Every finding on record at Respiratory and Nursing Center of Dayton

Based on medical record review, observation, staff interview, review of facility policy, and review of the Food and Drug Administration (FDA) Food Code, the facility failed to ensure staff properly sanitized their hands during meal service. This affected seven residents (#12, #19, #28, #36, #54, #58, and #71) observed during meal service. The facility failed to ensure the dishwasher sanitation was at adequate levels. This had the potential to affect 61 residents who ate food out of the kitchen. The facility identified 13 residents (#2, #9, #10, #11, #16, #32, #36, #63, #66, #67, #72, #74, and #80) who did not eat food prepared in the kitchen. The facility census was 74. Findings include: 1.Observations on 06/29/26 from 7:51 A.M. to 7:56 A.M. revealed Activities #17 and Activities Director #85 each donned gloves. Both wore the same gloves to serve breakfast trays to Resident #19, Resident #28, and Resident #54 in rooms on the 100 Hall. No hand hygiene was observed. Interview on 06/29/2026 at 7:56 A.M. Activities Director #85 and Activities #17 concurrently stated they washed their hands before donning gloves and served meal trays to multiple residents. They did not doff gloves or perform hand hygiene until after passing the last meal tray. Each were unanware of requirements to perform hand hygiene between passing each resident's tray. Review of policy titled Hand Hygiene, dated 11/28/2017, revealed hand hygiene will be performed before and after contact with residents. 2. Observations of made on 06/29/26 from 8:15 A.M. to 8:34 A.M. revealed Certified Nursing Assitant (CNA) #21 passed breakfast trays to residents, moved residents' personal items to setup breakfast trays, assisted with repositioning residents, and provided feeding assistance to Resident #12, Resident #36, Resident #58, and Resident 71 without performing any hand hygiene. Interview on 06/29/2026 at 8:34 A.M. CNA#21 verified he had passed breakfast trays to multiple residents, assisted with repositioning, and touched residents' personal items without washing or sanitizing his hands between residents. CNA #21 stated he washed hands before he started passing trays and did not perform hand hygiene again until he was completely finished passing all trays on multiple halls. 3.Observation of the dishwasher on 06/28/26 at 8:35 A.M. revealed it used sodium hypochlorite (bleach) as a sanitizer. Dietary Worker (DW) #26 was in the process of washing dishes with the dishwasher. When asked to check the dishwasher sanitation levels DW #26 was unsure how to. DW #26 used a test strip from on top the dishwasher and checked the sanitation level. The level of beach checked below 25 parts per million (PPM) on the test strip. DW #26 was unsure what the level should be. Review of a dishwasher sanitation log revealed dishwasher sanitation levels were not documented as being checked on 06/27/26 or 06/28/26. On 06/28/2026 at 8:40 A.M. Dietary Supervisor (DS) #16 checked the dishwasher sanitation level and again it checked below 25 PPM. DS #16 confirmed the level of bleach should check between 50 PPM and 200 PPM. DS #16 also confirmed dishwasher sanitation levels were not documented as being checked on 06/27/26 or 06/28/26. Review of facility provided documentation revealed 13 residents (#2, #9, #10, #11, #16, #32, #36, #63, #66, #67, #72, #74, and #80) did not eat food prepared in the kitchen. Review of the FDA Food Code (https://www.fda.gov/food/fda-food-code/food-code-2022) revealed a chemical-sanitizing dishwasher, must dispense unscented chlorine bleach (or an approved equivalent) at a concentration between 50 ppm and 200 ppm, with a water temperature of at least 120 degrees Farenheit (49 degrees Celsius).

Based on medical record review, observation, review of medication reconciliation logs for controlled medications, and staff interviews, the facility failed to ensure controlled medications available matched the number of controlled medications listed on the reconciliation logs. This affected five (#14, #33, #55, #65, and #67) of twenty residents sampled for narcotic medication administration. The facility census was 74. Findings include: 1.Review of the medical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure with tracheostomy status and dependence on oxygen, major depressive disorder, moderate dementia with anxiety, and quadriplegia. Review of the medical record revealed Resident #67 had physician orders for the controlled narcotic medication Norco 7.5-3.25 milligram (mg) give two tablets via gastrostomy tube (G-tube) every four hours as needed for pain. Observation on 06/29/26 at 1:48 P.M. revealed Resident #67's medication card for Norco7.5/325 mg had 23 pills on the card. The medication reconciliation log for controlled medications showed there were 24 pills as per the last entry. 2. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE]. Diagnoses included amyotrophic lateral sclerosis, dependence on a respirator, dementia, Raynaud's syndrome, traumatic brain injury, and benign neoplasm of the meninges. Review of the medical record revealed Resident #65 had physician orders for controlled narcotic medication oxycodone 5 mg tablet via G-tube every six hours as needed for pain. Observation on 06/29/26 at 1:48 P.M. revealed Resident #65's medication card for Oxy IR (oxycodone) 5 mg had 21 pills on the card. The medication reconciliation log for controlled medications showed there were 22 pills as per the last entry. Interview on 06/29/2026 at 1:49 P.M. Licensed Practical Nurse (LPN) #62 verified she had forgotten to sign the reconciliation log after the last administration of Norco for Resident #67 and had not signed off the log after the last administration of Oxy IR 5 mg for Resident #65. LPN #62 verified the reconciliation logs for controlled medications were not filled out correctly and should be reconciled at the time of administration. 3.Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses included Stage III chronic kidney disease, mild cognitive impairment, and unspecified secondary malignant neoplasm of the kidney and renal pelvis. Review of the medical record revealed Resident #14 had physician orders for controlled narcotic medications including Roxicodone (oxycodone hydrochloride) 5 mg one to two tablets by mouth every four hours as needed for pain and Roxicodone 5 mg two tablets by mouth four times daily for pain.Observation on 06/29/2026 at 2:10 P.M. revealed Resident #14's Oxy IR 5 mg medication card contained six tablets. The medication reconciliation log for controlled medications had a quantity of eight tablets listed. Interview on 06/29/2026 at 2:10 P.M. LPN #19 verified she forgot to sign off Resident #14's last administration of Oxycodone 5 mg. LPN #18 confirmed she was expected to maintain an accurate record and sign out medications at the time of administration. 4. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, episodic panic disorder, generalized anxiety disorder, and mild cognitive impairment.Review of the medical record revealed Resident #55 had physician orders for controlled medications including the antianxiety medication lorazepam 0.5 mg by mouth once daily for anxiety. Observation on 06/29/2026 at 2:11 P.M. revealed Resident #55's pill card for lorazepam 0.5 mg had four tablets on the card. The medication reconciliation log for controlled medications listed there were five pills available. Interview on 06/29/26 at 2:11 PM LPN #19 verified the quantity of Resident #55's lorazepam 0.5 mg did not match on the card and the medication reconciliation log for controlled medications. LPN #19 stated she had forgotten to sign out Resident #55's last dose of lorazepam after she administered it.5. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, chronic respiratory failure with hypoxia, major depressive disorder, chronic obstructive pulmonary disease, chronic kidney disease, and Alzheimer's disease.Review of the medical record revealed Resident #33 had physician orders for the controlled medications including the antianxiety lorazepam 0.5 mg one tablet by mouth at bedtime and every two hours as needed for anxiety or shortness of breath. Observation on 06/29/26 at 2:13 P.M. revealed Resident #33's pill card for lorazepam 0.5 mg had 16 tablets available for administration. The medication reconciliation log for controlled medications listed there were 15 pills available. LPN #19 had signed off she had last administered a pill on 06/29/26 at 12:23 P.M. Interview on 06/29/26 at 2:13 P.M. LPN #19 verified she had filled out Resident #33's lorazepam medication reconciliation log by mistake. LPN #33 stated she had not administered any lorazepam 0.5 mg to Resident #33 but had mistakenly signed the log when she had administered lorazepam to Resident #55.

Based on observations and staff interviews, the facility failed to ensure medications packages were labeled appropriately with the dated of opening for two (#5 and #33) residents. Additionally, the facility failed to ensure expired medications were removed from availability and destroyed in a timely manner. This had the potential to affect eight (Resident #1, #11, #14, #32, #33, #54, #55, and #62) of twenty residents sampled for medication storage. The facility census was 74. Findings include: 1.Observation on 06/29/2026 at 1:56 P.M. revealed the Central Medication cart had one box of ipatropium-albuterol 0.5-2.5 (3 milligram/milliliter {mg/ml}) solution belonging to Resident #5 contained two opened foil packages without dates or labels, one with one vial and the other with three vials of nebulizer solution. Another box of ipatropium-albuterol 0.5-2.5 (3mg/ml) solution belonging to Resident #33 contained one opened, undated, unlabeled foil package with two vials of nebulizer solution. Printed on the front of each foil pack were instructions to discard any unused vials within one week of opening the foil package. Interview on 06/29/2026 at 2:04 P.M. Licensed Practical Nurse (LPN) #19 verified that although the opened packages of ipatropium-albuterol 0.5-2.5 (3mg/ml) solution belonging to Resident #5 and Resident #33 were clearly marked with instructions to discard unused vials within one week of opening the foil packages, she was unaware the packages needed to be dated when opened. LPN #19 verified the opened packaged were not labeled with the date they were opened and she was unable to determine how long the the packages had been opened. 2. Observation made on 06/29/26 from 1:52 P.M. to 2:17 P.M. revealed one medication cart and two medication rooms contained nine unopened boxes of famotidine 20 mg tablets, 25 tablets each, which expired April 2026. There were two opened bottles of cetirizine 10 mg tablets with 100 tablets each which expired 05/2026. During interviews conducted on 06/29/2026 from 1:53 P.M. to 2:27 P.M. LPN #19 and LPN #62 each verified the bottles of cetirizine and boxes of famotidine medications were expired, should have been removed from shelves and carts, and should have been destroyed. During an interview on 06/29/2026 at 3:36 P.M. Regional Nurse #125 verified the facility had eight residents (Resident #14, Resident #1, Resident #32, Resident #33, Resident #54, Resident #55, Resident #11, Resident #62) who were prescribed famotidine 20 mg tablets, but the stated the medication was sent by the pharmacy in the pill packs. Regional Nurse #125 verified expired medications should be destroyed. The facility had no residents with active prescriptions for cetirizine 10 mg.

