or dirty. The DON stated if the CNA was unable to clean the residents' nails, they should let the nurse know. The DON stated the CNAs and nurses were supposed to sign the shower day skin inspection sheets, indicating whether care was provided. The DON stated the nurse should verify care was provided and if a resident refused care, the nurse should document a progress note. During an interview on 06/20/25 at 10:44 A.M., the Administrator stated her expectation was for the CNA to let the nurse know if the resident became combative, and they could not clean their nails. The Administrator stated her expectation was for staff to attempt nail care, communicate with the nurse if they were unable to complete nail care, and if nail care was not able to be completed, they should document the refusal. During an interview on 06/19/25 at 12:39 P.M., Corporate Clinician #20 stated the facility did not have a policy for nail care. Corporate Clinician #20 stated the provision of nail care was standard practice.

Based on observation, staff interview, and document review, the facility failed to ensure nurse staffing data was posted daily, at the beginning of each shift on the weekends, and contained the resident census as required. This deficient practices had the potential to affect all 90 residents who resided in the facility. The census was 90. Findings included: Review of the facility daily staffing forms, dated 04/01/25 through 06/18/25, revealed the resident census was not documented for each shift, each day. During an observation on 06/18/25 at 8:16 A.M., the posted daily staffing form, dated 06/18/25, located in a cabinet on a wall in a hallway, revealed the posting did not include the resident census. During an observation on 06/19/25 at 11:25 A.M., the daily staffing form for 06/19/25 was not posted in the wall cabinet of the facility. During an interview on 06/19/25 at 10:52 A.M., the Director of Nursing (DON) stated that either she or one of the unit managers completed the daily staffing form and posted the form. The DON stated the daily staffing form was typically completed between 7:00 A.M. and 8:00 A.M. during the weekdays and then posted; however, she had not posted the form for 06/19/25. The DON stated the facility had two shifts, 7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M. and the daily staffing form, which included the day and night shift totals, was only posted once per day. The DON stated she was not aware the staff posting was required to be posted at the beginning of each shift. The DON stated that the resident census was discussed in a morning meeting but was not included on the daily staffing forms. During a follow-up interview on 06/20/25 at 9:18 A.M., the DON stated that on Fridays, the facility posted projected staffing data for the weekend. Per the DON, there was no one designated to post the daily staffing form on the weekends. During an interview on 06/20/25 at 8:22 A.M., Corporate Clinician #20 stated the facility did not change the daily staffing form each shift during the weekends. During an interview on 06/20/25 at 10:34 A.M., the Administrator stated the nurse staffing data that was posted for the weekends was based on the number of staff who were scheduled. The Administrator stated she reviewed the posting to see that it was present and that the staffing numbers were based on the resident census and acuity. The Administrator stated if someone called off, the on-call nurses knew they would have to work if the shift could not be filled. Per the Administrator, she expected the daily nurse staffing data form to be completed and posted early in the shift. During an interview on 06/20/25 at 8:22 A.M., Corporate Clinician #20 stated the facility did not have a policy related to posting nurse staffing data. Per Corporate Clinician #20, the facility followed federal regulations.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital records, staff interviews and policy review, the facility failed to ensure a therapeutic medication interchange was reconciled timely resulting in a significant medication error for the resident's diabetic medication (insulin). This resulted in Actual Harm when Resident #102 did not receive her insulin as ordered on 11/20/22 which resulted in Resident #102 being admitted to the hospital with a high blood sugar reading of 964 milligrams (mg)/ deciliter (dL). This affected one (#102) out of the three residents reviewed for medications administration. The facility census was 85. Findings included: Review of the medical record for Resident #102 revealed an admitted [DATE] with medical diagnoses of protein calorie malnutrition, diabetic mellitus with ketoacidosis, dysphagia, and senile degeneration of the brain. Review of the medical record revealed Resident #102 was discharged to the hospital on 11/21/22 with altered mental status. Review of the medical record for Resident #102 revealed a discharge Minimum Data Set (MDS), dated [DATE], which indicated Resident #102 had short term memory loss and had modified independence with decision making. The MDS stated Resident #102 required extensive staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the medical record for Resident #102 revealed a physician order, dated 11/18/22 for Humalog solution (insulin) 100 units per milliliter (ml) per sliding scale, to inject insulin subcutaneous (SQ) before meals and every evening for diabetes mellitus. The sliding scale stated if blood sugar was 151-200 to give two units; 201-250 to give four units; 251-300 to give six units; 301-350 to give eight units; 351-400 to give 10 units and if blood sugar 401+ call medical director (MD). Review of the medical record revealed a physician order, dated 11/20/22 for Humalog Kwikpen 100 units/ml solution pen-injector. The order stated to inject before meals and every evening for diabetes mellitus per sliding scale. The sliding scale stated if blood sugar was 151-200 to give two units; 201-250 to give four units; 251-300 to give six units; 301-350 to give eight units; 351-400 to give 10 units and if blood sugar 401+ call MD. Review