Every finding on record at Swanton Valley Rehabilitation and Healthcare Cente

Based on medical record review, review of a dialysis communication binder, staff interview, and policy review, the facility failed to ensure collaborative communication was shared between the facility and the hemodialysis center. This affected one (#86) of one residents reviewed for hemodialysis. The facility census was 73. Findings include:Review of the medical record revealed Resident #86 was admitted to the facility on [DATE]. Diagnoses included syncope and collapse, type II diabetes, peritonitis, and end stage renal disease. Resident #86 was on peritoneal dialysis until 06/12/26, when he then transitioned to hemodialysis treatments. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #86 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. Resident #86's functional abilities included the resident was bedfast due to a recent syncopal episodes but did have the ability to move self in bed. Review of the admission care plan dated 06/11/26 revealed Resident #86 had impaired genitourinary status. Interventions included to coordinate Resident #86's care in collaboration with the dialysis center on Monday's, Wednesday's, and Friday's. Review of the undated binder titled, Hemodialysis Communication Record, for Resident #86 revealed the area to be completed by the licensed nurse prior to dialysis treatments was completed. The other two sections to be completed by the dialysis center and the licensed nurse post-dialysis treatment were both empty. Interview on 06/16/26 at approximately 8:00 A.M. with the Director of Nursing (DON) revealed the hemodialysis communication binder was normally stored at the nurse's station but it was found in Resident #86's room that day. The DON verified only the first part of Resident #86's Hemodialysis Communication Record was completed. The DON continued to verify there was no return communication and there was no documentation on the form of the receiving nurse completing an assessment of the resident post-dialysis. Review of Resident #86's nursing progress notes dated 06/15/26 revealed no documentation of the receiving facility nurse calling the dialysis center for a post-dialysis report. Review of the policy titled, Hemodialysis, dated 09/2021, revealed staff will coordinate with the dialysis center for residents receiving dialysis.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure staff members maintained proper infection control measures by wearing appropriate personal protective equipment when providing direct care for residents on enhanced barrier precautions. This affected two (#5 and #8) of two residents reviewed for enhanced barrier precautions. The facility census was 73.Findings Include: 1. Review of the medical record for Resident #5 revealed an admission date of 06/07/25 with diagnoses including malignant neoplasm of corpus uteri, chronic osteomyelitis, displacement of an indwelling urethral stent, infection and inflammatory reaction due to indwelling ureteral stent, sacral and sacrococcygeal osteomyelitis of the vertebra, extended-spectrum beta-lactamase resistance, type II diabetes mellitus, pressure-induced deep tissue damage of sacral region, stage three chronic kidney disease, retention of urine, and overactive bladder.Review of the most recent Significant Change Minimum Data Set (MDS) assessment, dated 03/16/26, revealed Resident #5 had moderately impaired cognition. Review of the medical record for Resident #5 revealed a physician order, dated 06/01/26, indicating Resident #5 was to be in enhanced barrier precautions (EBP) every shift for chronic non-healing wounds. Observation on 06/14/26 at 8:00 A.M. of Resident #5's room door revealed a sign indicating Resident #5 was on EBP and everyone must clean their hands, including before entering and when leaving room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities including dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care (any skin opening requiring a dressing). Do not wear the same gown and gloves for the care of more than one person. Observation on 06/14/26 at 8:21 A.M. of incontinence care for Resident #5, provided by Certified Nurse Aide (CNA) #150 revealed CNA #150 did not don (put on) a gown prior to providing incontinence care nor at any time while she provided incontinence care to Resident #5. Interview on 06/14/26 at 8:33 A.M. with CNA #150 verified Resident #5 had a current order to be in EBP and there was also EBP signage on Resident #5's door. CNA #150 verified she provided incontinence care to Resident #5 and did not put on a gown while providing the care. 2. Review of the medical record for Resident #8 revealed an admission date of 06/08/26 with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of the left middle cerebral artery, chronic respiratory failure, difficulty in walking, generalized muscle weakness, nonrheumatic aortic valve insufficiency, presence of prosthetic heart valve, encounter for attention for gastrostomy, encounter for attention to tracheostomy, esophageal obstruction, gastroesophageal reflux disease, and insomnia.Review of the medical record for Resident #8 revealed a physician order, dated 05/25/26, indicating Resident #8 was to be in EBP every shift for a tracheostomy (a tube that is inserted through a hole in the windpipe to assist with breathing) and a percutaneous endoscopic gastrostomy (PEG) tube (a small, flexible tube placed through the abdominal wall directly into the stomach which allows a person to receive nutrition, fluids, and medications without swallowing). Observation on 06/15/26 at 11:40 A.M. of Resident #8's room door revealed a sign indicating Resident #5 was on EBP and everyone must clean their hands, including before entering and when leaving room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities including dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care (any skin opening requiring a dressing). Do not wear the same gown and gloves for the care of more than one person.Observation on 06/15/26 at 11:43 A.M. of incontinence care for Resident #8, provided by Registered Nurse (RN) #151 revealed RN #151 did not put on a gown prior to flushing Resident #8's PEG tube with free water and administering tube feeding to Resident #8. Interview on 06/15/26 at 11:56 A.M. with RN #151 verified Resident #8 had a current order for EBP and there was also EBP signage on Resident #8's door. RN #151 verified she administered free water and tube feeding to Resident #8 and did not put on a gown at any time during the administrations. Review of the facility policy titled, Enhanced Barrier Precautions (EBPs), dated January 2024, revealed EBP are an infection control method used in the facility to reduce transmission of drug-resistant organisms (MDROs). EBP refers to the use of gown and gloves during high-contact care activities for residents with any of the following including known infection or colonization with a resistant organism with contact precautions do not otherwise apply, chronic wounds, and indwelling medical devices. Further review revealed chronic wounds included pressure ulcers, diabetic ulcers, non-healing surgical wounds, and venous stasis ulcer; and indwelling medical devices included central lines, hemodialysis catheter, urinary catheter, feeding tube, and tracheostomy. High-contact resident care activities included changing briefs or assisting with toileting, caring for or using an indwelling medical device (for example, central venous catheter, urinary catheter, feeding tube care, tracheostomy/ventilator care), and performing wound care. This deficiency represents non-compliance investigated under Complaint Number 3015949.