Based on medical record reviews, observation, staff interviews and policy review, facility failed to ensure Enhanced Barrier Precautions were being followed, failed to ensure staff sanitized hands between residents during medication administration, and failed to ensure contact precautions were being followed. This affected four residents (#12, #41, #49, and #59) of 74 residents reviewed for infection control practices. Facility census was 74. Findings include: 1. Review of the medical record revealed Resident #41 was admitted on [DATE]. Diagnoses included alcohol dependence with alcohol induced persisting dementia, muscle weakness, hypertension, and obstructive and reflux uropathy. Review of Resident #41's Care plan dated 06/01/26 revealed the resident had and indwelling urinary Foley catheter for diagnosis of obstructive and reflux uropathy. Interventions included enhanced barrier precautions. Observations on 06/28/26 at 10:18 AM revealed Resident #41 had a sign outside his door for enhanced barrier precautions. There was no cart outside of the room with personal protective equipment (PPE). Interview on 06/28/26 at 10:18 AM Registered Nurse (RN) #76 confirmed Resident #41 had Enhanced Barrier Precaution signage outside of room door with no PPE cart nearby. Observation on 06/29/26 at 3:22 PM revealed Certified Nursing Assistant (CNA) #24 entered Resident #41's room to provide catheter care. CNA # 24 had gloves on and pulled the covers off the resident. Resident #41 refused catheter care. CNA #24 did not have a gown on nor brought a gown into the room. Interview on 06/29/26 at 3:30 PM with CNA #24 confirmed she should have had a gown on for catheter care. She looked outside the room and did not find a cart for the PPE. CNA # 24 then confirmed there should be a cart with PPE outside the door. Review of the facility policy titled Standard and Transmission-Based Precautions, dated May 5, 2017, confirmed PPE shall be located in the general vicinity of the resident's room and readily available to staff. 2. Observations on 06/28/26 from 8:19 A.M. to 8:46 A.M. revealed Licensed Practical Nurse (LPN) #37 administered 25 medications to Resident #59 and Resident #49 without performing hand hygiene. Interview on 06/28/26 at 8:46 AM LPN #37 stated she had washed her hands with soap and water at the beginning of her shift and sanitized her hands before starting the first medication pass. She stated she did not remember if she sanitized her hands between passing medications to Resident #59 and Resident #49. LPN stated she washes her hands at the beginning of the shift, before leaving a room with transmission-based precautions, and both before and after giving treatments. Review of policy titled Hand Hygiene, dated 11/28/2017, revealed hand hygiene will be performed before and after contact with residents. 3. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure with hypoxia, dependence on a respirator, gastrostomy status, tracheostomy status, generalized anxiety disorder, complete paraplegia, and major depressive disorder. Review of the medical record revealed Resident #12 had a physician order dated 06/24/26 for contact barrier precautions for ten days. Observation on 06/29/26 at 8:21 A.M. revealed CNA #21 entered Resident #12's room carry a breakfast tray without sanitizing her hands or donning PPE. CNA #21 rearranged personal items on Resident #21's bedside table and began setting up the tray. Resident #12 indicated she wanted to eat the pancakes on the tray but not the eggs. CNA #21 set up the tray, applying butter and syrup to the pancakes and cutting them into bite-sized pieces. Resident #12 indicated she wanted to watch a specific program on television and CNA #21 used the television remote to adjust the channel. CNA #21 obtained assistance to pull the resident up in bed. CNA #58 responded and CNA #21 communicated Resident #12 needed to be pulled up in bed. CNA #58 sanitized hands and donned gloves before entering the room. CNA #21 and CNA #58 lay the head of bed flat and used the bottom sheet to pull Resident #12 up in bed. CNA #58 raised the head of bed and replaced the top blanket before washing her hands in the bathroom and exiting the room using the bathroom door of the adjoining resident's room. CNA #21 finished feeding breakfast to Resident #12 and left the room without washing his hands. He carried the breakfast tray to the meal cart at the far end of the 400 Hall and sanitized his hands with alcohol-based hand rub. During an interview on 06/29/2026 at 8:34 A.M. CNA #21 stated he washed hands before he started passing breakfast trays and sanitized his hands when he was completely finished passing all trays. CNA #21 stated he did not know why Resident #12 was on contact precautions and stated he did not have to wear PPE when feeding a resident in contact precautions. CNA #21 verified neither he nor CNA #58 wore gowns and he did not wear gloves to pull Resident #12 up in bed.

Based on record review, resident interview, staff interview, review of Self Reported Incidents, and policy review, the facility failed to report an allegation of neglect to the State Survey Agency for one (#59) of four residents reviewed for abuse and neglect allegations. The facility census was 74. Findings include:Review of the medical record revealed Resident #59 had an admission date of 05/16/19. Diagnoses included Alzheimer's disease, dementia, and schizoaffective disorder bipolar type. Interview on 06/28/2026 at 10:07 A.M. with Resident #59 revealed a Certifed Nursing Assistant (CNA) with red hair will refuse to provide her with assistance and give her attitude when she asks for help. On 06/28/2026 at 1:54 P.M. the Director of Nursing (DON) was notified of the statement from Resident #59. Review of the Self Reported Incidents on 06/30/26 revealed the facility did not report this allegation to the State Survey Agency.Interview on 06/30/2026 at 8:30 A.M. with the DON revealed after she was notified of the allegation she went to Resident #59 and asked her if she felt that she was abused. Resident #59 stated she was not abused. The DON stated she had not asked the resident if her care was being neglected. The DON verified a Self Reported Incident was not initiated with the State Survey Agency. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed the facility should immediately report all allegations of abuse, neglect, exploitation, and mistreatment of a resident to the Ohio Department of Health.

Based on record review, resident interviews, and staff interviews, the facility failed to ensure each resident had a comprehensive care plan that encompassed all aspects of resident care needs. This affected three (#2, #3, and #12) of 19 residents sampled for care plans. The facility census was 74. Findings include: 1. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, dependence on respirator, multiple sclerosis, contracture to left hand, left upper arm, and right upper arm, spastic hemiplegia and hemiparesis following cerebral infarction, bipolar disorder, and schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had severely impaired cognition and was dependent for all activities of daily living (ADLs). Review of the medical record revealed Resident #2 had physician orders dated 01/19/26 for right hand/wrist splint at bedtime only and left palm protector at bedtime only. Review of the current care plan initiated 01/10/25 revealed Resident #2 required assistance with ADLs related to multiple disease processes including contractures of bilateral hands. The care plan did not address any interventions for the contractures, or the use of hand splints and palm protectors. Interview on 06/29/2026 at 12:09 P.M. the Director of Nursing (DON) confirmed Resident #2 did not have a care plan for contractures with interventions for hand splints or palm protectors. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure with hypoxia, dependence on a respirator, generalized anxiety disorder, complete paraplegia, and major depressive disorder. Review of the medical record revealed Resident #12 received optometry services through 360-Care on 10/20/25 and received an order for new prescription eyeglasses. Review of the medical record revealed Resident #12 had no care plan to address vision needs. Interview on 06/28/2026 at 11:00 A.M. Resident #12 stated she received an eye exam a month ago and was supposed to be getting glasses. Interview on 06/29/2026 at 2:47 P.M. Activities Director #85 stated Resident #12 got a new pair of glasses six months ago and they were in a drawer in her room. Resident #12 was having trouble seeing far away and was seen by vision services last week. They issued a new order for new glasses. Interview on 06/29/2026 at 2:58 P.M. the DON verified Resident #12 had no care plan for vision needs. 3.Review of the medical record revealed Resident #3 had an admission date of 06/13/23 with diagnoses including post-traumatic stress disorder (PTSD). Review of the MDS assessment dated [DATE] revealed Residnet #3 was cognitively intact. Review of the psychiatric notes from 06/22/26 revealed Resident #3 has PTSD with symptoms including anxiety, flashbacks, hypervigilance and depression. Review of the care plan for Resident #3 revealed there was no care plan for PTSD. Interview on 06/30/26 at 11:07 A.M. with Social Services #20 verified she creates the care plans and Resident #3 did not have a care plan for PTSD.

Review of the medical record, resident interview, and staff interview, revealed the facility failed assess and treat Resident #5's hearing loss and ear pain. This affected one (#5) of two residents reviewed for communication and sensory. The facility census was 74. Findings include:Review of the medical record revealed Resident #5 had an admission date of 02/04/26. Diagnoses included end stage renal disease, dependence on renal dialysis, congestive heart failure, parkinsonism, schizoaffective disorder, and type 2 diabetes. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #5 was cognitively intact. Resident #5 was identified to have adequate hearing with no difficulty in normal conversation, social interaction, or listening to TV. Review of the physician orders dated 06/01/26 revealed Resident #5 was ordered Debrox Otic Solution 6.5% four drops in both ears two times per day for four days then flush. Review of the physician visit dated 06/02/26 at 7:00 A.M. revealed no documentation of Resident #5's ear condition. Review of the physician orders dated 06/23/26 revealed Resident #5 was ordered Debrox Otic Solution 6.5% four drops in both ears two times a day for four days, then flush. The medical record contained no documentation of any health care provider examining Resident #5's ear. Interview on 06/28/2026 at 10:37 A.M. Resident #5 stated she was having pain in her right ear, fluid in her right eye and difficulty hearing from her right ear. During the interview Resident #5 was observed have to turn her head so her left ear was facing the surveyor to hear properly. Resident #5 verified she was turning her head due to being unable to hear from the right ear. She stated this started about a month ago. She stated she thought it was an ear infection and the provider had ordered ear drops to help remove ear wax, however no one actually examined her ear. Interview on 06/29/2026 at 7:37 A.M. the Director of Nursing verified there was no evidence of Resident #65's ear being assessed by a health care provider.

