Every finding on record at Spring Meadows Nursing, A Villa Center

Based on medical record review, staff interviews, review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and review of facility policy, the facility failed to timely identify the resident's pressure until it reached an advanced stage and failed to ensure pressure ulcer preventions consistent with professional standards of practice were in place. This resulted in Actual Harm to Resident #55 who was at risk for pressure ulcers and the facility found Resident #55's avoidable pressure ulcer as a stage three pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed). This affected one (Resident #55) of two residents reviewed for pressure ulcers. The facility census was 80.Findings include:Review of the medical record for Resident #55 revealed he was admitted on [DATE]. Diagnoses included metabolic encephalopathy, epilepsy, right-sided hemiplegia, and type II diabetes mellitus. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #55 was dependent upon staff for all transfers and bed mobility. Resident #55 did not refuse care, was at risk for pressure ulcers, and did not have a pressure ulcer on admission. There were no skin and ulcer/injury treatments in place, including a turning and reposition program. Resident #55 was always incontinent of bowel and bladder. Review of the Braden Score assessment dated [DATE], revealed Resident #55 was at a high risk for acquiring pressure wounds. Review of the care plan dated 07/10/25 revealed Resident #55 was at a potential risk for impairment to skin integrity rule out bowel and bladder incontinence, diabetes mellitus, hemiplegia and weakness. Interventions included apply barrier cream per facility protocol to help protect skin from excess moisture, monitor skin when providing care, notify nurse of any changes in skin appearance, pressure reduction mattress, and wheelchair pressure reduction cushion. There was no intervention to turn and reposition Resident #55 every two hours as an intervention consistent with professional standards of practice for pressure ulcer prevention. Resident #55 had care plans in place for incontinence of bowel and bladder. Interventions included to provide skin care after each incontinent episode. There were no interventions for routine checks and changes for incontinence care in the care plan. There was no documentation in Resident #55's medical record to support Resident #55 had been turned and repositioned every two hours. Review of the weekly skin observations dated 07/22/25, 07/29/25, and 08/02/25 revealed Resident #55 did not have any new skin issues observed. The weekly skin assessment dated [DATE] for Resident #55 revealed a new stage three pressure wound to the resident's left buttock and coccyx. Review of the wound measurements for Resident #55 revealed on 08/05/25, the stage three pressure wound to his left buttock and coccyx measured 3.20 centimeters (cm) long by 2.50 cm wide by 0.10 cm deep. On 08/21/25, the pressure wound measured 5.0 cm long by 4.5 cm wide by 0.2 cm deep. Interview on 08/26/25 at 4:45 P.M. with Licensed Practical Nurse (LPN) #401 confirmed Resident #55 was immobile, at risk for pressure ulcers, and did not have the intervention consistent with professional standards of practice to turn and reposition every two hours. Interview on 08/26/25 at 5:03 P.M. with Wound Care Nurse #347 confirmed attempts to turn Resident #55 every two hours should have happened as an intervention to aid with the prevention of pressure wounds. Interview on 08/28/25 at 8:10 A.M. with LPN #401 revealed turning and repositioning was not a standard intervention in the facilities care planned interventions to prevent pressure ulcers. Interview on 08/28/25 at 8:40 A.M. with the Director of Nursing confirmed professional standards of practice for pressure ulcer prevention include turning and repositioning residents every two hours. Continued interview confirmed turning and repositioning every two hours is not in Resident #55's care plan, nor was there documentation to support this standard of practice occurring. Review of the facility policy titled Pressure Ulcer Treatment dated November 2013 revealed the facility would redistribute pressure as one intervention to help prevent pressure ulcers. Review of the NPUAP guidelines dated 2014 revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. The NPUAP further instructed to offload the pressure injury and to turn and reposition the individual.

Based on observations, staff interviews, and review of facility policies, the facility failed to serve food in a manner that prevented contamination. This affected seven (Residents #13, #19, #35, #45, #54, #86, and #87) observed for room tray service and had the potential to affect all residents in the facility except Residents #4, #9, #12, and #88 who do not receive food from the kitchen. The facility census was 80. Findings include:1. Observation on 08/26/25 at 8:05 A.M. of tray service on the 400-hall revealed Certified Nurse Assistant (CNA) #306 began passing breakfast trays and did not perform hand hygiene before he started. CNA #306 began with serving a breakfast tray to Resident #86 by setting the tray on her bedside table in her room. CNA #306 came out of her room, did not perform hand hygiene, then obtained another breakfast tray. CNA #306 took the tray to Resident #54's room, put the tray down on the bedside table, adjusted the resident's blanket, then prepared the breakfast tray by opening the milk, arranging beverages, removing lids from food containers, adding brown sugar to the oatmeal, and stirring the oatmeal with the resident's silverware. CNA #306 returned to the tray cart and obtained the next breakfast tray without performing hand hygiene. CNA #306 delivered the tray to Resident #19's bedside table, turned the overbed light on by pulling the cord and prepared the tray for the resident. CNA #306 returned to the tray cart and obtained the next breakfast tray without performing hand hygiene. CNA #306 delivered the tray to Resident #13 and cut up the food using the silverware on the tray. CNA #306 returned to the tray cart and obtained the next breakfast tray without performing hand hygiene. CNA #306 delivered the tray to Resident #35's bedside table then assisted Resident #87 with positioning. CNA #306 touched buttons on the bed, boosted Resident #87 up in bed, and touched the pullcord for the overbed light. CNA #306 returned to the tray cart and obtained the next breakfast tray without performing hand hygiene. CNA #306 delivered the tray to Resident #45's bedside table, went in the soiled workroom, then went in another resident's room, and returned with a folding chair. CNA #306 did not perform hand hygiene, unfolded the chair, and sat next to Resident #45 to feed him.Interview on 08/26/25 at 8:25 A.M. with CNA #306 confirmed he did not perform hand hygiene throughout the above noted observation of tray service that started at 8:05 A.M.Review of the facility policy titled Hand Hygiene Guideline dated 04/16/25 revealed hand hygiene would occur before and after the care of all residents, after touching a patient, and before assisting a resident with meals.2. Observation on 08/27/25 at approximately 11:30 A.M. of lunch service revealed [NAME] #374 touching pan lids, steam table surfaces, serving utensils, plates, spatulas, and a frying pan handle then touching a grilled cheese sandwich with the same contaminated gloved hand. The grilled cheese sandwich was placed on a plate and transferred to a tray cabinet to be served to a resident. Concurrent interview with Regional Food Services Director #500 revealed the grilled cheese should not have been touched with contaminated gloved hands.Observation on 08/27/25 at approximately 11:35 A.M. of lunch service revealed Dietary Aides #372 and #391 returned to the tray line and applied clean gloves without washing their hands. Concurrent interview with Regional Food Services Director #500 revealed hand washing should have occurred before putting gloves on.The facility identified Residents #4, #9, #12, and #88 who do not receive food from the kitchen.Review of the facility policy from the Food and Nutrition Manual titled Quick Resource Tool: QRT Hand Washing dated 09/01/21 revealed hands would be washed before putting on gloves, after handling soiled utensils and equipment, and as often as needed during food preparation.

Based on medical record review, resident and staff interview, observation, and review of facility policy, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's care needs. This affected two resident (#2 and #27) of 18 residents reviewed for MDS accuracy. The facility census was 80. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 07/11/25. Diagnoses included chronic respiratory failure with hypoxia (lack of oxygen), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. Review of Resident #27's hospital referral records dated 07/11/25 revealed there were Bilevel Positive Airway Pressure (BIPAP) orders to continue at night and during naps with settings for inspiratory pressure of nine and expiratory pressure of five. Review of Resident #27's physician orders for 07/11/25 to 07/13/25 revealed there were no orders for a BIPAP machine. Review of the admission MDS assessment dated [DATE] revealed Resident #27 was cognitively intact and Resident #27 did not utilize a BIPAP machine. Observation on 08/25/25 at 1:11 P.M. revealed Resident #27 was lying in bed with BIPAP sitting on her nightstand. Observation and interview on 08/26/25 at 8:12 A.M. revealed Resident #27 was resting in bed with her BIPAP on. Resident #27 stated she was on BIPAP at home and she did bring her BIPAP machine from home and has had it since she arrived at the facility. Interview on 08/26/25 at 12:30 P.M. with Licensed Practical Nurse (LPN) #401 stated Resident #27 required the use of a BIPAP machine while residing in the facility. LPN #401 verified the admission MDS assessment for Resident #27 had no indication she required the use of a BIPAP machine and the MDS should have reflected the use of BIPAP machine. 2. Review of the medical record for Resident #2 revealed he was admitted on [DATE]. Diagnoses included multiple sclerosis and paraplegia. Review of the care plan for Resident #2 revealed interventions for the management of bowel and bladder incontinence. Review of the annual MDS assessment dated [DATE] revealed Resident #2 was frequently incontinent of bowel and bladder. The quarterly MDS assessment dated [DATE] revealed Resident #2 was always continent of bowel and bladder. Interview on 08/28/25 at 9:45 A.M. with the Director of Nursing (DON) revealed Resident #2 was always incontinent of bowel and bladder. Interview on 08/28/25 at 9:50 A.M. with Licensed Practical Nurse (LPN) #401 verified the MDS assessments for Resident #2 dated 01/14/25 and 07/10/25 reflected incorrect data regarding Resident #2's continence status of frequently incontinent and always continent, respectively. LPN #401 verified Resident #2 was always incontinent of bowel and bladder. Review of the facility policy titled Villa Healthcare RAI Process Guideline (Resident Assessment Instrument) revealed the facility would conduct an accurate MDS assessment for each resident.

Based on medical record review, staff interview, and review of facility policy, the facility failed to regularly monitor a resident's weight according to physician orders and facility policy. This affected one (Resident #55) of one resident reviewed for nutrition. The facility census was 80. Findings include:Review of the medical record for Resident #55 revealed he was admitted on [DATE]. Diagnoses included metabolic encephalopathy, gastroesophageal reflux disease, and type II diabetes mellitus. Review of Resident #55's physician orders, dated 07/10/25, revealed an order to obtain admission weight, weekly for four weeks and then monthly. Review of Resident #55's weights revealed on 07/10/25 his weight was 225 pounds and on 08/04/25 his weight was 180.6 pounds. There were no other weights documented in this resident's medical record. There was a weight loss of 19.7 percent (%) over 24 days. Interview on 08/26/25 at 4:45 P.M. with Licensed Practical Nurse (LPN) #401 confirmed Resident #55's weights were not obtained according to physician orders, weights were not obtained according to facility policy, and the significant weight variance of 19.7% should have resulted in a reweigh to confirm the variance. Review of the facility policy titled Weight Monitoring Guideline dated 04/06/18 revealed residents would be weighed upon admission, weekly for four weeks post-admission, then monthly to ensure the maintenance of acceptable parameters of nutritional status. Additionally, the policy indicated a weight variance less than or greater than five pounds would constitute a reweigh.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure physician orders were obtained for use of oxygen therapy and Bilevel Positive Airway Pressure (BIPAP) use. This affected one (#27) of one resident reviewed for oxygen and BIPAP use. The facility identified 29 residents who require the use of oxygen and six residents who require the use of BIPAP machine. The facility census was 80. Findings include:Review of the medical record for Resident #27 revealed an admission date of 07/11/25. Diagnoses included chronic respiratory failure with hypoxia (lack of oxygen), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. Review of the hospital referral records dated 07/11/25 for Resident #27 revealed BIPAP orders to continue at night and during naps with settings for inspiratory pressure of nine and expiratory pressure of five and oxygen therapy at two to four liters per minute (LPM). Review of the admission assessment dated [DATE] for Resident #27 revealed she was admitted to the facility via wheelchair and oxygen by way of nasal cannula. Review of the current physician orders for 08/2025 for Resident #27 revealed there were no orders for BIPAP use and oxygen administration. Observation on 08/25/25 at 1:11 P.M. revealed Resident #27 was lying in bed with BIPAP sitting on her nightstand. Interview on 08/26/25 at 8:14 A.M. with Licensed Practical Nurse (LPN) #395 verified there were no physician orders for oxygen therapy and BIPAP machine use for Resident #27. Interview on 08/28/25 at 2:08 P.M. with LPN #402 verified she updated the physician orders for Resident #27 to include the orders for oxygen therapy and BIPAP use. Review of the facility policy titled Oxygen Administration Policy, revised 10/2010, revealed the purpose of the procedure is to provide guidelines for safe oxygen administration, review the physician's orders or facility protocol for oxygen administration. Review of the facility policy titled CPAP (Continuous Positive Airway Pressure)/BIPAP Support, revised 10/2020 revealed the purpose is to provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. Review the physician's order to determine the oxygen concentration and flow, and the positive end-expiratory pressure (PEEP), CPAP, bilevel positive airway pressure (BIPAP), and expiratory positive airway pressure (EPAP) for the machine.

