Every finding on record at Shepherd of the Valley Liberty

Based on record review, resident interview, and staff interview, the facility failed to have a system in place to provide well balanced meals to all residents during a power outage emergency. This affected four residents (#33, #37, #44, and #47) out of four reviewed for diet needs and had the potential to affect all eight residents identified by the facility as having orders for puree diet texture. The facility census was 66. Findings include:1. Review of the medical record for Resident #33 revealed an admission date of 11/27/19 and re-admission date of 05/13/25. Diagnoses included dementia, type two diabetes mellitus, adjustment disorder, and dysphagia oral phase. Review of the physician's orders for Resident #33 identified orders for a regular diet with pureed texture and honey consistency liquids effective 03/02/26 and house supplement two times daily effective 01/19/26. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 had severe cognitive impairment and required a mechanically altered diet texture. Review of the care plan revised 12/02/19 revealed Resident #33 was at risk for nutritional decline related to rectal sheath hematoma, dementia, hypertension, cerebral infarction, gastroesophageal reflux disease, and diabetes mellitus. Interventions included monitor oral intakes as needed (implemented 12/02/19), offer food alternatives when necessary (implemented 12/02/19), place food in bowls for all meals (implemented 12/05/24), house supplement as per order (implemented 07/23/25), and puree with thickened liquids (revised 08/04/25). Review of the progress notes, nurse aide tracking for oral intakes, and the Medication Administration Record (MAR) for Resident #33 revealed there was no documentation of any supplementation provided in addition to the routinely scheduled supplement ordered by the physician for 03/13/26 through 03/15/26. Review of the lunch and dinner tray tickets for 03/14/26 for Resident #33 revealed there was nothing on the tray tickets to indicate what foods were served for those meals. On 03/19/26 at 8:53 A.M., an interview with the Administrator verified the facility experienced a power outage which lasted from approximately 03/13/26 at 6:00 P.M. until 03/15/26 at 10:00 A.M. The Administrator stated facility operations continued on generator power. On 03/19/26 at 12:25 P.M., an interview with Dietary Supervisor #132 stated when the power was out, the gas stove was the only thing that worked in the kitchen. Dietary Supervisor #132 stated residents ordered pureed diet texture received mashed potatoes, stuffing, and tomato soup during the power outage because they could not use the food processor to puree anything. They could only serve foods that could be prepared using boiling water. Dietary Supervisor #132 was unable to state what protein sources were served to residents receiving pureed foods. Dietary Supervisor #132 further stated no record was kept of the foods served during the power outage. On 03/19/26 at 2:38 P.M., an interview with Dietary Director #105 confirmed the gas stove was the only thing that worked in the kitchen during the power outage because there were no red outlets (outlets connected to the generator) in the kitchen. Dietary Director #105 stated residents with orders for pureed diet texture received cream of wheat for breakfast during the power outage. On 03/19/26 at 3:38 P.M., an interview with Dietary Technician Registered (DTR) #123, with Regional Registered Nurse (RN) #102 present, stated she was only informed of the issues in the kitchen during the power outage after the fact. DTR #123 claimed all residents with orders for pureed diet texture also received nutritional supplements which provided protein. Regional RN #102 interjected and claimed the residents receiving pureed foods were provided protein sources during the power outage stating even tomato soup had three grams of protein per serving. Regional RN #102 indicated all residents receiving pureed foods received nutritional supplements to meet their protein needs. On 03/23/26 at 9:00 A.M., an interview with Registered Dietitian (RD) #120 confirmed residents were ordered supplements to meet daily nutritional requirements and was unable to state whether residents receiving pureed foods also received additional supplementation during the power outage. On 03/23/26 at 12:25 P.M., an interview with the Director of Nursing (DON) confirmed the tray tickets did not specify what foods were served during the power outage. 2. Review of the medical record for Resident #37 revealed an admission date of 03/10/25 with diagnoses including protein calorie malnutrition, gastroesophageal reflux disease, muscle wasting and atrophy, and diverticulosis. Review of the physician's orders for Resident #37 identified orders for a regular diet with pureed texture and regular consistency liquids effective 01/16/26 and house supplement two times daily effective 01/17/26. Review of the annual MDS assessment dated [DATE] indicated Resident #37 had no cognitive impairment and required a mechanically altered diet texture. Review of the care plan revised 07/11/25 revealed Resident #37 was at risk for nutritional decline related to protein calorie malnutrition, hypertension, diverticulosis, anemia, gastroesophageal reflux disease, and a history of significant weight loss on 04/24/25. Interventions included monitor daily oral intakes as needed (implemented 03/11/25), offer food alternatives when necessary (implemented 03/11/25), house supplement as per order (implemented 03/11/25), and pureed texture (implemented 01/29/26). Review of the progress notes, nurse aide tracking for oral intakes, and the Medication Administration Record (MAR) for Resident #37 revealed there was no documentation of any supplementation provided in addition to the routinely scheduled supplement ordered by the physician for 03/13/26 through 03/15/26. Review of the lunch and dinner tray tickets for 03/14/26 for Resident #37 revealed there was nothing on the tray tickets to indicate what foods were served for those meals. On 03/19/26 at 8:53 A.M., an interview with the Administrator verified the facility experienced a power outage which lasted from approximately 03/13/26 at 6:00 P.M. until 03/15/26 at 10:00 A.M. The Administrator stated facility operations continued on generator power. On 03/19/26 at 12:25 P.M., an interview with Dietary Supervisor #132 stated when the power was out, the gas stove was the only thing that worked in the kitchen. Dietary Supervisor #132 stated residents ordered pureed diet texture received mashed potatoes, stuffing, and tomato soup during the power outage because they could not use the food processor to puree anything. They could only serve foods that could be prepared using boiling water. Dietary Supervisor #132 was unable to state what protein sources were served to residents receiving pureed foods. Dietary Supervisor #132 further stated no record was kept of the foods served during the power outage. On 03/19/26 at 2:38 P.M., an interview with Dietary Director #105 confirmed the gas stove was the only thing that worked in the kitchen during the power outage because there were no red outlets (outlets connected to the generator) in the kitchen. Dietary Director #105 stated residents with orders for pureed diet texture received cream of wheat for breakfast during the power outage. On 03/19/26 at 3:38 P.M., an interview with DTR #123, with Regional RN #102 present, stated she was only informed of the issues in the kitchen during the power outage after the fact. DTR #123 claimed all residents with orders for pureed diet texture also received nutritional supplements which provided protein. Regional RN #102 interjected and claimed the residents receiving pureed foods were provided protein sources during the power outage stating even tomato soup had three grams of protein per serving. Regional RN #102 indicated all residents receiving pureed foods received nutritional supplements to meet their protein needs. On 03/23/26 at 9:00 A.M., an interview with RD #120 confirmed residents were ordered supplements to meet daily nutritional requirements and was unable to state whether residents receiving pureed foods also received additional supplementation during the power outage. On 03/23/26 at 9:24 A.M., an interview with Resident #37 stated she did not get enough to eat during the power outage. Resident #37 stated the facility provided some food, but not enough to satisfy her hunger and they did not provide anything additional like ice cream or health shakes. On 03/23/26 at 12:25 P.M., an interview with the DON confirmed the tray tickets did not specify what foods were served during the power outage. 3. Review of the medical record for Resident #44 revealed an admission date of 07/11/24 with diagnoses including dysphagia oropharyngeal phase, respiratory failure, gastroesophageal reflux disease, intellectual disabilities, and cognitive communication deficit. Review of the physician's orders for Resident #44 identified orders for a regular diet with pureed texture and nectar consistency liquids effective 10/21/24 and house supplement one time daily effective 05/01/25. Review of the care plan revised 04/24/25 revealed Resident #44 was at risk for nutritional decline related to respiratory failure, dysphagia, gastroesophageal reflux disease, and adult failure to thrive. Interventions included pureed diet with nectar thick liquids (implemented 10/21/24), monitor daily oral intake as needed (implemented 10/21/24), offer food alternatives when necessary (implemented 10/21/24), and house supplement as per order (implemented 04/24/25). Review of the quarterly MDS assessment dated [DATE] indicated Resident #44 had severe cognitive impairment and required a mechanically altered diet texture. Review of the progress notes, nurse aide tracking for oral intakes, and the Medication Administration Record (MAR) for Resident #44 revealed there was no documentation of any supplementation provided in addition to the routinely scheduled supplement ordered by the physician for 03/13/26 through 03/15/26. Review of the lunch and dinner tray tickets for 03/14/26 for Resident #44 revealed there was nothing on the tray tickets to indicate what foods were served for those meals. On 03/19/26 at 8:53 A.M., an interview with the Administrator verified the facility experienced a power outage which lasted from approximately 03/13/26 at 6:00 P.M. until 03/15/26 at 10:00 A.M. The Administrator stated facility operations continued on generator power. On 03/19/26 at 12:25 P.M., an interview with Dietary Supervisor #132 stated when the power was out, the gas stove was the only thing that worked in the kitchen. Dietary Supervisor #132 stated residents ordered pureed diet texture received mashed potatoes, stuffing, and tomato soup during the power outage because they could not use the food processor to puree anything. They could only serve foods that could be prepared using boiling water. Dietary Supervisor #132 was unable to state what protein sources were served to residents receiving pureed foods. Dietary Supervisor #132 further stated no record was kept of the foods served during the power outage. On 03/19/26 at 2:38 P.M., an interview with Dietary Director #105 confirmed the gas stove was the only thing that worked in the kitchen during the power outage because there were no red outlets (outlets connected to the generator) in the kitchen. Dietary Director #105 stated residents with orders for pureed diet texture received cream of wheat for breakfast during the power outage. On 03/19/26 at 3:38 P.M., an interview with DTR #123, with Regional RN #102 present, stated she was only informed of the issues in the kitchen during the power outage after the fact. DTR #123 claimed all residents with orders for pureed diet texture also received nutritional supplements which provided protein. Regional RN #102 interjected and claimed the residents receiving pureed foods were provided protein sources during the power outage stating even tomato soup had three grams of protein per serving. Regional RN #102 indicated all residents receiving pureed foods received nutritional supplements to meet their protein needs. On 03/23/26 at 9:00 A.M., an interview with RD #120 confirmed residents were ordered supplements to meet daily nutritional requirements and was unable to state whether residents receiving pureed foods also received additional supplementation during the power outage. On 03/23/26 at 12:25 P.M., an interview with the DON confirmed the tray tickets did not specify what foods were served during the power outage. 4. Review of the medical record for Resident #47 revealed an admission date of 05/01/25 and re-admission date of 11/07/25. Diagnoses included chronic obstructive pulmonary disease, gastroesophageal reflux disease, mild cognitive impairment, and major depressive disorder. Review of the physician's orders for Resident #47 identified orders for a regular diet with pureed texture and nectar consistency liquids effective 01/10/26, Magic Cup supplement with meals effective 01/21/26, and house supplement with meals for weight loss effective 01/28/26. Review of the care plan revised 01/21/26 revealed Resident #47 was at risk for nutritional decline related to chronic obstructive pulmonary disorder, respiratory failure, hypertension, depression, gastroesophageal reflux disease, heart failure, and history of significant weight loss on 10/02/25 and 01/21/26. Interventions included monitor daily oral intakes as needed (implemented 05/06/25), offer food alternatives when necessary (implemented 05/06/25), house supplement as per order (implemented 07/08/25), puree with nectar thick liquids (implemented 01/12/26), and Magic Cup as per order (implemented 01/21/26). Review of the quarterly MDS assessment dated [DATE] indicated Resident #47 had moderately impaired cognition, had experienced significant weight loss not on a prescribed weight loss regimen, and required a mechanically altered diet texture. Review of the progress notes, nurse aide tracking for oral intakes, and the Medication Administration Record (MAR) for Resident #47 revealed there was no documentation of any supplementation provided in addition to the routinely scheduled supplements ordered by the physician for 03/13/26 through 03/15/26. Review of the lunch and dinner tray tickets for 03/14/26 for Resident #47 revealed there was nothing on the tray tickets to indicate what foods were served for those meals. On 03/19/26 at 8:53 A.M., an interview with the Administrator verified the facility experienced a power outage which lasted from approximately 03/13/26 at 6:00 P.M. until 03/15/26 at 10:00 A.M. The Administrator stated facility operations continued on generator power. On 03/19/26 at 12:25 P.M., an interview with Dietary Supervisor #132 stated when the power was out, the gas stove was the only thing that worked in the kitchen. Dietary Supervisor #132 stated residents ordered pureed diet texture received mashed potatoes, stuffing, and tomato soup during the power outage because they could not use the food processor to puree anything. They could only serve foods that could be prepared using boiling water. Dietary Supervisor #132 was unable to state what protein sources were served to residents receiving pureed foods. Dietary Supervisor #132 further stated no record was kept of the foods served during the power outage. On 03/19/26 at 2:38 P.M., an interview with Dietary Director #105 confirmed the gas stove was the only thing that worked in the kitchen during the power outage because there were no red outlets (outlets connected to the generator) in the kitchen. Dietary Director #105 stated residents with orders for pureed diet texture received cream of wheat for breakfast during the power outage. On 03/19/26 at 3:38 P.M., an interview with DTR #123, with Regional RN #102 present, stated she was only informed of the issues in the kitchen during the power outage after the fact. DTR #123 claimed all residents with orders for pureed diet texture also received nutritional supplements which provided protein. Regional RN #102 interjected and claimed the residents receiving pureed foods were provided protein sources during the power outage stating even tomato soup had three grams of protein per serving. Regional RN #102 claimed that all residents receiving pureed foods received nutritional supplements to meet their protein needs. On 03/23/26 at 9:00 A.M., an interview with RD #120 confirmed residents were ordered supplements to meet daily nutritional requirements and was unable to state whether residents receiving pureed foods also received additional supplementation during the power outage. On 03/23/26 at 12:25 P.M., an interview with the DON confirmed the tray tickets did not specify what foods were served during the power outage. This deficiency represents non-compliance investigated under Complaint Number 2807611.