Based on observation, record review, interviews, and policy review, the facility failed to adequately obtain daily weights as ordered and failed to monitor a resident's weight loss nutritional status. This affected one (#68) of four residents reviewed for nutrition. The facility census was 74. Findings include:Review of the medical record revealed Resident #68 had an admissions date of 03/31/26. Diagnoses included benign neoplasm of meninges, dysphagia, cognitive communication deficit, anemia, depression, type 2 diabetes, and bipolar disorder. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #68 was cognitively impaired. Resident #58 had a feeding tube and was not assessed for the level of care needed for eating due to medical condition or safety concerns. Review of the care plan revealed Resident #68 has a potential for alteration in nutrition and hydration related to alternative nutrition via feeding tube, little desire to eat, age, and extended illness. Interventions included weights per protocol. Review of the hospital transfer form revealed on 03/01/26 Resident #68 weighed 173 pounds (lbs) prior to transfer to the facility. Review of the dietary progress note dated 04/01/26 at 11:52 A.M. revealed Resident #68 was 173.4 lbs with a BMI. Resident #68 was noted as overweight. Review of the physician orders revealed an order dated 04/03/26, and discontinued on 04/12/26, stating weigh daily, notify physician if weight is more than 2.5 pounds in 24 hours or more than 5 pounds in a week. Review of the Treatment Administration Record for April 2026 revealed Resident #68 was weighed on 04/03/26 at 173.6 lbs (lift scale), 04/04/26 at 173.8 lbs (mechanical lift), and 04/09/26 at 173.1 lbs (sitting). The record contained no evidence of any other daily weights from 04/03/26 through 04/12/26. Review of the radiology report for dysphagia consultation dated 04/28/36 revealed Resident #68 was 173 lbs. Review of the weight log revealed Resident #68 weighed 174.8 lbs on 05/07/26 (sitting). On 06/01/26 the weight was 115 lbs (sitting) for a 59 lbs/ 33.7% loss in 30 days and 58 lbs/ 33.5% loss in 90 days. Additional weights obtained revealed Resident #68 weighed 114.8 lbs on 06/10/26, 112.4 lbs on 06/17/26 (sitting), 113.8 lbs on 06/24/26 (sitting), and 115.5 lbs on 06/29/26 (standing). Review of the dietary progress note dated 05/08/26 at 3:09 P.M. revealed Resident #68's weight was stable at 174 lbs with no significant weight changes. Feedings were adjusted as Resident #68 has started a puree diet trials. Review of the dietary progress note dated 05/26/26 at 3:05 P.M. revealed Resident #68 weighed 174 lbs and had diet advanced to mechanical soft with nectar thick liquids on 05/20/26. Review of the dietary progress note dated 06/12/26 at 2:16 P.M. revealed Resident #68 weighed 115.2 lbs on 06/01/26 and was reweighed on 06/10/26 at 114.8 lbs. Prior weight had been 173-174 lbs. The note stated the resident's geri chair was likely included in the previous weights. No changes in diet or nutritional feedings were recommended. Review of the dietary progress note dated 06/28/26 at 4:02 P.M. revealed Resident #68's weight has been relatively stable the last couple weeks. Appetite is fair to good and should promote weight gain. No changes in diet or nutritional feedings were recommended. Review of the dietary progress note dated 06/29/26 at 2:02 P.M. revealed weight changes and trends were reviewed with Resident #68's representative and recommended an increase in tube feedings at night. Interview on 06/29/26 at 8:27 A.M. with Dietician #45 revealed she was unable to explain Resident #68's weight loss of 33.7% between 05/07/26 and 06/01/26. Dietician #45 verified she did request a reweight on 06/05/26, 06/08/26, and 06/09/26. She verified the facility did not complete the reweight until 06/10/26 and the reweight confirmed the weight loss. She also stated she would expect the facility to reweigh residents within about a day of a reweight being requested. Interview on 06/29/26 at 2:16 P.M. with Dietician #300 revealed she believed the weights in the 170 lbs area were incorrect and the weights included Resident's #68's geri chair. Dietician #300 was unable to explain the difference between Resident #68's weight and that some of the weights were not obtained in the facility or were done by a mechanical lift. Observation on 06/29/26 at 2:31 P.M. revealed Dietician #300 weighing a geri chair and it being 80 pounds. Interview at the same time as the observation with Dietician #300 revealed she still believed the initial weights included the geri chair. When asked about the geri chair weighing 80 pounds and Resident #68 losing 60 pounds, Dietician #300 stated that maybe Resident #68 actually had a weight gain. Observation on 06/29/26 at 2:46 P.M. revealed the Director of Nursing (DON) taking a standing weight of Resident #68 who was 115.5 lbs. DON #65 verified Resident #68 weighs 115.5 lbs. The DON stated she thinks the initial weights for were recorded incorrectly. Review of the facility policy titled, Weight Monitoring, dated 02/15/24, revealed the facility will ensure all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preference indicate otherwise.

Based on review of medical records, staff interview, resident interview, and review of the manufacturer's guidelines, the facility failed to monitor a resident's blood sugar levels before the administration of injectable insulin. This affected one (#40) of six residents reviewed for medications. The census was 74.Findings include:Review of Resident #40's medical record revealed an admission date of 12/19/11. Diagnoses listed included schizophrenia, hypertension, anxiety, and diabetes mellitus type two.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had intact cognition and received insulin injections.Review of medication orders revealed an order dated 06/22/24 for Lantus SoloStar (long-acting insulin) 100 units per milliliter (unit/ml) solution per pen injector. Inject 23 units subcutaneously at bedtime for diabetes mellitus type two. An order dated 03/05/25 for Accucheck (blood sugar check) every night at bedtime for Lantus usage was discontinued on 11/10/25. No documentation of the reason for Accuchecks being discontinued on 11/10/25 was present.Review of June 2026 medication administration records (MAR) revealed Resident #40 was currently receiving Lantus SoloStar daily at bedtime. The last documented administration was on 06/29/26.Review of Resident #40's documented blood sugar levels revealed the last recorded result was on 11/09/25.Interview with Resident #40 on 06/28/26 at 1:45 P.M. revealed staff had not been checking his blood sugar and he was concerned.Interview with the Director of Nursing (DON) on 06/30/26 at 8:05 A.M. confirmed Resident #40 was not having his blood sugar levels checked before being administered Lantus Solostar insulin daily. The DON confirmed the last documented blood sugar result was in 11/09/25. The DON confirmed there was no documentation of a reason for discontinuing Accuchecks on 11/10/25.Review of the manufacturer's step by step guide revealed Lantus Solostar should be taken once a day at the same time every day. Test your blood sugar levels while using insulin, such as Lantus Solostar.

Based on record review, resident interview, staff interview, and policy review, the facility failed to provide routine dental services to one (#8) of three residents reviewed for dental services. The facility census was 74. Findings include:Review of the medical record revealed Resident #8 had an admission date of 01/17/21. Diagnoses included Alzheimer's disease, dementia, and schizoaffective disorder. Review of the current care plan revealed Resident #8 has impaired dentition and is at risk for oral problems (i.e. pain, infection, difficulty chewing/swallowing, poor self-imagine) related to Resident #8 having her own natural teeth with some missing and some appearing decayed. Interventions included complete oral assessments and refer to dentist as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 is cognitively impaired. Resident #8 had no mouth or facial pain. Review of the progress note dated 05/13/26 revealed Resident #8 stated her front left tooth to her left side was loose and sometimes has pain. The medical record revealed no documentation of Resident #8 being provided routine dental services. Interview on 06/28/2026 at 11:42 A.M. Resident #8 revealed she has her natural teeth and was having pain. Resident #8 stated she would like to see a dentist. Interview on 06/29/2026 at 4:23 P.M. the Director of Nursing verified the facility had no documentation of Resident #8 being offered dental services. Review of the facility policy titled Dental Services, dated 11/14/17, revealed it is the facility policy, in accordance with residents' needs to assist residents in obtaining routine and emergency dental care.

Based on medical record reviews, staff interview, and review of the Resident Assessment Instrument (RAI) User's Manual 3.0, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed timely. This affected four (Residents #06, #08, #22, and #50) of 23 residents reviewed for timely MDS assessments. The facility census was 75 residents. Findings include: 1. Review of the medical record for Resident #06 revealed an admitted [DATE] with diagnoses including chronic respiratory failure, dependence on ventilator, multiple sclerosis (MS), spastic paraplegia, schizoaffective disorder, dementia, and diabetes mellitus (DM). Review of the quarterly MDS assessment for Resident #06 with an assessment reference date (ARD) of 07/03/24 revealed the resident had severely impaired cognition and was dependent upon staff for all activities of daily living (ADLs). Review of the MDS revealed a completion date of 08/05/24. 2. Review of the medical record for Resident #08 revealed an admitted [DATE] with diagnoses including chronic respiratory failure, DM, seizures, chronic obstructive pulmonary disease (COPD), and hypertension. Review of the quarterly MDS assessment for Resident #08 with ARD of 05/31/24 revealed the resident had severely impaired cognition and was dependent upon staff for all ADLs. Review of the MDS revealed a completion date of 06/24/24. 3. Review the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including MS, chronic respiratory failure, hypothyroidism, and hypertension. Review of the medical record for Resident #22 revealed a quarterly MDS assessment with ARD of 06/21/24 which indicated Resident #22 had moderate cognitive impairment and was dependent upon staff for all ADLs. The MDS revealed a completion date of 07/15/24. 4. Review of the medical record for Resident #50 revealed an admitted [DATE] with medical diagnoses of chronic respiratory failure, dependence upon a ventilator, tracheostomy, anoxic brain injury and hypertension. Review of the quarterly MDS assessment for Resident #50 with an ARD of 07/03/24 revealed the resident had severely impaired cognition and was dependent upon staff for all ADLs. Review of the MDS revealed a completion date of 08/05/24. Interview on 08/27/24 at 1:00 P.M. with Regional MDS Nurse #110 confirmed the quarterly MDS assessments for Residents #06, #08, #22, and #50 were not completed timely per RAI Manual guidelines. Regional MDS Nurse #110 further confirmed the facility utilized the RAI Manual for guidelines and instructions on how and when to complete the MDS assessments. Review of MDS RAI 3.0 User's Manual dated October 2023, pages two through35 revealed the quarterly MDS completion date must be no later than 14 days after the ARD.

Based on observation and staff interview, the facility failed to practice food service safety and maintain a sanitary environment to prevent food and beverage contamination. This had the potential to effect 63 residents who received food from the facility kitchen. The facility census was 75 residents. Findings include: 1.Observation on 08/27/24 at 10:05 A.M. with [NAME] #44 revealed Dietary Supervisor (DS) #52 placed a small bin of cooked carrots on prep table and did not cover the carrots. A ledge directly above the uncovered bin of carrots was covered with crumbs and debris. Above the ledge to the right was a window that housed a working air conditioner which blew cold air into the kitchen. On the right side of air conditioner there was a plastic accordion-style casing which sealed the unit to the window. The casing was covered with dust and black specks. The left side of the running air conditioner was smaller than the window and allowed for an approximately four-inch opening from the window directly to the outside. Interview on 08/27/24 at 10:05 A.M. with DS #52 confirmed the cooked carrots were uncovered and sitting directly below the ledge which was covered with crumbs and debris. The carrots were also adjacent to air conditioner casing which was covered with dust and to the window which was open to the outside. 2. Observation on 8/27/24 at 10:10 A.M. of food preparation revealed [NAME] #44 removed her gloves, discarded them, and donned new gloves without performing hand hygiene. Interview on 08/27/24 at 10:11 A.M. with [NAME] #44 confirmed staff are to wash their hands after removing gloves and prior to donning new gloves. 3. Observation on 08/27/24 at 10:20 A. M. of food preparation revealed DS #52 removed his gloves, lifted the lid to the garbage can, discarded the gloves, and walked to the stove and stirred the gravy. DS #52 did not perform hand hygiene after lifting the garbage can lid and discarding his gloves. Interview on 08/27/24 at 10:22 A.M. with Regional Dietitian (RD) #120 confirmed DS #52 should have washed his hands immediately after discarding his gloves and prior to continuing with food preparation. 4. Observation on 08/27/24 at 10:25 A.M. with RD #120 revealed the ice machine in the dining room had a scoop being stored directly in the ice. RD #120 removed the scoop. Interview on 08/27/24 at 10:26 A.M. with RD #120 confirmed the ice scoop should not be stored directly in the bin of ice.