Based on observation, record review and staff and resident interview, the facility failed to ensure medications were administered appropriately and not left unsecured in a resident room. This affected one (#15) of one resident reviewed for medications. The facility census was 76. Findings include: Review of the medical record for Resident #15 revealed an admission date of 5/22/25 with diagnoses of anxiety and enterocolitis (inflammation of the intestines) due to clostridium difficile. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 05/24/25, revealed Resident #15 had intact cognition and rejected care for one-to-three days during the assessment period. Review of the physician order dated 05/21/25 revealed Resident #15 received buspirone hydrochloride (HCl) (for anxiety) 15 milligrams (mg), one tablet three times daily and dicyclomine HCl (for gastrointestinal prophylaxis and cramping) 10 mg one capsule four times daily. Review of the Medication Administration Record for July 2025 revealed Resident #15's prescribed buspirone HCl and dicyclomine HCl were administered as ordered. Observation and interview on 07/07/25 at 4:15 P.M. with Registered Nurse (RN) #201 revealed two medications on Resident #15's floor next to her bed. RN #201 stated the medications were buspirone HCl and dicyclomine HCl. RN #201 stated Resident #15 received the two medications multiple times daily and could not state how long they were on the floor. RN #201 further stated she always stood with Resident #15 until Resident #15 consumed all of her medications. RN #201 confirmed nurses should always remain with residents until all medications are consumed. Resident #15 confirmed RN #201 stayed at her bedside while she consumed her medications. Resident #15 stated she did not know why there were medications on her floor. This was an incidental finding during the complaint survey.

Based on record review, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure Resident #16 who had a indwelling catheter received the appropriate treatment and services related to a urinary tract infection (UTI). This affected one (#16) of six residents reviewed for UTIs. The facility census was 76. Findings include: Review of the medical record for Resident #16 revealed an admission date of 05/01/20 with diagnoses of obstructive and reflux uropathy and type II diabetes mellitus. Resident #16 was admitted to Hospice on 05/25/25. Review of the significant change comprehensive Minimum Data Set (MDS) assessment, dated 05/30/25, revealed Resident #16 had impaired cognition and an indwelling catheter. Review of a urine culture and sensitivity, collected 05/26/25 and reported 05/31/25, revealed Resident #16 had bacterium Acinetobacter baumannii present at greater than 100,000 colony forming units per milliliter. The bacterium was susceptible only to amikacin (an antibiotic). There was nothing in the medical record indicating Resident #16 had symptoms of a UTI and notification to the physician of the results of the urine culture and sensitivity. Review of the current and discontinued physician orders dated 05/31/25 through current revealed no order for amikacin. Interview on 07/07/25 at 1:51 P.M. with Infection Preventionist (IP) #505 confirmed no signs or symptoms were documented in Resident #16's record indicating the purpose of the urinalysis. IP #505 confirmed the identification and testing for a UTI, per McGeer's criteria, required signs and/or symptoms of a UTI must be present before proceeding with a urinalysis. IP #505 confirmed no antibiotics were ordered to treat Resident #16's UTI. Additionally, IP #505 could provide no evidence a physician was notified regarding the results of the urine culture and sensitivity results. Review of facility policy titled Guideline for Infection and Prevention Surveillance Program dated 10/02/19 revealed the facility would have a system for preventing, identifying, reporting, investigating, and controlling infections. Review of the CDC guidance titled NHSN Long-term Care Facility Component Urinary Tract Infection dated January 2025 and found at https://www.cdc.gov/nhsn/ltc/uti/index.html revealed UTI is one of the most common sites of healthcare-associated infections (HAI), accounting up to 20 percent (%) of infections reported by long-term care facilities (LTCFs). There is criteria for catheter-associated symptomatic urinary tract infections (CA-SUTI). This included one or more signs and symptoms and a positive urine culture with no more than two species of microorganisms, at least one of which is a bacterium of 10 CFU/ml or greater. The criteria for asymptomatic bacteremia urinary tract infection (ABUTI) included no qualifying fever or signs or symptoms, a positive urine culture and a positive blood culture with at least one matching bacteria to the urine culture. This deficiency represents non-compliance investigated under Complaint Number OH00166471.

Based on observation, staff interview, and review of the menu spreadsheet, revealed the facility failed to provide adequate portions of food. Additionally, the facility failed to ensure adequate food was prepared to provide all residents with an appropriate portion of food. This had the potential to affect all residents in the facility except Resident #92 who received no food by mouth. Finally, the facility failed to ensure residents on a pureed diet received all items on the menu. This affected five (#13, #24, #39, #42, and #94) residents on a pureed diet. The facility census was 90. Findings include: 1. Observations and interviews on 03/12/25 beginning at 11:37 A.M. revealed [NAME] #301 serving the noon meal. [NAME] #301 stated the meal was chili, cornbread, salad, and pumpkin pie. [NAME] #301 stated residents on a regular texture diet and a mechanical soft texture diet received the same chili and cornbread. [NAME] #301 prepared pureed chili and pureed cornbread for residents on a pureed diet. [NAME] #301 used a serving spoon to serve chili to approximately ten residents who received either regular or mechanical soft textured chili. Observation on 03/12/25 at 11:55 A.M. revealed [NAME] #301 preparing Resident #94's pureed meal tray. [NAME] #301 scooped two scoops of pureed chili into the bowl, and one scoop of cornbread onto the plate. Observation on 03/12/25 at 11:59 A.M. revealed [NAME] #301 replaced the serving spoon with a spoodle utensil (a serving spoon with a defined measurement). Concurrent interview with [NAME] #301 confirmed she used a serving spoon used during preparation of the chili to serve chili portions to approximately the first eight resident trays. Interview and observation on 03/12/25 at 12:50 P.M. with [NAME] #301 revealed she was preparing Resident #39's pureed tray. [NAME] #301 scooped one scoop of chili, and then approximately half of a second scoop of chili into the bowl. [NAME] #301 stated she added some of a second scoop because the single scoop didn't look like enough. Observation on 03/12/25 at approximately 12:54 P.M. revealed one meal ticket remained with a request for two bowls of chili. [NAME] #301 scraped the last of the chili from the pan and produced one scoop. Dietary Manager (DM) #503 went to the attached Assisted Living Facility kitchen to obtain a second bowl of chili for the final meal ticket. Interview and observation on 03/12/25 at 12:55 P.M. revealed the spoodle used to serve chili to residents on regular and mechanical soft diets was 4 ounces. Additionally, the scoops used to serve both the pureed chili and the pureed cornbread were 1 and 5/8 ounces. Interview on 03/12/25 at approximately 12:57 P.M. with DM #503 and review of the menu spreadsheet revealed residents on a regular and mechanical soft diet should have received an 8 ounce portion of chili. Further review revealed residents on a pureed diet should have received 8 ounces of chili and 3 ounces of cornbread. Interview on 03/12/25 at 1:21 P.M. with DM #503 confirmed the facility did not prepare enough chili to provide the appropriate portions to residents on regular and mechanical soft diets. 2. Observations on 03/12/25 beginning at 11:37 A.M. revealed [NAME] #301 prepared pureed chili and pureed cornbread for residents on a pureed diet. Observation on 03/12/25 at 11:55 A.M. revealed [NAME] #301 preparing Resident #94's pureed meal tray. [NAME] #301 scooped two scoops of pureed chili into the bowl, and one scoop of cornbread onto the plate. Observation on 03/12/25 at 12:42 P.M. revealed Certified Nursing Assistant (CNA) #101 assisting Resident #24 in the dining room while he ate a pureed meal. CNA #101 confirmed she mixed the pureed cornbread into the pureed chili. No vegetable was observed with Resident #24's meal. Interview on 03/12/25 at 12:49 P.M. with [NAME] #301 confirmed she served residents on a pureed diet only chili and cornbread. Interview and observation on 03/12/25 at 12:50 P.M. with DM #503 revealed residents on a pureed diet received applesauce instead of a vegetable, and gelatin dessert instead of pumpkin pie because the pie was too frozen to scoop prior to meal service. Interview and observation on 03/12/25 at 1:08 P.M. with CNA #101 confirmed Resident #24 received cornbread, chili, a nutrition supplement drink, and a nutrition supplement ice cream. No vegetable, applesauce, or gelatin dessert were observed or provided. Interview with DM #503 on 03/13/25 at approximately 2:00 P.M. and concurrent review of the pureed menu for the noon meal on 03/12/25 confirmed residents on a pureed diet should have received a pureed cook vegetable and pureed pumpkin pie. This deficiency represents non-compliance investigated under Complaint Number OH00163287.