of the medical record for Resident #102 revealed the November 2022 Medication Administration Record (MAR) which indicated Resident #102 received her insulin as ordered on 11/19/22 but did not contain documentation to support the facility checked Resident #102's blood sugar levels or that Resident #102 was administered insulin on 11/20/22. Review of the medical record for Resident #102 revealed a nurse progress note, dated 11/21/22 at 9:32 A.M., which stated the nurse spoke with the resident around 7:30 A.M. and resident was noted to be sleepy but was able to answer questions. The note continued to state at 9:30 A.M. therapy staff reported Resident #102 was too sleepy for therapy. The note stated the nurse went to check on Resident #102 and to give medications and the resident was noted to be lethargic and not able to answer questions. The note stated the nurse called the physician and reported Resident #102's change of condition and a new order was received to send to the hospital. Vital signs were taken and blood sugar level before nine-one-one (911) arrived. Resident #102's blood sugar level was noted to be high. Review of the medical record for Resident #102 revealed a transfer out of facility assessment, dated 11/21/22, which stated Resident #102 was sent out to the hospital due to altered mental status change and recent fall. The assessment indicated the last recorded blood sugar was 333 ml/dL on 11/19/22. Review of the medical record revealed an emergency department (ED) report, dated 11/21/22, stated Resident #102 was seen in the ED for hyperglycemia. The report stated Resident #102 presented to ED with alert eyes and attempted to speak but was not easily understood. The lab work in the ED revealed a blood glucose level of 964 mg/dL and Resident #102 was diagnosed with hyperosmolar hyperglycemic state, dehydration, and metabolic encephalopathy. The note continued to state Resident #102 was admitted to the hospital. Interview with Administrator on 12/13/23 at 1:35 P.M. confirmed the medical record for Resident #102 did not contain documentation to support the facility staff checked Resident #102's blood sugar levels or administered insulin on 11/20/22. Administrator stated the pharmacy recommended a therapeutic interchange from Humalog insulin per sliding scale to Humalog Kwikpen injector per sliding scale on 11/19/22 but the nurses did not confirm the new order for the Humalog Kwikpen in Resident #102's electronic health record. Administrator stated since the nurses did not confirm the order for the Humalog Kwikpen, the insulin did not appear on the MAR for the nurses to check Resident #102's blood sugar levels or administer insulin on 11/20/22. Administrator stated the facility identified the concern related to therapeutic medication interchanges and insulin administration and completed all nursing staff education on 11/21/22 and 11/22/22. Review of the facility policy titled, Medication Administration, dated 06/21/17, stated the nurse was responsible for noting any changes on the MAR and medications would be administered by legally authorized and trained persons consistent with accepted standards of practice. The deficient practice was corrected on 12/09/22 when the facility implemented the following corrective actions: On 11/21/22, Resident #102 was transferred to a local hospital via emergency medical services after the physician was notified of a change of condition. On 11/21/22, immediate education was provided to Director of Nursing (DON) by corporate clinician on medication administration regarding diabetic residents, admission process, change of condition, therapeutic interchanges, and signs and symptoms of hyper/hypoglycemia. On 11/21/22, Assistant Director of Nursing (ADON) #09/nursing supervisor completed audits on all diabetic orders to ensure they were entered into the electronic health records correctly. On 11/21/22, DON provided education to all licensed nurses on medication administration regarding diabetic residents and therapeutic interchanges. On 11/22/22, DON provided education to all licensed nurses on medication administration for diabetic residents, admission process, change of condition, therapeutic interchanges, and signs of hyper/hypoglycemia. On 11/22/22, DON provided one on one education with ADON #09, unit managers, and nursing supervisors on medication administration for diabetic residents, admission/readmission process, change of condition, therapeutic interchanges, and signs and symptoms of hyper/hypoglycemia. On 11/22/22, Administrator provided education to Admissions Coordinator on admission process to ensure correct paperwork was given to nurses on admission and readmissions. On 11/22/22, an initial Quality Assurance and Performance Improvement (QAPI) plan was completed, and monitoring tools were completed weekly for four weeks on admission and readmission process, therapeutic interchange process along with the monitoring of diabetic medication orders to ensure entered in electronic health records correctly. Review of the QAPI revealed all monitoring tools were completed and no issues were noted. On 11/22/22, Licensed Practical Nurse (LPN) #315, who was responsible for Resident #102's medications on 11/20/22, was terminated for not administering medications as ordered and other non-related issues. On 12/09/22, all facility QAPI monitoring tools were completed and reviewed. No further issues were identified. On 12/13/23 two (#100 #104) additional residents medical records were reviewed regarding medication administration. No concerns were identified. On 12/13/23 between 8:41 A.M. and 11:18 A.M., LPN #300 and LPN #275 were observed passing medications to Resident #51, #55 and #63. No medication errors were observed. Interviews on 12/13/23 from 3:34 P.M. to 3:37 P.M. with LPN #275 and #311 confirmed the facility provided education in November 2022 on therapeutic medication interchanges, medication administration for diabetic residents, and signs and symptoms of hyper/hypoglycemia. This deficiency represents non-compliance investigated under Complaint Number OH00148476.

