Every finding on record at S.E.M. Haven Health Care Center

Based on interview, record review, and facility policy review, the facility failed to provide laboratory services in a timely and efficient manner to prevent the delay of treatment for residents symptomatic of urinary tract infections (UTIs) for 4 (Residents #58, #76, #84, and #22) of 5 residents reviewed for UTIs.Findings included:A facility policy titled, Diagnostic Services, revised 05/2020, revealed a section titled, Policy Interpretation and Implementation, specified, 2. Radiologic and other diagnostic services, including pathology and clinical laboratory services, are available 24 hours a day, seven days a week. The policy revealed a section titled, Urinary Culture Policy, specified, 1. Urine cultures will only be ordered when clinical indications meet McGeer's criteria for urinary tract surveillance. Routine or screening urine cultures in asymptomatic individuals are not permitted. The policy also revealed a section titled, Procedure, specified, 1. Nursing staff must document signs/symptoms and notify the provider. Nursing staff must complete the infection screening evaluation to ensure criteria are met. 2. A [brand name urine reagent strip] shall be performed and reported to the medical director and documented in the resident's chart. A [brand name urine reagent strip] is considered positive if both leukocytes and nitrites are present. 3. Staff will encourage fluids for 24 hours and then complete a second [brand name] urine reagent strip. Results and resident symptoms are reported to the provider. 4. Providers must verify that McGeer's criteria are met before ordering a urine culture. Providers will await the final urine culture and sensitivity before prescribing an antibiotic. 5. Providers can choose to prescribe a broad-spectrum antibiotic at their discretion if severe symptoms (i.e. [id est, that is], fever, leukocytosis, dysuria, flank pain, change in physical ability, etc. [ et cetera, and so forth]) are present.A facility policy titled, Infection Control Plan/Program, revised 03/2025, indicated that Diagnostic testing and procedures are performed as ordered and in a timely manner. The policy further indicated, Radiologic and other diagnostic services, including pathology and clinical laboratory services, are available 24 hours a day, seven days a week.1. An admission Record revealed the facility admitted Resident #58 on 04/30/2024. According to the admission Record, the resident had medical diagnoses that included benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, urinary tract infection, and bladder disorder. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/18/2025, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #58's Care Plan Report, included a focus area initiated on 08/07/2024, that stated the resident had diagnoses of BPH, obstructive and reflux uropathy and a bladder disorder. Interventions directed staff to monitor for signs and symptoms of UTI and notify the medical doctor as needed. Resident #58's nursing Progress Notes, dated 10/21/2024 at 2:00 PM, written by Licensed Practical Nurse (LPN) #8, revealed Resident #58 complained of urinary pain and burning at the indwelling catheter insertion site. The Progress Notes revealed a urine sample was obtained from the resident, which was observed to be yellow, cloudy, thick with mucous present and small blood clots noted. The Progress Notes revealed a strong foul odor was noted, and the urine dipstick was positive for leukocytes (white blood cells) and nitrites (a chemical compound formed primarily when bacteria converts nitrates, common in healthy urine, into nitrites). Resident #58's nursing Progress Notes, dated 10/21/2024 at 5:38 PM, written by LPN #8, revealed that Resident #58's urine was collected and placed with the admission Record and a laboratory (lab) requisition in the unit refrigerator. Resident #58's Order Recap [Recapitulation] Report for the timeframe from 09/01/2024 through 09/30/2025, revealed an order dated 10/21/2024 to obtain urine and place the sample in the refrigerator for pick up on 10/22/2024 one time only.Resident #58's Lab Results Report, with a report date of 10/24/2024 at 10:01 AM, revealed the resident's urine sample was collected on 10/21/2024 at 4:00 PM and was received by the lab on 10/22/2024 at 9:18 AM. The Lab Results Report revealed the urine culture had over 100,000 colony-forming units (CFUs) per milliliter (mL) of mixed pathology, indicating a contamination. Resident #58's Order Recap Report for the timeframe from 09/01/2024 through 09/30/2025, revealed an order dated 10/27/2024, to obtain a urinalysis and culture and sensitivity one time only for possible UTI. Resident #58's Lab Results Report, with a report date of 10/31/2024 at 3:44 PM, revealed the resident's urine sample was collected on 10/28/2024 at 9:00 AM and was received by the lab on 10/28/2024 at 11:24 AM. The Lab Results Report revealed the urine culture had over 100,000 CFUs/ml of proteus mirabilis (a bacteria commonly associated with UTIs). The Lab Results Report revealed the culture also yielded over 100,000 CFUs /ml of pseudomonas aeruginosa (a bacteria associated with UTIs). Resident #58's Order Recap Report for the timeframe from 09/01/2024 through 09/30/2025, revealed an order dated 10/31/2024, for ciprofloxacin hydrochloride tablet 500 milligrams (mg) with instructions to give one tablet two times daily for seven days for UTI.Resident #58's nursing Progress Notes, dated 07/25/2025 at 4:06 PM, written by LPN #8, revealed Resident #58 complained of urinary pain, burning, and frequency. The Progress Notes revealed the resident's urine was a concentrated dark-yellow color with foul odor. The Progress Notes revealed a urinalysis dipstick was performed on the resident's urine and was positive for leukocytes and nitrites. The Progress Notes revealed the facility encouraged clear fluids, and the nursing supervisor was notified. Resident #58's nursing Progress Notes, dated 07/26/2025, written by Registered Nurse (RN) #7, revealed Resident #58 had a second positive urinalysis dipstick. The Progress Notes revealed a urine sample was obtained through a straight catheter and placed in the unit refrigerator for the lab to pick up on Monday morning. Resident #58's Order Recap Report for the timeframe from 09/01/2024 through 09/30/2025, revealed an order dated 07/26/2025 (a Saturday) to obtain urine sample through a straight catheter and place in the refrigerator for the laboratory on Monday morning. Resident #58's Lab Results Report, with a report date of 07/31/2025 at 1:57 PM, revealed the resident's urine sample was collected on 07/27/2025 at 7:00 PM and was received by the lab on 07/29/2025 at 8:52 AM. The Lab Results Report revealed the urine culture yielded over 100,000 CFUs /ml of proteus mirabilis.Resident #58's Order Recap Report for the timeframe from 09/01/2024 through 09/30/2025, revealed an order dated 07/31/2025 with a start date of 08/01/2025, for amoxicillin and potassium clavulanate oral tablet 500 - 125 mg with instructions to give once in the morning for seven days related to a UTI.During an interview on 09/24/2025 at 2:08 PM, LPN #8 stated that for a resident with a suspected UTI, the nurse checked their vitals, assessed the resident's urine for foul odor, documented their findings, and informed the supervisor. LPN #8 stated nursing typically conducted a urine dip test for leukocytes and nitrites if they suspected a UTI. She stated that if the first dip test was positive, they obtained a second dip test within 24 hours and did an infection screening. LPN #8 stated after a second urine sample evaluated revealed a positive result, they obtained a third specimen to send to an outside laboratory to complete culture and sensitivity testing. She stated nursing did not usually obtain a urine sample to be sent to the laboratory prior to evaluating the second urine sample via dipstick method. LPN #8 stated that if everything went smoothly, the interval between the start of symptoms and start of treatment should be three to four days maximum. She stated the laboratory company could do a urinalysis on the weekends, but the culture and sensitivity could not be done on weekends. She stated that she had a situation arise where a sample needed to be obtained, but staff did not collect one because the lab would not run it on the weekend. LPN #8 stated Resident #58 experienced a delay in treatment from 10/21/2024 to 10/31/2024. She stated the resident should not have had the delay. LPN #8 stated Resident #58 also experienced a severe delay in treatment on the dates of 07/25/2025 - 08/01/2025 when the resident went six days without treatment. She stated that sometimes the laboratory returned a sample if there were multiple bacteria growing due to the laboratory evaluating the sample to be contaminated, but when that happened the next sample should be sent out that same day or the next at the most. She stated that there should not have been a four-day delay between the first sample being reported as contamination and the second sample being collected and received. During an interview on 09/25/2025 at 8:45 AM, LPN #11 stated that if a resident had a suspected UTI, the facility obtained a urine specimen to test via the dipstick method to evaluate the resident's urine for leukocytes and nitrites. She stated that they notified the supervisors of the results. She stated that if the test results were positive for leukocytes and nitrites, the facility encouraged fluids for 24 hours and then obtained a urine sample to perform a second test via the dipstick method in 24 hours. She stated that if the second specimen test results were positive, the facility ordered a specimen to be sent to the laboratory for a culture and sensitivity test to be performed to determine which antibiotic was appropriate to treat the infection. LPN #11 stated the floor nurses did not notify the doctors; only the supervisors contacted the medical provider. She stated that she was not sure why two positive tests via the dipstick method were required, but it was facility policy. She stated that once a sample went to the laboratory, results were returned within 24 - 48 hours. She stated a sample taken on a Sunday night would not have been sent until Monday morning. LPN #11 stated they may send the specimen to the laboratory STAT (statim, immediately) if the resident were declining, but ordinarily, if the second urinalysis dipstick was positive on a Friday, it could be the whole weekend before a sample for a culture and sensitivity was sent out to the lab. LPN #11 stated she was not sure what caused the delay in treatment for Resident #58 when the resident went from 10/21/2024 to 10/31/2024 before treatment was initiated. LPN #8 stated Resident #58's should not have experienced a delay in treatment on the dates of 07/25/2025 - 08/01/2025.During an interview on 09/25/2025 at 10:35 AM, RN #6 stated that when a resident has symptoms and nursing staff suspected a UTI, the facility obtained a urine specimen to evaluate for leukocytes and nitrites. RN #6 stated that once they have the result, the physician should be notified, and nursing staff pushed fluids. RN #6 stated the facility then collected a second sample to evaluate via the dipstick method, and the physician should again be notified. RN #6 stated treatment could not be started until the laboratory provided the results of the culture and sensitivity to the facility, which took approximately 48 hours. She stated that the urine culture could be performed on the weekends if the facility made it a STAT pickup. During a follow-up interview on 09/25/2025 at 11:25 AM, RN #6 acknowledged that Resident #58 had a delay in treatment from 10/21/2025 to 10/31/2025 and she stated another urine sample should have been sent back to the laboratory immediately when the first sample was reported to have a possible contamination. She stated she was not sure why that did not occur. RN #6 stated Resident #58's delay in treatment from 07/25/2025 to 08/01/2025 was however likely caused because the laboratory did not pick up the sample until 07/29/2025, which was a Tuesday. RN #6 stated this occurred if no one from the laboratory picked up the sample from the facility on Monday, 07/28/2025. She stated the laboratory was supposed to pick up samples daily from Mondays through Fridays. She stated that if the laboratory did not come to the facility to pick up laboratory specimens, the facility would be able to transport the specimen to the laboratory if they realized it was not collected in time. During an interview on 09/24/2024 at 1:25 PM, RN #13 stated that the facility did not send out to the lab a urine sample for suspected UTIs until two urine samples were collected and evaluated via the dipstick method and resulted with the sample containing leukocytes and nitrites. She stated the time from the start of a resident's symptoms until treatment should be three days. She stated the residents were to be monitored for symptoms, and if there were changes in the resident, more information should be sent to the doctor. RN #13 stated she was not sure why Resident #58 experienced a delay in treatment from 10/21/2024 to 10/31/2024 and she was uncertain why another urine specimen was not collected until 10/28/2025. RN #13 stated that the specimen should have been collected, and the facility should have received the results no later than 10/25/2024. RN #13 stated Resident #58 should not have experienced a delay in treatment from 07/25/2025 until 08/01/2025; she stated she was not sure why there was a two-day gap between the collection date and the received date. During a telephone interview on 09/25/2025 at 2:13 PM, the Medical Director stated that the facility does not send out a urine sample for a suspected UTI until two samples were evaluated via dip stick method and were determined to have positive results. She stated this was a good idea, and the facility has been utilizing this practice for the last seven years. The Medical Director stated that if a resident deteriorated while waiting for laboratory results, the facility could notify the provider to discuss what actions to take. She stated she did not remember Resident #58's delay in treatment on 07/25/2025 - 08/01/2025. The Medical Director stated laboratories were notoriously bad with how they operated. She stated she was not aware of any delay in treatment for Resident #58 from 10/21/2024 until 10/31/2024. During a telephone interview on 09/25/2025 at 2:46 PM, RN #7 stated that the facility required two positive urinalysis dipsticks for a resident with a suspected UTI before a sample was sent out. RN #7 stated there was a four-day period from start of symptoms to start of treatment. RN #7 stated the facility could not STAT out laboratory samples on the weekend. RN #7 stated they could send the sample to the hospital, but the hospital would not provide a culture and sensitivity result for that specimen. During a follow-up telephone interview on 09/25/2025 at 3:27 PM, RN #7 stated she did not know why the laboratory could not be sent out on the weekend or why Resident #58 had a delay in treatment from 10/21/2024 until 10/31/2024. RN #7 stated Resident #58's delay in treatment on 07/25/2025 - 08/01/2025 was longer than she expected. She stated there were a few days in July (2025) when laboratory staff did not pick up labs on Mondays, and she had to reschedule them to be transported the next day. She stated that occasionally, she drove the sample over to the laboratory. During an interview on 09/26/2025 at 8:17 AM, the Director of Nursing (DON) stated the reason the facility obtained two urine specimens to be tested via the dipstick method, pushing fluids between, before obtaining a culture and sensitivity test was because the Medical Director believed that sometimes the bacteria was located on the exterior portion of the urinary tract so if they encourage fluids and try to flush out the bacteria, sometimes the facility could treat the residents symptoms with fluids. She stated that after providing fluids, the second urine sample resulted as a negative 50% of the time. The DON stated Resident #58's experienced a delay in treatment from 10/21/2024 until 10/31/2024 because around October 2024, the laboratory was only transporting specimens from the facility twice a week. The DON confirmed that routine labs were supposed to be picked up daily on Mondays through Fridays, according to the lab services contract. During an interview on 09/26/2025 at 9:47 AM, the Executive Director (ED) stated that if the second urinalysis dipstick was positive for a resident with symptoms of a UTI, the facility collected a urine sample and sent it to the laboratory within 24 hours for a culture and sensitivity test. The ED stated they had issues getting laboratory services on the weekends, but that had been improving. The ED stated she thought the delay in treatment from 10/21/2024 to 10/31/2024 was caused when the laboratory did not pick up a sample that was scheduled. The ED stated they are supposed to pick up laboratory samples daily on Mondays through Fridays. The ED stated she was not sure what caused a delay in treatment from 07/25/2025 to 08/01/2025 for Resident #58; she stated treatment should have started before the resident was symptomatic for seven days.2. An admission Record revealed the facility admitted Resident #76 on 10/15/2013. According to the admission Record, the resident had a medical history that included a diagnosis of personal history of urinary tract infections (infection of the kidneys, ureters, bladder, or urethra). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2025, revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on staff for toileting hygiene and was always incontinent of bowel and bladder. Resident #76's Care Plan Report, included a focus area revised on 09/03/2024, that indicated the resident had an activity of daily living (ADL) self-care performance deficit related to a history of amputation of the resident's toes on the left foot and left arm below the elbow, pain, and activity intolerance. Interventions directed staff to provide assistance of one to two staff members to help with toileting, brief changes, and incontinence care. Resident #76's nursing Progress Notes, dated 08/12/2025 at 9:32 AM, revealed Resident #76 experienced hallucinations, facial flushing (redness of the skin due to increase blood flow to the area), and had foul smelling and dark colored urine which contained mucous. The Progress Note further indicated that the resident complained of burning during urination and showed facial grimacing during assessment using palpation (touch) of Resident 76's abdomen. The Progress Notes indicated that the Nurse Practitioner (NP) was made aware of Resident #76's symptoms. Resident #76's nursing Progress Notes, dated 08/12/2025 at 1:58 PM, indicated Resident #76 was seen by the NP and staff were instructed to obtain a (brand name) urinalysis dipstick. Resident #76's nursing Progress Notes, dated 08/12/2025 at 6:06 PM, indicated Resident #76's urinalysis dipstick test results indicated the resident's urine sample was positive for leukocytes (a white blood cell involved in counteracting foreign substances and diseases) and negative for nitrates. The Progress Notes revealed that the nursing supervisor (Registered Nurse [RN] #7) was notified of the results. Resident #76's nursing Progress Notes, dated 08/13/2025 at 1:30 PM, revealed Resident #76's urine was sampled for a second time with results that indicated a strong positive for leukocytes but remained negative for nitrates. The Progress Notes indicated Resident #76 continued to experience hallucinations causing the resident to believe they had a nail puncturing their (the resident's) skin. The Progress Notes revealed the resident had urine which appeared neon yellow with a green hue containing a large amount of mucous present. The Progress Notes revealed the resident stated that they felt burning during urination. Resident #76's nursing Progress Notes, dated 08/13/2025 at 3:04 PM, revealed an order to collect a urine sample via straight catheter to be sent to the laboratory for evaluation. Resident #76's nursing Progress Notes, dated 08/13/2025 at 4:15 PM, revealed a urine sample was obtained from Resident #76 via straight catheter. The Progress Notes indicated the urine sample contained large amounts of mucous, was foul smelling and appeared yellow in color with a green tinge. A Lab [Laboratory] Results Report, dated 08/15/2025, indicated a specimen was collected on 08/14/2025 at 1:00 AM and was received by the laboratory on 08/14/2025 at 6:58 AM. The Lab Results Report revealed that the lab reported the specimen was mislabeled and another specimen and laboratory requisition were needed to process the requested laboratory testing for Resident #76. The Lab Results Report indicated the facility was notified via fax with the reported time stamped as 08/15/2025 at 5:13 PM. Resident #76's Order Summary Report for the timeframe from 04/01/2025 through 09/30/2025, contained an order dated 08/17/2025 (two days after being notified by the lab of the mislabeled specimen) to obtain a urinalysis with culture and sensitivity for possible UTI. The Order Summary Report revealed an order dated 08/18/2025 to obtain a urine sample via straight catheter and place in the refrigerator for pickup by the lab. Resident #76's nursing Progress Notes, dated 08/18/2025 at 6:10 AM, revealed Resident #76 had combative behaviors throughout the shift and staff were unable to obtain the urine specimen due to the resident hitting and kicking all staff involved with the resident's care. Resident #76's nursing Progress Notes, dated 08/18/2025 at 6:18 PM, revealed a urine specimen was obtained from Resident #76 via straight catheter. The Progress Notes revealed the sample contained yellow urine with a large amount of sediment and had a foul odor. Resident #76's Lab Results Report, dated 08/22/2025, indicated a urine specimen was collected on 08/19/2025 at 1:00 AM and was received by the laboratory on 08/19/2025 at 7:28 AM. The Lab Results Report revealed the results were provided to the facility on [DATE]. The Lab Results Report revealed Resident #76's urine sample was extra turbid in clarity, positive for the presence of blood, protein, nitrates, and contained 4+ leukocytes (reference range indicated these items should be negative). The Lab Results Report revealed that the culture results indicated that Resident #76's urine sample contained greater than 100,000 colony forming units per milliliter (CFU/ml) of Citrobacter Koseri (a bacteria found in the gastrointestinal tract). During an interview on 09/24/2025 at 3:45 PM, Licensed Practical Nurse (LPN) #4 stated when a resident exhibited symptoms of a UTI, a urine sample would be collected and tested by facility staff via a dipstick method. LPN #4 stated that when the resident's urine was positive for both leukocytes and nitrites, the urine would be tested a second time after 24 hours. LPN #4 stated when the resident's urine was positive for both leukocytes and nitrites, they would encourage the resident to drink more fluids and notify the resident's physician. LPN #4 stated that when the second urine test was positive for leukocytes and nitrites, a urine sample would be collected to send to the lab for a urinalysis and culture and sensitivity. LPN #4 stated it would typically take one to two days to get results from the laboratory. During an interview on 09/25/2025 at 9:32 AM, RN #5 stated when a resident was showing signs of a UTI such as burning urination, flank pain, increased frequency, new incontinence, or blood in the urine, they would let the nursing supervisor know and collect a urine sample for testing. RN #5 stated they notified RN #7 of the resident's test results and re-tested the urine in 24 hours. RN #5 stated depending on the results of the second urine test, the nursing supervisor would notify the resident's physician, and a specimen would be sent to the laboratory for testing based on what orders the physician's provided. RN #5 stated the laboratory usually picked up specimens sometime between 5:00 AM and 9:00 AM unless it is ordered STAT (statim, immediately), which they would not be able to do for a culture and sensitivity test. RN #5 stated she spoke with Medical Doctor (MD) #2 a couple of weeks ago, who had a concern related to the amount of time that passed between a resident experiencing symptoms and the time the resident was treated, but she could not remember who the resident was. RN #5 stated she did not think residents should have to wait that long for treatment of UTI symptoms because it was important to treat the infection before it got too bad. During an interview on 09/25/2025 at 10:35 AM, RN #6 stated when staff reported a resident was having symptoms of a UTI, they would conduct a nursing assessment and obtain a urine sample to evaluate via the dipstick method. RN #6 stated when the resident's urine sample was positive for leukocytes and/or nitrites, the resident's physician would be notified, and the facility would encourage the resident to drink more fluids. RN #6 stated another sample would be collected and evaluated 24 hours after the initial test, and the results would be communicated to the resident's physician, who would determine the next steps in the process. RN #6 stated it would be up to the physician to determine when lab work would need to be sent to the laboratory. RN #6 stated the facility's antibiotic stewardship program required the resident's urine to be evaluated twice and was based on McGeer's criteria. RN #6 reviewed McGeer's criteria related to UTI's and could not find any information related to a requirement to evaluate a resident's urine multiple times. RN #6 stated that when a urine specimen was sent out to the laboratory, it took two to three days to get results. RN #6 stated the facility was allowed to request a urinalysis with culture and sensitivity be performed STAT if the facility notified the laboratory it needed to be picked up. RN #6 stated there had been occasions on the weekends when facility staff would transport specimens to the laboratory for testing. RN #6 stated when a sample was mislabeled, she would expect an order for a new specimen to be obtained within 24 hours, and she would expect nursing staff to document all attempts to collect a specimen from a resident. During a telephone interview on 09/25/2025 at 2:46 PM, RN #7 stated when a resident was experiencing symptoms of having a UTI, the resident's urine would be collected and evaluated to assess for presence of leukocytes and nitrites. RN #7 stated the facility staff would encourage the resident to drink more fluids and collect another sample for repeat testing in 24 hours to determine a true positive. RN #7 stated that when the resident's urine tested positive a second time, a third urine sample would be collected and sent to the laboratory to perform a urinalysis and culture and sensitivity. RN #7 stated when the facility received the results of the urinalysis and culture and sensitivity, the results were sent to the resident's physician, and they would start the resident on an antibiotic when ordered by the provider. RN #7 stated from the time symptoms began to the time the resident was treated should only be about four days. RN #7 stated the laboratory was not open on weekends, so there was sometimes a delay because the specimens had to be sent to a nearby hospital for testing and the laboratory did not process them correctly. RN #7 stated that when the laboratory rejected a sample for any reason, she would transcribe another order in the resident's medical record to obtain another sample, which might be a 24-hour delay. RN #7 stated she was familiar with Resident #76 and stated the period of then the resident's urine specimen was rejected to the time it was recollected again was a really long delay. RN #7 stated she did not know why there was such a delay, but Resident #76's specimen should have been collected on 08/15/2025 which was the day the specimen was rejected. During an interview on 09/26/2025 at 8:17 AM, the Director of Nursing (DON) stated that when a resident had a suspected UTI, the nurse would assess the resident, complete a screening evaluation, and try to obtain a urine sample to evaluate. The DON stated that when the resident's urine sample was positive for leukocytes, the resident would be encouraged to drink fluids and the resident's urine would be collected and evaluated again in 24 hours. The DON stated that when the second urine sample was positive, the resident's physician would be notified, and staff would obtain an order for a urine sample to be collected and sent to the outside laboratory for evaluation. The DON stated she expected nursing staff to notify the resident's physician following the first urine test because when the resident was also having other symptoms, the provider could prescribe a broad-spectrum antibiotic when needed. The DON stated treatment for a UTI could take four or five days based on when nursing staff was able to obtain the specimen. The DON stated the facility was aware that transportation of specimens was difficult, and, in the past, the facility staff drove specimens over to the laboratory to get the testing completed faster. The DON stated the facility also had difficulty getting laboratory testing completed at the local hospital because in the past, the laboratory failed to complete the requested culture and sensitivity from the urine sample. The DON stated the facility was unable to get urine specimens to the laboratory for STAT processing. The DON stated that when a sample was rejected by the laboratory, she expected another specimen to be collected immediately. The DON stated Resident #76's urine specimen was not collected until Monday, 08/18/2025, because the laboratory did not pick up specimens on the weekend. The DON stated the facility staff chose to wait because it was the lesser of two evils. During a telephone interview on 09/24/2025 at 11:13 AM, MD #2 stated he expressed concerns to facility administration that when a resident was showing symptoms of a UTI, the facility collected multiple urine tests before a urine sample could be collected to be sent to the laboratory to perform a urinalysis with culture and sensitivity. He stated this practice delayed treatment to residents who were symptomatic of a UTI. During a telephone interview on 09/25/2025 at 2:21 PM, the facility's Medical Director stated when a resident was presenting with signs and symptoms of a UTI, she would expect facility staff to evaluate the resident's urine and assess for any symptoms. The Medical Director stated that when the resident's urine was positive, her understanding was that the facility required an additional sample to be evaluated the following day for confirmation. The Medical Director stated the facility had a protocol, but she was not sure what it was because she did not have the protocol in front of her. The Medical Director stated she would expect the facility staff to notify her when the resident refused to provide a specimen for lab or when there was any issue with collecting a specimen to send to the lab. The Medical Director stated when the lab rejected a specimen sample for any reason, she would expect the nursing staff to collect another sample pretty quickly. The Medical Director stated laboratories were notoriously bad with how they operated. During an interview on 09/25/2025 at 9:46 AM, the Executive Director (ED) stated that when a resident had a suspected UTI, she expected nursing staff to evaluate the resident's urine and encourage fluids. The ED said, depending on the results from the first testing, a second test of the resident's urine may be completed in 24 hours. The ED stated that depending on the results of the second urine testing, a third specimen would be collected and sent out to the laboratory within 24 hours. The ED stated they had some issues with the laboratory on the weekends, because the laboratory struggled to keep staff at times. The ED stated facility staff transported specimens to the la[TRUNCAT