Based on observation, interview and record review, the facility did not ensure food was stored, prepared and served in accordance with professional standards for food safety. This had the potential to affect 54 residents who received meals from the kitchen. The facility identified seven residents (Resident #19, #6, #8, #33, #70, #71 and #1) who received nothing by mouth (NPO). The facility census was 61. Findings Include:Observation on 09/15/25 at 9:54 A.M. of the dry food storage room in the main kitchen revealed the following food items were not dated with the date received: four one-gallon tubs of mayonnaise, one one-gallon Caesar salad dressing tub, one one-gallon Thousand Island dressing tub, two seven-pound five-ounce cans of jellied cranberry sauce, two six-pound cans of diced beets, one six-pound can of fruit cocktail, three six-pound cans of diced peaches, nine six-pound nine-ounce cans of diced apples, nine six-pound nine-ounce cans of diced pears, and six six-pound three-ounce cans of shredded sauerkraut.Observation on 09/15/25 at 9:55 A.M. of the main kitchen dry food storage revealed the following food items were open and wrapped in plastic wrap, not dated of when opened nor were they marked with an expiration date on the following items: a blueberry muffin mix, and a five-pound powdered sugar.Observation on 09/15/25 at 10:00 A.M. of the main kitchen walk-in freezer revealed a clear plastic bag of potato wedges opened to air with no label or date on the bag, sweet potato fries in a plastic bag open to air not dated or labeled, and four rainbow sherbets were scooped in plastic serving bowls were not labeled or dated.Interview on 09/15/25 at 10:03 A.M. with Chef Dietary Director (CDD) #656 verified the freezer items were not labeled, dated when opened, and food was open to freezer air. CDD #656 also verified the food in the main kitchen dry food storage cans were not dated with a date received. CDD #656 stated the food items should be dated and employees should date food upon arrival at the kitchen and when the package was opened. CDD #656 confirmed food should not be left open to air exposure.Observation on 09/16/25 at 12:14 P.M. of the dining room kitchen revealed a Purell Foodservice Sanitizer Multipurpose Cleaner was on the resident food preparation area next to food being served during meal service. Interview on 09/16/25 at 12:20 P.M. with Dietary Aid #657 revealed cleaning chemicals were to be stored away from the resident food preparation area and verified the Purell Foodservice Sanitizer All-purpose cleaner was stored by the resident food preparation area during meal service. Review of facility education titled, Food Safety and Sanitation, dated 07/21/25, revealed storage guidelines of food consisting of first-in first-out, labeling and expiration checks.Review of the facility document titled State of Ohio Food Inspection Report, dated 09/10/25, revealed under the section Conformance with Approved Procedures, the facility was out of compliance with critical control point investigation. Observation included toxic materials improperly identified, stored and used. The Purell bottle on prep counter, the bottle was moved and stored chemicals away from food prep surfaces. The document was signed by the [NAME] County Health District. Review of facility policy titled, Food Safety Requirements , Use and Storage of Food and Beverage, Food Procurement, undated, revealed the facility would prevent foodborne illness when food was received from the vendor and continued throughout the facility food handling process.

Based on record review and interview, the facility administration failed to ensure an effective system was in place to maintain current cardiopulmonary resuscitation (CPR) certification for the licensed nurses for the highest practicable well being of all residents. This had the potential to affect all 61 residents residing in the facility. Findings include:Review of personnel files on [DATE] at 2:39 P.M. with Human Resources Director (HRD) #742 revealed Licensed Practical Nurse (LPN) #694's CPR (cardiopulmonary resuscitation) certification expired 03/2025 and was renewed on [DATE]. LPN #696's CPR certification expired [DATE] and was renewed on [DATE]. LPN #684's CPR certification expired 02/2025 and was renewed on [DATE]. LPN #690's CPR certification expired on 01/2025 and was renewed on [DATE]. LPN #697's CPR certification expired on 03/2024 and was renewed on [DATE]. LPN #691's CPR certification expired 06/2025 and was renewed on [DATE]. Registered Nurse (RN) #713's CPR certification expired 02/2024 and was renewed on [DATE]. LPN #686's CPR certification expired on 02/2025 and was renewed on [DATE]. The Director of Nursing (DON)'s CPR certification expired 07/2025 and was renewed [DATE]. Interview on [DATE] at 2:39 P.M. with HRD #742 verified the above findings. HRD #742 stated CPR certification was tracked and some lapses in the nurses CPR recertification were found through the tracking process.Interview on [DATE] at 9:34 A.M. with the DON revealed corporate takes care of CPR so the DON would not have been aware some nurses working in the facility did not remain current with CPR certification. The DON stated she took her CPR recertification through the American Heart Association and offered staff to attend if they wanted CPR certification. The DON stated they had very few codes in the facility. The DON confirmed staff who performed CPR were required to maintain current CPR certification. Review of the facility policy titled Cardiopulmonary Resuscitation Certification, updated [DATE], revealed it was the policy of the facility to ensure all direct care staff be trained and maintain certification for cardiopulmonary resuscitation. All nursing and direct care staff were required to maintain current CPR certification. This certification was a condition of employment. Failure to obtain certification within 30 days of expiration would result in removal from the work schedule and might lead to disciplinary action.This deficiency represents non-compliance investigated under Complaint Number 2584291.

Based on observation, interview, record review and review of facility policy, the facility did not ensure transmission-based precautions were followed by staff during resident care. This affected two residents (#57 and #71) of five residents reviewed for infection control and had the potential to affect an additional nine residents ( #33, #16, #35, #73, #6, #70, #8, #3, and #19) who resided on the 300 and 500 halls . The facility census was 61.Findings include:1. 1. Review of the medical record for Resident #57 revealed an admission date of 01/18/25 with diagnoses including spinal stenosis, atrial fibrillation, disease of larynx, malignant neoplasm of mouth, type two diabetes, hypertension, non-pressure chronic wound, urinary incontinence, and hematuria. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #57's cognition was intact. Resident #57 needed maximum assistance for toilet hygiene, bathing, and lower body dressing. Resident #57 needed moderate assistance to sit on the side of the bed, and was dependent on staff to stand and transfer from the bed to the chair, and to walk ten feet. Resident #57 was occasionally incontinent of urine and frequently incontinent of bowel. Resident #57 was on an antibiotic. Resident #57 received four days of restorative therapy that consisted of transfer and walking. Review of the care plan, date initiated 01/31/25 and revised 09/16/25, revealed Resident #57 was incontinent of bowel and bladder, needed assistance with toileting and peri care. Contact isolation due to pseudomonas in urine . Interventions included maintaining dignity of resident by maintaining comfort, good hygiene and intact skin. Check for incontinence episode upon rounds and as needed. Contact isolation. Peri care upon each incontinence episode and maintain turn schedule. Review of physician orders dated 08/26/25 revealed Resident #57 had an occupational therapy evaluation completed. Resident #57 was to be seen for 20 visits in 60 days for activities of daily living training, therapy exercise, and therapy activities. Review of a physician order dated 09/15/25 revealed Resident #57 was on Contact Isolation for psuedomonas of urine. Review of the facility document titled Occupational Therapy Treatment Encounter, start date 02/05/25, revealed Resident #57 had fall precautions and Contact Isolation precautions due to pseudomonas of urine and lower extremity skin sores. Review of the facility document titled Occupational Therapy Treatment Encounter, date of service 09/15/25, revealed Certified Occupation Therapy Assistant (COTA) #731 provided Resident #57 with skilled service that included bilateral upper extremities therapeutic exercise to increase strength, and range of motion. This included functional transfer from wheelchair level with minimal assistance, use pf four-wheel walker for support during dynamic activities, gross motor skills, and fine motor coordination. Observation on 09/15/25 at 2:00 P.M. of Resident #57 in his room standing behind a four-wheeled walker while COTA #731 provided hands on assistance holding on to Resident #57's gown and brief for support. COTA #731 was observed to make physical contact with Resident #57 without wearing gloves or a protective gown. Posted on the door to the resident's room was a Contact Isolation sign. Interview on 09/15/25 at 2:02 P.M. with COTA #731 verified Resident #57's door had a Contact Isolation sign posted on the front of the door . COTA #731 stated it slipped her mind and verified she did not wear personal protective equipment such as a gown or gloves while touching Resident #57. COTA #57 stated she was standing behind Resident #57 while holding the back of Resident #57's gown and brief for support. Observation on 09/15/25 at 2:32 P.M. of certified nurse assistant (CNA) #732 revealed Resident #57's call light rang, CNA #732 knocked on Resident #57's door and entered the room. CNA #732 was observed not to put on a protective gown or gloves prior to entering Resident #57's room. Interview on 09/15/25 at 2:37 P.M. with CNA #732 revealed she assisted Resident #57 to the toilet and CNA #732 verified a Contact Isolation sign was posted on Resident #57's door and stated she did not wear protective gown or gloves because she was not aware. Interview on 09/15/25 at 2:39 P.M. with Licensed Practical Nurse (LPN) #239 revealed Resident #57 was on Contact Precautions because of urinary issues that needed an antibiotic. LPN #239 stated gloves, and a protective gown should be worn especially if contact/touch assist was needed to care for Resident #57. Interview on 09/18/25 at 9:57 A.M. with the Assistant Director of Nursing (ADON) #627 revealed Resident #57 needed Contact Isolation due to multi-drug-resistant organism. ADON #627, who also served as the facility Infection Preventionist, stated staff were to wear a protective gown and gloves and wash hands prior to entering Resident #57's room. Review of facility policy titled, Transmission Based Precautions, dated 06/15/19, revealed Contact Precautions was intended to prevent transmission of infectious agents which spread by direct contact with the resident or resident environment. Healthcare personnel caring for residents with Contact Precautions wear gowns and gloves for all interaction that involve contact with the resident or potentially contaminated areas in the residents environment. Putting on personal protective equipment upon room entry and discarding before exiting the room was done to contain pathogens. 2. Review of Resident #71's medical record revealed an admission date of 08/05/25 and a re-entry date of 09/12/25. Resident #71's diagnoses included ventilator associated pneumonia, emphysema, and resistance to multiple antimycobacterial drugs. Review of Resident #71's Quarterly MDS 3.0 assessment dated [DATE] included Resident #71 was cognitively intact. Resident #71 required substantial to maximal assistance with personal hygiene, toileting hygiene and bathing. Review of Resident #71's physician orders dated 09/13/25 revealed Droplet Isolation precautions related to MRSA (Methicillin resistant staphylococcus aureus), CRO (carbapenem-resistant organisms), MDRO (multi-drug resistant organism), every shift. Review of Resident #71's care plan dated 09/17/25 included Resident #71 had a respiratory infection related to carbapenems organism. Resident #71 would be free from signs and symptoms of infection by the review date of 11/10/25. Interventions included to maintain strict Droplet Isolation precautions with all services including therapies if warranted with all staff wearing PPE of gloves, gown, mask and face shield while remaining in a private room with no roommates. Observation on 09/15/25 at 3:32 P.M. of Resident #71's room revealed Resident #71's room had a Droplet Isolation sign on the door and a plastic cart with PPE (personal protective equipment) was observed outside the entrance to Resident #71's room. Certified Nursing Assistant (CNA) #630 was observed in Resident #71's room, she was standing close to his bed and was talking to him. CNA #630 had not donned PPE such as not wearing face mask, isolation gown, gloves or face shield before she entered the room and began talking to Resident #71. Licensed Practical Nurse (LPN) #741 was observed in Resident #71's room adjusting his tube feeding and looking at his PEG (percutaneous endoscopic gastrostomy) tube. LPN #741 had gloves on but was not wearing a face mask, face shield, or isolation gown. Two visitors were observed in Resident #71's room and neither visitor had a face mask, face shield, isolation gown or gloves on. The visitors were sitting in chairs near Resident #71's bed. When asked if LPN #741 saw the Droplet Isolation sign on Resident #71's door and the plastic cart with PPE supplies LPN #741 stated she saw the Droplet Isolation sign, did not know why Resident #71 was on Droplet Precautions, but thought it was due to MRSA. LPN #741 confirmed she was not wearing a face mask, face shield or isolation gown and she should be. CNA #630 walked out of Resident #71's room and confirmed she was not wearing a face mask, face shield, isolation gown or gloves. CNA #630 did not know why Resident #71 was on Droplet Precautions and stated I was only talking to him. Interview on 09/15/25 at 3:54 P.M. of the Director of Nursing (DON) and Assistant Director of Nursing/ Infection Preventionist (ADON/IP) #627 revealed they were told LPN #741, CNA #630 and two visitors were in Resident #71's room and were not wearing appropriate PPE. ADON/IP #627 stated they should have donned PPE because Resident #71 was on Droplet Precautions for CRO. Review of the facility policy titled Transmission-Based Precautions revised 06/05/19 included Droplet Precautions was intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (for example, respiratory droplets that were generated by a resident who was coughing, sneezing, or talking). Make decisions regarding private room on a case-by-case basis after considering infections risks to other residents in the room and available alternatives. Healthcare personnel wear a mask for close contact with infectious resident.