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure fall interventions were implemented and thorough post-fall investigations were conducted. This affected one (#2) of three residents reviewed for fall prevention in a facility census of 79. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of the upper right lobe lung and bronchus, acute and chronic respiratory failure with hypoxia and hypercapnia, type II diabetes mellitus, chronic obstructive pulmonary disease, hypertension, pneumonia, bacteremia, congestive heart failure, atrial fibrillation, generalized anxiety, major depression, shortness of breath and chronic fatigue. Review of the most current Minimum Data Set (MDS) assessment revealed Resident #2 was assessed with moderately impaired cognition, utilized a wheelchair for mobility, required supervision/touching assistance with activities of daily living, partial to moderate assistance with toileting and chair/bed transfer, was always continent of bowel and bladder, had no falls since admission, and was not at risk for pressure ulcer development with no skin breakdown. In addition, the resident received oxygen therapy and hospice services. Review of fall risk assessments completed on 11/17/25, 12/23/25, and 12/26/25 revealed Resident #2 was assessed at high risk for falls. Review of Resident #2's nursing plan of care revealed a revision on 11/20/25 to address the resident's activity of daily living (ADL) self-care performance deficit related to congestive heart failure, chronic fatigue, generalized weakness. Interventions included the resident required a one person assist with transfer and toileting. Further review revealed, on 12/07/25, a nursing plan of care was revised to address Resident #2's episodes of bladder and bowel incontinence related to congestive heart failure, and diabetes. Interventions included to administer medications per physician order, assist with toileting needs, periodically evaluate the resident's pattern of urination and episodes of incontinence, and report if the resident had no output. In addition on 12/07/25, a plan of care was revised addressing Resident #2's risk for falls related to decreased strength and endurance, functional problems, generalized weakness, history of falls, needs assistance with ADLs. Interventions included to educate the resident and family to call for assistance before transferring, keep food/fluids within reach, implement preventative fall interventions/devices, maintain the call light within reach, educate the resident to use the call light, maintain needed items within reach, monitor for changes in mobility, and provide non-skid footwear. Review of a fall occurrence evaluation dated 12/23/25 at 9:00 P.M. revealed Resident #2 was found on the floor in her room by her bed, sitting on her buttocks. Resident #2 indicated she was attempting to use the bathroom when the fall occurred and no injury was documented. Interventions included to educate the resident and family to call for assistance before transferring, keep food/fluids within reach, and provide non-skid footwear. There was no intervention to include attempting a toileting schedule or assistant to bathroom which was the nature of the resident's fall. Review of a post fall risk evaluation dated 12/23/25 noted Resident #2 to have sustained previous falls, used a crutches, cane or walker, assessed with weak gait. Review of a fall occurrence evaluation dated 12/26/25 at 4:00 A.M. noted Resident #2 was discovered by staff passing in hall and noticed the resident scooting along on the floor. Resident #2's mask was sitting on resident's bed, and the bedside commode and walker were at the resident's bedside. Resident #2 indicated she was using the bathroom when she got shaky and sat on the floor so she did not fall and hurt herself. Vital signs were taken, a head-to-toe assessment was performed, and all findings were within normal limits with no new injuries or skin issues noted. Further review revealed the facility initiated a fall protocol with interventions including to educate the resident and family to call for assistance before transferring, keep food/fluids within reach, and provide non-skid footwear. There was no intervention to include a toileting schedule or assistant to use the bathroom which was the nature of the resident's fall. In addition, there was no documentation indicating interventions in place at the time of the fall when the resident was last observed or whether the resident's call light was activated or not. Observation on 12/30/25 at 1:40 P.M. noted Resident #2 seated on the bedside. Resident #2 was noted with anti-embolism stockings applied to the bilateral lower extremities with the socking toes dangling from the feet and not securely in place. There were no slip resistant footwear was applied to the resident's feet. Observation on 12/31/25 at 3:35 A.M. revealed Resident #2 was seated on the bedside commode with no slip resistant footwear applied. At 3:36 A.M., interview with Licensed Practical Nurse (LPN) #300 revealed she was unaware the resident was up at the bedside without supervision. LPN #300 indicated Resident #2 was to be assisted by staff to transfer from the bed and not to self-transfer. On 12/31/25 at 8:35 A.M., interview with the Director of Nursing (DON), during a review of Resident #2's medical record, verified no interventions were implemented to determine Resident #2 bowel and bladder habits or toileting schedule. The DON confirmed Resident #2 sustained falls related to self-transferring to the toilet and bedside commode, and according to the fall investigation documentation for the falls occurring on 12/23/25 and 12/26/25, no information was obtained to determine fall interventions in place at time of fall, when Resident #2 was last observed, or if the call light activated at time of the falls. Review of facility falls policy, dated September 2021, revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falls. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. If falling recurs despite initial interventions, staff will implement additional interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.This deficiency represents non-compliance investigated under Complaint Number 2689209.