Based on medical record review, observation, staff interviews, and review of the facility policy, the facility failed to ensure the staff utilized proper hand hygiene and infection control practices during tracheostomy care. This affected one (Resident #56) of 18 residents with tracheostomies. The facility also failed to ensure staff donned appropriate personal protective equipment (PPE) to prevent the spread of Coronavirus (COVID-19). This affected one (Resident #10) of two facility-identified COVID-19 positive residents. The facility census was 75 residents. Findings include: 1. Review of the medical record for Resident #56 revealed an admitted [DATE] with diagnoses including chronic respiratory failure with hypoxia, sepsis, end stage renal disease, anoxic brain injury, and tracheostomy. Review of the admission Minimum Data Set (MDS) assessment for Resident #56 dated 06/20/24 revealed the resident had severe cognitive impairment and was dependent upon staff for all activities of daily living (ADLs). Review of the physician's orders for Resident #56 revealed an order dated 06/11/24 to complete tracheostomy care every shift and as needed. Observation on 08/28/24 at 10:41 A.M. of tracheostomy care for Resident #56 per Respiratory Therapist (RT) #96 revealed the RT suctioned the resident which caused the resident to have a productive cough. After suctioning was completed, RT #96 then removed the old dressing covered with dried mucus from around Resident #56's tracheostomy site. RT #96 used the old dressing to wipe around Resident #56's tracheostomy site and discarded the dressing in the trash. RT #96 unlocked and removed Resident #56's disposable inner cannula and discarded it in the trash. RT #96 then inserted a new disposable inner cannula touching the outer locking portion of the cannula and locking it into place. RT #96 applied a new dressing around the tracheostomy site, connected the resident back to oxygen, removed gown and gloves, and performed hand hygiene. Interview on 08/28/24 at 10:49 A.M. with RT #96 confirmed she removed the soiled dressing from Resident #56's tracheostomy site and used it to wipe around Resident #56's tracheostomy. RT #96 confirmed she did not change gloves or perform hand hygiene after removing the soiled dressing and prior to insertion of new disposable inner cannula or new dressing applied. Review of the facility policy titled Infection control revised 11/28/17 revealed all staff should perform hand hygiene when coming on duty, between resident contacts, after handling contaminated objects, after personal protective equipment (PPE) removal, before/after toileting, and before going off duty. Review of the policy revealed gloves were changed and hand hygiene was performed before moving from a contaminated body site to a clean body site during resident care. 44070 2. Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses including sepsis, bipolar disorder, other psychotic disorder, autism, heart failure encephalopathy and paranoid schizophrenia. Review of the MDS assessment for Resident #10 dated 07/01/24 revealed the resident was cognitively impaired. Review of the care plan for Resident #10 dated 08/26/24 revealed the resident was COVID-19 positive with interventions including contact and droplet precautions and update the physician with any abnormal or new findings for possible evaluation or further treatment as needed. Review of physician's orders for Resident #10 revealed an order dated 08/26/24 to maintain droplet isolation precautions till 09/04/24. Interview on 08/25/24 from 9:45 A.M. with the Administrator confirmed the facility had two residents in the facility who tested positive for COVID-19 on 08/24/24, Residents #10 and #25. see nurse before entering sign on the door and a contact and droplet isolation above the isolation cart outside of Resident #10's room. Resident #10's door was open, and the resident was walking around her room when she fell to the ground. Licensed Practical Nurse (LPN) #106 observed the resident on the ground and informed LPN #113 and State tested Nurse Aide (STNA) #61 of the fall. LPN #113 and STNA #61 were wearing surgical masks and then donned gowns and gloves prior to entering Resident #10's room. Neither LPN #113 nor STNA #61 donned N-95 (respirator masks) and eye protection when they entered Resident #10's room. Interviews on 08/25/24 at 11:00 A.M. with LPN #113 and STNA #61 confirmed they did not don N-95 masks or eye protection prior to entering a COVID positive environment. They confirmed an N-95 mask and face shield along with a gown and gloves should have been donned prior to entering Resident #10's room. Interview on 08/25/24 at 11:19 A.M. with Infection Preventionist (IP) #105 confirmed staff should wear N-95, eye protection, gown and gloves when entering a COVID-19 positive resident room. Review of facility policy titled Infection Prevention and Control Program dated 11/28/17 revealed the facility shall maintain and establish infection prevention and control to ensure safe, sanitary and comfortable environment and prevent the transmission of communicable diseases. Review of facility policy titled COVID-19 Prevention, Response, and Reporting dated 05/11/23 revealed the facility should ensure appropriate interventions were implemented to prevent the spread of COVID-19. Source control measures included use of an N-95 filter mask or higher. When caring for residents with COVID-19 facility should initiate transmission-based precautions.

Based on medical record review and staff interview, the facility failed to properly inform the staff of interventions and approaches for care of residents with Post Traumatic Stress Disorder (PTSD.) This had the potential to effect one (Resident #27) of one resident reviewed for trauma-informed care. The census was 75 residents. Findings include: Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses including stroke, anemia, hypertension and post-traumatic stress disorder (PTSD). Review of the trauma assessment for Resident #27 dated 8/25/24 completed per Social Services Designee (SSD) #104 revealed the resident had served in the military during a war, had a history of a heart attack, and prior to the age of 18 had been physically punished and or beaten by someone he knew and had received bruises, cuts welts, lumps and other injuries as a result of the assault. Additionally Resident #27 he had been pressured into having unwanted sexual contact. No additional information was documented on the assessment other than loud noises and music could be triggering for the resident's PTSD. Review of the care plan for Resident #27 last updated 06/12/24 revealed the resident's diagnosis of PTSD was included, but the care plan did not include interventions to eliminate or mitigate triggers of the PTSD. Interview on 08/28/24 at 3:17 P. M. with SSD #104 confirmed she completed trauma assessment for Resident #27, but she had not asked the resident for details regarding his PTSD in order to identify what staff should do or not do related to triggering the resident's PTSD symptoms. Interview on 08/28/24 at 3:20 P.M. with Minimum Data Set Nurse (MDSM) # 84 and Regional MDS Coordinator #110 confirmed Resident #27's care plan did not include approaches to care for Resident #27 related to his PTSD diagnosis and did not include triggers to PTSD symptoms. Further interview confirmed the facility did not have a policy regarding trauma-informed care. Interview on 08/28/24 at 04:05 P.M. with Licensed Practical Nurse (LPN) #76 confirmed she worked on Resident #27's unit full time. LPN #76 confirmed she had no knowledge of interventions or ways to work with the resident if he should experience triggers of his PTSD. LPN #76 confirmed Resident #27 routinely got upset and angry with staff during incontinence care. Interview on 08/28/24 at 4:06 P.M. with State tested Nurse Aide (STNA) #95 confirmed she worked on Resident #27 full time, but she was not familiar with what the symptoms would be if the resident was experiencing episodes related to his PTSD diagnosis. STNA #95 confirmed the resident routinely refused incontinence care.

Based on medical record review, observation, resident representative interview, and staff interviews, the facility failed to ensure resident representative preferences were honored. This affected one (Residents #54) of six residents reviewed for activities of daily living (ADL) assistance. The facility also failed to honor resident needs and preferences regarding bathroom accomodations. This affected one (Resident #49) of six residents reviewed for ADL assistance. The facility census was 75 residents. Findings include: Review of the medical record for Resident #54 revealed an admitted [DATE] diagnoses including chronic respiratory failure, end stage renal disease, dependence on renal dialysis, atrial fibrillation, diabetes mellitus, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment for Resident #54 dated 06/27/24 revealed the resident had severe cognitive impairment, was dependent upon staff for toileting hygiene, bathing, and bed mobility, and did not transfer out of bed during the review window. Review of the social service note for Resident #54 dated 08/13/24 revealed the facility held a care conference was held with Resident #54's representative, the unit nurse, the dietician, and social service staff. Resident #54's representative requested staff transfer Resident #54 out of bed to a chair on Tuesday and Thursdays. Review of the ADL records for Resident #54 dated 07/30/24 to 08/28/24 revealed staff transferred the resident out of bed on 08/02/24 (Friday), 08/14/24 (Wednesday), and 08/30/24 (Friday). The record did not include documentation of staff transferring Resident #54 out of bed twice weekly on Tuesdays and Thursday per the resident representative's request. Interview on 08/25/24 at 12:25 P.M. with Resident #54's representative confirmed the staff had agreed to get Resident #54 out of bed and up into a chair on Tuesdays and Thursdays, but the staff had not accommodated the request. Resident #54's representative further confirmed the resident attended dialysis on Monday, Wednesday, and Fridays. Observation on 08/27/24 at 1:08 P.M. revealed Resident #54 was lying in bed. Interview on 08/28/24 at 10:40 A.M. with State tested Nursing Assistant (STNA) #43 stated she provided care for Resident #54 and had never seen the resident sitting in a chair. STNA #43 stated she was never informed of Resident #54's representative's request for the resident to be up in chair on Tuesdays and Thursday. Interview on 08/28/24 at 2:04 P.M. with Licensed Practical Nurse (LPN) #50 confirmed staff did not get Resident #54 out of bed and into a chair on Tuesdays or Thursdays, and she was not aware of the request to get the resident up made by Resident #54's representative. Interview on 09/03/24 at 10:53 A.M. with Director of Nursing (DON) confirmed Resident #54 was dependent on staff to transfer him out of bed. The DON confirmed Resident #54's record did not include documentation of staff transferring the resident out of bed to a chair on Tuesdays and Thursday per the resident representative's request. 36648 2. Review of the medical record for Resident #49 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, asthma, heart failure and depression. Review of the physician's orders for Resident #49 dated August 2024 revealed there were no orders for the resident to have a toilet riser to the commode. Interview on 08/25/24 at 10:35 A. M. with Resident #49 confirmed he was unhappy with his room. He recently returned to the facility from the hospital, and they changed his room upon his return. Resident #49 confirmed he had to use the restroom in the shower room to go to the bathroom because the commode in his room had a toilet riser. Resident #49 confirmed he was unable to sit on the commode with the toilet riser in place. Observation on 08/26 /24 at 11:00 A. M. of Resident #49's bathroom revealed there was a toilet riser on the commode in the resident's room. Interview on 08/26/24 at 11:00 A.M. with State tested Nurse Aide (STNA) #101 confirmed there was a toilet riser on the commode of Resident #49's bathroom. Interview on 08/27/24 at 02:44 P. M. with STNA #95 confirmed Resident #49 was able to go to the restroom independently but he did not use the commode in his room because there was a toilet riser on it.

Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to ensure comprehensive admission Minimum Data Set (MDS) assessments were completed timely. This affected one (Resident #56) of eight residents reviewed for timely assessments. The facility census was 75 residents. Findings include: Review of the medical record for Resident #56 revealed an admitted [DATE] with diagnoses including chronic respiratory failure with hypoxia, sepsis, end stage renal disease, anoxic brain injury, and tracheostomy. Review of the admission MDS assessment for Resident #56 with an assessment reference date (ARD) of 06/20/24 revealed the resident had severe cognitive impairment and was dependent upon staff for all activities of daily living. Review of the MDS revealed a completion date of 07/15/24. Interview with Regional MDS Nurse #110 confirmed Resident #56's comprehensive admission assessment was not completed as per RAI manual guidelines. Regional MDS Nurse #110 confirmed the facility utilized the RAI manual for guidelines and instructions on how and when to complete the MDS assessments. Review of RAI User's Manual dated October 2023, on pages two through 22 revealed an admission assessment was the comprehensive assessment for a new resident and that it must be completed by the end of day 14, counting the date of admission to the nursing home as day one.