Based on observation, record review and interview, the facility did not ensure Resident #28's Power of Attorney (POA) was notified of a change of condition. This affected one resident (#28) of three residents reviewed for change of condition. The facility census was 61.Findings include: Review of Resident #28's medical record revealed an admission date of 06/26/23 and diagnoses of cerebral infarction, hemiplegia affecting the left nondominant side and congestive heart failure.Review of Resident #28's care plan revised 06/30/25 included Resident #28 was incontinent of bowel and bladder, had weakness, fatigue, and needed assistance with toileting and peri care related to diagnoses of left sided hemiparesis on the non dominant side, cerebral infarction and other diagnoses. Resident #28 to be less incontinent of bowel and/or bladder over the next 90 days. Interventions included to monitor for episodes of incontinence and continence; monitor for signs of urinary infections such as odors, concentrated urine etcetera and report to the nurse, physician.Review of Resident #28's Annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #28 was cognitively intact. Resident #28 was dependent for toileting hygiene and required partial to moderate assistance with personal hygiene. Resident #28 was frequently incontinent of urine. Review of Resident #28's progress notes dated 08/27/25 at 4:18 P.M. revealed Physician #735 gave new orders for a urinalysis and urine culture and sensitivity. There was no evidence documented to reflect Resident #28's POA was notified of the order.Review of Resident #28's physician orders dated 08/27/25 revealed urinalysis and urine culture and sensitivity, discontinue order once specimen was obtained. Review of Resident #28's progress notes dated 08/28/25 to 09/03/25 revealed no evidence Resident #28's POA was notified of physician orders to collect a urinalysis for culture and sensitivity testing. Review of Resident #28's physician orders dated 09/03/25 at 7:17 A.M. revealed urine for urinalysis and urine culture and sensitivity, every shift, discontinue once obtained. Review of Resident #28's progress notes dated 09/04/25 at 10:48 P.M. included Resident #28 was straight cathed for urinalysis and urine culture and sensitivity and 75 cc of dark yellow urine was obtained. There was no evidence documented to reflect Resident #28's POA was notified.Review of Resident #28's lab report revealed Resident #28's urine was collected on 09/05/25 at 12:00 P.M., was received on 09/05/25 at 3:11 P.M. and reported on 09/09/25 at 2:39 P.M. Resident #28's final report included greater than 100,000 CFU (colony forming units) per milliliter of Providencia stuartii (gram-negative bacterium, causes healthcare associated infections).Review of Resident #28's progress notes dated 09/09/25 at 3:18 P.M. revealed Resident #28's final report for the urinalysis and urine culture and sensitivity was sent to Physician #735 and was awaiting response. There was no evidence documented to reflect Resident #28's POA was notified of the result.Review of Resident #28's progress notes dated 09/10/25 at 2:18 A.M. revealed new orders for cefpodoxime 100 mg, two times a day for seven days for UTI (urinary tract infection), if no allergies. There was no evidence documented to reflect Resident #28's POA was notified of the order.Interview on 09/15/25 at 12:04 P.M. with POA #736 revealed she was Resident #28's daughter and was also her POA. POA #736 stated she was not called by the facility and notified Resident #28 had a potential urinary tract infection or notified Resident #28 had a urinary tract infection. POA #736 indicated she was upset she was not contacted.Observation on 09/16/25 at 3:37 P.M. of Resident #28 revealed she was sitting in a chair in her room, was agreeable to have a conversation and answered questions appropriately. Resident #28 stated she was receiving antibiotics now and was having pain with urination before she started getting the antibiotics. Resident #28 indicated she told a nurse she was having discomfort when she went to the bathroom and now I am getting antibiotics. Resident #28 confirmed her daughter was POA and the facility was to keep her daughter informed about her care. Interview on 09/18/25 at 3:47 P.M. with the Director of Nursing (DON) verified no documented evidence Resident #28's daughter had been notified of the residents change of condition, urinalysis results and treatment with antibiotics.