Based on observation, medical record review, and staff interview, the facility failed to ensure interventions were implemented to address bladder incontinence and ensure incontinence care was provided in a timely manner. This affected one (#1) of three residents reviewed for bowel and bladder incontinence in a facility census of 79. Findings include: Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses included post-polio syndrome, Bell's palsy, osteoarthritis, muscle weakness, and bilateral myopia. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was assessed with intact cognition, rejected care four to six days during the seven day look back period, had bilateral upper and lower extremity range of motion impairments, was dependent on staff for the completion of activities of daily living, was always incontinent of bowel and bladder, and was at risk for pressure ulcer development with no skin impairment recorded. Review of a nursing plan of care dated 01/07/25 revealed a focus area was implemented to address Resident #1's episodes of bladder and bowel incontinence related to generalized weakness. Interventions included to assist the resident with toileting needs, periodically evaluate the resident's pattern of urination and episodes of incontinence, provide disposable incontinence products, provide peri-care after each incontinent episode. There were no scheduled toileting or a frequency to check for incontinence included or documented in the medical record. Review of a nursing plan of care dated 01/09/25 revealed a focus area was implemented due to Resident #1's refusal of care, showers, supplements, and treatments. Interventions included to approach the resident in a calm manner to avoid frustration and behavior escalation, encourage the resident to ask questions when concerned about medical condition, encourage the resident to participate in care, explain the potential adverse effects of refusals of care and offer alternatives when possible, monitor behavior episodes and attempt to determine underlying cause, monitor and document episodes of inappropriate behaviors, notify the physician/nurse practitioner/physician assistant when behaviors persist or will not deescalate, and provide a structured schedule for daily care when possible. Review of a bowel and bladder assessment completed on 10/20/25 revealed Resident #1 scored as a potential candidate for scheduled toileting. Further review of the medical record revealed no documentation to address attempts to schedule toileting for Resident #1.Observation and interview on 12/30/25 at 8:05 A.M. noted Resident #1 alert and awake in bed. Resident #1 stated she was currently incontinent of urine and was last checked for incontinence at 4:30 A.M. by the night staff. On 12/30/25 at 9:20 A.M., interview with Licensed Practical Nurse (LPN) #301 revealed she was working as Resident #1 certified nurse aide (CNA). LPN #301 stated she assumed care for Resident #1 at 5:00 A.M. that day and confirmed she had not checked the resident for incontinence. LPN #301 stated Resident #1 was incontinent with some chronic excoriation to the buttock and should be checked every two hours. LPN #301 stated Resident #1 would generally call out when she needed changed. Observation and interview on 12/30/25 at 9:48 A.M., revealed Registered Nurse (RN) #400 and LPN #301 went to assist Resident #1 with incontinence care. LPN #301 verified she had not asked Resident #1 if she needed checked for incontinence care until that time. RN #400 stated residents are to be checked every two hours per facility protocol. LPN #301 confirmed Resident #1 required incontinence check and changes, but was unable to indicate Resident #1's toileting schedule. RN #400 and LPN #301 repositioned Resident #1, removed her disposable incontinence brief, and noted the resident to be incontinent of a moderate amount of urine. Resident #1's bilateral buttocks were noted with areas of excoriated tissue. LPN #301 cleansed Resident #1's perinium and buttock with disposable wipes and applied a barrier ointment. RN #400 and LPN #301 then placed Resident #1 in a clean incontinence brief. On 12/30/25 at 12:35 P.M., interview with the Director of Nursing (DON) revealed Resident #1 frequently refused all aspects of care. The DON confirmed Resident #1 did not have an established toileting schedule in place as described in the bowel and bladder assessment and should have been asked if she needed checked or changed on 12/30/25. This deficiency represents non-compliance investigated under Master Complaint Number 2706213, Complaint Number 2702593, Complaint Number 2689209, and Complaint Number 2652724.

Based on review of the medical record, observation, resident interview, staff interview, review of the facility policy, review of documentation on the National Institute of Health (NIH) website, and review of Public Safety Network guidance, the facility failed to ensure the residents environment remained as free from accident hazards as possible when one resident (#11) continued to use vape pens (an electronic device that uses a battery to heat up a special liquid into an aerosol that users inhale) in the presence of oxygen. This resulted in Immediate Jeopardy and the potential for serious physical harm and/or injuries, when Resident #11 was allowed to keep her vape pen in her room and was known to use it while wearing her oxygen, which increased the risk of potentially causing the oxygen gas to ignite from the heat of the vape pen. This affected one (Resident #11) of three residents reviewed for using vape pens. Additionally, facility staff failed to follow the facility's policy for residents to return their vape pens to staff when not in use, and not to vape unless in the designated smoking area. This affected two (#11 and #12) of three residents reviewed for use of vape pens. The facility census was 83. On 06/05/25 at 3:05 P.M., the Administrator, the Director of Nursing (DON) and Chief Nursing Officer #400 were notified Immediate Jeopardy began on 04/21/25 when Registered Nurse (RN) #201 observed and documented Resident #11 using her vape pen in her room while wearing her oxygen. The facility did not provide additional supervision and/or monitoring to ensure Resident #11 followed the facility policy not to use the vape pen inside the facility while wearing oxygen. On 06/05/25 at 8:14 A.M., Resident #11 was observed in her room with the vape pen stored in a container on her overbed table. At the time of the observation, Resident #11 stated she uses her vape pen in her room while wearing her oxygen. The Immediate Jeopardy was removed on 06/06/25, when the facility implemented the following corrective actions: • On 06/05/25 at 9:30 A.M., Resident #11 had all electronic smoking devices removed by the Director of Environmental Services (#305). • On 06/05/25 at 4:23 P.M., the staff nurse completed a head-to-toe assessment on Resident #11 with no negative effects due to the resident vaping in the room while using oxygen. • On 06/05/25 at 4:45 P.M., Resident #11 was presented with an immediate discharge by the Administrator. The resident was accepted for admission to another skilled nursing facility in the same city. • By 06/06/25, the Administrator or designee will reassess residents who smoke and/or use electronic smoking devices for safety and/or needed supervision during smoking. • By 06/06/25, the Administrator or designee will audit all residents who smoke and/or use electronic smoking devices to ensure smoking materials are retained and distributed by the facility staff to the residents during the designated smoking times and/or when independent resident chooses to smoke. • By 06/06/25, the Administrator or designee will audit all residents who smoke and/or use electronic smoking devices to ensure they do not smoke or vape while using oxygen or in areas where oxygen is present. • By 06/06/25, the Administrator or designee will retrain all staff in all departments on the facility smoking policy and that smoking and/or vaping are prohibited while using oxygen or in areas where oxygen is present. • By 