Based on observation, staff interview, record review, menu review, and recipe review, the facility failed to ensure residents on a mechanical soft diet received appropriately textured food. This had the potential to affect 12 (#11, #15, #28, #29, #38, #44, #48, #55, #68, #69, #82 and #97) residents on a mechanical soft diet. Additionally, the facility failed to ensure residents received appropriate food textures and thickened beverages with their meals. This affected two (#24 and #42) residents on a pureed diet observed during meal service. The facility census was 90. Findings include: 1. Observations and interviews on 03/12/25 beginning at 11:37 A.M. revealed [NAME] #301 serving the noon meal. [NAME] #301 stated the meal was chili, cornbread, salad, and pumpkin pie. [NAME] #301 stated residents on a regular texture diet and a mechanical soft texture diet received the same chili and cornbread. Review of the facility's mechanical soft menu revealed residents should receive ground beef & bean chili. Interview on 03/12/25 at approximately 12:55 P.M. with Dietary Manager (DM) #503 and concurrent review of the mechanical soft menu revealed residents should receive ground beef & bean chili. DM #503 stated the meat they used was ground beef and she instructed staff to break it down into small pieces. DM #503 stated the facility did not prepare a different version of the chili for residents on a mechanical soft diet. Interview on 03/12/25 at 1:21 P.M. with DM #503 confirmed whole kidney beans were used in the chili provided to residents on a regular diet and residents on a mechanical soft diet. Follow-up interview on 03/12/25 at 2:23 P.M. with DM #503 revealed she could find no recipe for ground beef & bean chili. Interview on 03/13/25 at 12:20 P.M. with Regional Director of Dietary (RDD) #403, and concurrent review of a recipe for ground beef & bean chili revealed the recipe used pinto beans. Additional review of the regular beef & bean chili recipe revealed an alternative to use kidney beans. RDD #403 confirmed the ground beef & bean chili recipe did not list kidney beans as an alternative. 2. Review of the medical record for Resident #24 revealed an admitted [DATE] with a diagnosis of type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had impaired cognition. Review of the current physician order dated 02/13/25 revealed Resident #24 received a pureed diet with honey-thick liquids. Observation on 03/12/25 at 12:42 P.M. revealed Certified Nursing Assistant (CNA) #101 providing assistance to Resident #24 in the dining room while he consumed the noon meal. Observation on 03/12/25 at 1:08 P.M. revealed CNA #101 remaining by Resident #24's side in the dining room. Resident #24 consumed all of his meal, including chili, cornbread, a nutrition supplement drink, and a thickened ice cream nutrition supplement. Attempted interview with Resident #24 at that time revealed Resident #24 was hard of hearing and could not express whether he was still hungry after the meal. Observation on 03/12/25 at approximately 1:30 P.M. revealed CNA #101 feeding Resident #24 a white substance out of a small pre-packaged cup. Interview on 03/13/25 at 11:50 A.M. with CNA #101 confirmed she provided regular vanilla ice cream, not a thickened nutrition supplement, to Resident #24 during the noon meal on 03/12/25. CNA #101 could not verify Resident #24's diet order included thickened liquids. CNA #101 stated the ice cream was still frozen, and had not melted, when she fed Resident #24. Interview on 03/13/25 at approximately 4:00 P.M. with RDD #403 confirmed residents with orders for thickened liquids should not receive regular ice cream because ice cream melted to a thin liquid. 3. Review of the medical record for Resident #42 revealed an admitted [DATE] with a diagnosis of dysphagia (difficulty swallowing). Review of the Nursing Admission Evaluation dated 03/10/25 revealed Resident #42 was confused and had unclear speech. Review of the current physician order dated 03/10/25 revealed Resident #42 was on a pureed diet with nectar-thick liquids. Observation on 03/13/25 at approximately 12:40 P.M. revealed Resident #42's meal tray inside the meal cart in the hallway waiting to be served to Resident #42. Upon Surveyor request, observation on 03/13/25 at 12:44 P.M. revealed RDD #403 removing Resident #42's meal tray from the cart and carrying it to the conference room. Interview and observation on 03/13/25 at 12:46 P.M. with RDD #403 confirmed Resident #42 was on a pureed diet with nectar-thick liquids. Observation of the meal tray revealed a pureed bowl of soup, pureed cornbread, and pureed sweet potatoes. In a separate bowl was green gelatin dessert. Also on the tray was a glass of lemonade. RDD #403 confirmed the lemonade on Resident #42's cart was not thickened. Additionally, RDD #403 confirmed gelatin dessert was not appropriate for residents on thickened liquids and the gelatin liquefies (melts) in the mouth and becomes a thin liquid. RDD #403 subsequently ensured Resident #42 received an appropriate replacement meal tray. This deficiency represents non-compliance investigated under Complaint Number OH00163287.

Based on observation, staff interview, and policy review, the facility failed to ensure staff practiced proper hand hygiene during meal service. Additionally, the facility failed to ensure food was covered during delivery to resident rooms. This had the potential to affect all residents in the facility except Resident #92 who received no food from the kitchen. Additionally, the facility failed to ensure staff practiced proper sanitation practices when handling resident meal trays. This affected one (Resident #101) resident's tray observed during meal service. The facility census was 90. Findings include: Observations during noon meal preparation and service on 03/12/25 beginning at 11:32 A.M. revealed [NAME] #301 wearing disposable gloves, opening the reach-in refrigerator and picking up a bag previously opened and re-sealed shredded lettuce. [NAME] #301 proceeded to open the bag of lettuce while touching the outside of the bag with both gloved hands, then reached into the bag with her right hand and served portions of shredded lettuce into bowls. Interview on 03/12/25 at 11:36 A.M. with [NAME] #301 confirmed she did not change her gloves after opening the reach-in cooler and touching the exterior of the lettuce bag before reaching inside the bag to portion lettuce into bowls. Observations on 03/12/25 at 11:37 A.M., 11:39 A.M., and 11:43 A.M. revealed [NAME] #301 removing soiled gloves and putting on new gloves without washing her hands. Observation on 03/12/25 at 11:53 A.M. revealed [NAME] #301 wearing disposable gloves and leaving the serving line. [NAME] #101 returned wearing disposable gloves and carrying a slice of cheese. [NAME] #301 proceeded to prepare a cheeseburger by placing the cheese on a hamburger bun, then picking up a burger and tearing it into bite-size pieces, placing the burger on the bun and using both hands to put the cheese burger together and place on a plate. Concurrent interview with [NAME] #301 confirmed she did not wash her hands between glove changes and confirmed she retrieved the slice of cheese from the reach-in cooler and did not change her gloves between opening the cooler and preparing the cheeseburger. Continued observation on 03/12/25 at approximately 11:56 A.M. revealed the staff had prepared and loaded approximately six meal trays and loaded them into the tray cart when the staff realized no salads were on the trays. Observation on 03/12/25 at 11:58 A.M. revealed Dietary Aide #302 setting a resident's tray on the ground in order to view the tray behind it and add a salad. Concurrent interview with Dietary Aide #302 confirmed she set Resident #101's tray on the ground. Continued observations during the noon meal service on 03/12/25 at 12:00 P.M. revealed residents received pumpkin pie. Observation of the pie revealed it was plated but not covered by a lid or plastic wrap. Observations on 03/12/25 beginning at 12:15 P.M., during the passing of meal trays to resident rooms on the 300 hall, revealed resident trays with pumpkin pie. Further observation revealed the pumpkin pie was uncovered in the tray cart. Concurrent interview with Certified Nursing Assistant (CNA) #104 confirmed the pumpkin pie was uncovered on each tray. Observation and interview on 03/12/25 at 12:40 P.M. with CNA #102 on the 200 hall confirmed the pumpkin pie on residents trays inside the tray cart were uncovered. Interview on 03/12/25 at 12:54 P.M. with DM #503 confirmed the pies were sent on the tray carts without being covered because they were frozen and she left them uncovered to thaw. Review of the policy Food Preparation and Handling, dated 09/01/21, revealed staff were responsible for food preparation procedures that avoid contamination by potential harmful physical, biological, and chemical contamination. Review of the policy Hand Washing, dated 09/01/21, revealed staff should wash their hands before putting on gloves and as often as needed during food preparation and when changing tasks. Review of the policy Meal Distribution, dated 09/01/21, revealed all foods that are transported to dining areas that are not adjacent to the kitchen will be covered. This deficiency represents non-compliance investigated under Complaint Number OH00163287.

Based on record review, staff interview, review of email correspondence, and policy review, the facility failed to ensure resident representatives received copies of medical records in a timely manner. This affected two (#12 and #72) of two residents reviewed for medical record requests. The facility census was 90. Findings include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE]. Resident #12 discharged to another long-term care facility on 02/26/25. Review of the discharge Minimum Data Set (MDS) assessment completed 02/06/25 revealed Resident #12 had impaired cognition. Review of Resident #12's emergency contact information revealed the Emergency Contact #1 was Resident #12's son. Review of an email dated 02/11/25 from Resident #12's son to Social Services Designee (SSD) #501 revealed a request for copies of medical records. Further review revealed multiple people were carbon copied (CC) on the email, including several people with the same surname as Resident #12. Review of an email dated 02/11/25 from SSD #501 to Medical Records (MR) #502 revealed a request for MR #502 to respond to Resident #12's son regarding his request for copies of the medical record. The email from SSD #501 to MR #502 included the forwarded email from Resident #12's son. Review of an email dated 02/12/25 revealed MR #502 sent a Records Request form to one of the people CC'd in the original email and did not email Resident #12's son who submitted the request. Review of an email dated 02/21/25 from Resident #12's son to SSD #501 revealed he was still awaiting a copy of the records from the facility. Review of an email dated 02/21/25 from MR #502 to Resident #12 revealed MR #502 sent a copy of a Medical Records Release form to Resident #12's email address. Interview on 03/12/25 at 11:20 A.M. with MR #502 , along with a review of the email she sent on 02/12/25 revealed MR #502 did not know why she did not respond to Resident #12's son. Further interview confirmed she had not provided copies of the medical records to Resident #12's son at the time of the interview. 2. Review of the medical record for Resident #72 revealed an admitted [DATE] with diagnoses of Parkinson's disease and type II diabetes mellitus. Review of the quarterly MDS assessment, dated 01/27/25, revealed Resident #72 had intact cognition. Review of Resident #72's emergency contact information revealed the healthcare Power of Attorney (POA) was Resident #72's daughter. Review of a nursing progress note dated 11/19/24 revealed a care conference was held and Resident #72's POA attended and requested a copy of Resident #72's medical records. Review of an email dated 11/20/24 from Resident #72's POA to SSD #501 revealed Resident #72's POA had a court hearing scheduled for 11/27/24 and requested copies of the medical record no later than 11/25/24. Review of an email dated 11/25/24 from SSD #501 to MR #502 revealed all required release of health information forms were attached and SSD #501 requested MR #502 to follow up with providing records to Resident #72's POA. Review of an email dated 01/29/25 from MR #502 to Resident #72's POA revealed she forwarded the request for copies of Resident #72's medical records to the corporate office. Interview on 03/13/25 at 1:22 P.M. with MR #502 stated she made copies of Resident #72's medical records and planned to provide them to Resident #72's POA when she was informed the request needed to be processed through the corporate office. MR #502 confirmed the first time she forwarded the request, initiated by Resident #72's POA in writing on 11/20/24, was on 01/29/25. Review of the undated policy titled Release of Information, revealed a resident may obtain photocopies of his or her records by providing the facility with at least 48-hour (excluding weekends and holidays) advance notice. This deficiency represents non-compliance investigated under Complaint Number OH00163096.