Based on observation, interview and record review the facility failed to ensure assistance from staff was provided to maintain good hygiene for Resident #3. This affected one resident (Resident #3) out of three residents reviewed for assistance with activity of daily living (ADL). The facility census was 61.Findings include:Review of Resident #3's medical record revealed an admission date of 05/15/24 and a re-entry date of 12/24/24. Resident #3's medical diagnoses included multiple sclerosis, acute respiratory failure with hypoxia, quadriplegia, contracture of joint and flaccid neuropathic bladder.Review of Resident #3's Quarterly Minimum Data Set 3.0 assessment, dated 08/12/25, revealed Resident #3 was cognitively intact. Resident #3 had impairment of both sides of the upper and lower extremities. Resident #3 was dependent for Activity of Daily Living's (ADLs) including showering/bathing, personal hygiene and for bed mobility. Review of Resident #3's care plan, revised 05/16/25, revealed Resident #3 needed assistance with ADLs related to a diagnosis of Multiple Sclerosis. There were no specific ADL interventions listed regarding showering/bathing or hygiene. Observation on 09/18/25 at 8:48 A.M. of Resident #3 revealed he was lying in bed on his left side while watching television. The fingers on both hands were clenched tightly up against the palm of his hands, and his legs were contracted up towards his chest. Resident #3 was alert, oriented to person, place, time and situation and able to answer questions. There was a pervasive, sweet and unpleasant odor in the room. Interview on 09/18/25 at 8:51 A.M. with Licensed Practical Nurse (LPN) #684 revealed Resident #3's hands were always clenched. LPN #684 indicated Resident #3 always had that smell, and it could be related to a yeast infection he had in his [NAME] area, but she was not sure.Observation on 09/18/25 at 9:10 A.M. of Resident #3 with LPN #684 revealed he was lying in bed and a sweet, unpleasant odor was noticed when his room was entered. Certified Nursing Assistant's (CNA)'s #631, #634 and #740 were preparing to assist Resident #3 with a bed bath. CNA #740 stated this was not Resident #3's shower day but they were going to give him a bed bath because an odor was noted in his room. Resident #3's legs were bent up towards his chest and his hands were in a clenched position. LPN #684 was called out of Resident #3's room by another staff member, so she walked out of Resident #3's room. Upon closer observation of Resident #3's hands, it was observed that Resident #3's fingernails were approximately a half inch long, yellow in color and underneath each nail was brown material. CNA #740 confirmed Resident #3's fingernails were long, yellow in color with brown material under them. CNA #740 indicated she never cut his nails and would tell a nurse about them being long. CNA's #631, #634 and #740 proceeded to provide Resident #3's morning care and while washing his hands a moderate amount of yellow material was noted on the wash cloth. CNA #740 stated the yellow material smelled and that was where the sweet, unpleasant odor was coming from. CNA's #631, #634 and #740 confirmed Resident #3's hands were not being kept properly clean and there was a smell noted. Interview on 09/22/25 at 12:40 P.M. with Restorative Registered Nurse (RRN) #719 revealed there should always be towel rolls placed in Resident #3's hands due to the clenching and she would make sure going forward the towel rolls would be placed. RRN #719 confirmed Resident #3's fingernails were about a half inch long with some brown material underneath the nails. RRN #719 stated Resident #3 was a two person assist for hand care due to his contractures and another staff member assisted her to clean and trim Resident #3's fingernails. RRN #719 confirmed Resident #3 had an odor, and stated he is so moist, but she was not sure what the source of the odor was.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure thorough post-fall investigations were completed to identify, evaluate and analyze risks, implement appropriate interventions, and monitor for effectiveness of interventions to mitigate risk of subsequent falls for Resident #34. This affected one resident (Resident #34) out of three residents reviewed for falls. The facility census was 61.Findings include:Review of Resident #34's medical record revealed an admission date of 07/11/25 with diagnoses including ataxic gait, dementia, macular degeneration and Meniere's Disease. Review of Resident #34's Fall Risk Evaluation dated 07/16/25 revealed Resident #34 was at high risk for falls.Review of Resident #34's admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #34 had severe cognitive impairment. Resident #34 had upper extremity impairment on both sides. Resident #34 was dependent for toileting hygiene, required partial to moderate assistance with personal hygiene, and required substantial to maximal assistance with bathing and dressing. Resident #34 had a fall in the last month prior to admission to the facility.Review of Resident #34's care plan dated 07/23/25 included Resident #34 had a fall on 07/20/25 with no injury due to poor balance, poor communication, comprehension, psychoactive drug use, unsteady gait, and Meniere's Disease. Resident #34 would resume usual activities without further incident through the review date. Interventions included to check range of motion, continue interventions on the at-risk plan for no apparent acute injury, determine and address causative factors of the fall, monitor, document and report as needed for 72 hours to the physician for signs and symptoms of pain, bruises, change in mental status, and Physical Therapy consult for strength and mobility.Review of the facility incident log dated 08/21/25 at 4:00 P.M. revealed Resident #34 was found on the floor.Review of Resident #34's progress notes dated 08/21/25 at 10:32 P.M. revealed Resident #34 was found on the floor in front of her recliner. Resident #34 used the button incorrectly causing the chair to rise and she slid to the floor. Resident #34 had no visible injuries and stated she had the same pain in her knee that she had. ROM (range of motion) normal per resident. Assisted to bed. Physician #735 and Resident #34's daughter were notified. There was indication a new intervention was implemented to reduce reoccurrences.Review of Resident #34's Interdisciplinary Fall Incident Investigation, review date 08/22/25, revealed Resident #34 had a fall on 08/21/25 at 4:00 P.M There were no witnesses to the fall. Resident #34 was assisted to bed, neurological checks were initiated, range of motion and vital signs were within normal limits. There were no vital signs documented. While passing by Resident #34's room an aide (unidentified) found her on the floor in front of her chair. Resident #34 stated she used a button on her chair and it changed position causing her to slide to the floor. Resident #34 stated she pushed the wrong button on her recliner and instead of going up and back, she slid down to the floor. Resident #34 denied hitting her head and complained of knee pain which she had previous to the fall. The investigation indicated Resident #34's care plan was reviewed and updated.Review of Resident #34's progress notes dated 08/28/25 at 4:51 P.M. revealed Resident #34 was observed on the floor. Resident #34 was sitting in an upright position on the floor in front of her recliner. A head-to-toe assessment was completed and a 3.0 cm by 2.5 cm goose egg was found on top of Resident #34's head. Vital signs were obtained: blood pressure 164/79, temperature 97.7 Fahrenheit, heart rate 74, respirations 18 and Resident #34's oxygen saturation was 97 percent on room air. Resident #34 was one assisted into a wheelchair and taken to the dining area for supper. There was no evidence Resident #34 had a new individualized fall intervention implemented.Review of the facility incident log dated 08/28/25 did not reveal evidence Resident #34 experienced a fall on 08/28/25 at 4:51 P.M.Review of Resident #34's progress notes dated 08/28/25 at 6:12 P.M. included Resident #34's physician ordered her sent to the Emergency Department for evaluation due to the size of the goose egg on her head. Resident #34's daughter was updated.Review of Resident #34's fall investigations provided by the facility did not include a fall investigation for the fall on 08/28/25 at 4:51 P.M.Review of the facility incident log dated 09/12/25 revealed Resident #34 had a witnessed fall on 09/12/25 at 3:30 P.M. Review of Resident #34's progress notes dated 09/12/25 at 3:30 P.M. included a visitor notified the nurse that Resident #34 was sliding out of her recliner. Resident #34 was observed lowering herself to the floor, sliding down the recliner. Resident #34 denied pain and stated she was going to the bathroom to brush her teeth but couldn't stand up. Vital signs were checked and Resident #34 was assisted into bed. No bruising was noted to Resident #34's bottom. All safety measures in place and Resident #34 was placed on every two hour checks for 24 hours.Review of Resident #34's Interdisciplinary Fall Incident Investigation included the date of the witnessed fall was 09/12/25 at 5:45 P.M. (the progress notes and incident log stated the time was 3:30 P.M.) and the review date was 09/14/25. The Investigation report included the fall information from Resident #34's progress note on 09/12/25 at 3:30 P.M. Resident #34 was provided a quiet environment for rest, all safety measures in place, frequent checks, one-to-one interventions. Resident #34's care plan was reviewed and updated. Further review of Resident #34's care plan, last revised on 08/11/25, revealed no notation of falls occurring on 08/21/25, 08/28/25 and 09/12/25, nor any updates to interventions after 07/23/25 to try to prevent subsequent falls. Interview on 09/22/25 at 1:56 P.M. with Licensed Practical Nurse (LPN) #685 revealed Resident #34 was incontinent, confused at times, and sometimes would ask to go to the bathroom. LPN #685 stated Resident #34 required the assistance of one staff member and used a front wheeled walker. Observation on 09/22/25 at 2:06 P.M. with CNA #743 and CNA #744 revealed Resident #34 was lying in bed with her eyes closed and appeared to be sleeping. Certified Nursing Assistant (CNA) #743 stated Resident #34 asked to be toileted so CNA #743 assisted her for toileting then assisted her to bed using a gait belt and a wheelchair. CNA #743 indicated Resident #34 often asked to be toileted. CNA #744 stated she worked second shift and knew Resident #34 well. When asked if Resident #34 was at risk for falls, CNA's #743 and #744 stated Resident #34 was not a fall risk so she did not have fall mats by her bed. Interview with LPN #685 on 09/22/25 at 2:07 P.M. indicated she did not think Resident #34 was a fall risk, but would check her orders. LPN #685 checked Resident #34's orders and stated she was a one assist for transfers, wore non skid socks and an order dated 09/12/25 revealed she was on two hour checks for falls. LPN #685 indicated Resident #34 might be a fall risk. Interview on 09/22/25 at 2:39 P.M. of the Director of Nursing (DON) revealed a fall risk assessment was not and did not need completed after every fall for Resident #34. The DON stated a team huddle was completed after a resident fall including Resident #34 and the falls were reviewed. The DON indicated that after a fall happened, new person centered interventions were added to the resident's care plan and aide tasks for Resident #34 so the care staff knew what her needs were to prevent falls. The DON stated a fall paper packet was completed after a fall, but that fall paper packet was not included as part of the resident medical record.Review of the facility policy titled Falls, Incidents, undated, included when a resident was found on the floor, the facility was obligated to investigate to determine how he/she got there, and to put into place an intervention to prevent this from happening again. Once a fall incident occurred, the name of any witnesses and their accounts of the accident or incident, and the immediate corrective action taken must be included on the Incident Report. A nurse progress note would be completed and would include interventions identified to reduce reoccurrences, the resident's response to the incident and interventions.

Based on observation, interview, record review and review of lab reports the facility failed to ensure Resident #28 received appropriate care and services to assess for and treat a urinary tract infection (UTI). This affected one resident (Resident #28) out of four residents reviewed for UTI. The facility census was 61.Findings include: Review of Resident #28's medical record revealed an admission date of 06/26/23 and diagnoses of cerebral infarction, hemiplegia affecting the left nondominant side and congestive heart failure.Review of Resident #28's care plan revised 06/30/25 included Resident #28 was incontinent of bowel and bladder, had weakness, fatigue, and needed assistance with toileting and peri care related to diagnoses of left sided hemiparesis on the non dominant side, cerebral infarction and other diagnoses. Resident #28 to be less incontinent of bowel and, or bladder over the next 90 days. Interventions included to monitor for episodes of incontinence and continence; monitor for signs of urinary infections such as odors, concentrated urine etcetera and report to the nurse, physician.Review of Resident #28's Annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #28 was cognitively intact. Resident #28 was dependent for toileting hygiene and required partial to moderate assistance with personal hygiene. Resident #28 was frequently incontinent of urine. Review of Resident #28's progress notes dated 08/27/25 at 4:18 P.M. revealed Physician #735 gave new orders for a urinalysis and urine culture and sensitivity.Review of Resident #28's physician orders dated 08/27/25 revealed urinalysis and urine culture and sensitivity, discontinue order once specimen was obtained.Review of Resident #28's progress notes dated 08/29/25 at 4:49 A.M. revealed two attempts were made to obtain Resident #28's urine for urinalysis and culture and sensitivity via straight catheter and white sludge clogged the catheter both times. There was no evidence Physician #735 was notified of the failed attempts to obtain urine for a urinalysis and culture and sensitivity.Review of Resident #28's medical record including progress notes and Medication and Treatment Administration Records dated 08/29/25 through 09/03/25 did not reveal evidence of attempts to collect Resident #28's urine or notification of Physician #735 of any failed attempts to collect Resident #28's urine for urinalysis and culture and sensitivity as ordered on 08/27/25. Review of Resident #28's physician orders dated 09/03/25 at 7:17 A.M. revealed urine for urinalysis and urine culture and sensitivity, every shift, discontinue once obtained.Review of Resident #28's progress notes dated 09/04/25 at 5:42 A.M. revealed urinalysis and urine culture and sensitivity every shift, discontinue once obtained, was unable to be obtained this shift. There was no evidence Physician #735 was notified that Resident #28's urine was unable to be obtained and no reason why Resident #28's urine was unable to be obtained.Review of Resident #28's progress notes dated 09/04/25 at 10:48 P.M. included Resident #28 was straight cathed for urinalysis and urine culture and sensitivity and 75 cc of dark yellow urine was obtained.Review of Resident #28's lab report revealed Resident #28's urine was collected on 09/05/25 at 12:00 P.M., was received on 09/05/25 at 3:11 P.M. and reported on 09/09/25 at 2:39 P.M. Resident #28's final report included greater than 100,000 CFU (colony forming units) per milliliter of Providencia stuartii (gram-negative bacterium, causes healthcare associated infections).Review of Resident #28's progress notes dated 09/09/25 at 3:18 P.M. revealed Resident #28's final report for the urinalysis and urine culture and sensitivity was sent to Physician #735 and was awaiting response.Review of Resident #28's progress notes dated 09/10/25 at 2:18 A.M. revealed new orders for cefpodoxime 100 milligrams, two times a day for seven days for UTI (urinary tract infection), if no allergies. This was 14 days after Physician #735 ordered Resident #28's urine to be collected for a urinalysis and urine culture and sensitivity.Observation on 09/16/25 at 3:37 P.M. of Resident #28 revealed she was sitting in a chair in her room, was agreeable to have a conversation and answered questions appropriately. Resident #28 stated she was receiving antibiotics now and was having pain with urination before she started getting the antibiotics. Resident #28 indicated she told a nurse she was having discomfort when she went to the bathroom and now I am getting antibiotics.Interview on 09/17/25 at 2:24 P.M. with Nurse Practitioner (NP) #733 revealed Resident #28 received long term care at the facility and Physician #735 usually cared for residents receiving long term care. NP #733 stated she was not aware Physician #735 ordered Resident #28 to have a urinalysis and urine culture and sensitivity collected on 08/27/25, and if there was a problem collecting the specimen either she or Physician #735 should have been notified. NP #733 stated it was a long time to wait from 08/27/25 through 09/04/25 to collect Resident 328's urine specimen, especially if there was something going on.Interview on 09/18/25 at 12:19 P.M. of Physician #735 revealed he received a lot of phone calls and did not remember details regarding Resident #28's urine specimen orders on 08/27/25 and 09/03/25. Physician #735 stated he had no idea why Resident #28's urine was not collected until 09/04/25, but it absolutely should have been collected before then.Interview on 09/18/25 at 3:47 P.M. of the Director of Nursing (DON) revealed she was not sure why it took eight days for Resident #28's urine to be collected and sent to the lab for a urinalysis and urine culture and sensitivity. The DON stated she was not in the facility that week.