Based on observation, interview, record review, and facility policy review, the facility failed to implement an effective infection control and prevention program by failing to ensure staff conducted hand hygiene during 1 of 3 meal services observed, affecting 2 (Residents #38 and #76). Findings included:A facility policy titled, Infection Control Plan/Program, last revised in 03/2025, revealed It is the policy of the community to establish guidelines to follow to facilitate maintaining a safe, sanitary and comfortable environment; to proactively prevent and manage transmission of diseases and infections; to identify, reduce, control or prevent the risks of acquiring and transmitting infections among elders, employees, volunteers, visitors, and others; to investigate through surveillance to prevent infections in the facility; and to provide on-going elder and care partner education on infection control policies and procedures. The policy also revealed, Hand hygiene policies will be followed by all employees and volunteer workers. An undated facility policy titled, Hand Washing/Hand Hygiene revealed, Handwashing and use of hand sanitizer shall be regarded by this organization as the most important means of preventing the spread of infection. The policy also revealed a section titled, Policy Interpretation and Implementation that specified, 1. All personnel shall follow our established hand washing and use of hand sanitizer procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. Handwashing facilities will be readily available in laundry, dietary, resident rooms, utility rooms, and medication rooms and 2. Appropriate thirty15-20 [sic] second handwashing must be performed under the following conditions: h. After handling items potentially contaminated with blood, body fluids, excretions, or secretions. An admission Record revealed the facility admitted Resident #38 to the facility on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of moderate unspecified dementia with other behavioral disturbance and oral phase dysphagia (difficulty in the oral phase of swallowing). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/18/2025, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff assistance for eating. An admission Record revealed the facility admitted Resident #76 to the facility on [DATE] with a recent readmission on [DATE]. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus with diabetic neuropathy (complication of diabetes that damaged the nerves). A quarterly MDS, with an ARD of 09/18/2025, revealed Resident #76 had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required setup or clean-up assistance for eating. An observation of a dining room on 09/22/2025 at 9:36 AM revealed Resident #38 and Resident #76 were seated in their wheelchairs at a table. Registered Nurse (RN) #12 began to assist Resident #38 with their meal. RN #12 stopped assisting Resident #38 to cut up food for Resident #76 using Resident #76's cutlery, then returned to the table to resume assisting Resident #38 to eat. During the observation, RN #12 was not observed performing hand hygiene after feeding Resident #38 and before touching Resident #76's cutlery. During a telephone interview on 09/26/2025 at 12:53 PM, RN #12 stated she was taught to perform hand hygiene in between resident contact, before feeding a resident, and before touching resident food items. RN #12 stated she did not complete hand hygiene during the observation in the dining room on 09/22/2025 at 9:36 AM because she did not know she touched anything that required her to perform hand hygiene. During an interview on 09/26/2025 at 12:55 PM, the Director of Nursing (DON) stated she expected staff to perform hand hygiene after touching anything dirty and before serving food to a resident. The DON stated she would have expected RN #12 to perform hand hygiene between assisting multiple residents in the dining room. During an interview on 09/26/2025 at 12:55 PM, the Administrator (ADM) stated she expected staff to perform hand hygiene between tasks in the dining room and between assisting more than one resident with dining.