Based on medical record review, observation, and staff interview, the facility failed to ensure residents received services to prevent ongoing decline in range of motion (ROM). This affected one (#24) of three residents reviewed for contracture management/ROM. The facility census was 87. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses including dysphagia, polyarthritis, hemiplegia and hemiparesis, and cerebral infarction affecting left non-dominant side. Review of the Minimum Data Set (MDS) for Resident #24 dated 05/17/23 revealed the resident was cognitively impaired and required extensive assistance with activities of daily living (ADL's). Resident #24 was coded for functional impairment on both sides to upper and lower extremities. Review of the care plan for Resident #24 dated 10/09/20 revealed the resident may require assistance with ADL's, receive staff's extensive assistance to total care in completion of ADL care/functional needs. Mechanical lift was utilized for all transfer needs and resident used a reclining geri chair for out of bed mobility needs. Resident #24's cognition was impaired, and the resident had a history of stroke with left sided weakness and muscle weakness. Interventions included the following: provide assist for ADL's based on residents needs/abilities, provide necessary adaptive equipment to meet daily needs, therapy to screen and provide treatment as ordered, report any changes in ADL self-performance. Review of Restorative Nursing caseload list dated 06/30/23 revealed Resident #24 was not receiving restorative services. Observation on 06/30/23 at 12:19 P.M. of Resident #24 revealed the resident was compliant with peri care per State tested Nursing Assistants (STNA's) #425 and #555. Resident #24 was compliant with Licensed Practical Nurse (LPN) #275 application of lotion to her feet. Further observation revealed Resident #24's feet appeared to have slight footdrop and bilateral hands appeared to be somewhat contracted. Observations of Resident #24 revealed staff did not perform ROM and there were no splints observed. Interview on 06/30/23 at 12:24 P.M. of STNA's #425 and #555 confirmed Resident #24 was not on a ROM program nor did she have any orders for splints. STNA's #425 and #555 confirmed if resident required ROM services they would be provided by therapy or the facility restorative aides. Interview on 06/30/23 at 12:25 P.M. of LPN #275 confirmed Resident #24's fingers appeared slightly contracted and resident appeared to have slight foot drop bilaterally. Interview on 06/30/23 at 1:42 P.M. of the Administrator confirmed Resident #24 had not been seen or screened by therapy in over two years. Administrator confirmed the facility had a restorative program which was overseen by the Director of Nursing (DON). Administrator confirmed the facility did not have policies regarding contracture management, range of motion services, and/or therapy screening and referrals. Interview on 06/30/23 at 1:50 P.M. with Certified Occupational Therapy Assistant (COTA) #680 who also served as therapy program manager for the facility, confirmed the facility had not written policy for screening residents for appropriateness for therapy. COTA #680 confirmed the therapy department relied on nursing staff to report significant changes which might indicate resident would benefit from therapy. COTA #680 confirmed the therapy department worked closely with the restorative aides and would assist with setting up programs including restorative ROM programs. COTA #680 confirmed Resident #24 had not been on therapy caseload in recent years. Interview on 06/30/23 at 1:57 P.M. with COTA #680 after observation of Resident #24 confirmed the resident's fingers appeared to be contracted and feet showed slight signs of foot drop. COTA #680 confirmed it would be more appropriate to have an Occupational Therapist (OT) evaluate Resident #24's upper extremities and a Physical Therapist (PT) to evaluate the lower extremities. Interviews on 06/30/23 at 2:04 P.M. with Restorative Aide (RA) #120 and at 2:11 P.M. with RA #260 confirmed Resident #24 was not currently receiving any restorative services and had not been on restorative caseload at any time they could recall. Interview on 06/30/23 at 2:19 P.M. of PT #685 confirmed he observed Resident #24 on 06/30/23 and felt her feet showed slight dorsiflexion but did not feel the resident required ROM or restorative services or therapy services at this time. Interview on 06/30/23 at 2:19 P.M. of OT #690 confirmed she observed Resident #24 on 06/30/23 and felt the resident's hands had limited range of motion and weakness. OT #690 confirmed Resident #24 would benefit from a formal OT evaluation to determine appropriate services to prevent further decline in ROM. Interview on 06/30/23 at 2:38 P.M. of the DON confirmed Resident #24's MDS was coded for functional impairment to upper and lower bilateral extremities. DON confirmed Resident #24 had not been on therapy or restorative nursing caseload for the past two years and her care plan did not include interventions to prevent ADL decline except for PT and OT to evaluate as needed. This deficiency represents non-compliance investigated under Complaint Number OH00143648.

Based on observations, medical record review, staff interview, and policy review, the facility failed to ensure hand hygiene was completed during dining services and failed to ensure gloves were changed and hand hygiene was completed during a wound dressing change. This affected three (#57, #22 and #79) of 20 residents who ate in their room on 05/16/22 during lunch and affected one (#82) of two residents reviewed for dressing changes during the annual survey. The facility census was 91. Findings include: 1. Medical record review for Resident #82 revealed an admission of 07/30/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 was cognitively intact. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of a dressing change for Resident #82 on 05/18/22 at 1:55 P.M. with Licensed Practical Nurse (LPN) #115 revealed she washed her hands and put on gloves, removed the ABD pad and the dressing inside of the wound, sprayed wound cleanser on the wound, and cleaned the wound. LPN #115 proceeded to take the Dakins solution and placed it into the package that had a 4 X 4 in the package. LPN #115 did not change her gloves and took her right gloved hand and pulled out the 4 X 4, folded it up and placed it into the wound and removed her gloves and placed a clean pair of gloves onto her hands and placed a clean ABD pad on the wound. Interview with LPN #115 on 05/18/22 at 2:08 P.M. confirmed she should have changed her gloves and washed her hands after cleansing the wound and placed on new gloves to place the clean dressing into the wound. 2. Observation on 05/16/22 at 12:19 P.M. revealed State tested Nursing Aide (STNA) #135 went into Resident #57's room and dropped off a lunch tray and came out of the room and didn't sanitize her hands. She continued to enter Resident #22's room, which had a sign on the door for contact isolation, dropped off a lunch tray and touched the tray table and a wheelchair with her right hand on the way out of the room. She continued to take both of her hands and pull trays out of the dining cart and took a lunch tray into Resident #79 and didn't wash or sanitize her hands upon leaving this resident's room. Interview with STNA #135 on 05/16/22 at 12:30 P.M. confirmed she didn't wash or sanitize her hands in-between rooms especially the isolation room and confirmed she should have performed hand hygiene. Review of the facility's policy titled Infection Prevention and Control Program dated 08/10/18 revealed it was the policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. All staff shall perform hand hygiene between resident contacts and after handling contaminated objects. Gloves are changed and hand hygiene is performed before moving from a contaminated body site to a clean body site during resident care.