Based on observation, interview and record review the facility failed to maintain a clean environment, including mechanical lifts. This affected Resident #3 and had the potential to affect all 65 residents residing in the facility. Findings include: On 05/07/25 between 9:30 A.M. and 10:30 A.M. an initial tour of the building was conducted with the Assistant Director of Nursing (ADON) #112. Resident #3's room was noted to have a dirty floor with visible crumbs and a visible dust buildup behind the door. The toilet in Resident #3's room was noted to have a yellow and streaks around the outer bowl of the toilet. There was also a brown spot on the wall between the toilet and the sink that appeared to be dried feces. The baseboards in the 500 hall were noted to have a white dust buildup on them. The fireplaces in the 500 and 600 halls were noted to have a heavy dust buildup at the bases of each unit. The table in the hall between the skilled nursing unit and the common area was noted to have a heavy dust buildup on the bottom ring. There were no housekeepers noted in the resident areas. The [NAME] lift (a mechanical lift devise used to assist residents from a sit to stand position) located in the 500 hall was noted to have a white buildup on each of the side pads and a dirt buildup on the foot rest. A Hoyer lift (a mechanical lift utilized to lift a resident) located in the 500 hall was noted to have a visible dirt buildup at the base and a buildup ,of visible crumbs and debris on the foot rest. A Hoyer lift located in room [ROOM NUMBER] was noted to have a visible dirt build up at the base of the unit. The aforementioned findings were verified by ADON #112 at the time of the observation. On 05/07/25 at 10:35 A.M. an interview with Environmental Services Supervisor (ESS) #165 revealed resident rooms do not get cleaned every day. They get cleaned every three days. ESS #165 stated housekeeping services are subcontracted out to Serve Pro. ESS #165 stated he audits five rooms daily for cleanliness. ESS #165 also stated Serve Pro sends him pictures of rooms that were cleaned as they are completed. ESS #165 stated Resident #3's was cleaned on 05/05/25 and had pictures of the bathroom. A review of the photo titled the room number Resident #3 resided in revealed the toilet had visible brown and yellow streaks on the outer bowl. The photo also revealed the brown spot located on the wall between the toilet and the sink in Resident #3's room. ESS #165 verified the visible brown and yellow streaks on the outer bowl of the toilet and the brown spot located on the wall between the toilet and the sink in the picture. ESS #165 stated the porter is responsible for baseboard, fireplace and table cleaning. ESS #165 stated there is no set schedule for the porter cleaning but if they see dust they should clean it. On 05/07/25 at 10:45 A.M. an interview with Serve Pro Manager (SPM) #161 revealed housekeeping was provided to the facility seven days a week from 7:30 A.M. until 3:30 P.M. SPM #161 stated the facility cut housekeeping over the weekends to one person and cleaning in the skilled nursing units is only done as needed on the weekends. SPM #161 stated the porter is an employee of Serve Pro and should have wiped down the baseboards and the base of the fireplaces when they saw the dust on them. On 05/07/25 at 2:35 P.M. an interview with Housekeeper (HK) #162 revealed some rooms are cleaned daily and some rooms are cleaned every other day. HK #162 stated she cleans resident bathrooms as needed. A review of Resident Council meeting minutes dated 03/27/25 revealed ESS #165 was following up on Serve Pro issues. A review of Resident Council meeting minutes dated 04/24/25 revealed there are to be two Serve Pro employees in nursing every day. A review of the Resident Handbook page 20 that was undated revealed it is the goal to provide a clean and comfortable living arrangement and housekeeping will do a thorough cleaning once every day. A review of the document title; [NAME] Workflow Sheet that was undated revealed carpets on all nursing units are to be vacuumed twice per week. The flow sheet revealed walls are to be cleaned as you see them marked or have food on them. The flow sheet also revealed, If you see it, clean it. A review of the document titled; Audit Tool for Routine Daily Patient Room Cleaning dated 10/12/12 revealed toilets including attached seats, handle and underside of flush rim are to be cleaned. A review of the document titled; Nursing Environmental Audit that was undated revealed under the subtitle bathroom, the commode is cleaned and sanitized inside and out clear to the floor. This deficiency represents non-compliance investigated under Complaint Number OH00163463.

Based on observation, record review, interview, and facility policy review the facility failed prevent a fall with injury for Resident #20. Actual Harm occurred on 07/13/23 when Resident #20 who required extensive assistance of one person for bed mobility, did not have fall prevention interventions in place, fell from bed and sustained large left periorbital and front scalp hematomas (an injury that causes blood to collect and pull under the skin) and a fracture involving the left orbital roof extending into the left frontal sinus. This affected one resident (#20) of three residents reviewed for falls. The facility census was 60. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnosis including diabetes, kidney failure, heart disease, and dementia. Review of the fall risk evaluation dated 05/23/23 revealed Resident #20 was at risk for falls. Review of the care plan dated 06/26/23 revealed Resident #20 was at risk for falls due to confusion, incontinence, and balance problems. Interventions included a falling star magnet on the doorway to alert staff to risk of frequent falls, a fall mat to the open side of the bed when the resident was in bed, and the bed was to be against the wall and in the lowest position when in the resident was in bed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was severely cognitively impaired. The assessment revealed the resident required extensive assistance of two people for transfers and toilet use, extensive assistance of one person for bed mobility, dressing, and hygiene and supervision of one person for eating. The MDS revealed the resident had sustained one fall since the previous assessment. Review of a progress note dated 07/13/23 and timed 10:04 P.M. revealed Resident #20 was calling out when the State tested Nursing Assistant (STNA) and nurse walked into her room and found her on the floor. The (resident's) bed was at hip level and there was no fall mat on the floor. Resident #20 had a hematoma noted to her left eye, small skin tears to her right arm and left knee, and her right knee appeared swollen. Vitals were obtained and the resident was transferred to the Emergency Department (ED) via 911. Review of the hospital paperwork dated 07/14/23 revealed Resident #20 was treated for an unwitnessed fall from her bed. She had a hematoma above her left eye, abrasions on her left leg, and a bruise to her left upper lip. An x-ray of her left knee was obtained with no fracture identified and a computerized tomography (CT) scan of the head was completed with large left periorbital and front scalp hematomas discovered. Review of the fall investigation dated 07/14/23 revealed Resident #20 was observed on the floor in her room. She had a large hematoma to her left eye and a skin tear to her arm and leg. She was sent to the ED for evaluation. She was being treated for a urinary tract infection (UTI) at the time. The investigation revealed the resident had multiple interventions due to previous falls. However, there was no mat to the left side of her bed and her bed was not in the lowest position. The Treatment Administration Record (TAR) revealed the nurse had verified the interventions were in place. Interview on 10/04/23 at 2:36 P.M. with Licensed Practical Nurse (LPN) #515 revealed on 07/13/23 she and the agency STNA she was working with heard yelling which sounded like Resident #20. They went to her room and found her lying on the floor, her bed was at hip level, and there was no fall mat on the floor which was an ordered intervention. She revealed she told the agency STNA earlier in the shift to make sure they (the fall mat and bed in low position) were in place earlier, but she must not have. The resident was flat on her back and her face was bruised. She put a pillow under the resident's head while the STNA stayed with the resident, and called the family, the physician, and 911. She took the resident's vital signs, and her blood pressure was elevated. She revealed a hematoma over her left eye developed quickly, but she never lost consciousness. The LPN could not recall if the resident could tell her what she was doing, but stated she was often confused. LPN #515 revealed staff needed to do better about ensuring interventions were in place. She revealed she was not asked to complete a witness statement as part of a fall investigation, just a fall report. Interview on 10/05/23 at 9:42 A.M. with the Director of Nursing (DON) confirmed the investigation of the fall for Resident #20 revealed fall interventions were not in place at the time of the fall. If the fall interventions had been in place, Resident #20 may not have sustained the injuries she did. Review of the facility policy titled Falls Reduction Policy, dated 01/01/15, revealed the facility would put interventions in place to reduce falls and minimize the risk of injury.

Based on observation, staff interviews, and facility policy review the facility failed to ensure Residents were fed in a dignified manner. This affected six residents (#5, #18, #21, #22, #37, #50) out of eighteen residents the facility identified as needing physical assistance with meals. The facility census was 60. Findings include: Observation on 10/03/23 from 8:29 A.M. to 8:52 A.M. of staff members feeding and assisting resident with breakfast revealed the following concerns: Restorative Registered Nurse (RN) #507 was observed standing in the middle of a half circle table feeding Residents #5, #22, and #50 while standing up. Licensed Practical Nurse (LPN) #520 was observed feeding Residents #18 and #37 sitting at a square table standing up. State tested Nursing Assistant (STNA) #538 was observed feeding Residents #21 and #22, who were sitting at the half circle table, while standing up. RN #503 was observed feeding Resident #18, who was sitting at a square table, while standing up. Interview on 10/03/23 at 8:52 A.M., Speech Therapist #705 confirmed four staff members were standing while feeding residents their breakfast. Interview on 10/04/23 at 4:01 PM, Diet Technician #572 confirmed staff should be seated when feeding residents. Review of the facility policy titled Assistance with Meals, revised February 2014, revealed staff would not stand over residents while assisting them with meals.

Based on medical record review, staff interviews, and facility policy review the facility failed to develop comprehensive care plans for Residents #15, #56, #60, and #67. This affected four residents (#15, #56, #60, and #67) out of 20 residents reviewed for care plans. The facility census was 60. Findings include: 1. Review of the medical record for Resident #60 revealed an admitted [DATE]. Diagnoses included acute respiratory failure with hypoxia, anoxic (deficient in oxygen) brain damage, dysphagia (difficulty swallowing), persistent vegetative state, type two diabetes, and dependence on respirator status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was in a persistent vegetative state with no discernible consciousness; required total dependence on two persons for all activities of daily living; was on oxygen; needed suctioned; had a tracheostomy and used an invasive mechanical ventilator. Review of the care plan for Resident #60, initiated on [DATE], revealed there was no care plan for his tracheostomy. Interview on [DATE] at 8:20 A.M. with Registered Nurse (RN) #506 regarding Resident #60's care plan confirmed there should have been a care plan for his tracheostomy, but there was not one. She stated it was due to a lack of oversight. 2. Review of the medical record for Resident #67 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, and hyperkalemia (high potassium levels in blood). Review of the admission/Medicare five-day MDS assessment revealed Resident #67 had moderate cognitive impairment; required extensive assistance of two persons for bed mobility, total dependence of one person for locomotion, dressing, eating, toilet use, and personal hygiene, total dependence of two persons for transfers; and was on dialysis. Review of the progress note dated [DATE] revealed Resident #67 had expired in the facility. Review of the facility document Record of Discharge/Expiration revealed a final diagnosis of End Stage Renal Disease (ESRD), and his cause of death was from ESRD. Review of the care plan initiated [DATE] revealed there was no care plan for dialysis. Interview with Corporate Registered Nurse (RN) #706 on [DATE] at 4:01 P.M. confirmed there should have been a care plan for dialysis for Resident #67, but there was not one. 47568 3. Review of the medical record for Resident #56 revealed an admitted [DATE], medical diagnoses included Alzheimer's disease with late onset and saddle embolus of pulmonary artery with acute cor pulmonale. Review of the physician orders for Resident #56 revealed an order [DATE] to take coumadin (anticoagulant) 3 milligrams (mg) by mouth daily at 10:00 P.M. Review of the care plan dated [DATE] for Resident #56 revealed the care plan did not include that Resident #56 took an anticoagulant. Interview with LPN #520 on [DATE] at 3:22 P.M. confirmed Resident #56's care plan did not reflect that the resident took an anticoagulant. 45441 4. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included diabetes, chronic obstructive pulmonary disease (COPD), colitis, and osteoarthritis. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #15 was severely cognitively impaired. He required total assistance of two people for bed mobility, transfers and toilet use, total assistance of one person for hygiene, extensive assistance of one person for dressing, and limited assistance of one person for eating. He was on oxygen. Review of the physician's orders for [DATE] revealed an order for three liters of oxygen continuously. Review of Resident #15's care plan dated [DATE] revealed nothing related to oxygen use or respiratory care. Interview on [DATE] at 4:01 P.M. with LPN #520 confirmed oxygen had not been addressed in Resident #15's care plan. Review of the facility policy titled Care Plans-Comprehensive, dated [DATE], revealed each resident's comprehensive care plan would be designed to incorporate identified problem areas and incorporate risk factors associated with identified problems. Assessments of the residents would be ongoing and care plans would be revised as information about the resident and the resident's condition changed. The Care Planning/Interdisciplinary team would be responsible for the review and updating of care plans.