Based on medical record review and staff interview, the facility failed to update resident care plans regarding changes in condition. This affected one (Resident #68) of two residents for hospitalization s. The facility census was 75 residents. Findings include: Review of the medical record for the Resident #68 revealed an admitted [DATE] with diagnoses including chronic respiratory failure with hypoxia, dependence on respirator, non-traumatic intracerebral hemorrhage, embolism and thrombosis of thoracic aorta. Review of the care plan for Resident #68 last updated 04/19/24 revealed it was not updated to include the resident's behavior of pulling out her tracheostomy tube. Review of the nurse progress note for Resident #68 dated 07/11/24 revealed the respiratory therapist (RT) entered the resident's room in response to a pulse oximetry alarm and found the resident's tracheostomy tube had been pulled out and the resident was unresponsive. The RT replaced the tracheostomy tube, and the nurse and RT started cardiopulmonary resuscitation and called 911. The resident was transported to the hospital for an evaluation. Interview on 09/03/24 at 9:30 A.M. with Minimum Data Set (MDS) Coordinator #84 confirmed the care plan for Resident #68 had not been updated to include the resident's behavior of pulling out her tracheostomy tube and interventions and steps for staff to take in response to the behavior. Interview on 09/03/24 at 9:45 A. M. with the Director of Nursing (DON) confirmed Resident #68 had a history of pulling out her tracheostomy tube, and the behavior should be care planned. The DON confirmed the facility did not have a policy regarding care planning.

Based on medical record reviews, observations, and staff interviews, the facility failed to ensure activity of daily living (ADL) care and services were provided for dependent residents. This affected two (Residents #50 and #46) of six residents reviewed for ADL assistance. The facility census was 75. Findings include: 1. Review of the medical record for Resident #50 revealed an admitted [DATE] with diagnoses including chronic respiratory failure, dependence upon a ventilator, tracheostomy, anoxic brain injury and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #50 dated 07/03/24 revealed the resident had severely impaired cognition and was dependent upon staff for all ADLs and had limited range of motion (ROM) to bilateral upper and lower extremities. Review of the body assessment forms for Resident #50 dated 07/27/24, 07/31/24, 08/03/24, 08/07/24, 08/10/24, 08/14/24, 08/17/24, 08/21/24, and 08/24/24 were completed by State tested Nursing Assistants (STNAs) and signed by the nurse. Further review of the forms revealed Resident #50 received a bath on those days, but staff did not perform nail care. Observation on 08/26/24 at 8:10 A.M. of Resident #50 revealed the resident was in bed with contractures to bilateral hands and her fingernails were long and jagged. Observation on 08/27/24 at 1:19 P.M. with Licensed Practical Nurse (LPN) #42 revealed Resident #50's hands were contracted with long and jagged fingernails. Further observation revealed when LPN #42 opened the Resident #50's right hand there was dark brown debris and dirt on the resident's right hand. Interview on 08/27/24 at 1:19 P.M. with Licensed Practical Nurse (LPN) #42 confirmed Resident #50's hands were contracted, and her fingernails were long and jagged. LPN #42 further confirmed when she opened the resident's contracted hands there was dark brown debris and dirt on the resident's right hand. 44070 2.Review of the medical record for Resident #46 revealed an admitted [DATE] with diagnoses including acute respiratory failure, liver cirrhosis, chronic hepatitis C, heart failure, and anxiety. Review of the Minimum Data Set (MDS) assessment for Resident #46 dated 07/24/24 revealed the resident was cognitively intactand required extensive assistance of two staff for toileting. Review of the plan of care for Resident #46 dated dated 08/08/24 revealed the resident required assistance with ADLs and was at risk of developing complications associated with decreased ADL self performance. Interventions included two staff should use a Hoyer lift for all transfers and the resident required total care for toileting. Interview on 08/25/24 at 2:20 P.M. with Resident #46 confirmed the facility staffing was low and at times call lights took awhile to be answered. Resident #46 confirmed she needed assistance after using the bathroom and she would activate her call light on. Observation on 08/25/24 at 2:51 P.M. revealed Resident #46's call light remained activated since the resident had turned on the light at 2:20 P.M. Interview on 08/25/24 at 2:51 P.M. with Resident #46 confirmed the resident had been incontinent and staff had not provided incontinence care. Resident #46 confirmed the nurse came in and said an aide would be back to provide care. Observation on 08/25/24 at 2:54 P.M. revealed State tested Nursing Aide (STNA) #60 went into Resident #46's room, deactivated the call light and asked resident for the reason of her call light being on. Resident #46 told STNA #60 she needed help in getting cleaned up. STNA #60 informed Resident #46 she would let the assigned STNA know. Observation on 08/25/24 at 2:58 P.M. revealed STNA #60 returned to inform resident the assigned STNA would come back in five minutes. Interview on 08/25/24 at 3:01 P.M. with STNA #60 confirmed she turned Resident #46's call light off without preforming care and revealed she informed the assigned aide, STNA #43 that the resident needed assistance. Interview on 08/25/24 at 3:09 P.M. with STNA #43 confirmed she did not know Resident #46 had been waiting for approximately 49 minutes to receive incontinence care. STNA #43 further confirmed Resident #46 was incontinent and needed care. STNA #43 confirmed staff should be assisting each other and should not make a resident wait until their assigned aide was available. Interview on 08/27/24 from 3:00 P.M. with Administrator and the Director of Nursing (DON) confirmed the facility had no written policy regarding time frames for answering call lights.

Based on medical record review, observation, and staff interview, the facility failed to ensure staff properly positioned dependent residents in bed. This affected one (Resident #50) resident of four residents reviewed for positioning. The facility census was 75 residents. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE] with diagnoses including chronic respiratory failure, dependence upon a ventilator, tracheostomy, anoxic brain injury and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #50 dated 07/03/24 revealed the resident had severely impaired cognition and was dependent upon staff for all activities of daily living (ADLs) and had limited range of motion (ROM) to the bilateral upper and lower extremities. Review of the physician's orders for Resident #50 revealed an order dated 10/17/22 to place a pillow between resident's hands and face to offload pressure. Observation on 08/26/24 at 8:10 A.M. of Resident #50 revealed the resident was lying in bed on her side without a pillow placed between her hands and face. Resident #50's chin was pressed against her oxygen tubing to ventilator. Observation on 08/27/24 at 1:19 P.M. of Resident #50 revealed the resident was in bed and did not have a pillow placed between her face and hands as ordered. Interview on 08/27/24 at 1:19 P.M. with Licensed Practical Nurse (LPN) #42 confirmed Resident #50's body was contracted, and the resident had a physician's order to have a pillow placed between her hands and face. LPN #42 confirmed the pillow was not in place as ordered.

Based on medical record review, observation, staff interview, and policy review, the facility failed to provide care and services to prevent worsening of contractures and to prevent limited range of motion (ROM). This affected one (Resident #50) of four residents reviewed for ROM. The facility census was 75 residents. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE] with diagnoses including chronic respiratory failure, dependence upon a ventilator, tracheostomy, anoxic brain injury and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #50 dated 07/03/24 revealed the resident had severely impaired cognition, was dependent upon staff assistance with all activities of daily living (ADLs) and had limited ROM to the bilateral upper and lower extremities. Review of the care plan for Resident #50 revealed the resident was at risk for alteration in skin integrity care plan related to incontinence, impaired mobility, and joint contractures. Review of the occupational therapy (OT) discharge summary for Resident #50 dated 10/02/23 revealed the resident received treatment from 09/05/23 to 10/02/23 to maximize functional ROM to bilateral upper extremities for splint wear and to reduce risk of skin breakdown and contractures. Further review of the summary revealed the resident had good tolerance to ROM exercises and splint wearing and staff had a good understanding of splint wearing schedule. Review of the restorative flow records for Resident #50 dated October 2023 to December 2023 revealed the resident had a restorative splint program but the records did not indicate where the splints were to be applied, for how long the splints were to be applied, how the resident tolerated the program, or if any instructions were provided to staff upon discharge from the restorative program related to the splint/brace placement or maintenance. Review of the medical record for Resident #50 revealed it did not include documentation regarding the application of splints to the resident's bilateral upper extremities. Observation on 08/26/24 at 8:10 A.M. of Resident #50 revealed the resident was lying in bed with contractures to bilateral hands and had no splints in place. Further observation revealed Resident #50's bilateral hands were almost closed into a fist due to contractures to the bilateral hands. Observation on 08/27/24 at 1:19 P.M. revealed Resident #50 was lying in bed with no splints in place to the resident's bilateral hands. Interview on 08/27/24 at 1:19 P.M. with Licensed Practical Nurse (LPN) #42 confirmed Resident #50 had contractures to both hands and was not wearing splints. LPN #42 further confirmed Resident #50's record did not include documentation of splint application. Interview on 08/28/24 at 2:49 A.M. with Rehab Manager (RM)#126 confirmed upon Resident #50's discharge from OT services on 10/02/23, therapy had recommended staff to apply bilateral hand splints daily for up to four hours as tolerated. Interview on 09/03/24 at 9:51 A.M. with State tested Nursing Assistant (STNA) #61 confirmed Resident #50 was on a passive ROM restorative program to bilateral hands from October 2023 to December 2023. STNA #61 stated upon discharge from the restorative program the floor staff was told to place a carrot or splint into each of Resident #50 hands for three to four hours per day and to complete passive ROM daily with care. STNA #61 confirmed the facility had no record of placement of a carrot or splint to Resident #50's hands for 2024. Interview on 09/03/24 at 10:32 A.M. with Registered Nurse (RN) #38 confirmed he has taken care of Resident #50 for a long time and had never seen a splint/brace in place to bilateral hands. RN #38 confirmed Resident #50 did not have an order for a splint/brace to bilateral hands. RN #38 confirmed Resident #50 had carrots placed in bilateral hands today. Review of the facility polity titled Restorative Nursing Program revised August 2016 revealed residents would be provided with maintenance and restorative services designed to maintain or improve their highest practicable level.