Based on interview, record review, and facility policy review, the facility failed to ensure staff provided timely and appropriate treatment and services related to urinary tract infections (UTIs) for symptomatic residents. Specifically, the facility failed to initiate antibiotic therapy prescribed by a medical provider for 2 (Resident #76 and Resident #84) of 5 residents reviewed for urinary tract infections. Findings included:An undated facility policy titled, Corporate Compliance Standards of Conduct-Physician Orders, revealed, All care provided to residents of [facility name] must be based on written, dated and signed orders from a licensed physician or other authorized healthcare provider such as certified nurse practitioner. The policy also revealed, Orders shall be entered into the resident's medical record within a clinically appropriate period. STAT [statim, immediate] order shall be prioritized and documented accordingly. A facility policy titled, Diagnostic Services, revised 05/2020, revealed a section titled, Policy Interpretation and Implementation, specified, 2. Radiologic and other diagnostic services, including pathology and clinical laboratory services, are available 24 hours a day, seven days a week. The policy revealed a section titled, Urinary Culture Policy, that specified, 1. Urine cultures will only be ordered when clinical indications meet McGreer's criteria for urinary tract surveillance. Routine or screening of urine cultures in asymptomatic individuals are not permitted. The policy also revealed a section titled, Procedure, that specified, 1. Nursing staff must document signs/symptoms and notify the provider. Nursing staff must complete the infection screening evaluation to ensure criteria are met. 2. A [brand name urine reagent strip] shall be performed and reported to the medical director and documented in the resident's chart. A [brand name urine reagent strip] is considered positive if both leukocytes and nitrites are present. 3. Staff will encourage fluids for 24 hours and then complete a second [brand name urine reagent strip]. Results and resident symptoms are reported to the provider. 4. Providers must verify that McGeer's criteria are met before ordering a urine culture. Providers will await the final urine culture and sensitivity before prescribing an antibiotic. 5. Providers can choose to prescribe a broad-spectrum antibiotic at their discretion if severe symptoms (i.e. [id est, that is], fever, leukocytosis, dysuria, flank pain, change in physical ability, etc. [et cetera, and so forth]) are present. A facility policy titled, Antibiotic Stewardship Policy and Procedures, revised 06/13/2023, revealed a section titled, Community Actions, specified, 1. All antibiotic orders will come with the following: a. A specific prescribing order with dose and duration; b. A progress note explaining the reason for the antibiotic; c. If other treatment (example: COVID19) is to coincide with the antibiotic treatment, the Medical Director will verify the reason for the antibiotic prior to beginning the treatment; d. If a culture and sensitivity is performed and results are obtained, a re-evaluation will be undertaken to ensure proper spectrum coverage, e. For those orders that may not follow the standards of practice for prescribing antibiotics, they will be referred to the Director of Nursing for [facility name] for review and recommendations. 1. An admission Record revealed the facility admitted Resident #76 on 10/15/2013 and readmitted the resident on 10/10/2017. According to the admission Record, the resident had a medical history that included a diagnosis of personal history of urinary (tract) infections (infection of the kidneys, ureters, bladder, or urethra). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2025, revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderately impaired cognition. The MDS indicated the resident was always incontinent with bowel and bladder. The MDS revealed the resident was dependent on staff for toileting hygiene and toilet transfers. Resident #76's Care Plan Report, included a focus area revised on 09/03/2024, that indicated the resident had an activity of daily living (ADL) self-care performance deficit related to a history of amputation of the residents' toes on the left foot and left arm below the elbow, pain, and activity intolerance. Interventions directed staff to provide assistance from one to two staff members to help with toileting, brief changes, and incontinence care. Resident #76's nursing Progress Notes, dated 08/12/2025 at 9:32 AM, revealed Resident #76 experienced hallucinations, facial flushing (redness of the skin due to increase blood flow to the area), and had foul smelling and dark colored urine which contained mucous. The Progress Notes further indicated that the resident complained of burning during urination and showed facial grimacing during assessment using palpation (touch) of Resident #76's abdomen. The Progress Notes indicated that the Nurse Practitioner (NP) was made aware of Resident #76's symptoms. Resident #76's nursing Progress Notes, dated 08/12/2025 at 1:58 PM, indicated Resident #76 was seen by the NP and staff were instructed to obtain a (brand name) urinalysis dipstick. An Infection Screening Evaluation, dated 08/12/2025, indicated Resident #76 had acute dysuria and abdominal pain or tenderness. The Infection Screening Evaluation revealed a section titled, Infection Analysis, that indicated a Loeb's Criteria: Suspected UTI (SUTI) and McGreer's Criteria: Suspected UTI without indwelling catheter assessments were triggered. The Infection Screening Evaluation further revealed that the evaluation manually triggered a case to the IPC (Infection Prevention Consultant). Resident #76's nursing Progress Notes, dated 08/12/2025 at 6:06 PM, indicated Resident #76's urinalysis dipstick test results indicated the resident's urine sample was positive for leukocytes (a white blood cell involved in counteracting foreign substances and diseases) and negative for nitrates. The Progress Notes revealed that the nursing supervisor (Registered Nurse [RN] #7) was notified of the results. Resident #76's nursing Progress Notes, dated 08/13/2025 at 1:30 PM, revealed Resident #76's urine was sampled for a second time with results that indicated a strong positive for leukocytes but remained negative for nitrates. The Progress Notes indicated Resident #76 continued to experience hallucinations causing the resident to believe they had a nail puncturing their (the resident's) skin. The Progress Notes revealed the resident had urine which appeared neon yellow with a green hue containing a large amount of mucous present. The Progress Notes revealed the resident stated that they felt burning during urination. Resident #76's nursing Progress Notes, dated 08/13/2025 at 3:04 PM, revealed an order to collect a urine sample via straight catheter to be sent to the laboratory for evaluation. Resident #76's nursing Progress Notes, dated 08/13/2025 at 4:15 PM, revealed a urine sample was obtained from Resident #76 via straight catheter. The Progress Notes indicated the urine sample contained large amounts of mucous, was foul smelling and appeared yellow in color with a green tinge. A Lab [Laboratory] Results Report, dated 08/15/2025, indicated a specimen was collected on 08/14/2025 at 1:00 AM and was received by the laboratory on 08/14/2025 at 6:58 AM. The Lab Results Report revealed that the lab reported the specimen was mislabeled and another specimen and laboratory requisition were needed to process the requested laboratory testing for Resident #76. The Lab Results Report indicated the facility was notified via fax with the reported time stamped as 08/15/2025 at 5:13 PM. Resident #76's Order Summary Report for the timeframe from 04/01/2025 through 09/30/2025, contained an order dated 08/17/2025 (two days after being notified by the lab of the mislabeled specimen) to obtain a urinalysis with culture and sensitivity for possible UTI. The Order Summary Report revealed an order dated 08/18/2025 to obtain a urine sample via straight catheter and place in the refrigerator for pickup by the lab. Resident #76's nursing Progress Notes, dated 08/18/2025 at 6:10 AM, revealed Resident #76 had combative behaviors throughout the shift and staff were unable to obtain the urine specimen due to the resident hitting and kicking all staff involved with the resident's care. Resident #76's nursing Progress Notes, dated 08/18/2025 at 6:18 PM, revealed a urine specimen was obtained from Resident #76 via straight catheter. The Progress Notes revealed the sample contained yellow urine with a large amount of sediment and had a foul odor. Resident #76's Lab Results Report, dated 08/22/2025, indicated a urine specimen was collected on 08/19/2025 at 1:00 AM and was received by the laboratory on 08/19/2025 at 7:28 AM. The Lab Results Report revealed the results were provided to the facility on [DATE]. The Lab Results Report revealed Resident #76's urine sample was extra turbid in clarity, positive for the presence of blood, protein, nitrates, and contained 4+ leukocytes (reference range indicated these items should be negative). The Lab Results Report revealed that the culture results indicated that Resident #76's urine sample contained greater than 100,000 colony forming units per milliliter (CFU/ml) of Citrobacter Koseri (a bacteria found in the gastrointestinal tract). Resident #76's nursing Progress Notes, dated 08/22/2025 at 11:18 AM, revealed Resident #76 continued to have the presence of cloudy urine and was experiencing increased lethargy and needed additional assistance by staff with meals. Resident #76's Order Summary Report for the timeframe from 04/01/2025 through 09/30/2025, contained an order with a start date of 08/22/2025 and end date of 08/29/2025, for levofloxacin tablet (an antibiotic) 500 milligrams (mg) with instructions to give one tablet by mouth every night shift for UTI for seven days. The Order Summary Report revealed an order with a start date of 08/23/2025 and end date of 08/30/2025 for Augmentin oral tablet (an antibiotic) 500-125 mg with instructions to give one tablet by mouth two times a day for acute UTI for seven days. Resident #76's nursing Progress Notes, dated 08/26/2026 at 3:09 PM, revealed Resident #76 continued to experience cloudy urine with a presence of a strong odor after starting antibiotic therapy. Resident #76's nursing Progress Notes, dated 08/31/2025 at 11:45 AM, revealed Resident #76 continued to have dark colored urine with a foul smell present. Resident #76's physician Progress Notes, dated 09/04/2025, electronically signed by Resident #76's Primary Care Provider (Medical Doctor [MD] #2) revealed Resident #76's primary reason for assessment was recurrent urinary tract infection. The Progress Notes indicated Resident #76 was recently treated with Augmentin therapy that was completed with good clinical response without ill effects reported. The Progress Notes revealed that due to the resident's recurrent urinary tract infection, MD #2 recommended Trimethoprim (an antibiotic) 100 mg by mouth at night for 90 days along with lactobacillus (an oral medication which contains healthy bacteria that aid the gastrointestinal system) two tablets daily while on Trimethoprim therapy. The Progress Notes revealed the Current Medications list included an order for Trimethoprim 100 mg orally once a day for 90 days. Resident #76's nursing Progress Notes, dated 09/05/2025 at 4:59 PM, indicated Resident #76 continued to experience periods of combativeness, decrease appetite with meals, and was resistive to care to include medication administration. Resident #76's nursing Progress Notes, dated 09/09/2025 at 2:32 PM, revealed Resident #76 continued to experience poor oral intake. Resident #76's physician Progress Notes, dated 09/11/2025, electronically signed by MD #2, revealed an examination of the resident completed by MD #2 indicated that Resident #76 had no current complaints of dysuria and was afebrile but was recently prescribed Trimethoprim suppressive oral therapy (on 09/04/2025) and the order had been neglected. Resident #76's nursing Progress Notes, dated 09/11/2025 at 9:09 AM, revealed Resident #76 was seen by MD #2 with recommendations to continue Trimethoprim therapy for UTI prevention. Resident #76's Order Summary Report for the timeframe from 04/01/2025 through 09/30/2025, revealed no order for Trimethoprim 100 mg. Resident #76's Progress Notes for the timeframe from 09/04/2025 through 09/24/2025, revealed no documented explanation why MD #2's order for Trimethoprim for suppressive therapy was not transcribed and followed as prescribed. During an interview on 09/25/2025 at 9:32 AM, RN #5 stated she spoke with MD #2 a couple of weeks prior, and said MD #2 had a concern related to the amount of time that passed between a resident's initial symptoms and the time the resident was treated, but she could not remember who the resident was. RN #5 stated she did not think residents should have to wait that long for treatment of UTI symptoms because it was important to treat the infection before it worsened.During an interview on 09/25/2025 at 10:35 AM, RN #6 stated floor nurses were not allowed to transcribe physician orders into the medical record, and all order transcriptions were delegated to the nurse supervisor. RN #6 was unaware of why MD #2's order for antibiotic therapy for Resident #76 was neglected to be transcribed into the resident's medical record and started. RN #6 stated she expected to see documentation in the resident's medical record to reflect why the order was not followed. During a telephone interview on 09/25/2025 at 2:46 PM, RN #7 stated some providers wrote orders for antibiotic therapy prior to the results of the culture and sensitivity being received, but the facility preferred to wait for the culture and sensitivity results before initiating antibiotic therapy. RN #7 stated if a provider wrote an order for antibiotic therapy to start, and the resident was asymptomatic; she notified the provider that they were going to have to wait to receive the results of the culture and sensitivity. She stated even when a provider continued to provide an order to start an antibiotic, she did not transcribe the order in the resident's medical record because that was not allowed per the facility policy. RN #7 stated she does not document conversations between herself and the providers regarding medication orders that were not transcribed into the medical record because the providers knew the facility policy. RN #7 stated providers gave all orders needing transcription to her when they conducted rounds in the facility. RN #7 stated the facility did not allow residents to be placed on antibiotic suppressive therapy. RN #7 stated she did not notify MD #2 when his order was not transcribed. RN #7 confirmed Resident #76's prophylactic antibiotic therapy was not initiated when the prescriber wrote the order for them to be initiated. RN #7 stated it was the facility's protocol to allow the Director of Nursing (DON) to determine when to transcribe antibiotic orders in the medical record. RN #7 stated although the resident's provider determined the need for a resident to be placed on antibiotic therapy, she could not transcribe the orders because she had to follow the facility protocol. During a follow up interview on 10/09/2025 at 2:48 PM, RN #7 stated she printed out the lab requisition and the nurse obtained the urine sample and completed the label for the specimen. She stated LPN #8 completed the label for Resident #76 on 08/13/2025. She stated that when the lab results were unable to be processed for Resident #76, she did not contact or question the lab to determine how the specimen had been mislabeled because the lab no longer had the urine specimen to be processed. She said she provided education to the nursing staff related to labeling at the time. During a follow up interview on 10/09/2025 at 3:10 PM, RN #7 stated facility nurses could not obtain Resident #76's urine specimen on 08/18/2025 due to the resident's combative behavior. She stated the physician should have been notified of the delay in obtaining the urine specimen and of Resident #76's combative behavior; however, she did not see any documentation of notification to the doctor. RN #7 stated there was only one person that had documented the resident's behaviors and lethargy, which made it difficult to put the story together to determine what care was provided to Resident #76. She stated she did not know if Resident #76's symptoms continued following the treatment for the UTI because there was limited documentation. She stated that if the symptoms continued, the nurses were to document any symptoms and notify her. During a follow up interview on 10/09/2025 at 3:34 PM, RN #7 stated normally the facility does not allow orders for prophylactic antibiotics, and she normally took any prophylaxis orders to the DON before transcribing the order into the medical record. She stated she did not notify the physician when the antibiotics were not initiated. During an interview on 09/26/2025 at 8:17 AM, the DON stated that when a resident had a suspected UTI, the nurse assessed the resident, complete a screening evaluation, and obtain a urine sample to test. The DON stated if the resident's urine sample were positive for leukocytes, the resident's provider was notified, and the resident was encouraged to drink fluids. The DON stated another sample of the resident's urine was obtained for a second test in 24 hours. The DON stated if a second urine sample was abnormal, the resident's physician was notified, and the facility obtained an order for another urine sample to be collected and sent to the laboratory for testing. The DON stated she expected nursing staff to notify the resident's physician with results identified from each urine test and when the resident was also having other symptoms. The DON stated that the provider was then permitted to prescribe a broad-spectrum antibiotic, if needed. The DON stated provider orders were communicated via fax, email, and sometimes verbally to the nursing supervisor, who was responsible for transcribing all orders into the medical record. The DON stated if there were concerns with a provider's order, the prescribing provider was notified, and she expected the nursing supervisor to document discussions with the providers in the medical record. The DON stated she expected the facility staff not to ignore the provider's orders and stated, she would like to think we don't purposely ignore orders. The DON stated sometimes the provider was notified if the facility felt the medication was contraindicated, but these discussions were required to be documented in the resident's record. The DON reviewed Resident #76's Progress Notes, dated 09/11/2025 written by MD #2. The DON stated that the nursing supervisor was not allowed to make the decision not to follow the physician's order and could not choose to not transcribe the order. The DON stated discussion with the provider was needed for all orders that went against the facility's policy. She stated she still expected to see documentation in the resident's record as to why the order was not followed. During a follow up interview on 10/11/2025 at 5:16 PM, the DON stated her expectation was that she would like to see the whole timeline shortened from the urinalysis dipsticks to the start of the antibiotics if appropriate. During a telephone interview on 10/09/2025 at 5:07 PM, the NP stated she last saw Resident #76 on 08/12/2025. She stated she was not notified about the delay in obtaining Resident #76's lab nor the resident's behavioral symptoms and lethargy. The NP stated she attempts to order a urine specimen and start a resident on antibiotics quickly and then once we get a culture and sensitivity, we will change the antibiotic if necessary. She stated that the facility's unwillingness to follow provider orders for antibiotics has been a frequent problem at this facility. She stated when she saw Resident #76 on 09/04/2025 the antibiotic orders never got put in and then on 09/11/2025 MD #2's order for the antibiotic was never put in. She stated she saw Resident #76 this past Tuesday (10/07/2025) and the staff told her the resident's urine looked awful, and she ordered a urinalysis and culture and sensitivity laboratory test and then the resident was admitted to hospice services. She stated the facilities program that required two urine specimens to be evaluated by dipstick method in-house prior to sending a specimen to the laboratory to perform a urinalysis with culture and sensitivity was the providers struggle in properly caring for the resident's needs.During a telephone interview on 09/24/2025 at 11:13 AM, MD #2 stated he discovered the facility was not following his orders because of the facility protocol which caused residents of the facility to wait at least 72 hours after being symptomatic before being treated for the resident's UTI signs and symptoms. MD #2 stated that when a resident experienced symptoms of a UTI, he learned the facility's normal practice was to collect a urine sample and assess the urine using a dipstick method. MD #2 stated if the testing indicated the sample was positive, the urine was evaluated two to three more times 24 hours apart before a urine specimen was obtained and sent to a laboratory to determine the results for an ordered urinalysis and culture and sensitivity. MD #2 stated he had written orders for urinalysis with culture and sensitivity labs to be obtained when a resident was displaying signs and symptoms of a UTI, but dipstick urines were obtained instead because that was the facility's protocol. MD #2 stated he was told by RN #7 they could not start a resident on an antibiotic until the culture and sensitivity came back due to the facility's protocol. MD #2 stated following his visit to the facility, he expressed his concerns to the facility's DON and Executive Director (ED) via an email but received no response. MD #2 stated he reached out to the facility's Medical Director, but nothing was changed. MD #2 stated the facility's nursing staff needed to contact him and discuss concerns with medication if they were not going to transcribe and follow the physician's orders he provided. MD #2 stated he attempted to start Resident #76 on suppressive antibiotic therapy due to recurrent UTI infections, but RN #7 never transcribed the orders, and the resident was not started on the medication. MD #2 stated he discovered the resident was never started on the therapy because the DON felt that the facility could not allow a prophylactic antibiotic to be prescribed. MD #2 stated he was very familiar with Resident #76 and had been seeing the resident for years. MD #2 stated he no longer practiced medicine at the facility because the facility refused to follow his orders. During a follow up telephone interview on 10/10/2025 at 1:40 PM, MD #2 stated he assessed Resident #76 on 09/04/2025 and dictated in his notes that the resident had recently completed treatment with antibiotics for recurrent UTI with good response and stated he recommended suppressive therapy for 90 days. He stated he was not notified when the facility was not able to obtain the requested urine specimens nor when Resident #76's urine sample was mislabeled and required recollection. He stated, That is horrible! MD #2 stated had he been notified, he could have ordered the resident needed antibiotics; however, the resident would not have received them due to the facility saying, they needed the results first. He stated he was not notified that the facility did not have laboratory pick up on the weekends. He stated his opinion was that the facility put Resident #76 at risk of harm because they do not follow his physician's orders. MD #2 stated this practice placed Resident #76 at risk for septic shock from UTI. During a telephone interview on 09/25/2025 at 2:21 PM, the facility's Medical Director stated that when a resident presented with signs and symptoms of a UTI, she expected the facility staff to assess the resident's urine and assess for any further symptoms. The Medical Director stated if the resident's urine sample contained abnormalities, I think they dip it again. The Medical Director stated the facility had a protocol, but she was not sure what it was because she did not have the protocol in front of her. The Medical Director stated it was not normal practice to prescribe antibiotics before the results of the culture and sensitivity were received because she did not feel there was a need for it. The Medical Director stated she had no concerns with the facility not following her orders and stated she heard things about staff not following orders from other prescriber's but stated, I'm not privy to what all of the other doctors do. The Medical Director could not state why MD #2's orders were not followed by the facility and stated she did not know what other providers had ordered. During an interview on 09/25/2025 at 9:46 AM, the ED stated that if the prescriber ordered an antibiotic, the order was given to the nursing supervisor for transcription into medical record. The ED stated she was aware of a concern related to prophylactic antibiotic orders which were prescribed by providers not being transcribed into the medical record, but she thought they did not follow the facility's protocol. The ED stated that any issues with orders were to be discussed with the provider and documented. The ED stated it was not appropriate for the nursing supervisor to hold a prescriber's order or choose not to transcribe the order.An Order Summary Report, dated 10/10/2024, revealed an order for Nitrofurantoin Macrocrystal oral capsule 50 mg to be given by mouth at bedtime for recurring UTI for 90 Days, ordered on 07/04/2024 with an end date of 10/02/2024 and that it was completed. During an interview on 10/10/2025 at 4:00 PM, the DON reviewed the medical record and stated the suppressive therapy for Resident #76, Nitrofurantoin 50 mg along with Acidophilus therapy for 90 days in July of 2024 was administered as ordered. During an interview on 10/10/2025 at 5:18 PM, the ED confirmed that the antibiotic stewardship program for the facility had not changed since 2024. She stated she did not know why Resident #76 had suppressive therapy before and not now. She stated it was still the physician's determination of what he orders to be administered to the resident. During a follow up interview on 10/11/2025 at 5:18 PM, the ED stated her expectations aligned with the DON's expectation.2. An admission Record revealed the facility admitted Resident #84 on 08/26/2025. According to the admission Record, the resident had a medical history that included a diagnosis of overactive bladder (frequent urgency of urination). The admission Record revealed the resident was discharged from the facility on 09/07/2025 after a 12-day admission to the facility. A Medicare 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/30/2025, revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The MDS revealed Resident #84 required partial/moderate assistance with toileting hygiene, toileting transfers, and had occasional bladder incontinence. Resident #84's Care Plan Report, included a focus area initiated on 08/27/2025, that indicated the resident had chronic kidney disease. Interventions directed staff to administer medications as ordered by the physician, monitor changes in mental status, and monitor for signs and symptoms of infection. The Care Plan Report also included a focus area initiated on 09/03/2025 that indicated the resident had mixed bladder incontinence related to active infections with symptoms of UTI, chronic symptomatic infections, and impaired mobility. Interventions directed staff to clean the residents' perineal area with each incontinent episode; monitor/document for signs and symptoms of UTI; and monitor/document/report as needed for any potential causes of incontinence. Resident #84's nursing Progress Notes, dated 08/28/2025 at 12:21 PM, revealed Resident #84 had foul smelling urine. Resident #84's nursing Progress Notes, dated 08/28/2025 at 5:10 PM, revealed Resident #84's urine was cloudy and had a foul odor and RN #7 was notified. Resident #84's nursing Progress Notes, dated 08/29/2025 at 12:21 AM, revealed a urine dipstick specimen was obtained which showed Resident #84's sample appeared cloudy and contained leukocytes and protein and was negative for nitrates. Resident #84 nursing Progress Notes, dated 08/30/2025 at 12:30 AM, revealed Resident #84 had complaints of burning during urination and experienced polyuria (excessive urination) and a second urine sample was obtained from Resident #84's for a dipstick analysis. The Progress Notes indicated Resident #84's urine was cloudy with a strong odor and contained leukocytes and protein. Resident #84's Order Summary Report for the timeframe from 08/01/2025 through 09/30/2025, contained an order dated 08/28/2025 to obtain a (brand name) urine dipstick once. The Order Summary Report revealed an order dated 08/29/2025 to obtain a second (brand name) urine dipstick for possible UTI. The Order Summary Report revealed an order dated 09/02/2025 to obtain a urine specimen via straight catheter and send to the laboratory (lab) for processing of a urinalysis with culture and sensitivity. Resident #84's provider Progress Notes, dated 09/02/2025, electronically signed by the Nurse Practitioner (NP) revealed a section titled, History of Present Illness, that specified, Patient states, I know I have a UTI and the staff took 3 samples already, and, I was taking a maintenance Keflex (a medication used to treat infection) for frequent UTI's and somewhere along the line it was discontinued and now I have a UTI. The Progress Notes revealed Resident #84's treatment plan included orders to obtain a urinalysis with culture and sensitivity and to start ciprofloxacin hydrochloride (HCl) (an antibiotic) 250 milligrams (mg) with instructions to give one tablet by mouth every 12 hours and Lactobacillus. The Progress Notes also indicated there was a need for a follow-up every two to three days as needed due to the complexity of the resident's medical condition. Resident #84's nursing Progress Notes, dated 09/03/2025 at 3:40 PM, revealed a urine specimen was obtained from Resident #84 and placed in the refrigerator to be picked up by the lab. Resident #84's nursing Progress Notes, dated 09/04/2025 at 12:47 AM, revealed Resident #84 complained of burning during urination. The Progress Notes also indicated that the urinalysis was positive, and the culture and sensitivity were pending. Resident #84's Lab Results Report, dated 09/03/2025, revealed a urine specimen was collected on 09/03/2025 at 3:00 AM, received by the laboratory on 09/03/2025 at 8:06 AM, and reported to the facility on [DATE] at 2:55 PM. The Lab Results Report revealed Resident #84's urine was turbid in clarity, positive for nitrates, contained 4+ leukocytes, clumps of white blood cells, and contained 100,000 colony forming units per milliliter (CFU/ml) of Klebsiella Pneumoniae (a bacteria normally found in the gastrointestinal system). Resident #84's provider Progress Notes, dated 09/04/2025, electronically signed by MD #2, revealed the facility requested the provider follow-up on Resident #84's persistent dysuria. The Progress Notes indicated the resident complained of dysuria associated with urinary frequency and was not currently on the antibiotic therapy prescribed by the NP on 09/02/2025 and remained at high-risk for decline due to age and medical complexity. The Progress Notes revealed Resident #84's treatment plan included concerns for the resident's dysuria with notes that indicated Resident #84 was symptomatic with dysuria associated urinary frequency and had an abnormal urinalysis and MD #2 agreed with NP's assessment that Resident #84 should be prescribed an antibiotic and again wrote an order for Resident #84 to receive ciprofloxacin 500 mg with instructions to give one tablet by mouth two times a day for five days. Resident #84's nursing Progress Notes, dated 09/06/2025 at 2:45 [TRUNCATED]