Based on observation, medical record review, staff interviews, interviews with the Local Health Department (LHD), review of hospital medical records, review of water sample testing reports, review of chlorine level logs, review of the facility's water management plan and review of the facility's water treatment program, the facility failed to implement immediate action to protect residents from Legionella (bacteria that causes a severe form of pneumonia with exposure generally from droplets of water) when a water sample test detected Legionella on the 300 Hall on 06/03/24. This resulted in Immediate Jeopardy and serious life-threatening harm and the potential for additional negative health outcomes and/or death when one resident (#01), who resided on the 100 Hall, developed respiratory symptoms and experienced a change in condition on 06/13/24. On 06/14/24, Resident #01 was sent to the hospital for further evaluation and subsequently was admitted to the intensive care unit (ICU) with diagnoses including sepsis with acute renal failure and septic shock due to an unspecified organism and later tested positive for Legionella pneumonia (also known as Legionnaires' disease). Resident #01 remained hospitalized in the ICU with high flow oxygen and intravenous (IV) antibiotic therapy. The facility was notified by the hospital on 06/16/24 of Resident #01's positive Legionella pneumonia result. Following the notification to the facility that Resident #01 had tested positive for Legionella pneumonia, the facility did not notify the local health department (LHD) or implement any immediate actions to protect the remaining 86 residents of the facility, placing them at potential risk for Legionella bacteria exposure. The facility census was 87. On 06/18/24 at 12:03 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 06/16/24 when the facility was notified by the hospital Resident #01 tested positive for Legionella pneumonia. Review of the facility water test samples revealed on 06/03/24, a water sample from the 300 Hall tested positive for Legionella pneumophilia, serogroup one. At that time, the facility stopped use of the water on the 300 Hall but implemented no additional interventions for other areas of the facility. Review of Resident #01's medical record revealed the resident resided on the 100 Hall. Further review revealed on 06/13/24, Resident #01 developed respiratory symptoms, which included a wet cough. Resident #01's condition continued to decline, to include congestion and confusion. On 06/14/24, a chest x-ray was completed, which indicated a nonspecific left perihilar density that could be pneumonia. Resident #01 was transferred to the hospital for further evaluation and subsequently admitted to the ICU and was diagnosed with Legionella pneumonia. Resident #01 remained in the ICU on high flow oxygen and antibiotic therapy. The Immediate Jeopardy was removed on 06/18/24 when the facility implemented the following corrective actions: On 06/10/24, an additional 10 water samples were taken for legionella testing. Results for the 10 samples were received on 06/19/24 and each tested negative for Legionella bacteria. Beginning on 06/17/24, Maintenance Services Director (MSD) #301 will audit the recirculating pipe one time daily for two months to ensure appropriate temperatures are maintained. On 06/17/24 at 10:00 A.M., MSD #301 set the facility's circulating pump to continuous run. On 06/18/24 at 10:00 A.M., MSD #301 installed filtered shower heads on all showers. Beginning on 06/18/24, the DON will audit staff call-offs three times weekly for four weeks for signs and symptoms related to Legionella illness. On 06/18/24 at 12:00 P.M., Regional Director of Operations (RDO) #320 and Regional Director of Plant Operations (RDPO) #325 reviewed the facility's water management policy and updated it to meet the Centers for Disease Control (CDC) and the Ohio Department of Health's (ODH) recommendations. On 06/18/24 at 1:00 P.M., the Administrator re-educated MSD #301 and Maintenance Assistant (MA) #330 on flushing the whole water system utilizing the flushing documentation log and testing and documenting chlorine levels daily to ensure adequate sanitization to kill Legionella and to validate electronic measuring systems. On 06/18/24 at 1:00 P.M., Dietary Manger (DM) #306 inventoried the in-house bottled water and confirmed a sufficient supply was available to meet resident needs. On 06/18/24, Food Service Provider (FSP) #500 delivered bagged, bulk ice. Deliveries will continue two times weekly (Mondays and Thursdays) and as needed until the facility's water is deemed safe by the LHD. On 06/18/24 at 2:30 P.M., MSD #301 installed a medical grade ice machine filter (protects against Legionella) on the facility's ice machine. On 06/20/24 at 11:00 A.M., the refrigeration contractor serviced the medical grade ice machine filter for use. On 06/18/24 at 4:00 P.M., ADON #300 began all staff education on the facility's Legionnaires Guidelines, to include no use of facility faucets, bed pan washers, ice machine, kitchen faucets/sprayers or any other water source; nebulizer, CPAP, Bi-Pap and respiratory equipment to be rinsed with sterile water; proper use of alcohol-based hand sanitizer for residents and staff and utilizing bottled water for hand washing if hands are visibly soiled; and use of bottled water for drinking, brushing teeth and cleaning. Any staff, including agency staff, unable to be reached will receive the education from ADON #300 or designee prior to their next scheduled shift. On 06/18/24 at 5:15 P.M., MSD #301 covered all faucets, ice machine and all other water supply sources to ensure no resident or staff use. On 06/18/24 at 5:30 P.M., an Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held to review the facility's Legionella Policy and Procedures and the steps taken to remediate the immediacy of the concern. In attendance were the Administrator, the DON, Assistant Director of Nursing (ADON) #300, MSD #301, Certified Nurse Practitioner (CNP) #350, Registered Nurse Supervisor (RNS) #302, Housekeeping Supervisor (HS) #303, Social Worker (SW) #305, DM #306, RNS #310, Registered Dietitian (RD) #312, Physical Therapy Director (PTD) #313, Licensed Practical Nurse (LPN) #315, and Admissions Director (AD) #316. A root cause analysis was initiated to determine gaps in monitoring the Water Management System to prevent Legionella outbreaks and implement corrective actions in conjunction with the local health department (LHD). On 06/18/24 at 6:00 P.M., the DON completed a respiratory assessment on all residents with no new respiratory concerns identified. Beginning on 06/18/24, the DON or designee will complete respiratory monitoring on all residents each shift until the results of the final water samples, taken on 06/25/24, are received and the facility water is deemed safe by the LHD. On 06/18/24 at 6:00 P.M., Corporate Medical Director (CMD) #650 audited all residents sent to the hospital in the past 30 days for potential Legionella related illness. No areas of concern related to Legionella illness were identified. Beginning on 06/18/24, MSD #301 will audit water chlorine levels, water temperatures and flushing of dead legs two times weekly for two months. Any concerns will immediately be reported to the Administrator and follow up with the QAPI committee to determine appropriate interventions. Beginning on 06/18/24, the Administrator or designee will complete audits of three random staff three times weekly for four weeks then one time monthly for two months to ensure compliance with the Legionella education provided. Interviews on 06/20/24 from 10:25 A.M. through 10:30 A.M. with State tested Nurse Aide (STNA) #400, STNA #401, STNA #402, LPN #403, LPN #404 and LPN #405 verified education was provided regarding Legionella and protective measures to limit the transmission of Legionella bacteria. Observations on 06/20/24 from 10:25 A.M. through 10:40 A.M. confirmed the facility had bottled water and bagged ice available for residents. Additionally, all water faucets were covered with plastic to prevent resident and staff use. Review of two (#2 and #57) additional open resident records, reviewed for respiratory illness, revealed no concerns. The QAPI Committee will meet monthly to review audit results to ensure on-going compliance. An Ad Hoc QAPI will be held to address any immediate audit findings. Although the Immediate Jeopardy was removed on 06/18/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #01 revealed an admitted [DATE]. Diagnoses included multiple sclerosis with paraplegia and bilateral lower extremity wasting and contracture, peripheral vascular disease, chronic kidney disease, hypertension and paroxysmal atrial fibrillation. Review of the quarterly Minimum data Set (MDS) assessment dated [DATE] revealed Resident #01 was cognitively intact, independent with eating and oral care and dependent for toilet use, showers, and personal care. Resident #01 was frequently incontinent of bowel and bladder, had functional impairments to both lower extremities and utilized a manual wheelchair for mobility. Resident #01 was dependent on staff for mobility and transfers. Review of a progress note, dated 06/13/24 at 8:58 A.M., revealed Resident #01 had a wet cough with coarse breathing and dark urine. The physician was notified, and an order was received for Mucinex twice a day for seven days. Additional review of a progress note dated 06/13/24 at 2:10 P.M. revealed Resident #01 had an oxygen saturation on room air of 94%. Further review of the progress notes revealed on 06/13/24 at 10:26 P.M., Resident #01 continued with a nonproductive cough, with hoarse voice sounds and congestion. Resident #01 had difficulty feeding himself at mealtime and required staff assistance. On 06/14/24 at 7:13 A.M., Resident #01 was observed in bed with pale skin, was disoriented and confused and continued with a cough. On 06/14/24 at 2:45 P.M., Resident #01 had a chest x-ray completed. The results were called into the facility at 2:55 P.M. and revealed a nonspecific left perihilar density that could be pneumonia. Resident #01 was subsequently transferred via emergency medical services (EMS) to the hospital for further evaluation. Review of the Hospital Emergency Department (ED) notes, dated 06/14/24 at 3:51 P.M., revealed Resident #01 had not been feeling well for two days and report from the extended care facility showed lungs were collapsed and the intestines were pushing up into them, which is sepsis criteria. Temperature upon arrival was 103.1 degrees Fahrenheit (F), hypotensive at 101/58 with a pulse rate of 109 beats per minute, oxygen saturation of 92% on 4 liters of oxygen, and breath sounds were decreased with rhonchi (coarse, loud sounds caused by constricted larger airways) present in both the left middle and upper lobe. Resident #01 was treated for septic shock and responded well to intravenous fluids. Additional review of hospital documents dated 06/14/24 revealed a chest x-ray was completed while Resident #01 was in the ED. It showed left upper lobe consolidation suggesting pneumonia, and elevated right hemidiaphragm (muscle that separates the chest cavity from the abdomen and serves as the main muscle for respiration) raising the possibility for diaphragmatic paralysis. Resident #01 had a computed tomography (CT) which revealed a large left upper lobe consolidation concerning for pneumonia, elevated right hemidiaphragm which was new on comparison to previous radiographs completed on 04/23/24. Review of a CT of the abdomen and pelvis revealed concerns for pneumonia marked by elevation of the right hemidiaphragm, likely from diaphragmatic paralysis and phrenic nerve (controls the diaphragm) palsy. Lastly, review of the laboratory testing completed on 06/14/24 revealed a complete blood count (CBC) was obtained with results showing an elevated white blood count (WBC) of 12.9 (normal is 4.0-11.0) and platelets 135 (normal is 150-450). A urinalysis collected on 06/14/24 at 8:40 P.M. was positive for a large amount of leukocyte esterase (normal is negative) and hemoglobin (normal is absent or negative) with urine culture positive for the Legionella antigen. Resident #01 was admitted to the ICU with diagnoses including Legionella pneumonia, sepsis with acute renal failure and septic shock with a plan for 10 to 14 days of IV antibiotics and oxygen therapy. Review of a hospital pulmonary consult progress note dated 06/16/24 revealed Resident #01 experienced worsening respiratory failure and required additional oxygen with high flow oxygen and DuoNeb (breathing) treatments every six hours. The progress summary revealed Resident #01 had left upper lobe Legionella pneumonia and positive Legionella urinary antigen was reported to the local health department. The note indicated the facility must be notified as well. Review of a repeat chest x-ray, completed in the hospital on 06/16/24 due to respiratory distress, difficulty breathing, and shortness of breath revealed an increasing right pleural effusion (build-up of fluid around the lungs) and right lobe atelectasis (collapse of the lung/part of the lung) with stable left midlung consolidation. Review of a nursing progress note dated 06/16/24 at 5:17 P.M. revealed the facility checked with the hospital on Resident #01's condition. Resident #01 remained hospitalized and had been diagnosed with Legionella in the urine. Review of the facility's weekly water chlorine level testing from 05/12/24 through 06/07/24 revealed on 05/24/24 the low range result was 0.16 and the high range result was 0.3 (the normal chlorine control range is between 0.5 and 4.0). On 06/05/24 a low range test result was 0.46, which was below the 0.5 minimum reading required. Review of the facility water testing samples, taken 05/23/24 with results on 06/03/24, revealed a water sample collected on the 300 Hall had a positive result for L. pneumophilia, serogroup 1 at a concentration of 130 colony-forming unit/milliliter (CFU/mL). Further review revealed uncontrolled levels of Legionella bacteria were greater than or equal to 10 CFU/mL in potable (drinkable) water. Additionally, L. pneumophilia serogroup 1 was highly associated with Legionnaires' disease. Lastly, the document indicated at 130 CFU/mL, a high action level was required, which included adjusting biocide (disinfectants such as chlorine) treatments immediately or disinfect/clean within 30 days, review program and retest. Observations on 06/17/24 from 7:25 A.M. until 8:50 A.M. revealed staff providing bottles of water to residents. Residents were denied ice when requested. Interview on 06/17/24 at 8:20 A.M. with LPN #306 revealed Legionella was detected in the facility's water. LPN #306 reported a resident had been admitted to the hospital and tested positive for Legionella. Upon arriving to the facility on [DATE] for her morning shift, LPN #306 was told not to use the facility water and was provided bottled water for medication administration. Interview on 06/17/24 at 9:20 A.M. with the DON revealed the facility had conducted water testing and a sample from the 300 Hall came back positive for Legionella on 06/03/24. The DON stated the positive water sample result was questionable but respiratory assessments for all residents on the 300 Hall were initiated on each shift. However, Resident #01, who resided on the 100 Hall, exhibited respiratory symptoms on 06/13/24 and was subsequently sent to the hospital for evaluation on 06/14/24. The DON stated Resident #01 tested positive for Legionella and remained in the hospital. The DON verified the facility became aware of Resident #01 testing positive for Legionella on 06/16/24 but residents and staff were not instructed until the morning of 06/17/24 at approximately 6:00 A.M. to not use the facility water. Additionally, the DON confirmed the facility did not notify the LHD of Resident #01's positive Legionella result on 06/16/24. Interview on 06/17/24 at 12:19 P.M. with MSD #301 revealed routine annual water testing was completed on 05/23/24 with a water sample sent from rooms [ROOM NUMBERS]. On 06/03/24, testing results were received and revealed Legionella was detected in the water sample sent from room [ROOM NUMBER]. MSD #301 stated a meeting with the Administrator, the DON and corporate representatives occurred on 06/04/24 to discuss an action plan. The plan included changing the water faucet and the water lines in room [ROOM NUMBER] and for staff to stop using the shower room on the 300 Hall. MSD #301 verified the low chlorine test results on 05/24/24 and 06/05/24 and further verified no interventions had been implemented for the low chlorine levels on those dates. MDS #301 stated he did not recognize the chlorine levels as low. MSD #301 confirmed the filter on the facility's ice machine did not protect against Legionella and had been in use until the morning of 06/17/24. Interview on 06/18/24 at 11:55 A.M. with Local Health Department Epidemiologist (LHDE) #900 revealed the facility did not notify them, as required, of Resident #01 testing positive for Legionella. On 06/17/24, LHDE #900 stated they received notification from the hospital where Resident #01 was being treated. While the facility became aware on 06/16/24 (Sunday), the LHD had an after-hours phone number for facilities to call to report Legionellosis associated illness. LHDE #900 verified the first contact with the facility related to Resident #01 testing positive for Legionella was on 06/17/24 at approximately 9:00 A.M., when they reached out to the facility. Interview on 06/20/24 at 10:00 A.M. with LHDE #910 confirmed she became aware on 06/17/24 of Resident #01 testing positive for Legionella, when she received the notification from the hospital. LHDE #910 stated she reached out to the facility to begin their investigation and verified the facility did not notify the LHD as required. LHDE #910 stated the investigation revealed Resident #01 never left his room and had not left the facility since October 2023, therefore, the Legionella exposure had to of come from the facility. While the facility had one Legionella positive water sample on the 300 Hall, they had not been able to determine how Resident #01 contracted Legionella. LHDE #910 confirmed Legionella was not spread from person to person and transmission was through inhalation of contaminated, aerosolized water. LHDE #910 stated they were able to determine Resident #01 used no aerosol machines, such as breathing treatments, and the only known potential source was the facility's water supply. Additionally, LHDE #910 verified the facility did not begin implementing any interventions to protect the additional residents of the facility until the morning of 06/17/24. LHDE #910 confirmed they were currently working with the facility on their water mitigation plan and no additional cases of Legionella had been identified. Review of the facility's plan for water management titled Water Management Plan, dated 01/02/24, revealed procedures for minimizing the risk of Legionnaires' disease within the building water system. In the event of a known or suspected case of Legionellosis associated illness within the facility, directives issued by national authorities and regional and local health authorities should be followed, including where and when additional testing should be performed and procedures for emergency disinfection. Review of the undated facility policy titled Water Management Program, revealed the facility will conduct an annual review of the water system. All cases of Legionella shall be reported to the local/state health officials, followed by an investigation including: a review of the microbiology and medical records; actively identifying all new and recent residents with healthcare-associated pneumonia and testing them for Legionella using both a blood culture of lower respiratory secretions and an urinary antigen; evaluating potential environment exposures; performing an environmental assessment; decontaminate environmental sources; work with local and/or state health department staff to determine how long heightened disease surveillance and environmental sampling should continue. This deficiency represents non-compliance investigated under Complaint Number OH00154915.