Based on medical record review, record review, staff interview, and review of the facility's used clinical references, the facility failed to have justification for use of an antibiotic to treat a urinary tract infection for Resident #30. This affected one (Resident #30) of five residents reviewed for unnecessary medications. The facility census was 91. Findings include: Review of Resident #30's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact. Review of Resident #30's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medication administration records (MARs) revealed [MEDICATION(S)] was administered as ordered starting on 03/19/22. Further review of Resident #30's medical record revealed no documentation of a urine culture being obtained prior to the use of [MEDICATION(S)] in March 2022. There was no documentation of any physician recommendation to continue [MEDICATION(S)] without obtaining urine culture results. There was no evidence of Resident #30 having a fever or any painful urination. Review of the facility's infection control log revealed on 03/19/22, Resident #30 was noted as having a [CONDITION(S)]. No urine culture was obtained. Resident #30 was ordered [MEDICATION(S)] twice a day for seven days. Review of the facility's clinical reference used for a urinary tract infection, National Health and Safety Network Urinary Tract Infection Catheter-Associated Urinary Tract Infection (CAUTI) and Non-Catheter-Associated Urinary Tract Infection ([CONDITION(S)]) Events dated January 2022 revealed a resident that did not have an indwelling urinary catheter must have at least one of the following signs and symptoms to be considered a [CONDITION(S)]. Fever greater than 38 celsius, suprapubic tenderness, costoverbal angel pain of tenderness, urinary frequency, urinary urgency, or dysuria. The resident must also have a urine culture with has a urine culture with no more than two species of organisms identified of at least one of which is a bacterium of greater than 100,000 colony-forming units per milliliter (CFU/ml). During an interview on 05/18/22 at 3:30 P.M., Corporate Nurse (CN) #250 confirmed there was not a justified use of [MEDICATION(S)] for [CONDITION(S)] for Resident #30 on 03/19/22. CN #250 confirmed there was not any documentation of Resident #30 meeting the criteria for having an [CONDITION(S)].

Based on medical record review and staff interview, the facility failed to obtain a laboratory value as ordered by the physician for a resident. This affected one (Resident #49) of five residents reviewed for unnecessary medications. The facility census was 91. Findings include: Review of Resident #49's medical record revealed an admitted d of 10/07/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was assessed as being cognitively intact. Review of a pharmacy recommendation dated 02/09/22 revealed Resident #49 was currently on [MEDICATION(S)] 25 micrograms (mcg) daily and there was no evidence of a [CONDITION(S)] stimulating hormone (TSH) (laboratory value) in Resident #49's chart. A recommendation of a drawing a TSH now and at least yearly after was made. The physician signed and agreed with the recommendation on 02/17/22. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and in three months. Further review of Resident #49's medical record revealed no documentation of a TSH level being obtained from 02/18/22 to 05/17/22. During an interview on 05/18/22 at 1:43 P.M., Corporate Nurse (CN) #250 confirmed a TSH level was not obtained on 02/18/22 or after for Resident #49.

Based on record review and staff interviews, the facility failed to ensure the correct code status was available in the residents' chart. This affected one (Resident #47) of 20 residents reviewed for advance directives. The facility census was 91. Findings include: Review of the medical record for Resident #47 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had intact cognition. Review of the care plan revealed Resident #47's code status was do not resuscitate (DNR). Review of Resident #47's paper chart revealed a Do Not Resuscitate Comfort Care (DNR-CC) order signed on 12/02/20. Review of the electronic medical record revealed Resident #47 was a full code. There was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 5/17/22 at 9:37 A.M. with Registered Nurse (RN) #154 verified the electronic chart for Resident #47 contained a full code order dated 02/25/21 and the paper chart had DNR-CC paperwork signed 12/02/20.