Based on observation, interview, record review, and facility policy review, the facility failed to provide dining services in a dignified manner for 2 (Resident #11 and Resident #38) of 6 residents sampled for dependent dining. Findings included:An undated facility policy titled, Dining/Eating Program, revealed the section titled, Goals, included, 6. Promote resident's self-esteem and dignity. The policy revealed the section titled, Policy Interpretation and Implementation, included, 6. All department heads and supervisors should rotate to the dining area to interact with the residents and assist in serving meals. The nursing assistants and nurses actually do any feeding. This helps provide social interactions for the residents, reinforces teamwork and promotes [facility name]-wide restorative program. The policy revealed, 11. When feeding residents staff attention should be directed to the resident.A facility policy titled, Resident Rights, last reviewed on 07/2025, revealed the section titled, Resident Rights, included, 1. The right to be treated with dignity and respect. An admission Record revealed the facility admitted Resident #11 on 04/28/2025. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and dysphagia. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/01/2025, revealed Resident #11 had severe impairment in cognitive skills for daily decision-making and had a short- and long-term memory problem per a staff assessment of mental status (SAMS). Resident #11's MDS indicated the resident was dependent on staff for eating. Resident #11's Care Plan Report, included a focus area initiated on 04/28/2025, that indicated the resident had an activity of daily living self-care performance deficit related to cognitive and functional deficits. Interventions directed staff to supervise the resident with eating (initiated 04/28/2025).An admission Record revealed the facility admitted Resident #38 on 10/06/2018. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia with other behavioral disturbances and dysphagia. A quarterly MDS with an ARD of 07/18/2025 revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. Resident #38's MDS indicated the resident was dependent on staff for eating.Resident #38's Care Plan Report, included a focus area initiated on 08/27/2024, that indicated the resident had an activity of daily living self-care performance deficits. The focus area indicated that the resident required extensive to total assistance with all activities of daily living. Interventions directed staff to assist the resident as they allowed with eating (revised 08/06/2025).During an observation on 09/22/2025 at 9:36 AM in the unit dining room, Resident #11 and Resident #38 were observed seated in their wheelchairs at a table with three other residents eating at the table. Resident #38 was observed being assisted with their meal by Registered Nurse (RN) #12, who was seated at the end of the table between Resident #11 and Resident #38. Two small bowls of food were observed in front of Resident #11, and no staff were observed assisting Resident #11with eating. During the observation, RN #12 stopped providing feeding assistance to Resident #38, got up from her seat, and retrieved a beverage for another resident, before returning to her seat to resume providing feeding assistance to Resident #38. During the observation, RN #12 stopped providing feeding assistance to Resident #38 again, got up from her seat, and assisted another resident with cutting food, before returning to her seat to resume providing feeding assistance to Resident #38. During that time, Resident #11 was observed with two small bowls of food, and no staff were observed assisting the resident.During an observation on 09/23/2025 at 12:43 PM in the unit dining room, Resident #11 was observed seated in their wheelchair with three other residents eating at a table in the dining room. Two small bowls of pureed food were observed in front of Resident #11. No staff were observed assisting Resident #11 with the meal until 12:51 PM, when Certified Nursing Assistant (CNA) #9 sat down next to the resident and assisted them with eating. At 12:53 PM, Resident #38 was brought into the dining room and sat at the table in their wheelchair with Resident #11 and three other residents. Staff placed two small bowls of pureed food in front of the resident and two beverage cups with lids. Staff members were observed passing food to other residents in the dining room while Resident #38 sat at the table, unassisted by staff. At 1:12 PM, CNA #10 was observed seated next to Resident #38 and assisted the resident with their meal. During an interview on 09/23/2025 at 2:23 PM, CNA #9 stated the unit had two residents who were dependent on staff for eating, Resident #11, and Resident #38. CNA #9 stated the unit usually had two CNA staff at the table with the residents who needed assistance to assist them with the meal and one CNA staff member to serve the food to residents. CNA #9 stated residents were usually served by table, so residents would be served at the same time. CNA #9 stated staff would usually assist Resident #11 and Resident #38 with the meal at the same time as the other residents at the table, so residents were not eating alone. During an interview on 09/25/2025 at 3:43 PM, CNA #10 stated the unit had two residents who required full assistance at meals, Resident #11, and Resident #38. CNA #10 stated neither resident was able to feed themselves, but Resident #38 could, at times, hold and drink out of a cup without assistance. CNA #10 stated they would usually have one staff member sit with either Resident #11 or Resident #38 to start assisting one of them with their meal. CNA #10 stated once another staff member was available, they could assist in feeding the other dependent resident. CNA #10 stated if one of the dependent residents was still chewing their food, they could get up from the table and assist with passing out beverages to the other residents. CNA #10 stated sometimes Resident #11, and Resident #38 would be served last, but they usually served the residents at the same table at the same time, so no residents were left out. CNA #10 stated they would usually try and assist residents with eating as soon as they receive their food. During an interview on 09/25/2025 at 4:01 PM, Licensed Practical Nurse (LPN) #11 stated that the unit had two residents who required assistance with dining, Resident #11, and Resident #38. LPN #11 stated CNA staff usually provided feeding assistance to the residents at the table at the same time, so no residents were left out. LPN #11 stated that sometimes a CNA would provide feeding assistance to either Resident #11 or Resident #38 while the other CNA staff served the other residents in the dining room. LPN #11 said once the other CNA staff finished serving the meal, they would provide feeding assistance to the other resident. LPN #11 stated she would expect staff who were assisting a resident with their meal to keep assisting that resident and refrain from getting up from the service to attend to other needs. LPN #11 stated she would not expect residents to wait more than 10 minutes before being assisted with their meals. During an interview on 09/26/2025 at 7:46 AM, RN #12 stated she would occasionally provide assistance to dependent diners Resident #11 and Resident #38, usually during the breakfast meal. RN #12 stated Resident #38 was dependent on staff for eating but could lift a cup if they needed to. RN #12 stated Resident #11 could not feed themselves and required assistance from staff. RN #12 stated if more than one staff member were available to assist with eating, both residents would be assisted one-to-one. RN #12 stated there were times when she would assist both Resident #11 and Resident #38 at the same time using separate hands. RN #12 stated normally she would sit with the resident during the meal while assisting the resident with eating, but there had been times when she got up to assist other residents in the dining room. RN #12 stated that assisting residents on a one-on-one basis was more pleasant for the residents. She stated starting and stopping during the meal can be hard for the residents. During an interview on 09/26/2025 at 9:23 AM, the Director of Nursing (DON) stated all residents at the same table should be served their meal at the same time and residents should be assisted with tray set up and cutting of food as the staff member served the meal. The DON stated they would prefer staff to provide feeding assistance to residents on a one-to-one basis, but it was allowable for a staff member to provide feeding assistance to two residents at the same time if they used opposite hands. The DON stated staff who were assisting residents with their meal should only be engaged in assisting the resident with their meal, and she would expect the resident to be assisted within a few minutes of receiving their food. During an interview on 09/26/2025 at 10:28 AM, the Executive Director (ED) stated she would expect residents seated at the same table for meals to be served at the same time. The ED stated she would not expect residents who needed assistance with eating to have food sitting in front of them while other residents were eating. The ED stated she would not expect meal service to be interrupted unless it was an emergency.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure physicians were notified of all changes in a resident's medical condition and failed to notify the physicians when delay in initiation of medical orders occurred for 3 (Residents #76, #84, and #22) of 5 residents reviewed for urinary tract infections (UTIs). Findings included:A facility policy titled, Change in Resident's Condition or Status, revised on 05/2020, revealed, Our facility promptly notifies the resident, his or her attending physician, and responsible party of changes in the resident's condition and/or status. The policy revealed, 1. The Nurse Supervisor will notify the resident's attending physician when: b. There is a significant change in the residents' physical, mental or psychosocial status, c. There is a need to alter resident treatment or diagnosis related information; f. Deemed necessary or appropriate in the best interest of the resident. The policy revealed, 3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change in the resident's condition or status. The policy revealed, 5. The nurse will record in the resident's medical record any changes in the resident's medical condition or status as well as the resident response to care treatment and services.A facility policy titled, Corporate Compliance Standards of Conduct-Physician Orders, dated 07/2028, revealed, All care provided to residents of [facility name] must be based on written, dated and signed orders from a licensed physician or other authorized healthcare provider such as certified nurse practitioner. The policy also revealed, Nursing staff shall obtain and transcribe orders in a timely and accurate manner, monitor for side effects and notify the physician.A facility policy titled, Medical Records Content for Practitioners, last reviewed by the facility on 01/2022, revealed, A medical record shall be maintained for every resident admitted and treated at a [corporate provider] Community. The medical record is the primary tool used by multiple disciplines for communicating resident care information. To ensure accuracy, the documentation in the medical record shall be completed as care occurs or in as timely a manner as possible. The medical record shall contain the notes, the reports and documentation set forth below. The policy revealed a section titled, Medical Record Content Requirements, that indicated, Resident medical records shall contain the following information: 6. Physician Orders; 9. Orders for diet diagnostic testing, therapeutic procedures, and medications; 15. Progress Notes; and 17. Clinical Laboratory testing reports. The policy revealed a section titled, Orders, which specified, The practitioner's orders shall be placed within the electronic medical record utilizing Computerized Physician Order Entry (CPOE). The section titled, Verbal and Telephone Orders, specified, A practitioner may issue a verbal order only during an emergent or urgent situation that requires immediate action. Telephone orders are accepted from the practitioner when he/she is not on the premises. All Community based credentialed practitioner orders (including verbal and/or telephone orders) must be signed in the electronic medical record. All orders must be signed within 14 days.1. An admission Record revealed the facility admitted Resident #76 on 10/15/2013 and readmitted the resident on 10/10/2017. According to the admission Record, the resident had a medical history that included a diagnosis of personal history of urinary (tract) infections (infection of the kidneys, ureters, bladder, or urethra). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2025, revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderately impaired cognition. The MDS indicated the resident was always incontinent with bowel and bladder. The MDS revealed the resident was dependent on staff for toileting hygiene and toilet transfers. Resident #76's Care Plan Report, included a focus area revised on 09/03/2024, that indicated the resident had an activity of daily living (ADL) self-care performance deficit related to a history of amputation of the residents' toes on the left foot and left arm below the elbow, pain, and activity intolerance. Interventions directed staff to provide assistance from one to two staff members to help with toileting, brief changes, and incontinence care. Resident #76's nursing Progress Notes, dated 08/12/2025 at 6:06 PM, indicated Resident #76's urinalysis dipstick test results indicated the resident's urine sample was positive for leukocytes (a white blood cell involved in counteracting foreign substances and diseases) and negative for nitrates. The Progress Notes revealed that the nursing supervisor (Registered Nurse [RN] #7) was notified of the results. Resident #76's nursing Progress Notes, dated 08/13/2025 at 1:30 PM, revealed Resident #76's urine was sampled for a second time with results that indicated a strong positive for leukocytes but remained negative for nitrates. The Progress Notes indicated Resident #76 continued to experience hallucinations causing the resident to believe they had a nail puncturing their (the resident's) skin. The Progress Notes revealed the resident had urine which appeared neon yellow with a green hue containing a large amount of mucous present. The Progress Notes revealed the resident stated that they felt burning during urination. Resident #76's nursing Progress Notes, dated 08/13/2025 at 3:04 PM, revealed an order to collect a urine sample via straight catheter to be sent to the laboratory for evaluation. Resident #76's nursing Progress Notes, dated 08/13/2025 at 4:15 PM, revealed a urine sample was obtained from Resident #76 via straight catheter. The Progress Notes indicated the urine sample contained large amounts of mucous, was foul smelling and appeared yellow in color with a green tinge. A Lab [Laboratory] Results Report, dated 08/15/2025, indicated a specimen was collected on 08/14/2025 at 1:00 AM and was received by the laboratory on 08/14/2025 at 6:58 AM. The Lab Results Report revealed that the lab reported the specimen was mislabeled and another specimen and laboratory requisition were needed to process the requested laboratory testing for Resident #76. The Lab Results Report indicated the facility was notified via fax with the reported time stamped as 08/15/2025 at 5:13 PM.Resident #76's nursing Progress Notes, dated 08/18/2025 at 6:10 AM, revealed Resident #76 had combative behaviors throughout the shift, and staff were unable to obtain the urine specimen due to the resident hitting and kicking all staff involved with the resident's care. Resident #76's nursing Progress Notes, dated 08/18/2025 at 6:18 PM, revealed a urine specimen was obtained from Resident #76 via straight catheter, and the sample was described to contain yellow urine with a large amount of sediment and foul odor. Resident #76's Lab Results Report, dated 08/22/2025, indicated a urine specimen was collected on 08/19/2025 at 1:00 AM and was received by the laboratory on 08/19/2025 at 7:28 AM. The Lab Results Report revealed the results were provided to the facility on [DATE]. The Lab Results Report revealed Resident #76's urine sample was extra turbid in clarity, positive for the presence of blood, protein, nitrates, and contained 4+ leukocytes (reference range indicated these items should be negative). The Lab Results Report revealed that the culture results indicated that Resident #76's urine sample contained greater than 100,000 colony forming units per milliliter (CFU/ml) of Citrobacter Koseri (a bacteria found in the gastrointestinal tract).Resident #76's nursing Progress Notes, dated 08/22/2025 at 11:18 AM, revealed Resident #76 continued to have the presence of cloudy urine and was experiencing increased lethargy and needed additional assistance by staff with meals. Resident #76's Order Summary Report for the timeframe from 04/01/2025 through 09/30/2025, contained an order with a start date of 08/22/2025 and end date of 08/29/2025, for levofloxacin tablet (an antibiotic) 500 milligrams (mg) with instructions to give one tablet by mouth every night shift for UTI for seven days. The Order Summary Report revealed an order with a start date of 08/23/2025 and end date of 08/30/2025 for Augmentin oral tablet (an antibiotic) 500-125 mg with instructions to give one tablet by mouth two times a day for acute UTI for seven days. Resident #76's physician Progress Notes, dated 09/04/2025, electronically signed by Resident #76's Primary Care Provider (Medical Doctor [MD] #2) revealed Resident #76's primary reason for assessment was recurrent urinary tract infection. The Progress Notes indicated Resident #76 was recently treated with Augmentin therapy that was completed with good clinical response without ill effects reported. The Progress Notes revealed that due to the resident's recurrent urinary tract infection, MD #2 recommended Trimethoprim (an antibiotic) 100 mg by mouth at night for 90 days along with lactobacillus (an oral medication which contains healthy bacteria that aid the gastrointestinal system) two tablets daily while on Trimethoprim therapy. The Progress Notes revealed the Current Medications list included an order for Trimethoprim 100 mg orally once a day for 90 days. Resident #76's nursing Progress Notes, dated 09/05/2025 at 4:59 PM, indicated Resident #76 continued to experience periods of combativeness, decrease appetite with meals, and was resistive to care to include medication administration. Resident #76's physician Progress Notes, dated 09/11/2025, electronically signed by MD #2, revealed an examination of the resident completed by MD #2 indicated that Resident #76 had no current complaints of dysuria and was afebrile but was recently prescribed Trimethoprim suppressive oral therapy (on 09/04/2025) and the order had been neglected. Resident #76's nursing Progress Notes, dated 09/11/2025 at 9:09 AM, revealed Resident #76 was seen by MD #2 with recommendations to continue Trimethoprim therapy for UTI prevention. Resident #76's nursing Progress Note dated 09/11/2025 at 9:09 AM, written by RN #7, revealed Resident #76 was seen by MD #2 with recommendations to continue Trimethoprim therapy for UTI prevention. Resident #76's Order Summary Report for the timeframe from 04/01/2025 through 09/30/2025, revealed no order for Trimethoprim 100 mg. Resident #76's Progress Notes for the timeframe from 09/04/2025 through 09/24/2025, revealed no documented explanation why MD #2's order for Trimethoprim for suppressive therapy was not transcribed and followed as prescribed. During an interview on 10/09/2025 at 2:42 PM, RN #7 stated that when Resident #76 exhibited symptoms of a UTI, she notified the nurse to encourage fluids for the resident and transcribed an order for the nurse to do another urinalysis via the dipstick method the following day. RN #7 stated they did not notify the physician of ongoing symptoms or results of preliminary urinalysis performed in the facility and did not contact the physician to notify them until the facility received the test results from a urinalysis and culture and sensitivity test that was performed by an outside laboratory. During a follow-up interview on 10/09/2025 at 3:10 PM, RN #7 stated they facility could not obtain Resident #76's urine sample on 08/18/2025 as a result of the resident's combative behavior. RN #7 stated the medial provider should have been notified of the delay in obtaining the ordered lab and the resident's combative behavior, and she verified she could not locate documentation of the notification to the provider. During a follow-up interview on 10/09/2025 at 3:34 PM, RN #7 stated that on 09/04/2025, MD #2 recommended Trimethoprim and on 09/11/2025 he ordered Trimethoprim. She stated normally the facility did not allow prophylactic antibiotics, and she would have taken that to the Director of Nursing (DON) to make sure it was okay to order. She stated she did not notify MD #2 that orders could not be initiated because he was mad on 09/11/2025 about the antibiotic orders that were not initiated on 09/04/2025. She stated that she missed the 09/04/2025 order and that it was her mistake. She stated that for the prophylactic antibiotic orders, MD #2's order was reviewed with the Medical Director. She stated that the Medical Director would make the final decision to make sure it followed their antibiotic stewardship. During a follow up interview on 10/11/2025 at 12:37 PM, RN #7 stated she notified the DON verbally of the order by MD #2 for prophylaxis antibiotic therapy and she thought that it was escalated to the Medical Director for determination. She stated that she should have documented a note about the DON notification. She stated that the determination by the Medical Director was not given back to her in order to notify the physician that the order was not being followed.During an interview on 10/11/2025 at 12:50 PM, RN #7 stated she acknowledged she should have notified the physician when Resident #76's urine specimen was mislabeled, and she confirmed all notifications to the physician should be documented in the residents' medical records. During an interview on 10/09/2025 at 4:07 PM, the DON stated that the nursing staff should notify the medical provider of all lab results, behaviors, and symptoms. She stated she was unable to determine if MD #2 was notified because the medical record contained no documentation of the notification. During a follow up interview on 10/09/2025 at 4:12 PM, the DON stated she interpreted the 09/04/2025 order for the antibiotic for Resident #76 to be a recommendation and not an order and MD #2 knew that was against the facility's protocol. The DON stated Resident #76 had many medication allergies, had a MDRO (multi drug resistant organism), and the Medical Director stated she would not approve that order. She stated that the determination should have been documented in the medical record and MD #2 should have been notified. The DON stated for the suppressive therapy recommendation for Resident #76 they felt it was not good practice for the resident. She stated that typically the nursing supervisor (RN #7) would contact the doctor if an order was not implemented due to antibiotic stewardship protocol. She stated that the Medical Director made the decision not to allow the facility to implement this order. During a follow-up interview on 10/09/2025 at 4:25 PM, the DON stated the physician should have been notified that the prophylaxis antibiotic was not initiated for Resident #76 because the order did not follow the facility's antibiotic stewardship program; however, she was unable to verify if the physician was notified because the notification was not documented in the medical record. The DON stated Resident #76 was treated for a UTI, and the UTI had resolved following treatment. The DON stated the refusal to allow Resident #76 to receive prophylaxis antibiotic therapy was the decision of the Medical Director, but she was not able to verify when the Medical Director was notified, or when the decision was made by the Medical Director. During an interview on 10/11/2025 at 2:03 PM, the DON stated and confirmed she did not document her conversation with the Medical Director when orders for prophylaxis antibiotics ordered by MD #2 on 09/04/2025 for Resident #76 were not initiated and admitted she did not provide him an explanation that his orders for prophylaxis antibiotics were not initiated because they did not follow the facility's antibiotic stewardship policy. She stated her expectation would be that the nursing supervisor (RN #7) should notify the physician if there was a delay in labs and if orders were not initiated.During a telephone interview on 10/09/2025 at 4:47 PM, the Medical Director stated she was not notified MD #2 wrote orders for prophylaxis antibiotic therapy; however, if she were notified, she stated she would have declined the recommended order for treatment. She stated she did not believe in that (suppressive therapy), and it never worked. She said she was made aware of the concern later, although she could not verify the date she was notified. She stated that if she created an order, she expected them to follow it or to notify her of why the facility would not follow the order. During a telephone interview on 10/09/2025 at 5:07 PM, the Nurse Practitioner (NP) stated she last saw Resident #76 on 08/12/2025. She stated the facility staff did not notify her about delays in their ability to obtain laboratory specimens or results for the ordered urinalysis and culture and sensitivity. She stated the facility staff did not notify her that Resident #76 had experienced abnormal behaviors and lethargy. She stated the facility did not notify her when antibiotic orders were not initiated as ordered for Resident #76. During a telephone interview on 10/10/2025 at 8:30 AM, MD #2 stated that the facility did not notify him when ordered antibiotics were not initiated for Resident #76. During a follow-up telephone interview on 10/10/2025 at 1:40 PM, MD #2 stated he saw Resident #76 on 09/04/2025, and confirmed his progress notes included a statement that specified the resident had recent treatment with antibiotic therapy with good response and he stated he recommended suppressive therapy for 90 days. He stated he was also not notified when Resident #76's urine specimen had a delay in processing due to a specimen that was mislabeled. He stated he was also not notified of the resident not starting antibiotics until 08/22/2025. He stated he was not aware the lab did not pick up on weekends. 2. An admission Record revealed the facility admitted Resident #84 on 08/26/2025. According to the admission Record, the resident had a medical history that included a diagnosis of overactive bladder (frequent urgency of urination). The admission Record revealed the resident was discharged from the facility on 09/07/2025 after a 12-day admission to the facility. A Medicare 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/30/2025, revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The MDS revealed Resident #84 required partial/moderate assistance with toileting hygiene, toileting transfers, and had occasional bladder incontinence. Resident #84's Care Plan Report, included a focus area initiated on 08/27/2025, that indicated the resident had chronic kidney disease. Interventions directed staff to administer medications as ordered by the physician, monitor changes in mental status, and monitor for signs and symptoms of infection. The Care Plan Report also included a focus area initiated on 09/03/2025 that indicated the resident had mixed bladder incontinence related to active infections with symptoms of UTI, chronic symptomatic infections, and impaired mobility. Interventions directed staff to clean the residents' perineal area with each incontinent episode; monitor/document for signs and symptoms of UTI; and monitor/document/report as needed for any potential causes of incontinence. Resident #84's provider Progress Notes, dated 09/02/2025, electronically signed by the Nurse Practitioner (NP) revealed a section titled, History of Present Illness, that specified, Patient states, I know I have a UTI and the staff took 3 samples already, and, I was taking a maintenance Keflex (a medication used to treat infection) for frequent UTI's and somewhere along the line it was discontinued and now I have a UTI. The Progress Notes revealed Resident #84's treatment plan included orders to obtain a urinalysis with culture and sensitivity and to start ciprofloxacin hydrochloride (HCl) (an antibiotic) 250 milligrams (mg) with instructions to give one tablet by mouth every 12 hours and Lactobacillus. The Progress Notes also indicated there was a need for a follow-up every two to three days as needed due to the complexity of the resident's medical condition. Resident #84's Lab [Laboratory] Results Report, dated 09/03/2025, revealed a urine specimen was collected on 09/03/2025 at 3:00 AM, received by the laboratory on 09/03/2025 at 8:06 AM, and reported to the facility on [DATE] at 2:55 PM. The Lab Results Report revealed Resident #84's urine was turbid in clarity, positive for nitrates, contained 4+ leukocytes, clumps of white blood cells, and contained 100,000 colony forming units per milliliter (CFU/ml) of Klebsiella Pneumoniae (a bacteria normally found in the gastrointestinal system). Resident #84's provider Progress Notes, dated 09/04/2025, electronically signed by Medical Doctor (MD) #2, revealed the facility requested the provider follow-up on Resident #84's persistent dysuria. The Progress Notes indicated the resident complained of dysuria associated with urinary frequency and was not currently on the antibiotic therapy prescribed by the NP on 09/02/2025 and remained at high-risk for decline due to age and medical complexity. The Progress Notes revealed Resident #84's treatment plan included concerns for the resident's dysuria with notes that indicated Resident #84 was symptomatic with dysuria associated urinary frequency and had an abnormal urinalysis and MD #2 agreed with NP's assessment that Resident #84 should be prescribed an antibiotic and again wrote an order for Resident #84 to receive ciprofloxacin 500 mg with instructions to give one tablet by mouth two times a day for five days. Resident #84's Order Summary Report for the timeframe from 08/01/2025 through 09/30/2025, contained an order with a start date of 09/06/2025 and end date of 09/13/2025 for ciprofloxacin HCl 500 mg with instructions to give one tablet by mouth two times a day for seven days for acute UTI. The Order Summary Report revealed no orders for ciprofloxacin HCl prior to 09/06/2025. Resident #84's Progress Notes for the timeframe from 08/26/2025 through 09/07/2025, revealed no notes explaining why MD #2 and the NP's order for ciprofloxacin HCl were not followed prior to 09/06/2025 which was eight days after becoming symptomatic. During a telephone interview on 10/10/2025 at 8:30 AM, MD #2 stated the facility did not notify him when the antibiotic prescribed for Resident #84 was not initiated on 09/02/2025. During a follow-up telephone interview on 10/10/2025 at 1:40 PM, MD #2 stated he was concerned with the delay of initiation of Resident #84's ordered antibiotics because the resident went for six full days with an acute UTI without treatment. He stated the facility did not notify him until he discovered the error one week later when he realized the antibiotic had not been started. He stated he emailed the DON on 09/04/2025 and asked what occurred.During an interview on 10/11/2025 at 12:50 PM, Registered Nurse (RN) #7 stated she failed to notify the NP when antibiotics were not initiated for Resident #84 on 09/02/2025. During an interview on 10/10/2025 at 10:30 AM, the Director of Nursing (DON) stated she thought MD #2 wrote an order for antibiotics for Resident #84. The DON stated RN #7 verbally notified him that the results from the lab would be available that day (09/04/2025) and the culture and sensitivity were pending. The DON stated that RN #7 asked him if he wanted to see the culture. She stated she thought the physician was leaving the facility at the time but stated yes. The DON stated the facility did not receive results of Resident #84's urinalysis and culture and sensitivity until 09/05/2025. She stated her understanding was that the physician did not respond to the email to confirm he still wanted the order for ciprofloxacin to be initiated as previously prescribed until 09/06/2025. The DON reviewed RN #7's progress notes about Resident #84's urinalysis being complete and that the note was vague and did not address that the ordered ciprofloxacin was not initiated as ordered. She stated she was not aware of the missed orders for the ciprofloxacin written on 09/02/2025 and 09/04/2025 until MD #2 became upset. She stated she could not recall RN #7 notifying her about the order for ciprofloxacin on 09/04/2025. She stated that after reviewing the medical record, orders for Resident #84's ciprofloxacin were missed both on 09/02/2025 and 09/04/2025 and they were considered medication errors. The DON stated that if there was a medication error, she expected staff to notify the doctor, the pharmacy, and the family and document these notifications in the medical record. 3. An admission Record revealed the facility admitted Resident #22 on 05/15/2025. According to the admission Record, the resident had a medical history that included a diagnosis of obstructive and reflux uropathy.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/15/2025, revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #22 required substantial/maximal assistance of staff for toileting hygiene and partial/moderate assistance for toileting transfers. The MDS revealed the resident was frequently incontinent of bowel and bladder. Resident #22's Care Plan Report, included a focus area initiated on 05/21/2025, that indicated the resident had benign prostatic hyperplasia (BPH) (condition where prostate gland enlarges over time causing urinary problems). Interventions directed staff to monitor/record/report to medical doctor for signs and symptoms of a UTI such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, altered mental status, change in behavior, or change in eating patterns.Resident #22's Nursing Narrative Note, dated 08/21/2025 at 6:08 PM, revealed Resident #22 experienced increased voiding that was dark yellow in color with a foul smell and complaint of urinary pain with voiding. Resident #22's Nursing Narrative Note, dated 08/22/2025 at 2:05 PM, revealed a second urine specimen was obtained from Resident #22 and evaluated via a the dipstick method. The Progress Notes indicated Resident #22's urine sample was yellow in color with cloudy sediment and showed the specimen was positive for leukocytes and nitrites. The Progress Notes revealed the resident continued to complain of urinary pain and burning when voiding.Resident #22's Lab [Laboratory] Results Report, dated 08/28/2025, revealed that a urine sample was collected on 08/22/2025 at 4:00 PM and received by the lab on 08/23/2025 at 2:15 AM. The Lab Results Report revealed the lab was reported on 08/26/2025 at 2:34 PM. The Lab Results Report revealed the results section of the document was blank. Further review revealed there was no documentation as to why there were no results documented. Resident #22's Nursing Narrative Note, dated 08/26/2025 at 12:43 PM, revealed the resident's urine was obtained via straight catheter and sent to the lab for processing. The Nursing Narrative Note revealed that the Nurse Practitioner (NP) was notified.Resident #22's Nursing Narrative Note, dated 08/26/2025 at 6:09 PM, revealed Resident #22's urine was obtained via a straight catheter. The Nursing Narrative Note revealed Resident #22's urine was cloudy, light yellow, and had sediment with a foul odor. The Nursing Narrative Note revealed the resident's urine sample was placed in the refrigerator for the lab to pick up.Resident #22's Lab Results Report, dated 08/29/2025, indicated a specimen was collected on 08/27/2025 at 3:00 AM and received by the laboratory on 08/27/2025 at 8:29 AM. The Lab Results Report revealed the lab results were provided to the facility on [DATE] at 9:56 AM. The Lab Results Report revealed Resident #22's urine sample contained 4+ leukocytes (reference range indicated these items should be negative) and had greater the 50 white blood cells (reference range is less than six). The Lab Results Report revealed Resident #22's urine sample contained greater than 100,000 colony forming units per milliliter (CFU/ml) of Escherichia coli (a bacteria found in the gastrointestinal tract). The Lab Results Report revealed it was reviewed on 08/30/2025 at 10:28 AM. Resident #22's Lab Results note dated 08/30/2025 at 10:27 AM, revealed Medical Doctor (MD) #2 was notified of the lab results and Resident #22 was to start nitrofurantoin macrocrystal oral capsule 100 milligrams (mg) by mouth two times a day for seven days.During an interview on 10/11/2025 at 2:06 PM, the Director of Nursing (DON) stated that when RN #7 received the lab results for Resident #22 on Monday (08/25/2025), there was no culture or sensitivity results for the urine sampled on Friday (08/22/2025). The DON stated RN #7 called the hospital lab, and she was notified they did not do a culture and sensitivity on the weekends, and a culture and sensitivity required another sample to be submitted. The DON stated that the facility collected a urine specimen on 08/27/2025 and sent it to the laboratory for processing. During a follow-up interview on 10/10/2025 at 4:51 PM, the DON stated that the NP was notified on 08/26/2025 that another specimen was obtained and sent out to the lab. The DON stated the urine test results were received by the facility on 08/29/2025 and the provider was notified but antibiotics were not ordered until 08/30/2025 and Resident #22 received a dose of antibiotics that same day. During an interview on 10/10/2025 at 5:53 PM, the Executive Director (ED) acknowledged the facility's lack of documentation of communication with the provider and the Medical Director was a problem but thought the communication was completed but not documented. During a follow-up interview on 10/11/2025 at 5:14 PM, the DON stated that she acknowledged notifications to the physicians were not documented for Residents #76, #84, and #22, and her expectation was the physician was immediately notified of all delays of lab testing, lab results and not following physician orders and stated this should have been completed by the nursing supervisor or herself. During a follow-up interview on 10/112025 at 5:15 PM, the ED stated her expectation was that the physician would be notified immediately and the notification was documented in the medical record for each resident. This deficiency represents non-compliance investigated under Complaint Number OH2612855.