Based on record review, review of hospital records, and staff and laboratory (lab) technician interviews, the facility failed to timely treat a residents urinary tract infection (UTI). This affected one (#70) of three residents reviewed for change in condition. Facility census was 78. Findings include: Review of medical record for Resident #70 revealed an admitted [DATE]. Diagnoses included hemiplegia following unspecified cerebrovascular disease affecting left non dominant side, depression, chronic respiratory failure and anxiety. Review of Resident #70's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #70 required moderate assistance for eating, dependent for bathing, bed mobility, toileting, hygiene and resident refused transfer. Review of Resident #70's care plan relative to an alteration in elimination related to indwelling urinary (Foley) catheter with interventions to provide Foley catheter care every shift and as needed, monitor for signs and symptoms of a urinary tract infection (UTI), elevated temperature, dysuria, contact the physician to seek diagnosis and treatment immediately, and to monitor lab values as ordered and report to physician. Review of the progress note dated 09/14/23 revealed Resident #70 complained of not being able to urinate and complained of burning. An attempt to irrigate Resident #70's Foley was unsuccessful, and the catheter was removed. Once removed, Resident #70 refused to have it replaced. Certified Nurse Practitioner (CNP) #17 was documented as notified. Review of a progress note dated 09/15/23 revealed Resident #70 complained of burning upon urination. CNP #17 was notified and an order for a urinalysis was received. Review of Resident #70's physician progress notes revealed on 09/17/23 the physician documented a positive UTI, awaiting culture and sensitivity. Review of Resident #70's urine analysis (UA) results faxed to the facility on [DATE] at 5:01 A.M. revealed the result was initialed by CNP #17 with a handwritten note of culture pending dated 09/19/23. Review of the electronic charting for Resident #70 revealed a UA was collected on 09/15/23, received on 09/16/23, reported on 09/18/23, and marked as reviewed on 09/20/23 at 9:08 A.M. by the Director of Nursing (DON). The UA documented culture results were positive for greater than 100,000 colonies/milliliter for Proteus Mirabilis (gram-negative bacterium). Review of Resident #70's physician orders revealed no orders for an antibiotic for a positive urine culture. Review of Resident #70's progress notes revealed no documentation a provider had been informed of the UA results reviewed by the DON on 09/20/23. Review of Resident #70's nursing progress notes dated 09/20/23 at 8:01 P.M. revealed respiratory therapy informed the nurse of a decrease in oxygen levels of 80 percent (%) on room air and 90% on the ventilator. Resident #70 was assessed as alert, diaphoretic, abdomen distended with hypoactive bowels sounds. The CNP was updated, and the rescue squad was called for a change in condition. Resident #70 was transferred to the hospital. Review of the hospitalization record of Resident #70 for 09/20/23 through 09/30/23 revealed the resident had diagnoses which included acute hypoxic respiratory failure subsequent to subsegmental pulmonary embolism, and bilateral pleural effusions, Proteus Mirabella's bacteremia secondary to complicated UTI in the setting of left hydronephrosis and left ureteral calculus; urinary retention secondary to left hydronephrosis due to left ureteral calculus status post cystoscopy, left ureteral stent placement 07/23 with sepsis on admission. Further review revealed a Computed Tomography (CT) scan revealed a left nine-millimeter proximal ureteral stone. On 09/23/23, Resident #70 was taken to the operating room for a cystoscopy left retrograde pyelogram and left ureteral stent placement. Interview on 12/19/23 at 3:50 P.M. with Lab Technician #19 revealed Resident #70's UA was finalized on 09/19/23 at 12:19 P.M. and results were faxed to the facility and uploaded into the electronic charting system. Interview on 12/19/23 at 4:03 P.M. with the DON explained the reason Resident #70's electronic charting documented her review of the urine culture result was due to her usual morning routine. The DON stated it was her morning routine to check the electronic charting system for residents who had lab results returned for review, she then clicked reviewed although she did not actually look at the results. The DON stated she would document the resident, and the type of lab containing result on the morning report sheet for the primary nurse to follow up with. The DON confirmed Resident #70's UA results on 09/20/23 showing a UTI were not provided to the physician and the resident subsequently was hospitalized later that evening. Interview on 12/20/23 at 10:30 A.M. with LPN #10 verified she worked on 09/20/23 but did not recall receiving notification of UA results for Resident #70. LPN #10 was able to check SIGNAL (secure messaging system) on 09/20/23 and verified no notification of UA results were messaged to a provider. LPN #10 confirmed Resident #70's UTI was not timely treated and the resident was admitted to the hospital on 09/20/23. This deficiency represents non-compliance investigated under Complaint Number OH00149219.

Based on closed medical record review, observation, interviews and review of the emergency room (ER) report the facility failed to provide safe bed mobility for residents. This affected one Resident (#92) of four reviewed for falls. This resulted in actual harm to Resident #92 when a staff member provided bathing assistance by herself when the resident was assessed as requiring the assistance of two staff. The resident rolled off the bed and sustained a fracture to her left thigh. The census was 85. Findings include: Review of closed medical record revealed Resident #92 had [DIAGNOSES REDACTED]. The resident required a feeding tube in her stomach for all nutritional needs. Her admission minimum data set ((MDS) dated [DATE] revealed the resident required total extensive assist of two staff with all care including bed mobility. The resident was severely cognitively impaired. The resident could answer simple yes or no answers by shaking her head. Review of Resident #92's fall plan of care dated on 08/26/16 revealed interventions of a low air loss mattress with half rails, extensive two person assist for all care and a mechanical lift with two person assist for transfers. Review of the progress notes for 09/03/16 noted Resident # 92 rolled out of bed. The residents vitals were documented along with a head to toe assessment. The next entry on 09/04/16 was from an activity staff member revealed the resident was sent to the hospital on [DATE]. Review of the ER report dated on 09/03/16 revealed the resident presented with a abrasion to her face and her left leg was externally rotated. The resident grimaced with pain when moved. An X-ray was completed at the ER and revealed a closed intertrochanteric fracture of the left femur The resident was still in the hospital on [DATE]. Interview with the Administrator on 09/06/16 at 10:30 A.M. revealed Resident #92 did sustain a fall recently but the facility was unsure of the injuries the resident sustained [REDACTED]. Interview with Licensed Practical Nurse (LPN) #7 on 09/06/16 at 3:00 P.M. revealed State tested Nursing Assistant (STNA) #66 was giving the resident a bed bath. STNA #66 turned the resident over and the resident rolled out of the bed. LPN #7 revealed Resident #92 had a laceration on the right side of her face. LPN #7 revealed the resident had most likely hit her head so LPN #7 sent the resident to the hospital for evaluation. Interview with STNA #66 on 09/07/16 at 1:20 P.M. revealed she was given the resident a bed bath on 09/03/16. STNA #66 revealed she turned the resident and the resident slipped and rolled out of the bed landing on the floor beside the bed. STNA # 66 indicated she thought she could bathe the resident by herself. Interview with the Director of Nursing (DON) on 09/07/16 at 4:00 P.M. revealed the resident required two staff assistance with bathing. This deficiency substantiates Complaint Number OH 699 and Complaint Number OH 669.

Based on medical record review, staff interview and nurse practitioner interview, the facility failed to appropriately monitor an insulin dependent resident's blood sugar, resulting in actual harm when Resident #97 had to be sent out to the emergency room due to elevated blood sugars and was admitted to the intensive care unit on an insulin drip and had to receive intravenous fluids for dehydration related to evaluated blood sugars. This affected one (#97) out of three residents review of blood sugar monitoring. The facility identified 27 insulin dependant residents currently residing in the facility. Findings include: Review of medical record for Resident #97 revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #97's physician/ nurse practitioner (NP) progress note dated 04/15/16 documented the resident was admitted with a primary [DIAGNOSES REDACTED]. Further review of the document specifically under assessment and plan revealed instructions to continue to have finger sticks and sliding scale coverage for diabetes mellitus type two for Resident #97. Review of physician admission orders [REDACTED].M. and a short acting insulin ([MEDICATION NAME]) eight units to be given SQ three times a day before meals. Further review of admission orders [REDACTED]. Review of Resident #97's physician/ NP progress note date 04/18/16 documented resident had a history of [REDACTED]. At this time the plan was to evaluate finger sticks and provide sliding scale coverage. The resident was documented as currently receiving sliding scale coverage. Review of lab report dated 04/18/16 documented glucose of 330 milligrams per deciliter (mg/ dl) indicating a higher than normal reading. The normal range for fasting blood glucose is 65-99 mg/ dl. Review of physician's/NP progress note dated 04/21/16 documented resident had a history of [REDACTED]. At this time the plan was to evaluate finger sticks and provide sliding scale coverage. The resident was documented as currently receiving sliding scale coverage. Review of Resident #97's medicare Five Day Minimum Data Set assessment dated [DATE] documented the resident had a [DIAGNOSES REDACTED]. Review of physician progress notes [REDACTED].#97 had a fasting BS of 330 mg/ dl and would continue to monitor and provide the sliding scale as ordered. The progress note documented the resident was currently receiving sliding scale insulin. Review of entire medical record for Resident #97 lacked any documentation of blood sugar monitoring and/ or sliding scale insulin being ordered per the physician or NP from 04/15/16 thru 04/25/16. Review of Medication Administration Record [REDACTED]. Review of nurses notes from admission on 04/15/16 until 04/24/16 lacked any documentation of blood sugar monitor for Resident #97. Review of nurses' notes dated 04/24/16 at 10:25 P.M. documented Resident #97 family complained of resident not acting like himself. At this time Resident #97 blood sugar (BS) read was 592 mg/ dl. At this time the resident was scheduled long acting insulin [MEDICATION NAME] 25 units SQ was administered. Review of nurses note dated 04/25/16 at 2:00 A.M. a new order was received from on call NP #110 to administer insulin 10 units of [MEDICATION NAME] for BS of 592 mg/ dl and at this time the glucometer read HI and to recheck blood sugar in two hours. At 4:00 A.M. Resident #97's blood sugar was 579 mg/ dl, the NP was notified and a message was left on the on call voice mail system. At 8:25 A.M., NP #100 was notified of a blood sugar of 556 mg/ dl. At this time he ordered eight units of regular insulin and to recheck at 12:00 P.M. At 9:30 A.M. NP #100 was in to evaluate Resident #97 and referred him to the emergency to evaluate and treat. Review of hospital admission record dated 04/25/16 documented the resident had to be admitted to the intensive care unit with new [DIAGNOSES REDACTED]. During the course of his emergency room treatment he was given intravenous fluids for dehydration with [MEDICAL CONDITION]. Resident #97 was documented as having a sodium of 150 which was noted as high than normal. Resident #97 had to have an insulin drip due to his higher than normal blood sugar of 563 mg/ dl. The resident's labs revealed he had an increase white blood cell count of 14.9 indicative of infection. He also had lab work to indication dehydration and acute kidney failure with increase blood urea nitrogen of 51 and creatinine of 2.47. Review of urine analysis obtained on 04/25/16 was also completed that showed 2,000 milligrams per deciliter of glucose in his urine; however, there were no [MEDICATION NAME] present in the urine to indicate diabetic ketoacidosis. Review of hospital discharge record dated 05/05/16 documented resident was diagnosed with [REDACTED]. On 05/24/16 at 12:18 P.M. interview with Licensed Practical Nurse (LPN) #80 revealed any time a resident is on scheduled insulin she would check blood sugars and documented them in the resident record. LPN #80 stated if she was aware of the resident not having an order to monitor blood sugars she would notify the physician to clarify if monitoring was needed. On 05/24/16 at 12:20 P.M. interview with LPN #81 revealed she admitted Resident #97 from the hospital on [DATE]. LPN #81 stated he did not have any current orders for blood sugar monitor for Resident #97 but the resident was on long and short acting insulin. LPN #81 stated typical she would get an order for [REDACTED].#81 stated she review all of Resident #97's orders with NP #100 at the time of his admission. LPN #81 verified there was no order to monitor blood sugars or sliding scale insulin so it was not completed as documented in the physician/ NP progress notes. On 05/24/16 at 12:45 P.M. interview with Director of Nursing (DON) revealed the facility doesn't check blood sugar for residents on scheduled insulin unless there is an order per the physician or NP. The DON verified at this time the facility does not have a policy for monitoring blood sugars for insulin dependent residents. The DON also verified there was no blood sugar monitoring completed for Resident #97 due to the resident not having a physician's orders [REDACTED].>On 05/24/16 at 1:35 P.M. interview with NP #100 revealed if his progress notes documented Resident #97 was receiving accu-checks and insulin coverage per sliding scale he would assume there was an order for [REDACTED].#100 stated if the resident had an abnormally high glucose of 330 mg/ dl, he would have ordered the blood sugar checks at that time if they weren't ordered because that means he has uncontrolled diabetes and his insulin would need to be monitored and adjusted. NP #100 denies being aware of Resident #97 blood sugar not being not being monitored as documented on his progress note. This deficiency substantiates complaint number OH 517.