Based on medical record review, staff interviews, and facility policy review the facility failed to ensure care plans were updated timely for Residents #15, #43, #56, #60, and #67. This affected five residents (#15, #43, #56, #60, and #67) out of 20 residents reviewed for care plans. The facility census was 60. Findings include: 1. Review of the medical record for Resident #60 revealed an admitted [DATE]. Diagnoses included acute respiratory failure with hypoxia, anoxic (deficient in oxygen) brain damage, dysphagia (difficulty swallowing), persistent vegetative state, type two diabetes, and dependence on respirator status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was in a persistent vegetative state with no discernible consciousness; required total dependence on two persons for all activities of daily living; was on oxygen; needed suctioned; had a tracheostomy and used an invasive mechanical ventilator. Review of the care plan for Resident #60, initiated on [DATE], revealed there was no care plan for his tracheostomy. Interview on [DATE] at 8:20 A.M. with Registered Nurse (RN) #506 regarding Resident #60's care plan confirmed there should have been a care plan for his tracheostomy, but there was not one. She stated it was due to a lack of oversight. 2. Review of the medical record for Resident #67 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, and hyperkalemia (high potassium levels in blood). Review of the admission/Medicare five-day MDS assessment revealed Resident #67 had moderate cognitive impairment; required extensive assistance of two persons for bed mobility, total dependence of one person for locomotion, dressing, eating, toilet use, and personal hygiene, total dependence of two persons for transfers; and was on dialysis. Review of the progress note dated [DATE] revealed Resident #67 had expired in the facility. Review of the facility document Record of Discharge/Expiration revealed a final diagnosis of End Stage Renal Disease (ESRD), and his cause of death was from ESRD. Review of the care plan initiated [DATE] revealed there was no care plan for dialysis. Interview with Corporate Registered Nurse (RN) #706 on [DATE] at 4:01 P.M. confirmed there should have been a care plan for dialysis for Resident #67, but there was not one. 47568 3. Review of the medical record for Resident #43 revealed an admitted [DATE] and medical diagnoses including necrotizing fasciitis and cutaneious abscess of abdominal wall. Observation on [DATE] 4:38 P.M. of Resident #43's room revealed a sign on the door stating Resident #43 was in contact isolation. Review of the physician orders for Resident #43 revealed an order [DATE] stating contact isolation for possible carbapenem-resistant Enterobacteriaceae (CRE) of the abdominal wound. Review of the care plan dated [DATE] for Resident #43 revealed care plan did not include that Resident #43 was in contact isolation. Interview with Licensed Practical Nurse (LPN) #520 on [DATE] at 3:22 P.M. confirmed care plan for Resident #43 did not include contact isolation for possible CRE of the abdominal wound. 4. Review of the medical record for Resident #56 revealed an admitted [DATE], medical diagnoses included Alzheimer's disease with late onset and saddle embolus of pulmonary artery with acute cor pulmonale. Review of the physician orders for Resident #56 revealed an order [DATE] to take coumadin (anticoagulant) 3 milligrams (mg) by mouth daily at 10:00 P.M. Review of the care plan dated [DATE] for Resident #56 revealed the care plan did not include that Resident #56 took an anticoagulant. Interview with LPN #520 on [DATE] at 3:22 P.M. confirmed Resident #56's care plan did not reflect that the resident took an anticoagulant. 45441 5. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included diabetes, chronic obstructive pulmonary disease (COPD), colitis, and osteoarthritis. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #15 was severely cognitively impaired. He required total assistance of two people for bed mobility, transfers and toilet use, total assistance of one person for hygiene, extensive assistance of one person for dressing, and limited assistance of one person for eating. He was on oxygen. Review of the physician's orders for [DATE] revealed an order for three liters of oxygen continuously. Review of Resident #15's care plan dated [DATE] revealed nothing related to oxygen use or respiratory care. Interview on [DATE] at 4:01 P.M. with LPN #520 confirmed oxygen had not been addressed in Resident #15's care plan. Review of the facility policy titled Care Plans-Comprehensive, dated [DATE], revealed each resident's comprehensive care plan would be designed to incorporate identified problem areas and incorporate risk factors associated with identified problems. Assessments of the residents would be ongoing and care plans would be revised as information about the resident and the resident's condition changed. The Care Planning/Interdisciplinary team would be responsible for the review and updating of care plans.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, police records review, self-reported incident (SRI) review, and facility policy review the facility failed to ensure their abuse policy was implemented to prevent staff misappropriation of property from Resident #43. This affected one resident (#43) of twenty-one residents reviewed for abuse, neglect, and misappropriation. The facility census was 60. Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, major depressive disorder, and type two diabetes. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was severely impaired cognitively and exhibited disorganized thinking and altered level of consciousness behaviors which fluctuated. Resident #43 required limited assistance from one staff member for completion of his activities of daily living. Review of facility SRI tracking number (#)231572 dated 01/29/23 revealed Resident #43's daughter reported her father's debit card was stolen from his wallet and someone was using it. Interview on 10/03/23 at 8:18 A.M. with Resident #43 confirmed his credit card (debit) was stolen and someone used it. He stated they found the person, and there was a court case. Interview on 10/05/23 at 9:28 A.M. with the Director of Nursing (DON) verified their policy was not implemented as the video evidence brought in by Detective #704 on 02/06/23 confirmed Hospitality Aide #700 had taken Resident #43's debit card and used it to purchase items at Target and Starbucks. Review of the police report related to SRI #231572 revealed on 02/07/23 Group Home Supervisor #701, where Hospitality Aide resided, was shown video evidence by Detective #704 of fraudulent transactions, which Group Home Supervisor #701 confirmed was Hospitality Aide #700. When asked about the debit card by Detective #704, Hospitality Aide #700 claimed to have found the card on the ground and had not stolen it from Resident #43. Hospitality Aide #700 told Detective #704 she no longer was in possession of the card. Guardian #702 was informed by Detective #704 of Hospitality Aide #700's case and was made aware criminal charges would be forthcoming. Review of personnel file for Hospitality Aide #700 revealed a hire date of 01/16/23. Hospitality Aide #700 was terminated 02/02/23 because the criminal background check, completed by the Ohio Bureau of Criminal Investigation, showed criminal charges of theft. Review of the facility policy titled Abuse Prohibition, revised 06/27/23, revealed residents would be free of misappropriation, the deliberate wrongful use of a resident's belongings or money without the resident's consent. The deficient practice was corrected on 02/13/23 when the facility implemented the following corrective actions: Resident #43 was reimbursed on 01/29/23. All staff were re-educated on the Abuse Prohibition Policy on 1/30/23. Hospitality Aide #700 was terminated 02/02/23. On 02/03/23, the DON interviewed interviewable residents who were on the same hallway, and no other residents voiced concerns of misappropriated property. On 02/06/23, the police shared the video footage with the facility which also confirmed it was Hospitality Aide #700 using Resident #43's debit card. Beginning on 02/13/23 the DON/Designee randomly interviewed three staff members from all departments three times a week for three weeks on the Abuse Prohibition Policy.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, police report review, and facility self-reported incident (SRI) review the facility failed to ensure Resident #43 was free from misappropriation. This affected one resident (#43) out of twenty-one residents reviewed for misappropriation of property. The facility census was 60. Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, major depressive disorder, and type two diabetes. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was severely impaired cognitively and exhibited disorganized thinking and altered level of consciousness behaviors which fluctuated. Resident #43 required limited assistance from one staff member for completion of his activities of daily living. Review of facility SRI tracking number (#) 231572 dated 01/29/23 revealed Resident #43's daughter reported to the nurse that her father's debit card was stolen from his wallet and someone was using it. Review of the police report titled Investigative Report Supplement, dated 01/29/23, incident #23-0001124, revealed Detective #703 spoke with Resident #43's daughter, who stated her father's debit card was being used. She stated on 01/29/23 there were purchases made in [NAME], Ohio at Target for 5.95 dollars, Pandora for 80.00 dollars, and Buffalo Wild Wings for 15.78 dollars. There were also purchases made at [NAME] Wireless for 66.00 dollars and a Shell station for ten dollars. On 01/30/23 Resident #43's daughter stated to Detective #703 on 01/28/23 unknown persons attempted to make online transactions with the card at Amazon, CashApp, and T-Mobile; however, they were unsuccessful due to the person not having the proper security codes. Review of the police report titled Investigative Report Supplement, dated 03/16/23, incident #23-0001124, revealed on 02/07/23 Group Home Supervisor #701, where Hospitality Aide #700 resided, was shown video evidence of the fraudulent transactions by Detective #704, which Group Home Supervisor #701 confirmed was completed by Hospitality Aide #700. When asked about the debit card by Detective #704, Hospitality Aide #700 claimed to have found the card on the ground and had not stolen it from Resident #43. Hospitality Aide #700 stated to Detective #704 she no longer was in possession of the card. Guardian #702 was informed by Detective #704 of Hospitality Aide #700's case and was made aware criminal charges would be forthcoming. Interview on 10/03/23 at 8:18 A.M. with Resident #43 confirmed his credit card had been stolen and someone used it. He stated they found the person, and there was a court case. Interview on 10/05/23 at 9:28 A.M. with the Director of Nursing (DON) stated the police had brought in a jump drive of videos of Hospitality Aide #700 using Resident #43's debit card for her to view. The DON stated she saw Hospitality Aide #700 in those videos using Resident #43's card in Target and Starbucks and confirmed she had taken Resident #43's debit card. The DON stated Resident #43's bank had either reimbursed or stopped payment for items purchased with card. Review of personnel file for Hospitality Aide #700 revealed a hire date of 01/16/23. Hospitality Aide #700 was terminated 02/02/23 because the criminal background check, completed by the Ohio Bureau of Criminal Investigation, showed criminal charges of theft. The deficient practice was corrected on 02/13/23 when the facility implemented the following corrective actions: Resident #43 was reimbursed on 01/29/23. All staff were re-educated on the Abuse Prohibition Policy on 1/30/23. Hospitality Aide #700 was terminated 02/02/23. On 02/03/23, the DON interviewed interviewable residents who were on the same hallway, and no other residents voiced concerns of misappropriated property. On 02/06/23, the police shared the video footage with the facility which also confirmed it was Hospitality Aide #700 using Resident #43's debit card. Beginning on 02/13/23 the DON/Designee randomly interviewed three staff members from all departments three times a week for three weeks on the Abuse Prohibition Policy.

Based on observation, interview, record review, and facility policy review the facility failed to administer oxygen to Resident #15 as ordered by the physician. This affected one resident (#15) of three residents review for respiratory care. The facility census was 98. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included diabetes, chronic obstructive pulmonary disease (COPD), colitis, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was severely cognitively impaired. He required total assistance of two people for bed mobility, transfers and toilet use, total assistance of one person for hygiene, extensive assistance of one person for dressing and limited assistance of one person for eating. He was on oxygen. Review of the physician's orders for October 2023 revealed an order for three liters of oxygen continuously. Review of the care plan dated 08/10/23 revealed nothing related to oxygen use or respiratory care for Resident #15. Observation on 10/02/23 at 4:17 P.M. revealed Resident #15's oxygen was in use and set to one liter. Interview on 10/02/23 at the time of the observation with State tested Nurses Assistant (STNA) #534 confirmed the oxygen tank was set to one liter. Interview on 10/02/23 at 4:19 P.M. with Licensed Practical Nurse (LPN) #513 confirmed the order for Resident #15's oxygen was three liters. She entered Resident #15's room, confirmed the oxygen tank was set at one liter, and adjusted it to the correct setting of three liters. Review of the facility policy titled Oxygen Administration, dated 05/06/15, revealed the facility would review and verify the physician's order prior to oxygen administration.