Based on observation, interview, and facility policy review, the facility failed to ensure food items stored in the refrigerator were covered in 1 (Ripple Ridge) of 4 satellite kitchens. Findings included:Reference: The United States FDA (Food and Drug Administration) 2022 Food Code contained Chapter 3 Food, 3-305 Preventing Contamination from the Premises, which revealed, 3-305.11 Food Storage, (A) Except as specified in [paragraphs] (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (2) Where it is not exposed to splash, dust, or other contamination. Paragraph (B) was regarding food in packages and working containers being stored above the floor on case lot handling equipment and paragraph (C) was regarding the floor storage of pressurized beverage containers, cased food in waterproof containers, and milk containers in plastic crates, which did not apply here. 3.305.14 Food Preparation revealed the statement, During preparation, unPACKAGED FOOD shall be protected from environmental sources of contamination. Food Code 2022 | FDAA facility policy titled Food Storage, with a copyright date of 2023, revealed a section titled, 13. Refrigerated food storage that specified, f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded.A concurrent observation and interview on 09/23/2025 at 12:24 PM with the Dietary Director revealed a refrigerator located in the Ripple Ridge satellite kitchen had a metal container containing approximately 12 tomatoes slices, 12 cucumber slices, and 12 sliced eggs, as well as a dinner plate inside the refrigerator with several slices of light brown meat that were uncovered. The Dietary Director stated that, as long as the items were used within a reasonable timeframe, it was acceptable for them not to be covered, noting a reasonable timeframe was about one hour. During an interview on 09/25/2025 at 10:03 AM, Homemaker #3 stated she was responsible for covering all food items stored in the satellite kitchen's refrigerator. She stated the tomatoes, cucumbers, eggs, and the dinner plate containing meat were left uncovered because they were going to be used for the lunch meal on 09/23/2025. She stated she received training to cover all food items in the refrigerator during her orientation, with the exception of food for immediate use, which Homemaker #3 stated the Kitchen Manager told her did not have to be covered. She stated her understanding was that immediate use meant that same day. During an interview on 09/26/2025 at 9:00 AM, the Kitchen Manager stated everything stored in a refrigerator, including prepped items, should be covered, which she noted applied to all refrigerators, including satellite kitchen refrigerators. She stated the homemaker assigned to a unit was responsible for covering all food items. During a follow-up interview on 09/25/2025 at 11:10 AM, the Dietary Director stated she expected all food to be covered while being stored in a refrigerator, with the exception of premade foods items placed in the refrigerator as a preparation for meals. She stated the homemakers were responsible for the refrigerator in their units to ensure all items were stored per facility policy. She stated she and the Kitchen Manager were responsible for the daily monitoring of satellite kitchen refrigerators to ensure food storage items were correctly covered. During an interview on 09/25/2025 at 11:26 AM, Dietary Aide (DA) #4 stated she did not monitor the kitchen. Regarding expectations for refrigerator food storage, she stated she expected all food items to be covered. During an interview on 09/25/2025 at 11:37 AM, the facility's Registered Dietitian (RD) stated the storage of food in the refrigerator required, in part, covering the food, with the exception of food in the refrigerator that was prepped for meals that day, because the refrigerator was like a preparation station. The RD noted that preparation storage usually only meant that food could be stored for 15 to 20 minutes prior to a meal without covering the food. The RD also noted it was acceptable to have food items uncovered for 45 minutes, describing that immediate use food did not need to be covered. The RD stated that standard and best practice was to use the refrigerator as a staging area for items prepped for a meal, identifying that staging areas did not require the covering of food. During an interview on 09/25/2025 at 1:00 PM, the Director of Nursing deferred her expectation of food storage and procedures to the Dietary Director, but noted she expected facility policies to be followed. During an interview on 09/25/2025 at 1:13 PM, the Executive Director (ED) stated she expected staff to follow the facility's food storage policies, but thought it was an acceptable practice to store uncovered, prepped food in the satellite refrigerators. After reviewing the facility's policy, the ED stated that, ultimately, staff would follow the policy, which revealed all food should be covered. The ED also stated the policy was grey because it was a storage policy and, in the main kitchen, the refrigerators were only for storage but, in the satellite kitchens, the policy might need to be expanded because the refrigerators in the satellite kitchens were used as both preparation and storage areas.