Based on medical record review, resident and staff interview, review of facility Self-Reported Incidents (SRI's), review of a facility investigation, review of the facility employee handbook, and review of facility policy, the facility failed to report an allegation of financial exploitation to the Ohio Department of Health (ODH). This affected one (#53) of three SRI's for misappropriation reviewed. The census was 77. Findings include: Review of the medical record for Resident #53 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 04/23/21 revealed the resident was cognitively intact and required extensive assistance of one staff with activities of daily living (ADL's). Review of facility SRI's dated 12/01/20 through 07/16/21 revealed the facility had not reported any allegations of financial exploitation or misappropriation made by Resident #53. Review of facility investigation dated 05/26/21 revealed the facility investigated an allegation made by Resident #53 that she had loaned State tested Nursing Assistant (STNA) #100 ninety dollars ($90.00) cash sometime earlier in 2021 but the STNA had not paid her back. Further review of investigation revealed the facility was unable to substantiate any wrongdoing had occurred. Interview on 07/16/21 at 10:50 A.M. with Resident #53 confirmed she loaned State tested Nursing Assistant (STNA) #100 ninety dollars ($90.00) cash sometime earlier in 2021 but the STNA had not paid her back. Resident #53 further confirmed she reported her concerns to the facility at the end of May 2021 and the Administrator had reimbursed the $90.00. Interview on 07/16/21 at 12:03 P.M. with the Administrator confirmed Resident #53 made an allegation on 05/26/21 she had loaned STNA #100 the sum of $90.00 and STNA #100 had not paid her back. Administrator further confirmed the facility investigated the allegation but could not substantiate any wrongdoing had occurred and the facility had reimbursed Resident #53 the sum of $90.00 sometime in early June 2021 after the investigation was completed. Administrator further confirmed staff were not permitted to borrow money from residents. Administrator confirmed the facility had investigated the allegation made by Resident #53 towards STNA #100 but had not reported the allegation to ODH because she did not think it was reportable. Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property dated 11/21/16 revealed the facility would investigate and report all allegations of exploitation and misappropriation of resident property to the ODH. Further review of the policy revealed exploitation was defined as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. Review of the facilities undated Employee Handbook, pages 28-29 revealed employees may not borrow money or items from residents and adherence to this policy would avoid any potential conflict of interest or appearance of impropriety. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observations, staff interview, review of facility policy, and review of online resources per the Center for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore eye protection and N-95 facemask's as appropriate to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected two (#12 and #8) out of five residents reviewed for infection control practices. The census was 66. Findings include: 1. Review of the medical record for Resident #8 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders for Resident #8 revealed an order dated 03/24/21 maintain contact and droplet precautions every shift for 14 days from admission. Review of nurse progress note for Resident #8 dated 03/25/21 revealed transmission based precautions were being maintained by staff. Observation on 03/29/21 at 11:50 A.M. with the Administrator revealed Resident #8 had an isolation cart outside her room containing personal protective equipment (PPE) and a sign on the door indicating droplet precautions were indicated before entering the resident's room. Observation revealed Occupational Therapist (OT) #225 walked down the resident hallway and entered resident's room to complete therapy services. The observations revealed OT #225 was not wearing eye protection. Interview on 03/29/21 at 11:51 A.M. with OT #225 confirmed she had entered Resident #8's room to complete therapy services and was not wearing eye protection. Interview on 03/29/21 at 11:54 A.M. with the Administrator confirmed OT #225 had walked down the hallway and into Resident #8's room without wearing eye protection. The Administrator further confirmed Resident #8 was on droplet precautions because she was admitted on [DATE] and staff should wear an N-95 mask, a gown, gloves, and eye protection prior to entering the resident's room. Review of facility policy titled COVID-19 -Discontinuation of Transmission-Based Precautions dated 12/30/20 revealed newly admitted or readmitted residents will be placed on contact and droplet transmission based precautions and monitored for symptoms of COVID-19. Review of the facility policy titled Novel Coronavirus Prevention and Response dated 03/19/21 revealed the facility would educate staff on proper use of PPE including eye protection. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data-Test-Positivity-Rates/q5r5-gjyu/ revealed the county in which the facility was situated was experiencing a high spread of COVID 19 with a positivity rate of 10.3 percent (%) and the county was identified as red for the week ending in 03/23/21. Review of an online resource per the CDC at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply. 2. Review of the medical record for Resident #12 revealed an admitted [DATE]. Review of physician orders for Resident #12 revealed an order dated 03/24/21 maintain contact and droplet precautions every shift for 14 days from admission. Observation on 03/29/21 at 12:00 P.M. revealed Resident #12 had an isolation cart outside her room containing PPE and a sign on the door indicating droplet precautions were indicated before entering the resident's room. Further observation revealed Licensed Practical Nurse (LPN) #250 was at the medication cart wearing a surgical facemask and a face shield. Interview on 03/29/21 at 12:01 P.M. with LPN #250 confirmed she was Resident #12's nurse. LPN #250 confirmed she was wearing a surgical facemask and she had been wearing the surgical facemask for the entire shift including when she entered Resident #12's room to deliver nursing care. Interview on 03/29/21 at 12:03 P.M. with the Administrator confirmed staff should wear an N-95 mask when entering Resident #12's room to provide care due to resident being on droplet precautions due to recent admission to facility on 03/24/21. Administrator confirmed the facility did not have a shortage of N-95 masks and LPN #250 was not required to wear an N-95 mask because she had a doctor's note which said she couldn't wear one. Review of the facility policy titled Novel Coronavirus Prevention and Response dated 03/19/21 revealed the facility would implement staff wearing facemask's in accordance with regulatory requirements. Review of an online resource per the CDC at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed health care professionals (HCP) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection.