06/06/25, the Administrator or designee will retrain all residents who smoke and/or use electronic smoking devices on the smoking policy and have them all sign the policy. Residents will be retrained that smoking and/or vaping are prohibited while using oxygen or in areas where oxygen is present. • On 06/06/25 at 12:55 P.M., the facility initiated one-on-one monitoring of Resident #11 until she can be discharged . • Beginning 06/06/25 and continuing weekly for four weeks, the Administrator or designee will audit four residents who smoke and/or use electronic smoking devices to ensure smoking materials are retained and distributed by the facility staff to the residents during the designated smoking times and/or when independent resident chooses to smoke and to ensure they do not smoke or vape while using oxygen or in areas where oxygen is present. The audits will be submitted to the Quality Assurance (QA) committee for tracking, trending and recommendations. Although the Immediate Jeopardy was removed on 06/06/25, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record for Resident #11 revealed an admission date of 01/25/23. Diagnoses included heart disease, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and tobacco use. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/12/25, revealed Resident #11 had intact cognition. Review of the care plan initiated 01/25/23, and revised on 02/05/24, revealed Resident #11 was a smoker and was non complaint with the smoking policy. Interventions included informing the resident, or responsible party, if applicable, regarding the center's smoking rules, designated smoking areas, and storage of smoking materials. An additional intervention was to keep oxygen away from smoking materials and to ensure removal prior to the resident smoking. Review of the physician order initiated 04/11/24 and discontinued 02/21/25 revealed Resident #11 received oxygen at 4 liters via nasal cannula (NC) continuously. Review of a progress note dated 08/05/24 revealed the Administrator, the DON, [NAME] Unit Manager #310, and Social Services Director (SSD) #307 met with Resident #11 and her husband for a care conference. Further review revealed Resident #11 had been found vaping in her room on more than one occasion recently and had been asked to stop. Resident #11 had signed the smoking policy and was aware of the smoking guidelines. The Administrator went over the smoking policy one more time and alerted Resident #11 and her spouse to not bring anymore vape pens into the facility. Resident #11 stated her understanding but stated she was probably not going to do what she was asked. The Administrator notified Resident #11 if she was noncompliant again, they would need to discuss finding a more appropriate facility. Resident #11 and her spouse voiced understanding. Review of the current physician order dated 02/26/25 revealed Resident #11 received oxygen at 4 liters via NC continuously. Review of a nursing progress note dated 04/21/25 at 7:42 P.M., written by RN #201, revealed Resident #11 was observed smoking a vape pen in her bedroom while her husband was present. Resident #11 had been told by multiple staff members about not smoking in the room. Review of the Smoking Evaluation, completed 04/25/25, revealed Resident #11 was able to smoke independently. Observation and interview on 06/05/25 at 8:14 A.M. revealed Resident #11 sitting in her wheelchair with oxygen via NC running at 3.5 liters per minute. Resident #11 stated she vaped in her room and when she vaped, she did not remove her oxygen. Resident #11 stated she was aware she violated the facility policy when doing so. Resident #11 asked the surveyor not to say anything to the facility. Observation and interview on 06/05/25 at 9:02 A.M. with Resident #11 revealed the vape pen was in a plastic tote container on her overbed table directly within reach. Resident #11 again asked the surveyor not to say anything because Resident #11 stated she would Get in trouble. Interview on 06/05/25 at 9:09 A.M. with Certified Nursing Assistant (CNA) #102 revealed she was aware Resident #11 kept a vape pen in her room. CNA #102 stated she never observed Resident #11 smoking the vape pen. CNA #102 stated she was aware staff removed the vape pen from Resident #11's room and Resident #11's husband would bring another one in for her. Telephone interview on 06/05/25 at 9:45 A.M. with RN #201 confirmed she wrote the progress note dated 04/21/25 regarding Resident #11 vaping in her room. RN #201 confirmed Resident #11 was wearing oxygen at the time of the observation. RN #201 stated she removed the vape pen from the room and placed it with the other locked smoking items. RN #201 stated Resident #11's husband would bring another vape pen when he visited and leave it with Resident #11. RN #201 stated she observed Resident #11 smoking her vape pen in her room with oxygen running on more than one occasion. Interview on 06/05/25 at 10:57 A.M. with Licensed Practical Nurse (LPN) #202 confirmed she observed Resident #11 smoking her vape pen in her room while receiving oxygen via NC sometime in September 2024. Interview on 06/05/25 at 11:15 A.M. with the Administrator confirmed residents were not allowed to keep vape pens in their rooms. Observation on 06/05/25 at 11:27 A.M. revealed a No Smoking sign on Resident #11's doorframe visible from the hallway. Telephone interview on 06/05/25 at 12:16 P.M. with Resident #11's husband revealed the facility had not taken Resident #11's vape pen away in a while and further confirmed he would bring her vape pens. Further, Resident #11's husband was aware Resident #11 was supposed to turn in her vape pen and was not turning it in to nursing staff. Interview on 06/05/25 at 3:23 P.M. with Director of Environmental Services (DES) #305 revealed she conducted Concierge Rounds daily with Resident #11 for approximately the last four weeks. DES #305 stated she visited Resident #11 to check on her and assist Resident #11 with any concerns. DES #305 confirmed Resident #11 had a vape pen on her bedside table every day. DES #305 stated she educated Resident #11 regarding the facility's policy regarding vape pens being kept in the medication room. DES #305 further stated Resident #11 refused to give her vape pen to DES #305. Review of facility policy titled Smoking Policy, revised 09/2022, revealed resident smoking materials will be retained and distributed by the facility staff to the residents during the designated smoking times and/or when independent resident chooses to smoke. Further review revealed electronic smoking devices and vapor products are to be considered the same as smoking. Review of an article posted on the National Institutes of Health (NIH) website, pmc.ncbi.nlm.nih.gov/articles/PMC4390016/, titled E-cigarette Use In Patients Receiving Home Oxygen Therapy, published in 2015, under the heading of Hazards of E-cigarettes in Current Smokers: The basic components of most disposable or rechargeable e-cigarettes include a cartridge containing a liquid solution of propylene glycol (with or without nicotine), a battery and a heating element. This latter component reaches high temperature and aerosolizes the e-liquid to be inhaled. Consequently, it can conceivably ignite in the presence of oxygen. According to Public Safety Network (Agency for Healthcare Quality and Research), the use of any ignition source in the presence of oxygen is potentially hazardous. This issue was addressed specifically by the British Compressed Gases Association, which stated, electronic cigarettes are a potential ignition source and, in the context of oxygen-rich environments, have the same fire risks as traditional cigarettes. This opinion was supported by the Electronic Cigarettes Industry Trade Association, which agreed that in the context of oxygen use, it would be appropriate to describe electronic cigarette use as similarly hazardous to smoking. 