Based on medical record review, interviews, surveyor observations, review of the hospital emergency room documentation, police reports, and the weather report, the facility failed to ensure staff provided adequate supervision to prevent a cognitively impaired resident, residing on the locked behavior unit, from leaving the facility unsupervised. Harm occurred when the resident was gone from the facility without staff knowledge, was found 15 hours later, and subsequently sent to the hospital and treated for [REDACTED]. This resulted in Immediate Jeopardy for one (#81) of three sampled residents reviewed for risk of elopement. The facility identified 25 of 102 residents as being at risk for elopement. On 11/17/15 at 2:40 P.M., the Administrator, the Director of Nursing (DON), and Director of Clinical Services Registered Nurse (RN) #24 were informed Immediate Jeopardy began on 11/15/15 at 5:00 P.M. when Resident #81, who was assessed as high risk for elopement and required a locked behavior unit, exited the facility unsupervised without staff knowledge. State tested Nursing Assistant (STNA) #7 realized Resident #81 was missing three hours later and notified Licensed Practical Nurse (LPN) #22. Staff searched the facility and grounds for the resident and could not locate the resident. LPN #22 notified the Administrator, the DON, Unit Manager RN #26 and the police. The Administrator and DON drove around several areas searching for the resident and flyers were distributed with the missing resident's picture and information. Resident #81's whereabouts was not discovered until 15 hours later on 11/16/15 at 8:30 A.M. when the hospital emergency room phoned the Administrator informing him the resident was found lying on the ground at an abandoned house by a neighbor, about seven miles away from the facility. According to the history report on Accuweather, the local weather forecast, the low outside temperature in the area on 11/16/15 was 37 degrees Fahrenheit (F). Resident #81 was taken to the emergency room by the emergency squad and treated for [REDACTED]. The Immediate Jeopardy was removed on 11/17/15 at 6:00 P.M. when the facility implemented the following corrective actions: · On 11/15/15 at 9:00 P.M., all residents' wander guards and all door alarms were tested by Unit Manager RN #26 and found to be in proper working order. · On 11/15/15, the Administrator implemented new arrangements for the residents who reside on the locked unit to remain on the unit to eat, smoke and participate in activities. Any resident who resides on the locked unit will be on one-to-one supervision any time they are off the locked unit. · On 11/15/15 at 9:45 P.M. through 11/17/15 at 6:00 P.M., the administrative staff presented in-services related to elopement and the new arrangements for the residents who resided on the locked unit. The in-servicing continued until all facility staff were trained either in person or via a telephone call and completed on 11/17/15. · On 11/16/15 at 1:00 P.M., the door alarms were re-checked by the Administrator and it was determined, at times, the front door locking mechanism was not working properly. The front door was not locking when the handicap button was used to open the door even when a functioning wander guard bracelet was in place. The Administrator contacted a contractor to replace the handicap button and ordered an additional sensor. He also developed a schedule to have staff scheduled to monitor the front door until repairs were able to be completed. · On 11/16/15 at 3:00 P.M., Director of Clinical Services RN #24 inspected all the elopement kits to ensure all supplies were available. · On 11/16/15 when Resident #81 returned to the facility she was placed on 15 minute checks for increased supervision. · On 11/16/15, the Administrator initiated monitoring of the new handicap button, front door security, and supervision of the residents who reside on the locked unit. Additional monitoring of the wander guard and door alarm checks was also initiated. Negative trends will be reported to the Quality Assurance Performance Improvement committee. · On 11/16/15 through 11/17/15 at 2:00 P.M. all unit managers reviewed the elopement risk assessments for all residents. Care plans for residents at risk for elopement were reviewed by the Director of Clinical Services RN #24 to ensure they were current. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions to ensure monitoring for on-going compliance. Findings include: Review of the medical record for Resident #81 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition and required supervision with all care. Review of the plan of care for elopement updated on 11/02/15 revealed interventions for a wander guard alarm and resident to reside on a locked behavior unit. An elopement risk assessment dated [DATE] indicated Resident #81 was at risk for elopement due to behaviors of wandering and talking of leaving. The resident was being seen by a psychiatrist and had orders for psychoactive medications, Haldol Deconate 50 milligrams (mg) intramuscularly monthly and Risperdal 2 mg two times daily. Nurses notes dated 11/15/15 at 7:45 P.M. documented STNA #5 was passing ice and noticed Resident #81 was not in her room. At 8:00 P.M., LPN #22 called a Code Black (procedure for missing residents) and staff searched the building and the grounds. The Administrator, the DON, Unit Manager RN #26, and the police were notified Resident #81 was missing. Review of the police report dated 11/15/15 at 10:00 P.M. revealed the facility had contacted them at 8:00 P.M. about a missing resident. At 10:00 P.M., the police issued a Missing Adult Alert for Resident #81. Review of the hospital emergency room documentation dated 11/16/15 at 8:09 A.M. revealed Resident #81 was found wandering around near an abandoned house. Resident #81 stated she fell and complained of right ankle and left hip pain. emergency room staff was unable to obtain a core body temperature on Resident #81 and placed her in a bear hugger (a machine used to treat hypothermia). During an interview on 11/17/15 at 9:00 A.M., the Administrator stated the front door wander guard alarm system failed to activate when the handicap button was pushed. The Administrator stated Resident #81 was observed on the facility video tape exiting the front door at 5:00 P.M after she pushed the handicap button. During an interview on 11/17/15 at 10:15 A.M., Resident #81 stated she had been thinking of a way to leave the facility and on 11/15/15, after she ate her evening meal, she noticed staff were not watching her so she left the dining room and went out the front door. She stated she walked to a home she had previously lived at and spent the night there. She stated she did suffer a fall and had a hard time getting up after she fell . She stated she was very cold during the night and wished she would have stayed at the facility. Observations on 11/17/15 at various times including 10:20 A.M. and 4:05 P.M. and on 11/18/15 at 12:00 P.M. revealed no evidence of any residents with exit seeking behaviors. Staff was observed completing 15 minute checks on Resident #81. During a telephone interview with STNA #7 on 11/17/15 at 11:00 A.M., she stated on 11/15/15 at 4:30 P.M. she took four residents from the behavior unit to the main dining room for their evening meal. STNA #7 stated the last time she saw Resident #81 she had finished eating her meal and requested more coffee. STNA #7 stated she was assisting another resident and STNA #8 offered to return the residents to the behavioral unit for her. STNA #7 stated she thought all four residents were returned safely back to the behavior unit and when she returned to the unit she thought Resident #81 was in her bed. STNA #7 stated the STNA who brings the residents off the unit should be responsible for bringing the residents back to the unit. During a telephone interview with LPN #22 on 11/17/15 at 1:45 P.M., she stated on 11/15/15 she thought Resident #81 was in bed because the covers were pulled up over the pillows. LPN #22 stated around 7:50 P.M. she went to give Resident #81 her evening medications and realized she was not in her bed. LPN #22 stated she requested that STNA #6 see if the resident was in activities. STNA #6 reported to LPN #22 the resident was not in activities. LPN #22 stated the staff on the behavioral unit searched all the rooms on the unit at 7:55 P.M. and when the resident could not be located, she notified the rest of the staff, and they immediately began a search of the facility and the grounds. During an interview with the DON on 11/17/15 at 2:00 P.M., she stated there was no procedure in place for staff to utilize when they took the residents off the locked units for meals. She further stated the staff from the locked unit did not utilize a sign out / sign in sheet when the residents were off the unit for meals. This deficiency is an example of continued non-compliance from the annual and extended surveys of 11/16/15. This deficiency substantiates Master Complaint Numbers OH 534 and Complaint Number OH 529.