Based on medical record review and resident and staff interview, the facility failed to provide dependent residents timely assistance with using the bedpan. This affected one (#59) of three residents sampled. The census was 66. Findings include: Review of the medical record for Resident #59 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #59 revealed resident had a brief interview for mental status (BIMS) of a 15 out of 15 indicating the resident was cognitively intact. Further review revealed the resident required extensive assistance of two staff with activities of daily living (ADL's). Review of the care plan for Resident #59 dated 03/11/20 revealed the resident had a self-care performance deficit and received staff setup/supervision to total care in completion of ADL/functional needs. Interventions included the following: assist with bedpan, encourage resident participation while performing ADL's, explain all procedures prior to care, staff to anticipate needs and assist as needed, provide assist for ADL's based on residents needs/abilities, provide necessary adaptive equipment to meet daily needs, toileting assistance needed. Review of nurse progress note for Resident #59 dated 03/06/21 per Licensed Practical Nurse (LPN) #250 revealed a State tested Nursing Assistant (STNA) responded to resident's call light at lunchtime and resident requested assistance with getting on the bedpan. STNA explained that other STNA working on the hall was in a room and this STNA needed to finish passing trays. Further review of the note revealed the STNA finished passing trays and feeding before going back to assist resident with getting on the bedpan. Review of note revealed resident's representative was on the phone during the exchange between the STNA and Resident #59 and representative was upset, and verbalized staff were always passing trays when resident needed to use the bedpan. Review of care conference note for Resident #59 dated 03/09/21 revealed the conference was held to ensure the facility could meet the resident's needs and expectations. Further review of the note revealed the Director of Nursing (DON) explained the facility protocol regarding peri care during mealtimes. Interview on 03/29/21 at 12:40 P.M. with Resident #59 confirmed at times she does not get assisted onto the bedpan in a timely manner, particularly if she must use the bedpan and the STNA's are passing trays. Resident #59 confirmed nursing management told her staff cannot assist her when they are passing trays or assisting with meals and she sometimes waits for as long as 30 minutes before being assisted onto the bed pan. Interview on 03/29/21 at 3:03 P.M. with LPN #250 confirmed on 03/06/21 at lunchtime a STNA responded to Resident #59's call light and the resident requested STNA put her on the bedpan. LPN #250 further confirmed the STNA told resident she could not assist her because she was passing trays and the other STNA working the hall was in a room. LPN #250 confirmed Resident #59 was on the phone with her representative at the time and representative was upset when he heard the STNA tell resident she could not assist her due to passing trays. LPN #250 confirmed the STNA finished passing trays and feeding and then assisted the resident onto the bedpan. LPN #250 confirmed she did not offer to assist Resident #59 onto the bed pan because it usually took two staff to assist resident onto bedpan, although some staff could assist resident with one staff. Interview on 03/29/21 at 3:10 P.M. with the DON confirmed the facility did not have a written protocol or policy for assisting residents with toileting needs during mealtime but STNA's should not stop the tray pass or feeding residents to assist with toileting needs. DON further confirmed other staff could assist with toileting needs during meal times within their scope of practice. This deficiency substantiates Complaint Number OH 934.

Based upon record review, staff interview, and facility procedure review the facility failed to follow physician orders [REDACTED]. This affected one (Resident #4) of three resident reviewed for skin issues. The facility identified 12 residents with current wounds. The census was 83. Findings include: Review of the medical record for former Resident #4 revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was discharged from the facility on 08/28/19. Review of pressure ulcer risk assessment for Resident #4 dated 06/04/19 revealed resident was at high risk for the development of pressure ulcers. Review of the Minimum Data Set (MDS) assessment, dated 06/14/19, revealed Resident #4 was cognitively impaired and required extensive assistance of one staff with activities of daily living. Review of care plan for Resident #4, dated 06/17/19, revealed the resident was at risk for alteration in skin integrity. Interventions included the following: dietary consults, do not massage bony prominences, encourage and assist to elevate heels, encourage and assist to turn and reposition, linens dry and wrinkle free, notify physician and family of changes, pressure reduction chair cushion, and skin care as needed Review of the physician orders [REDACTED]. incontinent episode; and foam dressing to coccyx change daily and as needed for preventative. Review of Treatment Administration Record (TAR) for Resident #4 for (MONTH) 2019 revealed the foam dressing to coccyx change daily completed on 08/10/19 and 08/15/19. Monitor scabbed areas on left forearm, leave open to air, and report signs/symptoms of infection daily was not completed on 08/24/19 and 08/25/19. Apply moisture barrier ointment to peri area and buttocks every shift was not completed on night shift on 08/18/19. Apply house moisture cream to heels for preventative skin care every shift was not completed on night shift on 08/18/19. Leave steri-strips in place to left forearm and monitor every shift was not completed on night shift on 08/18/19. Skin prep to coccyx, bilateral heels, and behind bilateral ears every shift was not completed on day shift on 08/10/19 or on night shift on 08/18/19. Interview with the Director of Nursing (DON) on 09/05/19 at 11:31 [NAME]M. confirmed the above listed treatment were not documented as completed on 8/10/19, 08/15/19, 08/18/19, 08/24/19 and 08/25/19. Review of the undated facility procedure titled Skin/Wound Best Practice revealed wound and skin treatments should be administered per physician order [REDACTED]. This deficiency substantiates the allegations contained in Master Complaint Number OH 674.