Based on record review and interview, the facility failed to ensure a resident with a significant change in mental status had the pre-admission screening and resident review (PASARR) screening revised. This affected one (Resident #48) of five residents reviewed for PASARR screening. The facility census was 92. Record review of Resident #48 revealed the resident was admitted to the facility on [DATE]. Diagnoses included for Resident #48 included dementia and Parkinson's disease. Review of PASARR screening, dated 02/07/19, revealed the resident did not have indications of a serious mental illness and did not required a level two mental health screening. Record review revealed new diagnosis of psychotic disorder with delusions on 11/10/21 and frontotemporal neurocognitive disorder on 12/08/21. Record review revealed no new PASARR was completed after the resident was newly diagnosed with a mental illness. During interview on 12/07/22 at 3:30 P.M., the Director of Nursing verified Resident #48 had new psychiatric diagnosis after the original PASRR had been completed and a revision should have been submitted to the Ohio Department of Job and Family Services.

Based on record review and interview, the facility failed to accurately complete pre-admission screening and resident review (PASARR) screening for residents. This affected two (Residents #36 and #56) of five residents reviewed for PASARR screening. The facility census was 92. Findings include: 1. Record review revealed Resident #36 was admitted on [DATE]. Diagnoses included major depressive disorder, insomnia, anxiety disorder and unspecified psychosis. Review of the PASARR screening, dated 01/29/21, revealed there was no diagnoses of anxiety or psychosis diagnoses listed for Resident #36. During interview on 12/07/21 at 12:14 P.M., Admission Marketing Staff #213 verified Resident #36 most recent PASARR was completed on 01/29/21 and the anxiety and psychosis diagnosis was not coded on the PASARR. 2. Record review revealed Resident #56 was admitted on [DATE]. Diagnoses included behavioral disturbance, generalized anxiety disorder, psychosis, major depressive disorder, dementia and insomnia. and hyperlipidemia. Review of the PASARR screening revealed the diagnoses of anxiety and psychosis were not identified. Review of the 12/05/22 PASARR on 12/05/22 revealed there was no diagnosis of anxiety or psychosis documented for Resident #56. During interview on 12/07/22 at 12:11 P.M., Admission Marketing Staff #213 verified the diagnoses of anxiety and psychosis was not coded on the PASARR.