Based on medical record review, observations, staff interviews, and review of manufacturer's recommendations for use of a reverse seatbelt, the facility failed to ensure one resident (#70) remained free of accident hazards while in a tilt-n-space wheelchair with a reverse seatbelt on (double restraint). This resulted in Immediate Jeopardy when Resident #70 was observed by a surveyor with a reverse seatbelt up around her neck and no facility staff present in the area. This affected one of three residents reviewed for reverse seatbelt restraints. The facility identified a total of eight residents using restraints. On 10/21/15 at 11:45 A.M., the Administrator, Director of Nursing (DON), and Corporate Nurse #1 were notified Immediate Jeopardy began on 10/20/15 at 2:30 P.M. when Resident #70 was observed by a surveyor in the common area by the north nursing station. The resident was found in a reclined tilt-n-space wheelchair with a reverse seatbelt on. The resident had slid down in the chair causing the reverse seatbelt to move up her body. Resident #70 had put her left arm under the reverse seatbelt raising it up to her neck level. The resident was agitated and was continuing to slide towards the front of the wheelchair causing the restraint to go higher on her neck. There was no facility staff present. The surveyor attempted to loosen the restraint from the resident's neck while holding her in the chair. The surveyor called for assistance from Certified Nurse Practitioner (CNP) # 1 who was at the nursing station. While the surveyor held the resident in the chair, CNP #1 released the restraint. The surveyor and CNP #1 pulled the resident up into the proper position in the tilt-n-space wheelchair. The resident remained agitated. The Immediate Jeopardy was removed on 10/20/15 when the reverse seatbelt was removed from Resident #70 by State tested Nursing Assistant (STNA) #241, and the seven additional residents utilizing physical restraints were reassessed to assure appropriate restraint use and application was in place, and the facility implemented the following corrective actions: · On 10/20/15 at 2:36 P.M., Resident #70's reverse seatbelt was removed by State tested Nursing Assistant (STNA) #241 and she was transferred to her room and placed in bed. · On 10/20/15 at 2:40 P.M., a skin and pain assessment was completed on Resident #70 and she was placed on every 15 minute checks by the DON. · On 10/20/15, the remaining seven residents (#66, #71, #93, #101, #120, #122 and #133) with physical restraints were reassessed by the DON to assure appropriate restraint use and application was in place. There were no other issues identified. · On 10/20/15 at 3:00 P.M., nursing management began immediate in-servicing of all nursing staff, including STNAs, regarding appropriate physical restraint application, when to check and release restraints, and how often assessments needed completed. · Observations of eight residents identified with restraints (#66, #70, #71, #93, #101, #120, #122 and #133), including two with reverse seatbelts, from 10/20/15 beginning at 3:00 P.M. through 10/22/15 at 4:00 P.M. revealed the restraints were applied in accordance with manufacturer ' s instructions and resident care plans. No other residents were identified as having a double restraint. · On 10/21/15 at 8:30 A.M., observation of Resident #70 revealed the resident was in a low bed, against the wall with a mat on the floor. · On 10/26/15 between 3:30 P.M. and 4:15 P.M., interviews were conducted with eight staff regarding physical restraint application. Licensed Practical Nurse (LPN) #286, and #283, Registered Nurse (RN) #267, and State tested Nursing Assistants (STNAs) #226, #208, #242, #247 and #301 revealed they were in-serviced and aware of the correct way to place a physical restraint on a resident. They also were aware of when restraints needed checked and released. The nurses correctly identified how often assessments were completed and what was needed in a physician's order [REDACTED]. Although the Immediate Jeopardy was removed on 10/20/15, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions to ensure monitoring for on-going compliance. Findings include: Medical record review for Resident #70 revealed she was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the Rehabilitation Services Screening dated 06/02/15, completed by Certified Occupational Therapy Assistant/Licensed (COTA/L) #1, revealed the tilt-n-space wheelchair belonged to the resident. A seatbelt was needed to assist with the resident's positioning and for safety. Review of the attending physician's note dated 06/03/15 revealed the nursing staff had noted increased behaviors of screaming, scooting self out of wheelchair, and releasing seatbelt. LPN #316 administered Ativan (anti-anxiety) prior to transportation to dialysis. The medications, as well as consoling, were ineffective. The LPN received orders to discontinue the self-releasing seat belt and to initiate the use of the reverse seatbelt for the resident's safety. A nursing note dated 09/14/15 revealed the resident was up in her wheelchair in the common area, attempting to get out of her wheelchair repeatedly. The resident was becoming a danger to herself and the resident was then transferred to her bed, left in the lowest position, with a mat on the floor next to the bed. A nursing note dated 09/18/15 revealed the resident fell out of her bed at 11:00 P.M. She was found on the floor, on the mat by STNA #216. The resident was transferred to her wheelchair where she began trying to get herself out of the wheelchair. She was very combative and agitated. Review of the latest comprehensive assessment dated [DATE] revealed the resident was severely impaired with short and long term memory. The resident exhibited physical behavior directed towards others. She required extensive assistance of two staff for bed mobility, transfers and toilet use. A trunk restraint was used daily. The plan of care identified the resident as being at risk for falls and a reverse seatbelt would be used at all times while up in the tilt-n-space wheelchair. The resident was to be checked every 30 minutes while restrained and released every two hours for 10 to 15 minutes for repositioning. The care plan also identified the resident as having unawareness of safety needs, extreme agitation at times, flipping legs over arms of wheelchair, not easily controlled, and was in danger of injury. Observation on 10/20/15 at 2:30 P.M. revealed Resident #70 was in the common area by the north nursing station. The resident was found by the surveyor in a reclined tilt-n-space wheelchair with a reverse seatbelt on. The resident had slid down in the chair with half of her bottom off the seat, causing the reverse seatbelt to move up her body. Resident #70's left arm was under the seatbelt and the seatbelt was at her neck level. The resident was agitated and was continuing to slide towards the front of the wheelchair causing the seatbelt to go higher on her neck. The surveyor attempted to loosen the seatbelt off the resident's neck while holding her in the chair. There was no facility staff in the area. The surveyor called for assistance from Certified Nurse Practitioner (CNP) #1 who was at the nursing station. While the surveyor held the resident in the chair, CNP #1 released the seatbelt. The surveyor and CNP #1 pulled the resident up into the proper position in the chair. The resident continued to remain agitated. During an interview on 10/20/2015 at 2:50 P.M. the DON stated Resident #70 is difficult to keep in the chair and they were looking at something different for her. Interview with STNA #242 on 10/20/15 at 3:18 P.M. revealed she had put the reverse seatbelt on the resident while she was in an upright position in the chair. STNA #242 stated there were two fingers of space between the resident and the reverse seatbelt. She stated she reclined the tilt-n-space wheelchair and was very busy and would check on the resident every hour or two. She also stated she had not looked at the resident's care sheet for a while, including the day of the incident. She confirmed she had checked Resident #70 approximately 20 minutes prior to the surveyor finding the resident with her seatbelt around her neck. STNA #242 stated at that time the seatbelt had moved up to the resident ' s chest, mid-nipple line. STNA #242 further stated she adjusted the restraint and repositioned the resident in the tilt-n-space wheelchair. STNA #242 stated Resident #70 was usually agitated when she was tired, wanted to lie down or had to go to the bathroom. She stated she wanted to lay the resident down, however the nurse told her to keep the resident up as she had not been out of bed very long. Interview on 10/20/15 at 3:55 P.M., COTA/L #1 stated Resident #70's tilt-n-space wheelchair was her own personal chair and was custom molded. COTA/L #1 stated the resident previously had a self-releasing seatbelt, then an alarming seatbelt. When the alarming seatbelt failed, the reverse seatbelt was ordered. She further stated if the reverse seatbelt was applied while the resident was in an upright position and then reclined, the reverse seatbelt would need to be adjusted. Otherwise the reverse seatbelt would be loose. Interview on 10/20/15 at 4:35 P.M. with the DON, and the Administrator present, the DON provided assessments for Resident #70's reverse seatbelt and tilt-n-space wheelchair. The assessments were dated August 2015. The DON confirmed Resident #70's assessments were not completed until August 2015, two months after the reverse seatbelt was put in place for the resident. Interview with the attending physician for Resident #70 on 10/22/15 at 3:00 P.M. revealed he had been the Medical Director of the facility for a few months. He stated the facility notified him regarding the incident which had just occurred on 10/20/15. He stated the facility notified him regarding an incident on 06/26/15 where leg restraints were applied to Resident #70 without a physician's orders [REDACTED]. Review of a statement written by CNP #1 on 10/22/15 documented he was at the north unit nursing station on 10/20/15. He documented he was asked to assist one of the surveyors to reposition Resident #70. The resident was in a wheelchair and had slid down underneath her reverse seatbelt. Review of the manufacturer's recommendations for the use of the reverse seatbelt revealed the reverse seatbelt was to help the resident remain upright in the chair. The reverse seatbelt encircles the resident and crosses in the back, looping onto the kick spurs. The manufacturer's information had no safety data sheets or other safety information available. Neither the manufacturer's information for the reverse seatbelt or the tilt-n-space wheelchair had safety information available in the facility or on line. Review of an alternate manufacturer's information (Posey) for a reverse seatbelt revealed there was a risk of chest compression or suffocation if the patient's weight is suspended off the seat.¿@

Based on closed record review, staff interviews, policy review and information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement aggressive preventative interventions and early identification of pressure areas. This resulted in harm for one Resident (#43) of four reviewed for pressure ulcers; when the facility identified an avoidable stage three (full thickness tissue loss, slough may be present and may include undermining and tunneling) pressure area to the upper back and aggressive preventative measures were not in place. The facility census was 102. Findings Include: Closed record review revealed Resident #43 was admitted to the facility 05/05/15 with [DIAGNOSES REDACTED]. Review of the skin admission assessment dated [DATE] revealed an unstageable (full thickness tissue loss, slough or eschar may be present on some parts of the wound bed) ulcer to the right heel. Review of the admission plan of care dated 05/05/15 revealed the potential for alteration in skin break down related to decreased mobility and weakness. Interventions included inspect skin during routine care, lift sheet with transfer and bed mobility, lotion to skin, pad and protect skin and turn and reposition. Review of the pressure ulcer risk assessment dated [DATE] revealed the resident had a score of seven. A total score of eight or greater, or a history of a stage three or four pressure ulcer or current pressure ulcer the resident should be considered high risk and a preventative protocol should be implemented immediately. Review of the comprehensive assessment dated [DATE] revealed Resident #43 had mild cognitive impairment, required extensive assistance of two staff for bed mobility and was totally dependent on staff for transfer. There were no pressure areas documented. Review of the nurse's note dated 06/07/15 revealed a bloody drainage was observed on the residents sheet while she was being changed. The resident was rolled on her side and there was an open area on her upper back with slough and drainage present. The area measured 2 centimeters (cm) by 2.5 cm. The note further documented the doctor was notified and a dressing applied. The record revealed no evidence of a treatment order. During a telephone interview on 10/22/15 at 11:44 A.M., Licensed Practical Nurse (LPN) #263 stated she called the physician regarding Resident #43's open area. She further stated she put the duoderm on Resident #43's open area to her spine. LPN #263 stated she did not document the actual order obtained from the physician. She further stated she never saw Resident #43 with any padding or protection to the area on her spine. Review of the Treatment Administration Record (TAR) dated May 2015 documented no preventative measures were in place. The TAR dated June 2015 revealed the treatment to the pressure area began 06/10/15. Review of the wound nurse practitioner's (CNP) #600 note dated 06/09/15 revealed Resident #43 had a mid spine unstageable pressure ulcer with a large amount of purulent yellow, tan, green drainage, loose adherent yellow slough and necrotic tissue which measured 3.8 cm by 4.0 cm with the depth obscured, with 100% necrotic tan/brown slough. The Periwound was red and warm with purulent drainage. Orders included the treatment changed to santyl ( an enzymatic debridement), [MEDICATION NAME] (an antibiotic), air mattress and to turn and reposition. During a telephone interview on 10/22/15 at 11:58 A.M., CNP #600 stated she first looked at Resident #43's wound on 06/09/15 and it was an unstageable pressure area and stated the area showed some improvement with the santyl treatment and then it kind of hit a plateau and had undermining and tunneling. She further stated she was not on an air mattress prior to her order on 06/09/15. She confirmed early identification of a pressure area would help in healing. During an interview on 10/22/15 at 12:55 P.M., the Director of Nursing (DON) and Corporate Clinician #602 stated they had identified a problem with skin assessments and documentation in June. They implemented a new treatment nurse, however they did not have documentation of ongoing monitoring. During a telephone interview on 10/22/15 at 2:25 P.M., the former Medical Director (FMD) #601 stated she was not on call the date of 06/07/15, however no one in her practice would have ordered duoderm for a stage three or four pressure ulcer with drainage. She stated there was a facility wound protocol and it was not followed. She also confirmed early identification of pressure areas could prevent further skin break down and the correct treatment would aid in healing. Review of the policy titled Skin: Pressure Ulcer Risk Assessment and Prevention, revised August 2015 revealed interventions to eliminate or minimize risk factors would be introduced at the earliest possible time. Use pillows to keep bony prominence from direct contact, apply pressure reducing support surface to bed and inspect skin daily. Review of the facility wound treatment algorithm dated November 2006 documented treatment for [REDACTED]. According to information from the NPUAP a Category/Stage III: Full thickness skin loss is described as a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occipital and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.