Based on observation, interview, record review, and facility policy review, the facility failed to adequately notify the physician and obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one of four residents reviewed for urinary tract infections. The facility census was 52. Findings include: Review of the closed medical record for Resident #54 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #54 was discharged to the hospital on 11/11/21 due to pale color, oxygen saturation of 80% on room air, and being unresponsive to verbal and tactile stimuli. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of two. The resident required extensive assistance of two staff for toileting, bed mobility, and transfers. The extensive assistance of one staff member was required for eating, dressing, personal hygiene, and bathing. The resident was identified to be incontinent of bowel and bladder. Review of the plan of care dated 10/18/21 revealed the resident was incontinent of bladder related to impaired cognitive function and decreased mobility. Interventions included checking for episodes of incontinence and providing peri-care with each episode of incontinence during rounds and as needed. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 11/06/21 at 5:00 P.M. revealed Resident #54 was incontinent of dark brown urine. A call was placed to the physician for notification of the dark colored urine. The note stated the nurse was awaiting a response. The progress notes lacked information regarding physician response or interventions related to the notification of onset of dark yellow urine discovered on 11/06/21. There was no follow-up attempt to contact the physician regarding the dark urine. Interview on 12/09/21 at 11:06 A.M. via email with the Director of Nursing (DON) verified the lack of documentation of follow-up by nursing regarding physician response to the onset of dark yellow urine noted for Resident #54 on 11/06/21. DON stated Resident #54 did not meet criteria for a urinary tract infection ([CONDITION(S)]). A document was provided by the physician dated 12/09/21 at 10:51 A.M. stating a report in the charting from the facility on 11/06/21 stated the facility left a message with him regarding dark urine with no other signs or symptoms. Based on information the physician was given at that time, he determined there was no need to order a urine test or treat a [CONDITION(S)]. The resident's dark urine was probably a reflection of the type of fluids she was drinking and/or dehydration. This information was dated during the time of the survey and no physician communication was documented during the time Resident #54 resided in the facility. Review of facility policy titled Urinary Tract Infections/Bacteriuria-Clinical Protocol revised 02/2014, revealed the facility staff would identify individuals with signs and symptoms suggesting a possible [CONDITION(S)]. The physician would help nursing staff interpret the significance of the signs, symptoms, and laboratory test results. Asymptomatic [CONDITION(S)]'s should not be treated routinely and was based on physician order. Review of facility policy titled Infections-Clinical Protocol revised 04/2013, revealed infection may be suspected based on signs and symptoms and/or temperature. Based on identified sign/symptoms of infection, the nurse would notify the physician of all pertinent details about the resident's condition. The physician would determine course of action. This deficiency substantiates Complaint Number OH 787.

Based on record review, staff interview, and review of facility policy the facility failed to ensure they met quarterly for the Quality Assurance and Performance Improvement (QAPI) committee and failed to have the Medical Director in attendance. This had the potential to affect all 55 residents currently residing in the facility. Findings include: Review of the QAPI meeting attendance sign in sheets from 07/29/20 through 07/29/2021 revealed the facility only met on 04/29/21 and 07/21/21. There was no Medical Director signature on the 04/29/21 minutes. Interview on 07/29/21 at 4:15 P.M. with the Director of Clinical Services (DCS) #900 verified the facility only met on 04/29/21 and 07/21/21 and she stated she believed due to the COVID-19 pandemic they did not have to meet. She stated they met virtually prior to this, however, they did not have attendance sheets or minutes. DCS #900 stated the Medical Director was in Florida during the 04/29/21 meeting and there was no evidence he reviewed the meeting minutes on his return. She stated prior to April 2021, the last in person QAPI meeting was held in March 2020. Interview on 07/29/21 at 5:34 P.M. with DCS #900 revealed she found additional QAPI meeting minutes dated 02/10/21 and a signature page which included the Medical Director's signature. She verified they still had not met for quarterly meetings nor had the Medical Director present. Review of the undated facility policy titled Quality Assurance Performance Improvement Plan revealed the committee should be made of the administrative staff, the medical director, and other staff representatives. The policy stated the committee should meet quarterly and maintain an attendance record and meeting minutes.

Based on interview, record review and facility policy the facility failed to ensure agency staff were tested for COVID-19 by the facility or verified agency staff vaccination or testing status. This affected two employees (Agency State tested Nursing Assistant (STNA) #600, and #601) out of three agency employees reviewed and had the potential to affect all 55 residents residing in the facility. Findings include: Interview on 07/27/21 at 10:06 A.M. with Registered Nurse (RN) #604 and RN/ Infection Control #603 revealed they utilized agency staff routinely at the facility. They revealed they did not track the vaccination or testing status of the agency staff that worked at the facility. They revealed they did not test any of the agency staff that worked at the facility unless the staff wanted to be tested . Interview on 07/28/21 at 10:15 A.M. with Agency STNA #600 revealed she had worked at the facility routinely through an agency. She revealed she was not vaccinated for COVID-19 and stated the facility had not asked her regarding her vaccination status. She confirmed she was not tested by the facility and was last tested over a month ago which was completed at another facility. Interview on 07/28/21 at 11:38 A.M. with Agency STNA #601 revealed she worked at the facility routinely through an agency. She revealed she was not vaccinated for COVID-19 and that the facility had not asked her regarding her vaccination or testing status. She reported she worked at other facilities and it depended if another facility required testing as to how often she was tested . Sometimes it was once a week but other times it was longer. Interview on 07/28/21 at 11:40 A.M. with Agency STNA #602 revealed she was vaccinated but the facility had never asked her for her vaccination status. Interview on 07/29/21 at 9:05 A.M. with the Director of Nursing (DON) and RN #604 verified they did not have COVID-19 testing documentation for unvaccinated Agency STNA #600 and Agency STNA #601 of when they were tested last for COVID-19 or have evidence of Agency STNA #602's vaccination. Review of the facility COVID-19 testing log from 06/01/21 to 07/28/21 revealed the facility did not test or have evidence of when agency staff were tested including Agency STNA #600, and #601. Review of facility policy labeled, Coronavirus Testing last updated 05/05/21 revealed all fully vaccinated staff do not need to be routinely tested . The policy revealed all unvaccinated staff would be tested at least twice per week. The policy did not include how the facility would ensure agency staff was tracked regarding their vaccination or testing status. Review of Ohio Department of Health Amended Directors Order labeled, RE: Director's Amended Order for the Testing of the Residents and Staff of all Nursing Homes dated 05/04/21 revealed each nursing home licensed by the Ohio Department of Health or certified by the United States (U.S.) Department of Health and Human Services Centers for Medicare and Medicaid and Medicaid Services (CMS) shall perform COVID-19 testing for residents and staff in order to protect the health and safety of the residents and staff. The order revealed all unvaccinated staff would be tested at least twice per week. The order revealed unvaccinated referred to a person who does not fit the definition of being fully vaccinated including people whose vaccination status was not known for the purpose of this order. The order revealed fully vaccinated staff do not have to be routinely tested . The order defined fully vaccinated staff as a person who was greater than two weeks following receipt of the second dose in a two- dose series or greater than two weeks following receipt of one dose of a single-dose vaccine.

Based on medical record review and staff interview the facility failed to ensure the Ombudsman was notified in writing of residents' transfer or discharge to the hospital. This affected four residents (Residents (#1, #17, #32 and #63 ) of four reviewed for hospitalization . The facility census was 55. Findings include: 1. Review of the medical record revealed Resident #17 was admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed the resident had an unplanned discharge to the acute hospital with return anticipated. Review of the medical record from 05/24/21 revealed the resident was admitted to the hospital on 05/21/21 and discharged back to the facility on [DATE] with primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed it was absent of any notification to the Ombudsman regarding the hospitalization . 2. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day MDS dated [DATE] revealed the resident required extensive assistance of two people for bed mobility and toilet use. The resident was totally dependent for transfers and locomotion and needed the extensive assistance of one person for dressing and personal hygiene. The Brief Interview of Mental Status (BIMS) score of 08 indicated moderate cognitive impairment. A review of the progress notes from 03/21/21 through 07/27/21 revealed Resident #32 was hospitalized on [DATE], 04/04/21, 04/05/21, 04/16/21, 04/25/21, and 05/13/21. The Ombudsman was not notified of any of the hospitalization s. 3. Review of the medical record for Resident #63 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was discharged to the hospital on 05/09/21 and did not return to the facility. Review of progress notes dated 05/09/21 revealed Resident #63's lower left extremity was mottled and cold. The physician was called and an order was obtained to send to the emergency room for evaluation and treatment. The son was also called and selected preferred hospital. Review of the medical record revealed there was no notification of transfer to the Ombudsman. 4. Review of medical record for Resident #1 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in her medical record the Ombudsman was notified of her transfer to the hospital on 06/30/21. Review of the annual MDS dated [DATE] revealed Resident #1 had impaired cognition. She had verbal, and physical behaviors. Review of nursing notes authored by Licensed Practical Nurse (LPN) #605 dated 06/30/21 at 9:01 A.M. revealed Resident #1 was having emesis with taking of medication and pulling out her intravenous access. Resident #1's Primary Care Physician #606 was notified and ordered to have Resident #1 sent to the emergency room . Review of nursing note authored by Registered Nurse (RN) #607 dated 06/30/21 at 11:29 P.M. revealed Resident #1 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 7/29/21 at 8:52 A.M. with Admissions/Marketing coordinator #310 revealed she had been sending the list of transfers and discharges to the Ohio Department of Health (ODH). She had not sent the list of transfers and discharges to the Ombudsman. Admissions/Marketing coordinator #310 was not aware that needed to be done. Review of facility policy labeled, Procedure for Bed Hold/ Transfer Notice Notification dated 05/15/18 revealed nearly all hospital transfers, even if planned, would be considered facility initiated and a list of transfers would be emailed to the Ombudsman within 30 days.