2) Review of the medical record for Resident #12 revealed an admission date of 01/15/25. Diagnoses included multiple sclerosis, stroke, and anxiety. Review of the quarterly MDS assessment, dated 04/20/25, revealed Resident #12 had intact cognition. Review of the current care plan initiated 01/15/25, and revised on 03/04/25, revealed Resident #12 was resistant to care and non-complaint with smoking policy. The care plan revealed Resident #12 was a supervised smoker. Interventions included following and verbalized understanding regarding the facility rules for designated smoking areas and smoking material. Review of a nurse's progress note dated 03/02/25 revealed Resident #12 was found with a vape pen in her room. The nurse told Resident #12 if she wished to use the vape pen, she needed to go outside. Resident #12 told the nurse she would put the vape pen in her pocket. Review of the nursing progress notes dated 03/03/25 revealed SSD #307 and a CNA went to Resident #12's room to speak with the resident regarding vaping in her room. Resident #12 admitted to vaping in her room. SSD #307 explained vaping in the room was against the facility smoking policy. Resident #12 was pleasant, stated she understood, and handed over her vape pen to SSD #307. SSD #307 gave the vape pen to the DON to keep until Resident #12 discharged to home. Review of the Smoking Evaluation, dated 06/05/25, revealed Resident #12 was able to smoke independently. Observation on 06/05/25 at 8:41 A.M. revealed Resident #12 was lying in bed. A rechargeable vape pen was observed on her overbed table within reach. During a concurrent interview Resident #12 stated she did not smoke, but did use a vape pen. Resident #12 confirmed her vape pen was on her overbed table. Resident #12 stated she never smoked inside the facility and always went outside to use her vape pen. Resident #12 was aware she was not supposed to smoke in her room. Interview on 06/05/25 at 10:09 A.M. with CNA #103 confirmed she saw a vape pen on Resident #12's overbed table. CNA #103 stated she did not remove the pen but reported it to the night shift nurse and a Unit Manager. Interview on 06/05/25 at approximately 11:21 A.M. with Resident #12 revealed she was not aware she was supposed to return her vape pen to nursing staff after she came back into the facility after using it. Interview on 06/05/25 at 2:01 P.M. with the Dietary Manager and Housekeeping and Laundry Supervisor (DMHLS) #308 revealed she was assigned to Resident #12 to provide daily Concierge Rounds. DMHLS #308 stated she observed the vape pen on Resident #12's overbed table while doing rounds on 06/05/25 at approximately 9:15 A.M. DMHLS #308 stated she educated Resident #12 to return the vape pen to staff when she finished using it. DMHLS #308 stated 06/05/25 was the first time she observed a vape pen in Resident #12's room. This deficiency represents non-compliance investigated under Complaint Number OH00166252.

Based on observation and staff interview the facility failed to ensure dishes were cleaned and properly stored. This had the potential to affect 75 residents who received food from the kitchen. The facility identified one resident (#52) who received no food by mouth. The facility census was 76. Findings include: Observation on 12/02/24 at 8:12 A.M. of the kitchen revealed no designated storage area for clean cups, bowls, plates or trays. The clean clear bowls and adaptive equipment were stored on a rack in the dish room, cups were stored on the drink carts, trays were stored at the end of the steam table and opaque soup bowls were stored in racks under the steam oven. Observation on 12/03/24 at 9:58 A.M. of three coffee cups from 200 hall drink cart revealed a dried powdery residue coating on the inside of the cup. The residue could be easily removed by rubbing a finger across the coating. Coinciding interview with the Administrator verified the cups appeared unclean. Observation on 12/03/24 at 11:18 A.M. of the kitchenware storage rack in the dishwashing room revealed two plates and a bowl on the racks with food residue. In addition, the clear bowls were stacked wet with the bowl facing up. Coinciding interview with Corporate Dietary Manager (CDM) #610 verified the dishes had food debris and were stored improperly on the storage racks. CDM #610 confirmed the rack was for dishes that were to be washed and not clean dish storage. Observation on 12/03/24 at 11:43 A.M. of the meal delivery carts being prepared for lunch meal service revealed two clear bowls on the 400 hall serving cart with a brown substance on them and were unclean. Interview on 12/03/24 at 11:44 A.M. with CDM #610 verified the two clear bowls being used on the 400 hall food cart were unclean, removed them from the cart and replaced them with two clean clear bowls. Observation on 12/04/24 at 6:35 A.M. of the dish storage rack in the dishwashing room revealed the dishes appeared to be rewashed, were clean, were stacked properly but were stacked wet. Coinciding interview with Dietary Staff (DS) #511 verified the racks were for clean dishes, the dishes on the racks had been rewashed and were stacked wet.

Based on observation, resident interview, staff interview and review of facility policy, the facility failed to ensure room temperatures were comfortable for the residents. This affected four residents (#57, #19, #34 and #71) of four residents reviewed for comfortable room temperatures. The facility census was 76. Findings include: 1. Review of the medical record for Resident #57 revealed she was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the annual Minimum Data Set (MDS) assessment, dated 09/02/24, revealed Resident #57 was cognitively intact. Observation on 12/02/24 at 8:35 A.M. revealed Resident #57 was sitting in a wheelchair in her room. The resident was wearing long sweatpants and a sweatshirt and had a blanket covering her. Concurrent interview with Resident # 57 revealed the she was cold. 2. Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses of COPD and diabetes mellitus. Review of the quarterly MDS assessment, dated 11/08/24, revealed Resident #19 was cognitively intact. Observation on 12/02/24 at 11:28 A.M. revealed Resident #19 was wrapped in blankets in his room. Coinciding interview with Resident #19 revealed the resident complained of his room being cold. 3. Review of the medical record for Resident #34 revealed an admitted [DATE] with diagnoses of COPD, asthma and chronic respiratory failure. Review of the quarterly MDS assessment, dated 10/28/24, revealed Resident #34 had mild cognitive impairment. Observation on 12/02/24 at 9:30 A.M. revealed Resident #34 curled in the fetal position in her bed, bundled under blankets pulled up to her chin. Concurrent interview with Resident #34 revealed she complained of her room being cold. 4. Review of the medical record for Resident #71 revealed an admitted [DATE] with diagnoses of multiple sclerosis and dementia. Review of the quarterly MDS assessment, dated 11/07/24, revealed Resident #71 had mild cognitive impairment. Observation on 12/03/24 at 9:15 A.M. revealed Resident #71 was in her room, dressed in long pants, a long sleeve shirt and a sweatshirt. Concurrent interview with Resident #71 revealed she complained of her room being cool. Interview on 12/02/24 at 2:03 P.M. with Maintenance Director (MD) #535 revealed the facility heat was not turned on yet. DM #535 further state it's warm enough compared to outside. Observation on 12/02/24 at 2:15 P.M. with MD #535 of room temperatures revealed Resident #19's room was 70.1 degrees Fahrenheit (F), Resident #34's room temperature was 70.3 degrees F, Resident #57's room temperature was 70.5 degrees F and Resident #71's room temperature was 69.2 degrees F. Coinciding interview with MD #535 verified Resident #19, Resident #34, Resident #57 and Resident #71's room temperatures were below 71 degrees F. Review of the facility policy titled Facility Temperature Policy, dated September 2021, revealed the facility was to provide comfortable and safe temperatures for the residents in the facility. Heating, ventilation, and air conditioning systems should be capable of maintaining an acceptable temperature range of 71-81 degrees Fahrenheit throughout resident areas.