Based on record review, observation, interview and policy review, the facility failed to ensure a resident was changed into night clothing. This affected one (Resident #71) of two residents reviewed for dignity. The facility census was 92. Findings include: Review of the medical record for the Resident #71 revealed an admitted [DATE]. Diagnoses included cognitive communication deficit, mood disturbance, anxiety, unspecified dementia, and emphysema. Review of the plan of care dated 08/26/22 revealed the resident have an activity of daily living self-care performance deficit. Interventions includes dressing: set up assist shirt while assisting. Pants when supine in bed and footwear. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/18/22, revealed the resident had impaired cognition. The resident required extensive assistance with one person assist for dressing. During observation on 12/04/22 at 10:35 A.M., Resident #71 stated she was wearing the same clothing as the day before. She was wearing a floral shirt. Resident stated she preferred to be in her night clothes. During observation and verified by State tested Nursing Assistant (STNA ) #133, Resident #71 had several pairs of pajamas in her dresser drawer. During interview on 12/04/22 at 10:45 A.M., STNAs #131, #188 and #250 stated they had not changed Resident #71's clothing today on day shift and night shift had not changed her clothing. Review communication sheet from night staff to day staff; revealed Resident #71 did not get dressed from night shift. During observation on 12/05/22 at 10:30 A.M., Resident #71 was sitting in her room watching television wearing an orange T-shirt. During observation on 12/05/22 at 5:20 P.M.,Resident #71 was in bed. Resident #71 was still wearing the orange T-shirt. Resident #71 stated she was in bed for the night and was waiting on staff to change her into her evening clothes. During observation on 12/06/22 at 9:12 A.M., Resident #71 was lying in bed, still dressed in the same orange T-shirt as the day prior. Resident #71 stated no one changed her into her evening clothes again. During interview at the time of the observation, STNA #252 stated she had not changed Resident #71's clothing nor was her clothing changed on night shift. Review of the facility policy titled Resident Rights, dated October 2019, revealed residents have autonomy and choice, to maximum extent possible, about how they wish to live their lives and receive care, subject to the SEM Haven Resident and Family Information booklet and that describes nursing and personal care issues and daily life at our home.

Based on observation, record review, and interview the facility failed to maintain adequate infection control practices during wound care. This affected one (Resident #39) out of one resident reviewed for wound care. The facility census was 92. Findings include: Record review revealed Resident #39 was admitted on [DATE]. His diagnoses included urinary tract infection, hypotension, rhabdomyolysis, bacterial pneumonia, syncope, visual hallucinations, chronic kidney disease, constipation, dysphasia, anemia, vascular dementia, anxiety, and hyphenate. Review of the physician orders for Resident #39 revealed an order dated 10/04/22 to apply betadine moist gauze to bilateral buttocks pressure ulcer and cover with army battle dressing (ABD) pad twice daily every 12 hours for wound care and every 1 hours as needed for wound care. During observation on 12/06/22 at 1:37 PM, Licensed Practical Nurse (LPN) #146 completed wound care. LPN #146 washed her hands, donned gloves and removed the old dressing from Resident #39's wound. She then cleaned the wound with saline and gauze. Without washing her hands, LPN #146 donned clean gloves and completed the treatment. During interview at the time of the observation, LPN#146 confirmed she failed to wash her hands after removing the soiled dressings and prior to applying the clean dressings to Resident #39. Review of the facility policy titled Dressing Change-Clean, dated May 2011, documented Procedure- 10. Put on gloves. Remove old dressings carefully, touching only edges and place in plastic bag. 11. Assess the area for signs of infection, drainage and/or signs and symptoms of healing. 13. Change gloves and wash hands. 14. Apply treatment/dressings. Review of the facility policy titled Hand Washing/Hand Hygiene, dated June 2011, documented Handwashing and use of hand sanitizer shall be regarded by this organization as the most important means of preventing the spread of infections. Appropriate thirty 15-20 second handwashing must be preformed under the following conditions: After handling items potentially contaminated with blood, body fluids, excretions, or secretions.

Based on record review and interview, the facility failed to complete a discharge summary for a resident. This affected one (Resident #87) of two residents reviewed for discharge. The facility census was 92. Findings include: Record review revealed Resident #87 was admitted to the facility on [DATE] and discharged on [DATE] to home. Review of the closed record for Resident #87 revealed no documentation of the recapitulation of the resident's stay from admitted [DATE] through 11/08/22 including the resident's clinical status, and care instructions to ensure coordination of transition from the facility to home. During interview on 12/06/22 at 10:36 A.M., the Director of Nursing verified a discharge summary had not been completed by the interdisciplinary clinical team employees for Resident #87 after discharge.

Based on observation, staff interview, record review and manufacturer's instruction review, the facility failed to ensure an insulin pen was primed prior to administration. This resulted in a significant medication error. This affected one (Resident #21) of five residents reviewed for medication administration. The facility census was 22. Findings include: Record review revealed Resident #21 was admitted on [DATE] with diagnoses including type two diabetes mellitus. During observation on 12/06/22 at 9:22 A.M., Licensed Practical Nurse (LPN) #183 prepared a Levimir insulin pen for Resident #21. She dialed up 10 units and administered the insulin to Resident #21. She did not prime the pen prior to administering the dose. During interview on 12/06/22 at 9:35 A.M., LPN #183 verified she did not prime the insulin pen prior to administering Resident #21 insulin. LPN #183 stated she does not know how to prime an insulin pen. Review of the Levemir flextouch pen-injector medication insert, dated 07/01/22, revealed priming your Levemir Flextouch Pen Turn the dose selector to select two units. Hold your pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows zero. A drop of insulin should be seen at the needle tip. If not change the needle and repeat the procedure no more than six times.

Based on medical record review, staff and resident interview, review of the care kardex, review of the self-reported incidents, and policy review, the facility failed to report an allegation of sexual abuse to the state agency. This affected one resident (#51) out of three residents reviewed for abuse. The facility census was 83. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment for Resident #51 dated 07/08/22 revealed the resident had impaired cognition. No hallucinations, delusions, or rejection of care were noted on the assessment. The resident required total dependence from staff for toilet use and locomotion on the unit. Resident #51 required extensive assistance from staff for bed mobility, transfers, dressing, and hygiene. Supervision was required when eating. Review of the plan of care for Resident #51 dated 01/11/22 revealed the resident had impaired cognitive function and impaired thought processes, trouble concentrating related to dementia. Interventions included administering medications as ordered, keeping routines and caregivers as consistent as possible, and monitoring/documenting/reporting any changes in cognitive function. Interview on 08/01/22 at 12:55 P.M., with Resident #51 revealed some time recently a bald man who worked on the night shift checked her inappropriately and examined her internally. The resident showed some moments of confusion during the interview however, confirmed she told her caregiver and son about the incident with the bald man employee. Resident #51 said her son told her to be firm with the employee and tell them not to do it again. When asked if she did that, the resident responded she told the bald man to stop and was yelling, but no one came to help. Interview on 08/01/22 at 1:25 P.M., with the Director of Nursing (DON) verified during the week of 07/25/22 through 07/29/22 she was told by the son and caregiver for Resident #51 there was a male who was checking her private areas and she didn't like it. No more details were given to her about the resident concerns. The DON verified she had not reported, or investigated the claim made by the son and caregiver of Resident #51. The DON also verified there was a male State tested Nursing Assistant (STNA) who worked at the facility on the same unit the resident was residing. The DON was not made aware until the week of 07/25/22 the family or the resident did not want the resident to have male caregivers. The DON said she immediately put that intervention into place when she was notified of the request. Review of the State Reported Incidents (SRI) filed by the facility revealed no SRI for the incident was started as of 08/01/22. Review of the facility care kardex for Resident #51 dated 08/01/22 revealed no specific directions for the resident not to have male caregivers. A follow-up interview on 08/01/22 at 1:45 P.M. with the DON verified nowhere on the kardex for Resident #51 documented the resident could not have male caregivers. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, Injuries of Unknown Source & Misappropriation of Resident Property, undated It is the policy of the facility to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source, in accordance with this policy and to ensure that all individuals who report incidents and allegations are free from retaliation or reprisal for reporting the incident. Additionally, the administrator or his/her designee will notify the SDH of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown source as soon as possible, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. This deficiency substantiates Complaint Number OH 518.

Based on medical record review, staff and resident interview, review of the care kardex, review of the self-reported incidents, and policy review, the facility failed to investigate an allegation of staff to resident sexual abuse. This affected one resident (#51) out of three residents reviewed for abuse. The facility census was 83. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment for Resident #51 dated 07/08/22 revealed the resident had impaired cognition. No hallucinations, delusions, or rejection of care were noted on the assessment. The resident required total dependence from staff for toilet use and locomotion on the unit. Resident #51 required extensive assistance from staff for bed mobility, transfers, dressing, and hygiene. Supervision was required when eating. Review of the plan of care for Resident #51 dated 01/11/22 revealed the resident had impaired cognitive function and impaired thought processes, trouble concentrating related to dementia. Interventions included administering medications as ordered, keeping routines and caregivers as consistent as possible, and monitoring/documenting/reporting any changes in cognitive function. Interview on 08/01/22 at 12:55 P.M., with Resident #51 revealed some time recently a bald man who worked on the night shift checked her inappropriately and examined her internally. The resident showed some moments of confusion during the interview however, confirmed she told her caregiver and son about the incident with the bald man employee. Resident #51 said her son told her to be firm with the employee and tell them not to do it again. When asked if she did that, the resident responded she told the bald man to stop and was yelling, but no one came to help. Interview on 08/01/22 at 1:25 P.M., with the Director of Nursing (DON) verified during the week of 07/25/22 through 07/29/22 she was told by the son and caregiver for Resident #51 there was a male who was checking her private areas and she didn't like it. No more details were given to her about the resident concerns. The DON verified she had not reported, or investigated the claim made by the son and caregiver of Resident #51. The DON also verified there was a male State tested Nursing Assistant (STNA) who worked at the facility on the same unit the resident was residing. The DON was not made aware until the week of 07/25/22 the family or the resident did not want the resident to have male caregivers. The DON said she immediately put that intervention into place when she was notified of the request. Review of the State Reported Incidents (SRI) filed by the facility revealed no SRI for the incident was started as of 08/01/22. Review of the facility care kardex for Resident #51 dated 08/01/22 revealed no specific directions for the resident not to have male caregivers. A follow-up interview on 08/01/22 at 1:45 P.M. with the DON verified nowhere on the kardex for Resident #51 documented the resident could not have male caregivers. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, Injuries of Unknown Source & Misappropriation of Resident Property, undated It is the policy of the facility to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source, in accordance with this policy and to ensure that all individuals who report incidents and allegations are free from retaliation or reprisal for reporting the incident. Additionally, the administrator or his/her designee will notify the SDH of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown source as soon as possible, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. This deficiency substantiates Complaint Number OH 518.

Based on staff interview, record review, and policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards when they failed to timely put in an anitibiotic eye drop ([MEDICATION(S)]) order for Resident #33. This affected one (Resident #33) of three residents reviewed for medications. The facility census was 83. Findings include: Record review of Resident #33 revealed an admitted [DATE] with pertient diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 02/18/22 significant change Minimum Data Set (MDS) assessment revealed Resident #33 was moderately cognitively impaired and required total dependence for locomotion on unit, bathing, and transfers. She required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. The Resident used a wheelchair to aid in mobility and was always incontinent of bowel and bladder. Review of progress note dated 03/14/22 at 5:40 P.M. revealed new orders for [MEDICATION(S)] eye drops for seven days. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed Registered Nurse (RN) #10 put the order in for [MEDICATION(S)] eye drops for seven days. Interview on 03/29/22 at 1:15 P.M. with RN #10 revealed the facility did not keep the [MEDICATION(S)] (eye antibiotic) eye drops on hand. She stated the process of putting in orders was left for the charge nurse. RN #10 was not sure why it took so long for the order to get put into the system. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Interview on 03/29/22 at 2:54 P.M. with the Director of Nursing via e-mail, verified the Nurse Practitioner saw Resident #33 on 03/14/22 and gave the order for the eye ointment that day. The order was missed and it was found on 03/16/22 and put in the computer that day. Interview on 03/31/22 at 10:10 A.M. with Licensed Practical Nurse (LPN) #12 revealed Resident #33 was complaining of her eyes watering and being uncomfortable and they were red. LPN #12 reached out to her supervisor to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 03/31/22 at 5:35 P.M. with Nurse Practitioner #40 revealed her expectation would be for the antibiotic order of [MEDICATION(S)] eye drop to be in place and given within 24 hours of her giving the order on 03/14/22. This deficiency substantiates Complaint Number OH 172.