Based upon medical record review, review of incident investigation notes, and resident and staff interview, the facility failed to develop a care plan to address resident sexual health concerns. This affected one (Resident #1) of three residents sampled for abuse concerns. The census was 83. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment for Resident #1, dated 08/02/19, revealed the resident was cognitively intact and required supervision of one staff with activities of daily living (ADLs). Review of nurse progress note for Resident #1, dated 08/18/19 timed at 6:00 [NAME]M., revealed the resident was not in his room and had failed to sign out of the facility. The staff searched for the resident and found the resident in the parking lot of the facility in a private vehicle. Review of care plan for Resident #1 revealed the care plan was silent regarding resident's sexual health, including offering counseling regarding safe sexual activity. Review of incident investigation notes for Resident #1, dated 08/19/19, revealed former State tested Nursing Assistant (STNA) #30 was assisting in the search for Resident #1 at approximately 6:00 [NAME]M. on 08/18/19. STNA #30 found Resident #1 in the backseat of a private vehicle of the facility parking lot accompanied by a female whose face he could not identify. Per STNA #30's report he told the nurse he was concerned Resident #1 was engaged in intimate activity with a female, Visitor #60, in the backseat of a private vehicle of the facility parking lot. The resident came back inside the facility at approximately 6:10 [NAME]M. on 08/18/19. Review of investigation notes for Resident #1, dated 08/19/19, revealed that resident was interviewed on 08/19/19 by the Director of Nursing (DON). The resident alleged that on 08/18/19 from approximately 12:01 [NAME]M. to 6:00 [NAME]M. he left the facility and met with a female visitor in the backseat of her vehicle in the parking lot of the facility. Interview with the DON on 09/04/19 at 3:01 P.M. confirmed she had investigated the incident of Resident #1 being found missing on 08/18/19, but did not consider it to be an allegation of sexual abuse as the resident was alert, cognitively intact, and able to consent to sexual activity. Interview with Resident #1 on 09/04/19 at 10:02 [NAME]M. confirmed he had left the facility sometime after 12:01 [NAME]M. on 08/18/19 and met with Visitor #60 in the backseat of her vehicle parked in the facility parking lot. He went back inside the facility at approximately 6:00 [NAME]M. on 08/18/19. Interview with Resident #1 further confirmed that he wanted to be sexually active again following his recent stroke and that he had been pursuing romantic relationships with women outside of the facility. Interview with Social Service Designee (SSD) #70 on 09/04/19 at 4:06 P.M. confirmed she interviewed Resident #1 on 08/22/19. SSD #70 stated the resident said he met with Visitor #60 on 08/18/19 from approximately 12:01 [NAME]M. to 6:00 [NAME]M. in the backseat of her private vehicle parked in the facility parking lot. He had met Visitor #60 on an online dating website and he was pursuing romantic relationships with women outside of the facility. He told SSD he hoped he would still be able to function sexually following his recent stroke. Further interview with SSD #70, confirmed she had spoken with Visitor #60 by phone sometime after 08/22/19 and Visitor #60 confirmed meeting with Resident #1 on 08/18/19 in the facility parking lot in her private vehicle and that she was involved in consensual romantic relationship with Resident #1. SSD #70 confirmed the facility had not developed a care plan for Resident #1 that involved resident's sexual health, including offering counseling regarding safe sexual activity. Interview with the DON on 09/05/19 at 11:31 P.M. confirmed that Resident #1's care plan was silent regarding resident's sexual health, including offering counseling regarding safe sexual activity. This is an incidental citation discovered during the complaint investigation.

Based on observation, staff interview, review of the planned menus approved by a Registered Dietitian (RD) and review of Diet Type report the facility failed to prepare and serve food to residents on pureed consistency diets as specified in the planned menus. This affected six Residents (#8, #9, #12, #33, #34, and #49) who were identified with orders for pureed diets. The facility census was 88. Findings include: On 06/01/19 at 4:15 P.M., Cook #95 was observed setting up the steam table with the hot food to be served to residents. At that time she took the temperatures of the hot food with a sanitized thermometer, and all temperatures were above the minimum acceptable standard of 135 Fahrenheit (F). Observation of the food prepared and ready for service on the steam table included meatballs in a stroganoff gravy, buttered noodles, carrots, purred meat balls, mashed potatoes, and pureed carrots. The planned menu specified that resident's on pureed diets were to receive the following hot food: 2-#10 scoops (total of six ounces) of pureed meatball stroganoff; #8 scoop (1/2 cup) of pureed egg noodles; and four ounces of pureed carrots. Tray assembly for the evening meal in the central kitchen began on 0601/19 at 4:30 P.M. Observation of menu items served, and portion sizes of the menu items served, versus the planned menu for pureed diets revealed that Cook #95 was plating one #8 (four ounces ) of pureed meatballs stroganoff for pureed diets, not the six ounces planned; the meat was under served. In addition, the cook substituted mashed potatoes for the pureed egg noodles; no pureed egg noodles were prepared. The cook continued to assemble trays for all the pureed diets for the evening meal On 06/01/19 at 5:00 P.M. Cook #95 affirmed that she was serving the six residents on pureed diets a #8 scoop, or four ounces, of pureed meatball stroganoff. On 06/01/19 at 5:12 P.M. Dietary Manager (DM) #90 was asked to observe the menu items prepared and served to residents on pureed diets, and respective portion sizes of the food served. DM #90 reviewed the planned/approved menu and confirmed that Cook #95 was only serving residents on pureed diet four ounces of pureed meatball stroganoff instead of the planned six ounces, and that mashed potatoes had been served versus the planned pureed egg noodles. Review of the the facility Diet Type Report which was taken from current physician's diet orders in the electronic health records effective 06/01/19 revealed that six Residents #8, #9, #12, #33, #34, and #49 all had diet orders for pureed consistency diets. This deficiency substantiates Complaint Number OH 437.