Based on observation, medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure adaptive equipment to support resident's independence was provided during meals. This affected one (#40) of six residents reviewed for dining. The facility census was 76. Findings include: Review of Resident #40's medical record revealed an admitted [DATE]. Diagnoses included dementia with psychotic disturbance, protein calorie malnutrition, muscle weakness, restlessness and agitation and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/25/24, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of five, indicating Resident #40 was severely cognitively impaired. Resident #40 required supervision with eating and had no discomfort or difficulty with chewing at the time of the review. Review of the care plan, initiated 12/09/22, revealed Resident #40 was at risk for altered nutritional status related to dementia, depression and malnutrition. Interventions included encourage/provide intake of fluids throughout the day. Review of Resident #40's physician orders revealed an order dated 06/22/24 for a regular diet, mechanical soft texture, regular thin consistency, straws with liquids and fortified foods. Observation on 12/02/24 at 11:35 A.M. of the lunch meal service revealed Resident #40 sitting in the secured unit dining room. Resident #40 was provided a purple drink in a regular cup , with no straw, by Activity Aid (AA) #505. Observation on 12/02/24 at 11:41 A.M. revealed Resident #40 continued to sit at the table in the dining room with her drink in front of her. Resident #40's hands were observed to be tremoring slightly. The two other residents at the table were drinking independently from their cups. Continuous observation revealed at 11:49 A.M., Certified Nursing Assistant (CNA) #546 prompted AA #505 to get Resident #40 a lidded cup with a straw ([NAME] Cup) for her beverage. Coinciding interview with AA #505 revealed she did not help on the secured unit very often and was unaware Resident #40 required a special cup for her beverages and verified she provided Resident #40 with a regular cup. Continued observation on 12/02/24 at 11:55 A.M. of the lunch meal service revealed CNA #546 asked Resident #40 if she wanted her drink in a Kennedy cup and the resident responded yes. CNA #546 poured Resident #40's drink into the lidded cup with a straw and placed it in front of Resident #40. Interview on 12/02/24 at 11:58 A.M. with Resident #40 revealed the resident was alert and aware. Resident #40 reported she was able to drink out of a regular cup but it was very hard for her. The lidded cup with the straw and handle helped her to drink independently and not spill it on herself. Resident #40 stated she wanted to drink the beverage she had been provided but needed the special cup so she did not make a mess and get it all over. Observation on 12/03/24 at 12:10 P.M. of the lunch meal service revealed Resident #40 sitting at a dining table in the secured unit dining room. Resident #40 was provided ice tea, with no straw or Kennedy cup, by AA #502. Resident #40 was observed using two hand to raise her regular cup to her mouth. Resident #40's hands were observed to be shaking while she drank. Resident #40 put the cup down, placed her head in her hands, appeared frustrated and pushed the cup away from her. Interview on 12/03/24 at 12:17 P.M. with CNA #546 verified Resident #40 required the use of a straw or a Kennedy cup for all of her drinks and she had not been provided one with her lunch meal. Review of the facility policy titled, Assistance with Meals, revised September 2021 revealed adaptive devices would be provided for residents who needed or requested them. These may include devices such as silverware with enlarged handles, plate guards, and or specialized cups.

Based on observation, medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure residents received routine dental services. This affected one (#40) of three residents reviewed for dental services. The facility census was 76. Findings include: Review of Resident #40's medical record revealed an admitted [DATE]. Diagnoses included dementia with psychotic disturbance, protein calorie malnutrition, muscle weakness, restlessness and agitation and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/25/24, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of five, indicating the resident was severely cognitively impaired. Resident #40 required supervision with eating, and moderate assistance with oral hygiene. Resident #40 required a mechanically altered diet and had no broken or loosely fitting dentures, no mouth or facial pain and had no discomfort or difficulty with chewing at the time of the review. Review of the care plan, revised 10/01/24, revealed Resident #40 had dental problems related to poor nutrition and poor oral hygiene. Interventions included to complete oral hygiene at least daily, notify physician of any changes, medication and treatment as ordered and refer for dental services. Review of the Consent and Authorization to Treat for Ancillary Services, signed 02/08/23, revealed Resident #40's representative authorized dental services to be provided/arranged by the facility. Further review of Resident #40's medical record revealed no evidence Resident #40 was seen by the dentist. Observation on 12/02/24 at 8:48 A.M. of Resident #40 revealed she had one bottom tooth and the remaining upper teeth were brown, broken or missing. Coinciding interview with Resident #40 revealed the resident was alert and oriented. Resident #40 reported staff assisted with oral care but she was unsure of when she last saw a dentist. Resident #40 reported she did not think she had seen a dentist since her admission to the facility. Interview on 12/03/24 at 10:49 A.M. with the Administrator verified Resident #40 had not been seen by the dentist since she was admitted to the facility on [DATE]. The dentist came to the facility every three months and Resident #40 would be on the list for the next visit. The Administrator reported the dentist was there on 10/24/24 and would be back during the third week of January. Review of the facility policy titled, Availability of Services, Dental, revised August 2007, revealed dental services were available to all residents requiring routine and emergency dental care. Social Services was responsible for making necessary dental appointments.