Based on observation, medical record review, resident and staff interview, and review of facility policies, the facility failed to ensure medications were kept secure at all times. This affected one (#17) of three residents observed for medication storage. The facility census was 85. Findings include: Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included acute bronchiolitis due to respiratory syncytial virus, pulmonary embolism, acute respiratory failure, type II diabetes mellitus, protein calorie malnutrition, chronic kidney disease, atrial fibrillation, heart failure, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 03/22/24, revealed Resident #17 was cognitively intact. Review of the current physician orders revealed Resident #17 was ordered the diuretic Bumex one (1) milligram (mg) two tablets by mouth, the supplement cholecalciferol 125 micrograms (mcg) by mouth, the supplement ferrous sulfate 325 mg by mouth, the supplement magnesium oxide 400 mg by mouth, the antidepressant Zoloft 50 mg with instructions to give one and one-half tablets to equal 75 mg by mouth, the anticoagulant apixaban five (5) mg by mouth, the blood pressure medication Coreg 12.5 mg by mouth, the acid reducer 20 mg by mouth, the stool softener sennosides-docusate sodium 8.6-50 mg by mouth, and the phosphorus-lowering medication sevelamer carbonate 800 mg by mouth all ordered for morning administration. Review of Resident #17's May 2024 medication administration record (MAR) on 05/02/24 at 8:01 A.M. revealed the morning medications had been signed off as administered. Interview on 05/02/24 at 7:51 A.M. with Registered Nurse (RN) #101 verified she has found resident medications at the bedside. RN #101 stated when medications are found, RN #101 told the other nurses they cannot leave medications at the bedside. Observation on 05/02/24 at 8:00 A.M. of Resident #17's room revealed a medication cup with several pills inside on the over bed table sitting in front of Resident #17. Resident #17 was awake and sitting upright in bed with no nurse in the room or vicinity. Interview on 05/02/24 at 8:03 A.M. with the Assistant Director of Nursing confirmed medications are not to be left at bedside and the nurses were to observe residents taking all medications provided. Observation on 05/02/24 at 8:05 A.M. with the Assistant Director of Nursing verified an unsecured cup full of pills for Resident #17 remained on the over bed table in front of Resident #17. Interview on 05/01/24 at 8:30 A.M. with Resident #17 revealed nurses sometimes left medications at bedside. Review of the facility policy titled, General Standards for Medication Administration, revised 10/15/18, revealed medications are administered at the time they are prepared. Review of the undated facility policy titled, Medication Labeling and Storage, revealed nursing was responsible for maintaining medication storage and preparation in a clean, safe, and sanitary manner. Medications are not to be left unattended if open. This deficiency represents non-compliance investigated under Master Complaint Number OH00153054 and Complaint Number OH00152502.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure dependent residents received showers according to their schedule and as needed. This affected three (#28, #87 and #88) of three residents reviewed for Activities of Daily Living (ADLs). The facility census was 84. Findings included: 1. Review of Resident #28's medical record revealed an admitted [DATE]. Diagnoses included encephalopathy, muscle weakness, respiratory failure, diabetes, staph infection, heart disease, pressure ulcer sacral region, diabetic foot ulcer, vascular disease, altered mental status, and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact and required extensive assistance of one to two staff for mobility and transfers. Review of the medical record for the previous 30 days revealed Resident #28 only one shower documented as provided, which was on 10/23/23. Observation on 11/01/23 at 12:40 P.M. of Resident #28 revealed he had unkempt facial hair and his hair was uncombed and appeared greasy. Concurrent interview of Resident #28 revealed he had not been assisted with hygiene or showers in approximately one week. Follow-up interview on 11/02/23 at 12:50 P.M. with Resident #28 revealed he did not receive regular baths or showers, scheduled for twice weekly, and stated staff did not assist him with getting cleaned up in a timely manner. Resident #28 stated he had gone over one week without a bath. 2. Review of Resident #88's medical record revealed an admitted [DATE] and a discharge date [DATE]. Diagnoses included spinal stenosis, weakness, muscle wasting, diabetic foot ulcer, chronic osteomyelitis, central cord syndrome, diabetes, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] was not finalized, but revealed Resident #88 was cognitively intact. Review of the medical record from 10/20/23 through 10/25/23 revealed no evidence Resident #88 received a shower during his admission at the facility. 3. Review of Resident #87's medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included malnutrition, muscle weakness, bacteriuria, urinary tract infection, COVID-19, pressure ulcer, sacral ulcer, Alzheimer's disease, dementia, anemia, and pneumonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was cognitively impaired and required extensive assistance of one to two staff for all mobility and transfers. Review of the medical record found no evidence Resident #87 received a shower or bed bath at any time in the previous 30 days. Interview on 11/02/23 at 12:55 P.M. with Licensed Practical Nurse (LPN) #201 revealed staff documented showers and bed baths in the electronic medical record under tasks. Interview on 11/02/23 at 1:15 P.M. with the Director of Nursing (DON) revealed a change in documentation got things messed up related to task documentation, including showers. The DON provided weekly skin checks, but verified the skin checks did not indicate whether showers and/or bed baths were provided. The DON confirmed Resident #28 had one documented bed bath in the last 30 days and Residents #87 and #88 had no documented baths or showers. Interview on 11/02/23 at approximately 2:00 P.M. with the Administrator confirmed documentation provided was for skin checks and not shower sheets. The Administrator verified the facility had no evidence of showers being given to Residents #28, #87, and #88. Review of facility policy titled Bathing, undated, revealed each resident would be provided a bath or shower twice weekly to promote cleanliness and provide comfort. This deficiency represents non-compliance investigated under Complaint Numbers OH00147873 and OH00147931.