Based on observation, staff interview, and record review, the facility failed to ensure the environment was free of accident hazards when a facility dog injured three Residents. This affected three (Resident #26, #29, and #33) of three Residents reviewed for accidents. This had the potential to affect all 17 Residents (#23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, and #39) residing on the hallway where the dog was kept. The facility census was 83. Findings include: Observation on 03/29/22 revealed the dog appeared to be a boxer or pit bull mix puppy that resided in a crate set up in the lounge area of the 200 hallway. The dog freely roamed the 200 unit and was witnessed in a resident's room with multiple pairs of the resident's shoes in her mouth and playing with them and chewing on them. Interview with the DON on 03/29/22 at 11:40 A.M. revealed they have had the dog a few weeks, and it was a stray a nurse had found on the side of road and it was now the facility's dog. When asked if the dog had bit anyone or scratched anyone, the DON stated three residents had been scratched Resident #26, Resident #29, and Resident #33. Example #1. Record review of Resident #26 revealed an admitted [DATE] with pertinent diagnosis of: dementia, malignant neoplasm of colon, non-infective gastoenteritis and [CONDITION(S)], joint pain, muscle weakness, [CONDITION(S)], COVID-19, dysphagia, cognitive communication deficit, [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], spinal stenosis, hypertension, major depressive disorder, postlaminectomy syndrome, [CONDITION(S)], chronic obstructive pulmonary disease, [CONDITION(S)], anxiety disorder, asthma, [CONDITION(S)], [CONDITION(S)], polyneuropathy, heart failure, muscle wasting and atrophy. Review of the 02/25/22 annual Minimum Data Set (MDS) assessment revealed Resident #26 was severely cognitively impaired and required extensive assistance for Activites of Daily Living (ADLs). Review of an accident report dated 03/09/22 revealed Licensed Practical Nurse (LPN) #10 came into the unit at the start of her shift and Resident #26 was sitting in the middle of the hallway and the new household puppy was trying to play with her feet and tore a two inch long cut on the top of the right foot. LPN #10 immediately removed the puppy from the area and placed in her cage. Guaze was applied with pressure until the bleeding stopped then the wound was cleansed and steri strips were applied. Observation on 03/29/22 at 11:50 A.M. with the Director of Nursing (DON) revealed Resident #26 was sitting in the 200 hallway dining room and the DON removed her left sock and she still had an unhealed wound to the top of her left foot with three steri-strips in place. The wound appeared to be about two inches in diameter. The DON verified that wound was from the dog but the original note was incorrect and stated it was on the right foot. Interview with Licensed Practical Nurse (LPN) #11 on 03/31/22 at 9:45 A.M. revealed she witnessed the incident on 03/09/22 with Resident #26. LPN #11 reported Resident #26 was in the hallway petting the puppy. The next thing she knew, the puppy had taken off Resident #26's sock and the resident was bleeding from her left foot. LPN #11 stated she just looked at the wound this morning and it still had steri strips on it and the wound is crescent shaped and about one and a half inches in diameter. Example #2: Record review of Resident #29 revealed an admitted [DATE] with pertinent diagnosis of: Alzheimer's disease, cerebral infarction, major depressive disorder, [CONDITION(S)], dementia, hypertension, covid-19, fracture of right lower leg, cognitive communication deficit, [CONDITION(S)], muscle wasting and atrophy, volume depletion, traumatic ischemia of muscle, weakness, dehydration, and acute posthemorrhagic [CONDITION(S)]. Review of the 12/17/21 significant change Minimum Data Set (MDS) assessment revealed Resident #29 was severely cognitively impaired and required extensive assistance with ADLs. Review of an accident report dated 03/09/22 revealed while removing Resident #29's geri sleeves, it was found there were two small skin tears on Resident #29's right forearm. While lifting the puppy up to show her to the resident, the puppy pawed at the residents face and caused a red mark. The area was superficial and did not break the skin. Redness resolved within a few hours. Observation on 03/29/22 at 11:52 A.M. with the DON revealed Resident #29 was sitting in the 200 hallway dining room and the DON pointed out an area to her chin that had a red mark that was healed where the dog scratched her. Example #3: Record review of Resident #33 revealed an admitted [DATE] with pertinent diagnosis of: [CONDITION(S)] disease, dry eye syndrome, frontotemporal dementia, psychotic disorder with delusions, spastic [CONDITION(S)], [CONDITION(S)], cerebral infarction, repeated falls, hypertension, [CONDITION(S)], major depressive disorder, [CONDITION(S)], gastroeophagael reflux disease, retention of urine, [CONDITION(S)], vascular dementia with behavioral disturbance, peripheral vascular disease, tremor, restless leg syndrome, creutzfeldt-[NAME] disease, anxiety disorder, low back pain, age related nuclear cataract, and solitary cyst of left breast. Review of the 02/18/22 significant change Minimum Data Set (MDS) assessment revealed Resident #33 was moderately cognitively impaired and required total dependence or extensive assitance with ADLs. Review of progress note dated 03/21/22 5:00 P.M. revealed Resident #33 reported the puppy scratched her. Upon inspection, writer noticed several superficial scratches on resident's right forearm. The area was cleaned and aquaphor applied for protection. A new intervention of instructing staff to keep the puppy in play pen when not able to keep her in direct line of sight was initiated. Observation on 03/29/22 at 11:52 A.M. with the DON revealed Resident #33 did not have any signs of the dog scratching her. Review of the facility undated Pet and Service/Assistance Animal Policy and Guidelines revealed pets resided at the facility as part of their [NAME] Alternative philosophy. The policy also provides for those using service/assistance animals (SEM Haven residents or the general public) to be afforded independent access. All animals must be clean, have a good disposition, be well groomed and up to date with vaccinations as per veterinary guidelines. The facility reserves the right to ask that any pet be removed from the premises. How to handle adverse events or issues (aggressiveness, complaints, injuries): The pet was immediately removed from the situation and placed in an area with a closed door, the nurse in charge assesses any injuries and refers to M.D. if necessary, incident reports were filed if applicable, administration was notified, the situation was investigated to determine if the pet can remain in the facility, veterinarian is involved if applicable, and documentation would be kept in administration. This deficiency substantiates Complaint Number OH 172.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL, review of the facility's staff vaccination matrix, review of Time Sheets, staff interviews, and review of the facility's policy, the facility failed to have an appropiate vaccination policy and monitor staff members to ensure that 100% (percent) of staff have received at least one dose of a COVID-19 vaccine, have a pending request for exemption, or have been identified as appropriate for a temporary delay per Centers for Disease Control (CDC) guidance. The vaccination rate for the facility was calculated at 98.7%. The facility's census was 83. Findings include: Review of the undated facility staff COVID-19 vaccination matrix on 03/29/22 revealed the facility had a total of 162 employees. There were 117 employees fully vaccinated for COVID-19, 38 employees with medical or non-medical exemptions, five employees who were new hires with temporary delay, and two employees who were not completely vaccinated without exemption/delay. The facility's vaccination rate was 98.7%. Review of staff time sheets from 03/15/22 to 03/29/22 revealed there was one State tested Nurse Aide (STNA) #30 and one Licensed Practical Nurse (LPN) #31 that were not fully vaccinated, with no exemption who had been working since 03/15/22. Interview on 03/29/22 at 11:03 A.M. the Director of Nursing (DON) verified since 03/15/22 there was one STNA and one LPN that did not have any exemptions and was not fully vaccinated against COVID-19 that had worked. The DON verified STNA #30 worked on 03/16/22, 03/23/22 and 03/29/22. The DON verified LPN #31 on 03/15/22, 03/18/22, 3/19/22, 03/20/22, 03/21/22, 03/22/22, 03/23/22, 03/24/22, and 03/28/22. Interview on 03/29/22 at 11:05 A.M. the DON verified there had not been any resident cases of COVID-19 in the last 30 days. Review of the Centers for Medicare & Medicaid Services (CMS) memorandum, QSO-22-09-ALL regarding COVID-19 health care staff vaccination, dated 01/14/22, revealed CMS expected all providers' and suppliers' staff to have received the appropriate number of doses by the time frames specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by the Centers for Disease Control (CDC). Facility staff vaccination rates under 100% constitute non-compliance under this rule. Within 60 days after issuance of this memorandum, less than 100% of all staff have received at least one dose of a single-dose vaccine, or all doses of a multiple-dose vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is non-compliant under the rule. Review of the facility policy titled, Covid-19 Staff Vaccine Policy, revised 03/25/22 revealed staff would not be permitted to provide care, treatment, or other services for the communicty and/or its residents unless they met the following requirements: All staff hired or engaged before April 15, 2022 must have received, at a minimum, the first dose of a primary series or single dose COVID-19 vaccine by April 14, 2022. All staff hired or engaged before April 15, 2022, must be fully vaccinated against COVID-19 by May 14, 2022, unless completion of the vaccination process is delayed per CDC recommendations. Interview with the Administrator on 03/31/22 at 1:25 P.M verified the dates of the QSO-22-09 ALL memo and the facility policy were not in agreement. The QSO memo gave dates of single vaccine dose by 02/14/22 and the facility policy stated 04/14/22. While the QSO memo stated staff should be fully vaccinated by 03/15/22 and the facility policy stated 05/14/22.

Based on observation, staff interview, review of facility policy, and review of online resources from the Centers for Disease Control (CDC) and the Ohio Department of Health (ODH), revealed six randomly observed facility staff (Receptionist #100, State tested Nursing Assistant (STNA) #200, Administrator, Director of Nursing (DON), Registered Nurse (RN) #300 and Homemaker #400) failed to wear appropriate facemasks inside the facility to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). In addition, the facility failed to ensure residents wore facemasks when they were out of their rooms in the common areas of the nursing units/households. This had the potential to affect 17 (#19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34 and #35) residents residing on the Ripple Ridge unit/household, nine (#36, #37, #38, #40, #41, #42, #42, #43 and #45) residents residing on the Rehab unit/household, 17 (#46, #47, #48, #49, #50, #51, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62 and #63) residents residing on the McCormick Landing unit/household and 19 (#64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81 and #82) residents residing on the Canfield Court unit/household. Faciliy census was 79. Findings include: 1. Observations on 08/26/20 at 8:40 A.M. of Receptionist #100, at 8:55 A.M. of STNA #200, at 8:57 A.M. of the Administrator, at 8:59 A.M. of the DON, at 9:07 A.M. of RN #300, and at 9:12 A.M. of Homemaker #400 revealed employees were wearing cloth face coverings inside the facility. Interviews on 08/26/20 at 8:40 A.M. with Receptionist #100, at 8:55 A.M. with STNA #200, at 8:57 A.M. with the Administrator, at 8:59 A.M. with the DON, at 9:07 A.M. with RN #300, and at 9:12 A.M. with Homemaker #400 confirmed employees were wearing cloth face coverings while inside the facility. Interview on 08/26/20 at 9:20 A.M. with the Administrator confirmed staff were provided medical facemasks but were permitted to wear cloth face coverings if they preferred. Administrator further confirmed if staff were working on the Gatch unit/household which had confirmed COVID cases they would wear N-95 masks and face shields. Administrator confirmed on the other units/households (Ripple Ridge, Rehab, McCormick Landing, Canfield Court) staff were permitted to wear cloth face coverings if they were not providing direct resident care. Administrator confirmed the facility was experiencing an outbreak of COVID 19 with ten confirmed resident cases of COVID 19 in the facility all residing on the Gatch unit/household, and the remaining units (Ripple Ridge, Rehab, McCormick Landing, Canfield Court) were all under quarantine. Review of policy titled COVID 19 Plan updated 07/23/20 revealed all staff who entered the building must wear a mask and surgical masks should be prioritized for direct care personnel. Further review of the policy revealed all non-direct care staff should wear a cloth facemasks at all times, if not providing direct care to residents but should consider having health care personnel wear personal protective equipment (PPE) for all resident interactions if there were multiple cases of COVID 19 in the facility. The policy also revealed the facility would gain updated guidance from the CDC and ODH as it became available. Review of online resource from the CDC (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html) revealed the following information regarding cloth face coverings versus surgical facemasks and N-95 respirators: cloth face coverings are not considered PPE, cloth face coverings are not considered an appropriate substitute for PPE, health care workers should wear surgical masks or respirators (like N95 respirators) in the workplace to protect the wearer. 2. Observations on 08/26/20 at 9:07 A.M. of the Ripple Ridge unit/household, at 9:22 A.M. of the McCormick Landing unit/household, at 9:30 A.M. of the Canfield Court unit/household, and a 9:32 A.M. of the Rehab unit/household revealed multiple residents were out of their rooms in common household areas such as lounges or tv rooms but were not wearing face covering or facemasks. Interview on 08/26/20 at 9:07 A.M. with the Administrator confirmed residents on Ripple Ridge, McCormick Landing, Canfield Court, and Rehab units/households were not offered or recommended to wear masks when they were out of their rooms provided they remained on their unit/household, but residents would wear a mask if they needed to leave the unit for any reason. Interview on 08/26/20 at 9:20 A.M. with the Administrator confirmed the facility was experiencing an outbreak of COVID 19 with ten confirmed resident cases of COVID 19 in the facility all residing on the Gatch unit/household, and the remaining units (Ripple Ridge, Rehab, McCormick Landing, Canfield Court) were all under quarantine. Observation on 08/26/20 at 10:40 A.M. of the Ripple Ridge unit/household revealed residents were wearing facemasks while seated in the common area. Interview on 08/26/20 at 10:40 A.M. with Licensed Practical Nurse (LPN) #800 confirmed she thought residents were not required to wear masks when out of their rooms unless they had to leave the unit and the residents had not been wearing facemasks while out of their rooms at the start of her shift on 08/26/20. LPN #800 further confirmed she had been directed by the DON on 08/26/20 sometime in the morning after the surveyor's initial tour to ensure the residents wore facemasks when they were out of their rooms. Interview on 08/26/20 at 10:53 A.M. with the DON, the facility's infection preventionist, confirmed on 08/26/20 sometime after the surveyor's initial tour she directed the staff on Ripple Ridge, McCormick Landing, Canfield Court, and Rehab units/households to ensure residents wore facemasks when out of their rooms. The facility confirmed his had the potential to affect 17 (#19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34 and #35) residents residing on the Ripple Ridge unit/household, nine (#36, #37, #38, #40, #41, #42, #42, #43 and #45) residents residing on the Rehab unit/household, 17 (#46, #47, #48, #49, #50, #51, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62 and #63) residents residing on the McCormick Landing unit/household and 19 (#64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81 and #82) residents residing on the Canfield Court unit/household. Review of the facility policy titled COVID 19 Plan updated 07/23/20 revealed if a household was in isolation or quarantine, then residents would wear facemasks outside of their rooms on the household. Review of online resource from the CDC regarding preventing the spread of COVID-19 (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html) revealed the following guidance: COVID-19 can be spread to others even if you do not feel sick, everyone should wear a mask in public settings and when around people who don't live in the same household to prevent infecting others, continue to maintain a distance of about six feet between yourself and others, a mask is not a substitute for social distancing. Further review of information from the CDC specific to nursing homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) revealed residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. Cloth face coverings should not be placed on anyone who has trouble breathing, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance. In addition to the categories described above cloth face coverings should not be placed on children under two. Review of an online resource from ODH (https://coronavirus.ohio.gov/wps/portal/gov/covid-19/public-health-advisory-system/) on 08/26/20 revealed Clermont County, the county in which the facility was situated, was experiencing a very high exposure and spread of COVID 19 at the time of the survey. Review of ODH Director of Health order dated 07/23/20 revealed facial coverings were required at all times in the State of Ohio in any indoor space that was not a private residence.

Based on medical record review, observation, interview, review of manufacturer guidelines, review of International Pharmacopeia (YEAR) and review of facility policy the facility failed to discard medications after the recommend date and failed to label medications when opened. This directly affected one Resident (#238) whose insulin pen was not dated. The facility identified seven residents who received insulin with pens. This also directly affected three Residents (#22, #63, #68) who had eye medications that were dated beyond 30 days. The facility identified 61 residents who received eye drops. The census was 89 residents. Findings include: 1. Review of Resident #22's medical record revealed an admitted [DATE] and [DIAGNOSES REDACTED]. Review of (MONTH) 2109 physician orders [REDACTED]. 2. Review of Resident #63's medical record revealed an admitted [DATE] and [DIAGNOSES REDACTED]. Review of (MONTH) 2019 physician orders [REDACTED]. 3. Review of Resident #68's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of (MONTH) 2019 physician orders [REDACTED]. 4. Review of Resident #238's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of (MONTH) 2019 physician orders [REDACTED].>Observation on 08/21/19 from 11:00 [NAME]M. to 11:35 [NAME]M. of resident room medication storage areas revealed Resident # 22 had a bottle of artificial tears with a handwritten date of 04/17/19, Resident #63 had a bottle of artificial tears with a handwritten date of 01/15/19, Resident #68 had a bottle of Refresh [MEDICATION NAME] Gel with a handwritten open date of 07/18/19, and Resident #238 had an Basaglar insulin pen without any date written on the affixed label, there was a blank open date line. Interview during the observations with the facility Director of Nursing (DON) verified the above findings. She also stated she expected all insulin pens to be dated when removed from the refrigerator. Interview on 08/21/19 at 11:19 [NAME]M. with Licensed Practical Nurse (LPN) #422 reported the Basaglar insulin pen for Resident #238 was undated, currently in use, and should be discarded 28 days after usage began. Review of Lilly Pharmaceutical online instructions for Basaglar usage indicated - once you begin injecting with a Pen throw it away after 28 days. Review of International Pharmacopeia, Seventh Edition, dated (YEAR) revealed ophthalmic drop preparations may be used for up to four weeks after the container is initially opened. Review of facility policy titled Medication Storage, undated, revealed medications are stored under necessary conditions to ensure stability.

Based on record review and interviews, the facility failed to ensure a resident's discharge status or location was accurately documented the discharge assessment. This affected one (Resident #86) of 21 residents reviewed for accuracy of assessments. The facility census was 89. Findings include: Record review revealed Resident #86 was admitted to the facility on [DATE] with the following diagnoses; encounter for other specified after care, presence of right artificial hip join, unilateral primary [MEDICAL CONDITIONS] with lower urinary tract symptoms, retention of urine, hypertension, [DIAGNOSES REDACTED], anxiety disorder, [MEDICAL CONDITION], elevated white blood cell count, muscle wasting and atrophy and [MEDICAL CONDITION]. Further review of Resident #86's chart revealed resident discharged from the facility to an assisted living on 07/29/19. Review of Resident #86's discharge Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required supervision with bed mobility. transfer, dressing, eating and personal hygiene. Further review of the MDS revealed the resident discharged to an acute hospital. Review of Resident #86's progress note dated 07/29/19 revealed the resident was discharged to an assisted living on 07/29/19. Review of Resident #86's social services note dated 07/29/19 revealed the resident discharged to an assisted living on 07/29/19. Interview with Registered Nurse (RN) #340 on 08/21/19 at 2:29 P.M. verified Resident #86 discharged to an assisted living on 07/29/19. RN #340 confirmed Resident #86's discharge MDS dated [DATE] did not accurately reflect Resident #86's discharge status or location.