Based on observation, resident interview, staff interview and review of facility policy, the facility failed to ensure oxygen was administered per physician orders. This affected three (#34, #57 and #5) of three residents reviewed for oxygen administration. The facility identified 10 residents who received oxygen therapy. The facility census was 76. Findings include: 1. Review of the medical record for Resident #34 revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), asthma and chronic respiratory failure. Review of the current physician orders revealed Resident #34 was ordered oxygen at fours liter per minute (lpm) via nasal cannula (NC). Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/28/24, revealed Resident #34 had mild cognitive impairment. Review of the current care plan revealed Resident #34 had impaired respiratory status. Interventions included oxygen per physician orders. Observation on 12/02/24 at 9:16 A.M. of Resident #34 revealed her oxygen was applied and the oxygen concentrator was set at three lpm. Interview on 12/02/24 at 9:26 AM with Licensed Practical Nurse (LPN) #598 verified Resident #34's oxygen concentrator was set between two and three lpm and further confirmed the current physician's order was for oxygen at four lpm. 2. Review of the medical record for Resident #57 revealed an admitted [DATE] with diagnoses of COPD and chronic respiratory failure. Review of the current physician orders revealed Resident #57 was ordered oxygen at four lpm via NC. Review of the annual MDS assessment, dated 09/02/24, revealed Resident #57 was cognitively intact. Review of the current care plan revealed Resident #57 had impaired respiratory status. Interventions included oxygen as ordered by the physician. Observation on 12/02/24 at 8:42 A.M. of Resident #57 revealed her oxygen was applied and the oxygen concentrator was set at two lpm. Concurrent interview with Resident #57 revealed the oxygen concentrator was to be set at four lpm. Interview on 12/02/24 at 9:24 A.M. with LPN #598 verified Resident #57's oxygen concentrator was set at two lpm and further confirmed the physician's order was for oxygen to be set at four lpm. 44815 3. Review of the medical record for Resident #5 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included COPD, congestive heart failure and dementia. Review of the annual comprehensive MDS assessment, dated 10/16/24, revealed Resident #5 had impaired cognition. Review of the physician's order dated 10/15/24 revealed Resident #5 received oxygen at three lpm via NC. Review of the current care plan for Resident #5 revealed she had impaired respiratory status related to COPD. Interventions included providing oxygen as ordered by the physician. Observation on 12/02/24 at 8:33 A.M. revealed Resident #5 lying in bed with oxygen applied and the oxygen concentrator was set at four lpm. Interview on 12/02/24 at 9:24 A.M. with LPN/Unit Manager (UM) #607 confirmed Resident #5's oxygen was running at four lpm. Further interview and concurrent review of the electronic medical record confirmed Resident #5's physician order for oxygen was three lpm. Review of the facility policy titled Oxygen Administration, dated September 2021, revealed oxygen therapy was the administration of oxygen at concentrations greater than room air with the intent of treating or preventing the symptoms and manifestations of hypoxia (low levels of oxygen in body tissues). The initial need is determined by documented hypoxemia or a physician order.

Based on observation, resident interview, staff interview and review of the medical record, the facility failed to ensure range of motion (ROM) exercises were provided to prevent further decline. This affected one (#46) of two residents reviewed for ROM. The facility census was 76. Findings include: Review of Resident #46's medical record revealed an admitted [DATE]. Diagnoses included cerebrovascular disease, cerebrovascular infarction (stroke) affecting left side resulting in hemiplegia and hemiparesis, osteoarthritis, chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, dysphagia, mood disorder, major depressive disorder, neuropathy, anxiety disorder, hypertension and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 10/06/24, revealed Resident #46 had moderately impaired cognition, had no refusals of treatment, had ROM impairment to one side upper and lower extremity and required substantial to maximal assistance with activities of daily living (ADLs). Review of the plan of care, revised 04/07/22, revealed Resident #46 had impaired neurological status related to cerebral vascular accident (stroke), hemiplegia (left side) and neuropathy. Interventions included the following: assist with normal daily tasks as needed, provide support to weakened left side and physical therapy (PT)/occupational therapy(OT)/speech therapy(ST) evaluation and treat as needed. Review of an OT evaluation and plan of treatment documentation revealed Resident #46 was to receive OT services between 09/04/24 and 10/03/24. Resident #46 was referred to OT skilled services by nursing staff due to increased joint tightness and stiffness at the affected left upper extremity. Caregiver goals included providing stretching to the affected left upper extremity and accept provided education. Observation on 12/02/24 at 8:50 A.M. revealed Resident #46 in bed with the left upper and lower extremities immobile. Resident #46's left hand was in a closed fist. Concurrent interview with Resident #46 revealed he was discharged from therapy and was utilizing a hand/wrist splint with exercises while in therapy. Resident #46 further stated since discharge from therapy, staff did not apply the splint or assist with exercises to the left upper and lower extremities. Interview on 12/03/24 at 8:39 A.M. with Certified Nurse Assistant (CNA) #595 revealed Resident #46 did not have a hand/wrist splint in use and no exercises were provided to the resident's left upper or lower extremities. Interview on 12/03/24 at 9:40 A.M. with Therapy Director (TD) #610 confirmed Resident #46 was discharged from therapy and was to have bedside exercises provided to his left upper and lower extremities. TD #610 stated no splint was ordered due to the resident reporting pain during application. A follow-up interview on 12/03/24 at 11:48 A.M. with TD #610, during a review of OT functional maintenance program documentation, revealed on 11/15/24, CNA #595 was informed exercises were to be administered each day to Resident #46's upper and lower extremities. TD#610 confirmed no additional staff were informed of the maintenance program exercises. A follow-up interview on 12/03/24 at 11:55 A.M. with CNA #595 verified Resident #46 exercises were not provided daily and CNA #595 further stated she was not aware of the specific exercise regimen or functional maintenance program recommenced by therapy. Interview on 12/04/24 at 8:30 A.M. with the Director of Nursing (DON), during a review of Resident #46's medical record, verified there was no documentation contained in the record referring to the OT maintenance program or that ROM exercised were provided to Resident #46.