Based medical record review, resident interview, staff interview, review of hospital records, and review of facility policy, the facility failed to complete a thorough investigation after an injury of unknown origin was identified. This affected one (#23) of three residents reviewed for injury. The facility census was 84. Findings include: Review of Resident #23's medical record revealed an admitted [DATE]. Diagnoses included multiple sclerosis, anxiety, neuromuscular dysfunction, chronic pain, sepsis, displaced fracture of right femur for closed fracture, osteoporosis, and encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact and dependent for transfers. Review of the plan of care dated 10/26/23 revealed Resident #23 had an Activities of Daily (ADLs) self-care deficit, paraplegia, contractures of the bilateral lower extremities and weakness. Interventions included to provide assistance with ADLs. Additionally, the plan of care revealed Resident #23 had limited physical mobility related to paraplegia, contractures and scoliosis. Interventions included non-weight bearing and monitor for signs and symptoms of immobility. Review of a physician progress note dated 10/09/23 revealed Resident #23 endorsed significant right lower extremity pain and stated the fentanyl patch was not helpful. The physician recommended to consider increase of pregabalin, pain managed by Palliative care. Review of a nursing progress note dated 10/09/23 at 10:39 P.M. revealed Resident #23 had slow, slurred speech, elevated temperature, and stated she could not hear. On-call provider contacted and resident was sent to the hospital for further evaluation. Review of a hospital history and physical dated 10/09/23 revealed Resident #23 was seen due to a temperature of 101 degrees Fahrenheit (F), less talkative for the past one and one-half hours, and gets like this when she has a Urinary Tract Infection (UTI). Resident complained of pain all over, including head, chest, abdomen, and right leg. Resident #23 denied any injury or fall. Review of a radiology report, dated 10/10/23, and completed due to complaint of right leg pain, revealed Resident #23 had an intertrochanteric fracture of the proximal right femur (hip fracture). Review of an Orthopedic Surgery Operative Report, dated 10/11/23, revealed the right proximal femur fracture was surgically repaired without complications. Review of Self-Reported Incidents, located in the Certification and Licensure System (CALS), revealed the facility did not report Resident #23's right femur fracture as an injury of unknown origin to the state agency. Interview on 10/31/23 at 10:58 A.M. with Resident #23 revealed her leg and hip hurt her prior to going to the hospital, but stated she had chronic pain and was unable to decipher between new and existing pain. Resident #23 revealed she did not know how the fracture occurred and confirmed she did not have a fall or another injury at the facility. Resident revealed she had surgery at the hospital and was on a pain medication to help control pain. Interview on 10/31/23 at 11:45 A.M. with Assistant Director of Nursing (ADON) #135 revealed she did not have any documentation indicating where Resident #23's injury/fracture occurred, whether at the facility or after her transfer to the hospital. Interview on 10/31/23 at 4:01 P.M. with the Administrator revealed the facility was under the impression Resident #23's right femur fracture occurred while hospital staff were providing care to her. The Administrator was unable to state where this information came from and had no evidence the fracture occurred after Resident #23 was transferred to the hospital. Interview on 10/31/23 at 4:20 P.M. with the Director of Nursing (DON), Administrator, and ADON #135 confirmed the physician saw Resident #23 on 10/09/23, prior to her hospitalization . While Resident #23 complained of uncontrolled and increased pain in her right lower extremity, it could not be proven Resident #23 had a fracture at the facility and, therefore, they were not required to initiate an investigation for an injury of unknown origin. After further discussion, the Administrator verified an injury of unknown origin was defined as an injury with unknown cause, which was why they needed to be reported and investigated. The DON stated if it was that big of a concern, the hospital should have reported the injury of unknown origin. Review of facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/28/17, revealed injuries of unknown origin included injuries that occurred when the source of the injury was not observed by any person or could not be explained by the resident, and the injury is suspicious because of the extent of the injury or location or the number of injuries over time. The abuse policy indicated injuries of unknown origin shall be promptly and thoroughly investigated. This deficiency represents non-compliance investigated under Complaint Number OH00147259.

Based on review of physician orders, observations, resident interviews, staff interviews, and review of dietary spreadsheets, the facility failed to provide therapeutic diets according to physician order. This affected two (#51 and #28) of three residents reviewed for diabetic (carbohydrate consistent - CCD) diet orders, with the potential to affect 19 (#2, #5, #8, #10, #13, #16, #18, #22, #31, #38, #40, #42, #45, #48, #53, #69, #78, #80, and #89) additional residents identified by the facility with physician ordered CCD diets. The facility census was 84. Findings include: 1. Review of Resident #51's medical record revealed an admitted [DATE]. Diagnoses included hypotension, muscle weakness, diabetes, chronic obstructive pulmonary disease (COPD), and muscle atrophy. Review of current physician orders revealed Resident #51 was ordered a carbohydrate consistent (CCD) diet with no added salt. Interview on 11/01/23 at 12:02 P.M. with Resident # 51 revealed she recently admitted to the facility and was surprised she did not receive a diabetic diet (carbohydrate controlled/carbohydrate consistent - CCD) , as she was used to at home. Resident #51 stated she believed she received the same food items and portions as non-diabetic residents. Concurrent observation, with State tested Nurse Aide (STNA) #203, verified Resident #51 was served a full plate of fettuccine alfredo with chicken, a scoop of broccoli, two slices of garlic bread, and a berry crumble dessert. 2. Review of Resident #28's medical record revealed an admitted [DATE]. Diagnoses included diabetes, encephalopathy, heart disease, diabetic foot ulcer, and heart failure. Review of current physician orders revealed Resident #28 was ordered a CCD diet with no added salt. Observation on 11/01/23 at 12:40 P.M. of Resident #28 revealed the resident was served a lunch plate full of fettuccine alfredo with chicken, broccoli, two slices of garlic bread, and a berry crumble dessert. Interview of Licensed Practical Nurse (LPN) #150 verified the meal served to Resident #28. Interview on 11/01/23 at 1:10 PM with Dietary Manager (DM) #155 revealed staff were trained about therapeutic diets and should be honoring therapeutic and physician ordered diets. Review of the dietary spreadsheet with DM #155 revealed residents on a CCD diet should have received a half portion of garlic bread and a fruit cup instead of the berry crumble dessert. DM #155 was not aware CCD ordered diets should have received a half portion of garlic bread and a fruit cup instead of the berry crumble dessert. DM #155 verified residents on a CCD diet were served full portion sizes of all foods and received the regular dessert instead of the fruit cup indicated on the spreadsheet. Interview on 11/01/23 at 3:00 P.M. with Registered Dietician (RD) #209 verified the lunch meal served did not match the dietary spreadsheet for CCD ordered diets and confirmed facility should be following the resources they had to ensure proper meals were provided. Facility was unable to provide a policy related to providing resident therapeutic diets as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00147873.

Based on medical record review, resident interview, staff interview, hospital record review, review of facility incident report, and review of facility policy, the facility failed to report an injury of unknown origin to the state agency for Resident #23 and failed to report a resident to resident incident to the state agency for Resident #84. This affected two (#23 and #84) of three reviewed for abuse and neglect. The facility census was 84. Findings include 1. Review of Resident #23's medical record revealed an admitted [DATE]. Diagnoses included multiple sclerosis, anxiety, neuromuscular dysfunction, chronic pain, sepsis, displaced fracture of right femur for closed fracture, osteoporosis, and encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact and dependent for transfers. Review of the plan of care dated 10/26/23 revealed Resident #23 had an Activities of Daily (ADLs) self-care deficit, paraplegia, contractures of the bilateral lower extremities and weakness. Interventions included to provide assistance with ADLs. Additionally, the plan of care revealed Resident #23 had limited physical mobility related to paraplegia, contractures and scoliosis. Interventions included non-weight bearing and monitor for signs and symptoms of immobility. Review of a physician progress note dated 10/09/23 revealed Resident #23 endorsed significant right lower extremity pain and stated the fentanyl patch was not helpful. The physician recommended to consider increase of pregabalin, pain managed by Palliative care. Review of a nursing progress note dated 10/09/23 at 10:39 P.M. revealed Resident #23 had slow, slurred speech, elevated temperature, and stated she could not hear. On-call provider contacted and resident was sent to the hospital for further evaluation. Review of a hospital history and physical dated 10/09/23 revealed Resident #23 was seen due to a temperature of 101 degrees Fahrenheit (F), less talkative for the past one and one-half hours, and gets like this when she has a Urinary Tract Infection (UTI). Resident complained of pain all over, including head, chest, abdomen, and right leg. Resident #23 denied any injury or fall. Review of a radiology report, dated 10/10/23, and completed due to complaint of right leg pain, revealed Resident #23 had an intertrochanteric fracture of the proximal right femur (hip fracture). Review of an Orthopedic Surgery Operative Report, dated 10/11/23, revealed the right proximal femur fracture was surgically repaired without complications. Review of Self-Reported Incidents, located in the Certification and Licensure System (CALS), revealed the facility did not report Resident #23's right femur fracture as an injury of unknown origin to the state agency. Interview on 10/31/23 at 10:58 A.M. with Resident #23 revealed her leg and hip hurt her prior to going to the hospital, but stated she had chronic pain and was unable to decipher between new and existing pain. Resident #23 revealed she did not know how the fracture occurred and confirmed she did not have a fall or another injury at the facility. Resident revealed she had surgery at the hospital and was on a pain medication to help control pain. Interview on 10/31/23 at 11:45 A.M. with Assistant Director of Nursing (ADON) #135 revealed she did not have any documentation of how Resident #23 sustained the right femur fracture and did not know if it occurred at the facility or at the hospital. Interview on 10/31/23 at 4:20 P.M. with the Administrator, Director of Nursing (DON), and ADON #135 verified the facility did not report Resident #23's right femur fracture as an injury of unknown origin to the state agency because, although the resident complained of right leg pain prior to going to the hospital, it could not be proven Resident #23's fracture occurred at that facility, therefore, they would not need to report it as an injury of unknown origin. 2. Review of Resident #84's medical record revealed an admitted [DATE]. Diagnoses included epilepsy, dementia, macular degeneration, anxiety, psychoactive substance abuse, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 was cognitively intact and required supervision for mobility and transfers. Review of the care plan dated 10/11/23 revealed Resident #84 had cognitive delay related to dementia and encephalopathy with interventions to ask yes or no questions and monitor cognitive decline. Their was no mention in the residents care plan of a relationship between Resident #84 and a male resident. Review of incident report dated 08/07/23 revealed Resident #84 had reported to social services a male resident, #31, had been bringing her gifts and kissing her. Resident #84 stated the male resident made her uncomfortable by kissing her and sticking his tongue in her mouth. Resident #84 did not want to get Resident #31 in trouble, but but revealed he had made her uncomfortable by kissing her and sticking his tongue in her mouth and did not want it to happen again. Staff informed Resident #84 they would need to talk with Resident #31 to make sure he knew not to do this again. Review of Self-Reported Incidents, located in the Certification and Licensure System (CALS), revealed the facility did not report the Resident to Resident incident in August 2023. Interview on 11/01/23 at 10:10 A.M. with the Administrator revealed a grievance log entry was created for Resident #84 who had reported a male resident stuck his tongue in her mouth. Resident #84 revealed, at times, she would kiss this male resident on the cheek or a peck on the lips but the french kiss was uncomfortable and she did not want this to occur again. Resident #84 had reported to floor staff as well as Social Service Director (SSD) #183, who reported to the Administrator. The Administrator revealed staff spoke with Resident #31 regarding the situation and since Resident #84 did not report concerns and did not report being uncomfortable with the situation, he did not feel it needed to be reported to the state agency. The Administrator reviewed the incident report completed by staff and confirmed Resident #84 stated it made me feel uncomfortable. Review of facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/28/17, revealed injuries of unknown origin included injuries that were not observed by any person or could not be explained by the resident and the injury is suspicious because of the extent of the injury or location of the injury. Sexual abuse was defined as any non-consensual sexual contact of any type with a resident. The abuse policy included steps the facility would take, which included reporting to the state agency. This deficiency represents non-compliance investigated under Complaint Number OH00147259.