Based on observation, record review and interview the facility failed to ensure Resident #64, who was dependent on staff for bed mobility and transferring, received adequate assistance during a transfer which resulted in the resident falling and sustaining a fracture. The facility also failed to ensure safety interventions were in place as care planned for Resident #12 to prevent a fall with hip fracture. Harm occurred when after assisting Resident #64 to the side of the bed, the staff present in the room, left the resident's side. The resident slid from the side of the bed to the floor, was assessed for injury and transferred to the hospital where she was found to have a fractured left humerus and fractured left hip. Harm also occurred to Resident #12, who sustained a fall with hip fracture, after the alarming device care planned to alert staff of unassisted transfers did not function properly. This affected two residents (Resident #64 and #12) of three residents reviewed for accidents. Findings include: 1. Resident #64 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and did not have any mood or behavior issues. The assessment also revealed the resident required extensive assistance from two people for bed mobility and transfers. Review of an interdisciplinary fall/incident investigation form dated 12/17/13 at 10:30 A.M. revealed while the resident was being transferred with a sit to stand lift with two staff assist the resident fainted and was lowered to the ground. The intervention initiated after that fall was the use of a mechanical (Hoyer) lift with the assist of two staff. A current plan of care related to fall risk, revealed the plan of care was updated on 12/17/13 to reflect the resident required a mechanical (Hoyer) lift with two staff for all transfers. A physician order, dated 01/20/14 revealed a standing lift could be used for transfers. The care plan interventions were not updated the change in transfer status at that time. Record review revealed on 02/11/14 at 10:15 A.M. Resident #64 sustained a fall in her room. Review of the interdisciplinary fall incident investigation form revealed two State tested nursing assistants (STNA's) were present in the resident's room at the time of the fall. The resident was sitting at the edge of the bed and requested a different (red) shirt to wear. One STNA went to the closet to get the red shirt. The other STNA stayed at the bedside. The resident slid to the floor. The STNA closest to the resident tried to break the fall, but the resident fell too fast. The nurse was notified and the resident was assessed for injuries. The resident's left elbow was bleeding. The resident was made comfortable on the floor until the ambulance arrived. The resident was transported to the hospital. Per the investigation form, the resident was admitted with fractures at multiple sites. The resident had surgery related to her injuries but subsequently passed away at the hospital on [DATE]. The progress notes authored by the licensed practical nurse (LPN) #5 dated 02/11/14 at 10:30 A.M. (entered on 02/11/14 at 3:27 P.M.) indicated the pupil size equaled three millimeters (mm), the pupils were reactive to light, the pupils were round bilaterally, motor reaction to pain was appropriate and the hand grasps right and left equal. The notes authored by LPN #5 dated 02/11/14 at 10:42 A.M. indicated she was called to the resident's room, the resident was noted lying on the floor next to the bed. The resident's head was toward the head of the bed and feet were extended toward the foot of the bed. The resident slipped off the right side of the bed (if one was standing by the foot of the bed facing the bed). The resident complained of left arm pain. A skin tear was visible to the left elbow with a mild amount of bleeding. The resident stated she bumped her head when she fell to the floor and also complained of left leg pain. The nurse practitioner was in the facility, was updated and gave new orders to send the resident to the hospital. The physician was phoned and a message was left. The resident's vital signs were obtained: blood pressure was 96/52, pulse 66 and oxygen saturation was 96 percent. At 10:45 A.M., the facility contacted the resident's family and messages were left. At 10:53 A.M. the daughter returned the call and was updated that the resident was being sent to the emergency room for an evaluation. At 11:00 A.M. the ambulance arrived and it required four people to transfer the resident from the floor to the stretcher. The emergency trauma flowsheet from the local hospital, dated 02/11/14 revealed the resident was alert and oriented while in the emergency room . A nursing progress note, dated 02/11/14 at 6:55 P.M. and completed by LPN #27 revealed the resident was admitted to the hospital with [REDACTED]. Additional nursing progress notes, dated 02/12/14 at 2:35 P.M. and completed by LPN #5 revealed there were two STNA's present when the nurse entered the room. The resident was lying flat on her back. When asked to perform range of motion, she raised her right arm, but not the left arm. The resident refused to perform range of motion with either of her legs. The resident was being dressed for the day, as she had her clothes, socks and shoes on. Neurological checks were performed and the resident was alert and oriented to self and place. On 03/04/14 at 3:00 P.M., interview with LPN #5, with corporate quality assurance nurse #66 present revealed STNA #36 told LPN #5 the resident slid out of bed. The resident was lying on the floor when the LPN entered the room. The resident was lying on her back on the right side of the bed, (if one is at the foot of the bed, facing the bed). The LPN indicated the height of the bed was about "waist high". The LPN stated she obtained vital signs and checked the resident's neurological status. The LPN stated STNA #33 had gone to the closet to get a top for the resident while the resident sat at the edge of the bed. She stated STNA #36 was positioning the sit to stand lift when the resident slid off the bed. Per her knowledge, neither of the STNA's were within reach of the resident at the time of the fall. The LPN verified the resident was a two person assist with the sit to stand lift for transfers. The LPN verified she entered additional nursing progress notes on 02/11/14 at 3:27 P.M. and other progress notes on 02/12/14 at 2:37 P.M. following the incident. On 03/04/14 at 3:50 P.M., interview with the director of nursing (DON) verified Resident #64 sustained a fall on 02/11/14 at 10:30 A.M. per the fall investigation report. She verified the documentation of neurological checks was dated 02/11/14 at 10:30 A.M., but was entered at 3:27 P.M. by LPN #5, without mention of any fall. The progress note dated 02/11/14 by LPN #5 at 10:42 A.M. indicated she was called into the room by one STNA, STNA #36 and found the resident on the floor at that time. She verified an entry was made on 02/12/14 at 2:35 P.M. by LPN #5 that indicated there were two STNA's in the room. The DON verified there was documentation with two different dates and different times regarding the resident's fall entered by LPN #5. On 03/05/14 at 9:45 A.M., interview with the physical therapy assistant (PTA) #67 revealed the resident had received therapy services prior to the fall on 02/11/14. The PTA verified the physical therapy discharge summary, dated 02/09/14 revealed the resident received physical therapy services 01/20/14 to 02/07/14. He verified the summary indicated there was progressive instruction with nursing in the use of the mechanical lifts to allow the use of the Sara (sit to stand) lift, which the resident desired over the use of the Hoyer lift. He verified there was no documentation regarding the specific instructions given or which staff were instructed. During the interview the PTA indicated one person should have been directly next to the resident while she was sitting on the side of the bed. He stated the resident required hands on cues. On 03/05/14 at 10:40 A.M., interview with STNA #36 with the DON present revealed on 02/11/14 she and STNA #33 had assisted Resident #64 with changing positions from lying in bed to sitting on the edge of the bed. STNA #36 stated after assisting the resident to the side of the bed, STNA #33 went across the room to the closet to retrieve another top for the resident. At the same time, STNA #36 stepped away from the resident and over to the sit to stand lift and began to push the lift in front of the resident. The STNA stated the position of the bed was such that it was raised to about knee level. STNA #36 stated the resident then slipped out of the bed onto the floor. She stated the lift was between her and the resident and the other STNA remained across the room. She stated there was no one next to the resident. During the interview, the STNA indicated the resident's sitting balance was poor and due to her size, there was normally someone who was always next to her holding her when she was sitting at the bedside. STNA #36 stated she was going to get the resident on the lift herself. On 03/05/14 at 11:40 A.M., interview with STNA #33 with the DON present revealed she and STNA #36 had assisted the resident to a seated position on the side of the bed on 02/11/14. The resident had her pants on, but wanted a different top. STNA #33 stated she went across the room to the resident's closet to get another top. She was facing the closet when she heard STNA #36 yell something. When STNA #33 turned around she saw the lift in front of the resident and the resident slide off the bed onto the floor. She stated it usually took two people to sit the resident up, but her sitting balance was usually good. The resident fell on to her left side from the bed. STNA #33 stayed with the resident while STNA #36 went to get the nurse. The resident stated her arm was broken and the left arm was bleeding. The STNA stated the position of the bed was about waist high when the resident fell . On 03/05/14 at 11:50 A.M., STNA #33 and STNA #36 performed a demonstration of the events of 02/11/14 prior to the resident's fall. The DON was also present for the demonstration, which took place in the room Resident #64 resided in during her stay. STNA #33 stood at the closet, facing away from the resident. The closet was located across the room near the entry door. Based on the observation made, STNA #36 was approximately three feet away from the resident with the sit to stand lift between her and the resident. The STNA's indicated the resident was sitting at the bedside with her legs straight out and feet flat on the ground. A transfer bar on the side of the bed was in the down position. Both STNA's explained the resident was sitting on the bed without any physical support or assistance and slid onto the floor on her left side. The STNA's indicated the resident's head was under the bed after she landed on the floor. STNA #33 stated she moved the bed away from the resident. Both STNA's verified they were not close enough to the resident before she fell . They stated usually someone remained next to the resident after she was assisted to a sitting position. 2. Record review revealed Resident #12 had [DIAGNOSES REDACTED]. A fall risk assessment, dated 12/02/13 revealed the resident was at risk for falls. A current plan of care related to falls revealed the resident was to have bed and chair alarms. The alarms were to be checked for placement and function every shift. Record review revealed on 01/23/14 at 4:15 P.M. the resident was found lying on the floor on the right near the head of her bed. The resident had been resting in the recliner prior to the incident. The foot rest was still elevated on the recliner. The resident had a skin tear to the right hand with moderate bleeding and complained of right hip and leg pain. The resident was sent to the hospital emergency room . The note dated 01/23/14 at 9:07 P.M. revealed the resident was admitted to the hospital with [REDACTED]. The interdisciplinary fall/incident investigation dated 01/23/14 revealed the resident's husband alerted staff the resident was lying on the floor in her room in front of the recliner. There was a skin tear to the right hand while the resident was lying on her right side. The foot rest of the recliner was still in the up position. The chair alarm was not connected therefore it did not sound. The resident was sent to the hospital, diagnosed with [REDACTED]. The clip for the alarm had slipped out of the box causing the alarm not to sound. The intervention was for all the chair alarms to be assessed for intact clips. The alarms with broken clips were taken out of service and replaced. Resident #12 was observed on 03/04/14 at 9:30 A.M. in bed with a perimeter mattress and her eyes closed. On 03/05/14 at 3:10 P.M., interview with the DON verified the clip to the alarm that was used for Resident #12 to alert staff of unassisted transfers was broken on 01/23/14 when the resident was found on the floor. She verified the alarm did not activate due to the clip portion of the alarm being broken. She verified the resident fractured her right hip and required surgery as a result of the fall on 01/23/14. This deficiency substantiates Complaint Number OH 737.

Based on observation, record review and interview, the facility failed to ensure an avoidable unstageable pressure ulcer did not develop on Resident #65's right heel. This affected one of two residents (#65) reviewed who had documented pressure ulcers, of 21 sampled residents. The facility census was 87 residents. Findings include: Resident #65 had [DIAGNOSES REDACTED]. The skin assessment dated [DATE] indicated the resident was high risk for pressure ulcers. The admission Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident's cognition was severely impaired. The resident required extensive assistance with personal hygiene and activities of daily living. The care plan regarding skin, dated 11/22/10, had interventions that included a pillow that was to be under the resident's calves when in bed to prevent skin breakdown on his heels. The nurse's progress notes dated 12/23/10 at 8:09 P.M. indicated that during a shower, a state tested nurse aide (STNA) notified the nurse of a 4.3 centimeter (cm) long by 3.9 cm wide dark brown area noted on the resident's right heel. The resident showed signs and symptoms of pain during the assessment. The area and surrounding skin was red and non-blanchable. Skin prep was applied and suspension boots in place. The skin condition report dated 12/23/10 indicated the resident had developed a right heel diabetic ulcer the measured 4.3 cm in length and 3.9 cm in width. The ulcer was a dark brown area with pain noted and surrounding skin red in color. Pedal pulses were weak. The physician orders [REDACTED]. The heels were to be floated and elevated off of the surface of the bed with Achil-Ease while in bed. The skin care plan dated 01/06/11 indicated the resident had a pressure ulcer on the right heel. The interventions included an Achil-Ease to the foot of the bed at all times to keep the heels elevated off the bed, and to float the heels with pillows under the calves while in bed. The right lower extremity venous study that was done on 12/29/10 revealed the deep venous system was well defined and no vascular anomaly. The arterial Doppler study done on 12/30/10 revealed scattered low-level plaque especially involving the distal small vessels, but with no evidence of complete obstruction. The flow velocities were within normal limits throughout. The skin condition report dated 01/19/11 indicated the right heel wound had slough and/or eschar covered; the length was 2.5 cm and the width was 3.5 cm. In the affected extremity, pedal pulses were strong. In the other extremity, pedal pulses were strong. An observation was made of the resident on 01/20/11 at 8:25 A.M. while the resident was in bed. Both of the resident's heels were flush against the mattress. The Achil-Ease was under the resident's knees. State tested Nurse Aide (STNA) #11 verified the Achil-Ease was not positioned correctly, and the resident's heels were flush on the mattress at the time of the observation. The STNA verified the left heel was red. She verified the heels were supposed to be elevated off the mattress. An observation on 01/20/11 at 10:30 A.M. revealed the resident's left heel was flush against the mattress. Licensed Practical Nurse (LPN) #7 verified the observation at that time. Registered Nurse (RN) #12 verified the Achil-Ease was not positioned correctly to elevate the heels off the bed during the same observation. She also verified there was no pillow under the resident's calves. The left heel was pink, but blanchable. An interview with RN #12 on 01/20/11 at 1:30 P.M. verified the reports for the venous ultrasound and the arterial Doppler study indicated no vascular anomalies. She verified the resident had palpable, strong pedal pulses. She verified the right heel wound was documented as a pressure ulcer on the care plan. An interview with the resident's wife on 01/20/11 at 2:06 P.M. revealed the resident did not move his right leg about the second week in December because of the pain due to a screw coming out of his right hip. She stated he kept his leg in the same position on the bed because it caused him too much pain when he moved the leg. She stated he just had surgery last week to correct the surgery and relieve the pain. She stated the resident had been diabetic for about [AGE] years and had never had any issues with any diabetic wounds.