Based on medical record review, observation, staff and resident interview, review of diet cards, review of census and review of menus approved by the Registered Dietitian (RD) the facility failed to serve residents on mechanical soft diets in accordance with physician's orders [REDACTED]. The deficit practice directly affected four (#58, #66, #74 and #80) of four reviewed. The facility identified a total of 19 Residents (#5, #11, #13, #25, #28, #29, #30, #37, #43, #47, #54, #55, #58, #66, #74, #75, #80, #84, and #88) with physician's orders [REDACTED]. The facility census was 88. Findings include: On 06/01/19 at 4:15 P.M., Cook #95 was observed setting up the steam table with the hot food to be served to residents. At that time she took the temperatures of the hot food with a sanitized thermometer, and all temperatures were above the minimum acceptable standard of 135 Fahrenheit (F). Observation of the food prepared and ready for service on the steam table included meatballs in a stroganoff gravy, buttered noodles, carrots, purred meat balls, mashed potatoes, and pureed carrots. The small half ounce meatballs were observed to be a frozen prepared product. When compared to the planned menu approved by an RD revealed that ground meatballs were to have been prepared for residents on mechanical soft diets. Tray assembly then began with Cook #95 plating the food, and Diet Aide (DA) #105, and Dietary Manager (DM) #90 assembling the trays with other cold food items, beverages, and silverware. On 06/01/19 at 5:37 P.M., Resident #74 was observed feeding herself in her room. The resident's diet card specified she was on a mechanical soft diet. However, she was served whole meatballs not the ground meatballs specified on the planned menu. The resident reported no difficulty chewing or swallowing the meatballs. Licensed Practical Nurse (LPN) #123 viewed the resident's tray with the surveyor and affirmed the meatballs on Resident #74's plate were not ground. On 06/01/19 at 5:41 P.M., Resident #58 was observed feeding himself in his room. The resident's diet card specified he was on a mechanical soft diet. However, he was served whole meatballs not the ground meatballs specified on the planned menu. The resident reported no difficulty chewing or swallowing the meatballs. Resident #58 shared that sometimes his meat is ground, and sometimes it is not, adding that he did not have any teeth. On 06/01/19 at 5:45 P.M., DM #90 was asked to observed the steam table with the surveyor as Cook #95 was finishing serving the main dining room, and verify no ground meat balls were prepared per the planned menu. DM #90 checked the steam table and spoke with Cook #95 and verified no ground meat had been prepared although the planned menu specified ground meatball stroganoff. Cook #95 then stated at 5:46 P.M. that the former dietary manager told her it was okay to serve the residents on the mechanical soft diets the small meatballs, but could not state for sure if the change had been approved by the RD and speech language pathologist (SLP). On 06/01/19 at 5:50 P.M. Resident #66 was observed in the dining room feeding himself the meatballs. The resident's diet card specified that he was on a mechanical soft diet. When asked if he was able to adequately chew and swallow the meatballs he stated he was without any problems. On 06/01/19 at 5:52 P.m. Resident #80 was observed being spoon fed in the dining room by State tested Nurse Aide (STNA) #108. The resident's diet care specified the resident was on a mechanical soft diet. STNA #108 had cut the meatballs into small bites and stated the resident was not having any difficulty chewing or swallowing the meatballs. STNA #108 then mashed a cut up piece of meatball with a fork and it easily fell apart. DM #90 was asked if there were any guideline, or diet manual, specifying what could and could not be served to residents on a mechanical soft diet. DM #90 provided a document titled mechanical soft guidelines. Under the Protein section the document specified the for most entrees to shred, grind, or change it to a softer item, and for exceptions to this see the mechanical soft adjustments sheet. There was no document titled mechanical soft adjustment sheet provided at the time of the survey. The document did include a notation that these were only guidelines for mechanical soft diets, resident's diets may still be individualized to best meet their needs per approval of the facility's RD and SLP. The medical records of Residents #58, #66, #74, and #80 were reviewed. Each of the four resident's had physician's orders [REDACTED]. Review of the census revealed a total of 19 Residents (#5, #11, #13, #25, #28, #29, #30, #37, #43, #47, #54, #55, #58, #66, #74, #75, #80, #84, and #88) had physician's orders [REDACTED]. This deficiency substantiates Complaint Number OH 437.

Based on review of the facility's Legionella Water Management Program policies and procedures, review of water monitoring, and staff interview, the facility failed to develop and implement a water management program which specified and monitored control measures to ensure the plan was effective in the destruction of Legionella bacteria. This had the potential to affect all 81 residents residing in the facility. Facility census was 81. Findings include: The facility's Legionella water management program was reviewed with Maintenance Staff (MS) #73 on 03/28/19. Review of the plan revealed the facility was monitoring the chlorine level in facility water supply in select resident room, and water temperatures at the point of delivery within the facility. The monthly total chlorine and total free chlorine reading of the water in the facility was 0.0 on 02/14/19 and on 03/04/19, and when checked with MS #73 at 10:37 A.M. The chlorine level inspection sheet the facility was using did not specify what the desired/acceptable parameter for chlorine levels in the facility water supply were or what actions to take if they fell below an acceptable range. The water temperature monitoring log indicated the control limit for the water was 105 degrees Fahrenheit (F) to 120 F, that water temperatures were tested weekly was maintained in this range. The water temperature log did not specify where the water temperatures were taken, i.e. at the hot water heater or the point of delivery. However, while the control limit for hot water was consistent with safety requirements at the point of delivery, it was not sufficient for the destruction of Legionella bacteria. MS #73 reviewed the facility's current water management plan and affirmed the facility water registered 0.0 ppm of chlorine, and that the goal was to maintain water temperatures in between 105 F and 120 F. MS #73 was then queried about the temperature of the water in the hot water heater, and a tour of the facility was taken at 03/28/19 at 11:17 A.M. to observe the hot water heaters. There was a temperature gauge on the C Hall hot water heater for the C Hall, central kitchen, and laundry, indicated the temperature of the water in the heater was 125 F. The remainder of the hot water heaters in the building supplying resident rooms in A, B, D, E, and F halls did hot have temperature gauges. MS #73 reported he did not monitor the temperature of the water in the water heaters, only at the point to delivery. The facility confirmed this had a potential to affect all 81 residents residing in the facility. Review of the Policy and Procedure titled Legionella specified the facility would identify control measures and monitoring such as water temperatures, sanitizer levels, and disinfectant levels. The procedure included measuring of water quality throughout the system to ensure that changes that may lead to Legionella growth (such as a drop in chlorine levels) are not occurring, and maintaining appropriate temperature levels for water heaters.