Based on record review, policy review, and family and staff interview, the facility failed to conduct quarterly care conferences routinely. This affected seven (Residents #28, #32, #46, #56, #63, #70, and #71) of 10 residents reviewed for care planning. The facility census was 91. Findings include: 1. Review of the medical record for Resident #32 revealed an admitted [DATE] with diagnoses including end stage renal disease, type two diabetes, dependence on renal dialysis, anemia, duodenal ulcer, anxiety, chronic kidney disease stage four, heart failure, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact. Review of the care conference note dated 08/08/22 revealed Resident #32, social services, and activity director attended the care conference. Further review of the medical record revealed no care conferences were held between 08/08/22 and 02/24/23. Review of the Interdisciplinary Care Conference dated 02/24/23 revealed Resident #32 and son was invited to the care conference. The son did not attend. Interview on 05/08/23 at 11:53 A.M. with Social Service Director (SSD) #531 verified care conferences were not held quarterly for Resident #32. SSD #531 stated she was working on getting care conferences caught up. 2. Review of the medical record for Resident #46 revealed an admitted [DATE]. Diagnoses included major depressive disorder, severe with psychotic symptoms, muscle weakness, muscle wasting and atrophy, anxiety, insomnia, osteoarthritis, constipation, bipolar disorder, schizoaffective disorder, gastro-esophageal reflux disease, and anorexia. Review of the MDS assessment dated [DATE] revealed Resident #46 was cognitively intact. Review of the Social Service Note for Resident #46 dated 11/22/22 revealed a 48-hour care conference held with Social Service Designee (SSD), MDS Coordinator and the resident's brother via phone attended the care conference. Further review of the medical record revealed no care conferences were held between 11/22/22 and 04/28/23. Review of the Interdisciplinary Care Conference for Resident #46 dated 03/28/23 revealed the resident and brother were invited to attend the care conference. The brother did not attend. Interview on 05/08/23 at 11:53 A.M. with SSD #531 verified care conferences were not held quarterly for Resident #46. 3. Review of the medical record for Resident #63 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, muscle wasting and atrophy, type two diabetes mellitus, morbid obesity, anxiety, depression, and seasonal allergic rhinitis. Review of the MDS assessment dated [DATE] revealed Resident #63 was cognitively intact. Review of the Care Management note for Resident #63 dated 08/08/22 revealed the initial care conference was held on 08/08/22. Further review of the medical record revealed no care conferences were held between 08/05/22 to 05/02/23. Review of the Interdisciplinary Care Conference note late entry for 05/02/23 revealed a care conference was held on this day. Interview on 05/08/23 at 11:53 A.M. with SSD #531 verified care conferences were not held quarterly for Resident #63. 31638 4. Review of Resident #28's medical record revealed an admitted [DATE]. Diagnoses included atrial fibrillation, dysphagia, chronic kidney disease, bilateral below the knee amputation, peripheral vascular disease, and neuromuscular bladder. Review of Resident #28's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #28's care conferences revealed conferences were held on 08/01/22, and 05/03/23. There were no other care conferences held in the year 2022 and only one thus far for the year 2023. Interview on 05/08/23 at 11:53 A.M. with SSD #531 verified care conferences were not held quarterly for Resident #28. SSD #531 stated she was working on getting care conferences caught up. 5. Review of Resident #56's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, diabetes mellitus, dementia, and coronary artery disease. Review of Resident #56's quarterly MDS assessment dated [DATE] revealed she was unable to complete the brief interview for mental status. Review of Resident #56's most recent care plan revealed she had terminal/end stage prognosis related to Alzheimer's disease was was under Hospice care. Review of Resident #56's social service notes care conferences were held on 07/20/22, 10/31/22, and 01/11/23. There were no other care conferences held between January 2022 to June 2022 and no other care conference was held this year besides 01/11/23. Interview with the family member of Resident #56 on 05/08/23 at 10:30 A.M. revealed care conferences were not being regularly for a long time. Interview on 05/08/23 at 11:53 A.M. with SSD #531 verified care conferences were not held quarterly for Resident #56. SSD #531 stated she was working on getting care conferences caught 6. Review of Resident #70's medical record revealed an admitted [DATE]. Diagnoses included pressure ulcer, paraplegia, and blepharon conjunctivitis. Review of Resident #70's quarterly MDS assessment dated [DATE] revealed the resident had a high cognitive function. Review of Resident #70's social service notes revealed care conference meeting was held only once on 02/01/23. Care conferences were not conducted in 09/2022 and 12/2022. Interview on 05/08/23 at 11:53 A.M. with SSD #531 verified care conferences were not held quarterly for Resident #70. SSD #531 stated she was working on getting care conferences caught 7. Review of Resident #71's medical record revealed an admitted [DATE]. Diagnoses included diabetes mellitus, malnutrition, acute kidney failure, acute renal failure, and a sacral pressure ulcer. Review of Resident #71's social service notes revealed care conferences were held on 09/28/22 and 03/29/23. A care conference was not completed in 12/2022. Interview on 05/08/23 at 11:53 A.M. with SSD #531 verified care conferences were not held quarterly for Resident #71. SSD #531 stated she was working on getting care conferences caught Review of the policy titled Care Plan Standard Guideline, dated 11/28/17, revealed the care plan will be reviewed throughout the resident's stay upon admission, quarterly, and with changes in condition. The care plans will be reviewed and revised at the care conference in collaboration with resident and/or resident representative.

Based on medical record review, observation, and resident and staff interview, the facility failed to ensure care and maintenance was provided for a midline catheter. This affected one (#30) of one residents reviewed for peripheral venous catheters. The facility census was 91. Findings include: Review of Resident #30's medical record revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included multiple sclerosis (MS), paraplegia, neuromuscular dysfunction of bladder, acute pyelonephritis, and urinary tract infection (UTI). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact and had an indwelling catheter. Review of the plan of care focus area initiated 10/22/22, revealed Resident #30 had a midline catheter to the left upper extremity. Interventions included midline flushes and dressing changes as ordered. Review of a hospital After Visit Summary (AVS) dated 05/05/23 revealed Resident #30 had an anterior left upper arm peripheral IV with discharge instructions including sodium chloride flush, infuse 10 milliliters (ml) into venous catheter in the morning and at bedtime for midline maintenance. Review of a Nursing Evaluation dated 05/05/23 revealed Resident #30 had a midline catheter. Review of the current physician orders revealed no orders for the care and maintenance of Resident #30's midline catheter. Observation and interview on 05/07/23 at 11:04 A.M. revealed Resident #30 had a midline catheter placed on the inside of her left upper arm. There was no date on the dressing indicating when it was last changed. Resident #30 stated she had been sick off and on for several months had had received antibiotics through the midline catheter. Resident #30 stated she returned from the hospital a couple of days ago and facility staff had not provided any type of care for the midline catheter. Interview on 05/08/23 at 10:01 A.M. with State tested Nurse Aide (STNA) #559 confirmed Resident #30 had a midline catheter placed to her left anterior upper arm. Interview on 05/08/23 at 4:49 P.M. with Assistant Director of Nursing (ADON) #507 confirmed residents with a peripheral venous catheter should have orders for the care and maintenance of the line, including dressing changes and flushes. ADON #507 verified Resident #30 had no orders for the care and maintenance of her midline catheter. Additionally, ADON #507 confirmed the hospital after visit summary, dated 05/05/23, included instructions to flush the midline catheter with 10 milliliter (ml) sodium chloride each morning and bedtime for maintenance. ADON #507 stated she would have the nurse get physician orders for the care of Resident #30's midline catheter.

Based on medical record review, review of Resident Council meeting minutes, resident and staff interview, and review of the facility policy, the facility failed to ensure residents received showers per the resident's preference. This affected two (Residents #32 and #76) of two residents reviewed for choices. The facility census was 91. Findings include: 1. Review of the medical record for Resident #32 revealed an admitted [DATE]. Diagnoses included end stage renal disease, duodenal ulcer, anxiety, rheumatoid arthritis, major depressive disorder, heart failure, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment for dated 04/07/23 revealed Resident #32 was cognitively intact. Resident #32 required supervision for activities of daily living and hands on assistance for bathing. Review of the shower documentation for Resident #32 dated March 2023 revealed resident did not receive a shower on 03/12/23, 03/15/23, and 03/19/23. Review of shower documentation for Resident #32 dated April 2023 revealed resident did not receive a shower on 04/09/23 and 04/23/23. Review of the Resident Council Minutes dated 04/17/23 revealed Resident #32 reported she was only receiving one shower per week. Interview on 05/07/23 at 11:38 A.M. with Resident #32 stated she only received one shower last week and she was supposed to receive a shower twice a week on Wednesday and Saturday. Interview on 05/10/23 at 9:29 A.M. with Director of Nursing (DON) verified showers were not documented on 03/12/23, 03/15/23, 03/19/23, 04/09/23, and 04/23/23. The DON stated that resident prefers not to be showered by a male state tested nursing aide (STNA) and could be the reason for the showers not being given. 42489 2. Review of Resident #76's medical record revealed an admitted [DATE]. Diagnoses included Parkinson's disease, dementia, and muscle weakness. Review of the plan of care initiated 02/16/23 revealed Resident #76 had an Activities of Daily Living (ADLs) self-care performance deficit related to weakness, Parkinson's disease, and dementia. Interventions included physical assistance with bathing and dressing and provide a sponge bath when full bath or shower was not tolerated. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was moderately cognitively impaired, required extensive assistance with dressing, and personal care. In addition, it was very important for Resident #76 to be choose between a tub bath, shower, bed bath, or sponge bath. Review of the State tested Nurse Aide (STNA) documentation from 04/09/23 through 05/09/23 revealed Resident #76 received bed baths on 04/11/23, 04/14/23, 04/22/23, 04/23/23, 04/25/23, and 05/01/23 and a shower on 05/09/23. Interview on 05/07/23 at 2:44 P.M. with Resident #76 revealed while she had been provided bed baths, she was unable to recall the last time she had a shower. Resident #76 stated she preferred showers to bed baths and felt refreshed after receiving a shower. Subsequent interview on 05/09/23 at 2:00 P.M. with Resident #76 revealed she received a shower that day (05/09/23). Resident #76 again stated she preferred a shower over a bed bath and felt much better after receiving a shower. Interview on 05/09/23 at 2:36 P.M. with the Director of Nursing (DON) revealed all shower documentation was completed in the Electronic Medical Record (EMR) and the facility did not have paper shower sheets. The DON verified the documentation in Resident #76's medical record revealed from 04/09/23 through 05/09/23, the resident only received one shower, which was documented on 05/09/23. The DON confirmed there was no evidence Resident #76 had received more than one shower since 04/09/23. Review of the facility policy titled Activities of Daily Living, dated 05/07/20, revealed in accordance with the comprehensive assessment, together with respect for individual resident needs and choices, the facility provides care and services including, but not limited to, bathing, dressing, and grooming. This deficiency represents non-compliance investigated under Complaint Number OH00139270.

AMENDED 11/06/19 Based on medical record review, staff and physician interview, policy review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure appropriate interventions were in place to prevent pressure ulcer development for residents who required assistance with positioning in wheelchairs. This resulted in actual harm when Resident #2 developed an avoidable deep tissue injury pressure ulcer to the right heel due to a wheelchair that did not fit properly. Additionally, the facility failed to ensure pressure ulcers were appropriately identified, assessed and had ordered treatments carried out for Resident #1, which placed the resident at risk for potential harm. This affected two (#1 and #2) out of four residents reviewed for pressure ulcers. The facility identified one resident currently with pressure ulcers. The facility census was 96. Findings include: 1. Review of the closed medical record for Resident #2 revealed the resident was originally admitted to the facility on [DATE] and had a recent readmission on 08/16/19. Resident #2 was discharged from the facility on 10/13/19. [DIAGNOSES REDACTED]. Review of Resident #2's plan of care revealed the resident's potential for skin breakdown was discontinued on 08/13/19 when the resident was transferred to the hospital and was not resumed upon readmission to the facility on [DATE]. The review of the care plan further revealed there was no plan of care for the actual pressure ulcer when it was discovered on 09/13/19. Review of Resident #2's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had significant cognitive deficits. The resident had no rejection of care but did have other behavioral symptoms not directed towards others one to three days of the assessment period. Resident #2 required extensive assistance for all activities of daily living and was totally dependent on staff for bathing. The resident had an indwelling catheter and was always incontinent of bowel. The resident did not have a terminal illness or experience falls. An unstageable pressure ulcer was acquired while in the facility. Pressure reduction devices were in place. Resident #2 also received Speech, Occupational and Physical Therapies and had occasion mild pain. Further review of the physicians order revealed Resident #2 had an order for [REDACTED]. There was no documentation on 07/12/19 or 07/14/19. Review of the TAR dated 08/2019 revealed skin prep was not documented on 08/03/19 and 08/09/19. Review of progress notes dated 08/07/19 revealed the resident had been attempting to stand unassisted all day and therapy was to re-evaluate for a different wheelchair. Review of physician orders [REDACTED]. The Mighty Shakes were discontinued on 08/13/19. Review of a re-admission assessment dated [DATE] revealed Resident #2 had no skin issues on re-admission to the facility. Review of a photo taken by the facility, identified as Resident #2 on 09/13/19 at 10:43 [NAME]M. revealed a facility acquired pressure ulcer had been identified. The photo revealed a fluid filled blister on the resident's heel with irregular edges. The photo was part of a wound assessment details report and revealed the wound measured 4.5 centimeters (cm) by 5.2 cm by unknown depth and also said the edges of the wound were normal. The new plan was to have offloading as tolerated with pre-clinical boots, pad and protect with abdominal pads and Kerlix. Physician orders [REDACTED]. Review of the orders revealed the order was changed to one daily on 10/06/19. Review of the physicians orders revealed an order for [REDACTED]. Review of a skin risk assessment dated [DATE] revealed the resident scored a 13 which put the resident at moderate risk for development of skin breakdown. Review of a Pressure Ulcer Unavoidability sheet on 09/16/19 revealed the resident developed a pressure ulcer on the right heel which was a deep tissue injury, measuring 4.5 cm by 5.2 cm. Risk factors included being chairfast and a history [MEDICAL CONDITION]. Current interventions to be implemented included an offloading boot to the resident's right foot. Prior interventions included floating the resident's feet on pillows. The summary was a suspected deep tissues injury to the right heel possibly from an ill fit from wheelchair foot pedals. This was completed by Licensed Practical Nurse (LPN) #40. Review revealed Occupational Therapy was started on 09/17/19 to address functional deficits. Further review of Resident #2's Wound Assessment Details Report dated 09/19/19, 09/25/19, 10/01/19 and 10/18/19 revealed the right heel was measured on each date as being 4 cm by 4.4 cm with no depth. The area was noted as a deep tissue issue on all of the assessments. A picture was taken by facility and viewed on the report within the medical record and the area to the heel was noted to be dark in color. Further review of the TAR's dated 09/2019 revealed the resident was to have bilateral heels cleansed with normal saline, skin prep applied and covered with an abdominal dressing. The TAR revealed the treatment was not applied on 09/14/19, 09/21/19, 09/22/19, 09/24/19, 09/26/19, 09/27/19, 09/28/19 and 09/30/19. TAR's dated 10/2019 revealed the resident's heels were to be cleansed with normal saline, have skin prep applied and covered with and abdominal dressing twice daily. This was not documented on 10/01/19, 10/02/19, 10/03/19, 10/04/19 or 10/05/19. The treatment was changed to daily on 10/05/19 and was not documented on 10/06/19 or 10/07/19. Review of TAR's dated 09/2019 revealed an entry for offloading boot to the right foot was not documented on 09/14/19, 09/26/19, 09/27/719, 09/30/19, 10/02/19, 10/04/19, 10/14/19, 10/15/19 and 10/16/19. There further was no documentation of the resident refusing the offloading boot on any of the above mentioned days. Interview with the Director of Nursing (DON) on 10/18/19 at 11:07 [NAME]M. verified Resident #2 developed a deep tissue injury on the right heel and it was discovered on 09/13/19. The DON stated the facility reports revealed the cause for Resident #2's pressure ulcer on the right heel was an ill fitting wheelchair and the pressure ulcer was not avoidable. The DON stated however, even with the comorbidities, a wheelchair foot pedal that did not fit would have been something that could have been addressed and avoided skin breakdown. The DON further verified the plan of care for Resident #2 did not address Resident #2's pressure ulcer and there was no written plan for pressure ulcer prevention. Further interview with the DON on 10/18/19 at 2:00 P.M. verified there was no further documentation was available to indicate the skin prep had been applied as ordered prior to the resident development of the pressure area and after the area was discovered. The DON further verified the off-loading boot was not documented as applied according to the TAR and there was no further documentation to show it had been completed as ordered. The DON verified there had been no interventions put into place to reduce pressure on wheelchair pedals and she was unaware there was an issue with the fitting of the wheelchair until today when the surveyor brought it to her attention. The DON confirmed the skin prep ordered for Resident #2's lower extremities was clearly assessed as to the area affected and was completely on all the day. The DON confirmed according to the orders the offloading boots order was ordered and for an unknown reason was discontinued on the same day dated 09/13/19; however, the order for the boots was added on the TAR but it was not signed off as being completed on every day. The DON confirmed the treatment to Resident #2's right heel was not completed as ordered. Interview with Director of Rehab #30 on 10/18/19 at 12:25 P.M. revealed Resident #2 did receive Physical therapy and Occupational therapy. She stated neither therapy worked with the resident on wheelchair positioning prior to 09/13/19 and she was unaware of the need to evaluate for a new wheelchair. She stated on 09/19/19 she spoke with nursing staff about possible foot buddies to used protect the resident's heels while in the wheelchair. She stated there was no suggestions of a new wheelchair or new foot pedals. She stated she was not aware the wheelchair pedals did not fit. She further stated the only suggestions from the therapy department were for foot buddies and range of motion for the resident's hamstrings to help him have more leg strength. Interview with State tested Nursing Assistant (STNA) #45 on 10/18/19 at 10:30 [NAME]M. revealed Resident #2 did not refuse care and would wear the offloading boot if they were offered. She stated the resident did have issues with positioning in his wheelchair and would have to repositioned frequently. STNA #45 further stated Resident #2's right heel would rub and move against the resident's wheelchair foot pedal and the resident's foot required frequent repositioning. 2. Review of the closed medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a discharge Minimum data Set (MDS) assessment dated [DATE] revealed the resident was discharged from the facility with no return anticipated. The resident was rarely or never understood and had severely impaired cognitive skills. No abnormal behaviors, rejection of care or wandering were observed. The MDS further revealed the resident was totally dependent on staff for bed mobility, locomotion, dressing, toileting, bathing and personal hygiene and required extensive assistance for transfers and eating. The resident was always incontinent of urine and frequently incontinent of bowel. No urinary infections or pressure ulcers were present. The resident did receive antibiotics for five days. Review of an admission nursing evaluation dated 09/20/19 revealed the skin assessment was not completed by staff. The resident was incontinent of bladder. Review of weekly skin observation dated 09/27/19 at 8:30 [NAME]M. revealed no skin issues were observed. Review of a Skin event dated 09/27/19 at 2:00 P.M. revealed a STNA informed the nurse that Resident #1 had a small red area on her buttock. No drainage was noted. A dressing was applied and the facility wound care nurse was to follow the wound progress. Barrier cream was to be applied to the area. The resident condition revealed the area was documented as other redness, not pressure. Possible causative factors included the resident met criteria for an unavoidable pressure ulcer as the resident had confusion and sensory motor deficits. It further revealed the area was classified as Moisture Associated skin Damage (MASD). It revealed the resident was a respite stay, was incontinent and was up in a chair a lot per recommendation from the family. Review of a Skin/Wound Note dated 09/27/19 at 3:36 P.M. revealed Resident #1 had new skin breakdown which was not over a bony prominence. The resident had strong smelling urine and was incontinent at the time. The area around the skin breakdown was documented as red but blanchable and was assessed as MASD and the family and physician were notified. Review of a facility photo, identified with the name of Resident #1, name of facility, dated 09/27/19 at 1:59 P.M. which was part of the medical record, revealed the resident had a small red area on her buttocks. The photo revealed a small focal open area at the base of the tailbone on the coccyx area. The wound had an open red circular center, with white edges along the wound. The skin around the wound and also on the buttock and coccyx area was pinkish red. There were no further areas of maceration. Interview with Registered Nurse (RN) #25 on 10/17/19 at 12:20 P.M. revealed she assessed Resident #1 immediately after the area discovered. She stated the resident was on her side at the time and the wound was not observed to be on a bony prominence. RN #25 verified the wound was midline coccyx and at the end of the sacral bone but felt and looked like it was off to the side of the bone. She further stated the skin could have been in a different position when the resident was in a sitting position. Review of information from the NPUAP revealed a deep tissue injury is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DEEP TISSUE INJURY to describe vascular, traumatic, neuropathic, or dermatologic conditions. Further review revealed medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. Review of facility policy titled Skin Management Guideline dated 11/28/17 revealed residents were to be properly identified and evaluated for increased risks of impaired skin integrity and pressure ulcers. The facility was to implement preventative measures and to provide appropriate treatment modalities for wounds according to industry standards of care. An individualized plan of care was to be developed and updated quarterly or with resident changes. A care plan for Skin Integrity was to be evaluated and revised based on the resident outcome and response to treatment and needs of the resident. A therapy evaluation request was to be requested for positioning and treatment as appropriate Review of an undated facility policy titled Wound Staging: A Practical Guide revealed the definition of a pressure ulcer was a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in a combination with shear and or friction and referenced the NPUAP as its source. Examples of external surfaces included mattresses, wheelchairs, side rails, improperly fitting shoes, pillows and side rails. It further revealed an unavoidable pressure ulcer was the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical conditions and pressure ulcer risk factors, defined and implemented interventions that were consistent with resident needs, goals and recognized standards of practice, monitored and evaluated the impact of the interventions and revised the approaches as appropriate. A stage II pressure ulcer was defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. And could present as an intact or open blister. It presented as shiny or dry and was not to be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. Incontinent Associated [MEDICAL CONDITION] was defined as an inflammation of the skin that occurred when urine or stool came in contact with the perineal or peri-genital skin. It was diffuse, partial thickness skin loss. This deficiency substantiates Master Complaint Number OH 776 and Complaint Number OH 494.