Based on observation, staff interview and review of the facility policy, the facility failed to ensure residents received a dignified assisted dining experience. This affected one (#30) of three residents observed for staff assistance with eating. The facility identified 12 additional residents (#4, #6, #21, #35, #37, #39, #42, #45, #49, #50, #58, and #64) who required staff assistance with eating. The facility census was 76. Findings include: Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses of heart failure, dementia and lack of coordination. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/13/24, revealed Resident #30 had severely impaired cognition. Further review revealed Resident #30 required partial/moderate staff assistance with eating. Review of the current care plan revealed Resident #30 had an activities of daily life (ADL) self-care performance deficit. Interventions included one person assistance with eating. Observation on 12/02/24 at 12:11 P.M. during meal service in the main dining room revealed Certified Nursing Assistant (CNA) #587 assisting Resident #30 with eating. CNA #587 stood next to Resident #30's wheelchair while offering her bites of chili and vegetables. Interview on 12/02/24 at 12:13 P.M. with CNA #587 confirmed she was standing while assisting Resident #30 with eating. CNA #587 stated she was aware staff should sit and be at eye level when providing meal assistance. CNA #587 stated she had been previously helping another resident and, therefore, was not sitting while assisting #30. Interview on 12/04/24 at 5:20 P.M. with the Director of Nursing (DON) confirmed staff should be seated at eye level with residents while providing assistance with eating. Review of the facility policy titled Assistance with Meals, dated September 2021, revealed residents who cannot feed themselves will be fed with attention to safety, comfort and dignity.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to notify the resident representative of changes of condition requiring as needed intramuscular injection for behavior. This affected one resident (#100) of one resident reviewed for notifications. The facility census was 82. Findings include: Review of the medical record for Resident #100 revealed he was admitted on [DATE] and discharged on [DATE]. Resident #100 was admitted with diagnoses of Alzheimer's, dementia with behavioral disturbance, delirium, restlessness, and agitation. Review of the physician orders for 07/24 for Resident #100 revealed he was ordered geodon (used for agitation) 10 milligram (mg) intramuscular (IM) as needed (PRN), and Zyprexa (used for agitation) 10 mg IM PRN. Review of the Medication Administration Record (MAR) for 07/24 for Resident #100 revealed he was administered Zyprexa 10 mg IM on 07/04/24 at 5:35 P.M. for agitation and Geodon 10 mg IM on 07/22/24 at 8:59 P.M. and on 07/27/24 at 9:03 P.M. for agitation. Review of the nursing progress notes for Resident #100 revealed there was no documentation of notification to the resident's representative regarding PRN antipsychotic medication administration. Interview on 10/01/24 at 10:43 A.M. with the Director of Nursing (DON) verified the nursing progress notes for Resident #100 did not document notification that a PRN antipsychotic medication was ordered for administration. Further interview with the DON revealed it was the expectation for staff to contact family and notify of change in behavior and need for PRN medication. Interview on 10/01/24 at 12:09 P.M. with Licensed Practical Nurse (LPN) #372 stated the expectation of the nursing staff would be to contact family or guardian and notify them of the behaviors and the need for PRN antipsychotic medication. Interview on 10/01/24 at 1:30 P.M. with Clinical Nurse Practitioner (CNP) #371 stated the expectation would be to notify family of the need for PRN medication and change in behavior. CNP #371 further stated sometimes family is able to help redirect a resident. Review of the undated facility policy titled, Change in Resident's Condition or Status, revealed the facility will notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. This deficiency represents non-compliance investigated under Complaint Number OH00157829.

Based on staff schedule review, staff interview, review of the facility assessment the facility failed to maintain the services of a registered nurse for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 84 residents currently residing in the facility. The facility census was 84. Findings include: Review of the nursing staff information and staff schedule from 01/29/24 to 02/04/24 revealed no registered nurses (RN) were present working in the facility on 02/03/24 and 02/04/24. Review of the Facility assessment dated [DATE] stated staffing and staff assignments are determined by the Nursing Administration and Administrative leadership utilizing various reports to analyze the number of patients, velocity of expected admissions and discharges, diagnosis, the total number and type of tasks and services required of nursing, nursing assistants, and other ancillary personnel. Staff assignments are driven by the burden of care, patient location, and acuity. Additionally, staffing is reviewed quarterly and with significant change in facility operation, each position is reviewed to determine that all staff positions required for facility operations have been listed and have appropriate minimum education levels and licensure requirements. All positions, even if the position is currently vacant, are listed including the sufficient number of staff considering the number, acuity, and diagnosis of facility population for continuity of care. Interview on 02/08/24 at 9:35 A.M., with the Administrator verified the facility did not have any RN on duty in the facility on 02/03/24 and 02/04/24.

Based on observation, medical record review, testing log review, staff interview, review of material data sheet for disinfectant, and policy review, the facility failed to maintain appropriate infection control practices when cleaning a resident's room in isolation precautions for Clostridium Difficile (C-Diff) infection; utilize proper hand hygiene; and failed to ensure water monitoring for Legionella was completed. This had the potential to affect all 84 residents. The facility census was 84. Findings include: 1. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, morbid obesity, pulmonary hypertension, lymphedema, hypertension, anxiety disorder, depression, insomnia. Resident #16 tested positive for C-diff on 01/27/24. Review of the care plan for Resident #16 revealed the resident had a C-diff infection and required contact isolation precautions with a goal for Resident #16 to have no complications related to the C-diff infection. Review of the current physician orders revealed an order written on 01/27/24 for Resident #16 to be placed in contact isolation precautions, and to administer vancomycin 125 milligrams (mg), one capsule by mouth every six hours for ten days starting 01/29/24 for the treatment of C-diff. Interview on 02/07/24 at 02:18 P.M., with the Director of Environmental Services #297 revealed Neutral Disinfectant Cleaner for all flat surfaces and is used to clean contact isolation rooms including C-diff isolation. Observation on 02/07/24 at 3:01 P.M., revealed Housekeeping Aide #224 don gloves prior to entering Resident #16's room. Housekeeping Aide #224 removed two yellow isolation bags of trash were removed from the room and placed them in the cleaning cart trash bin using gloved hands to open the cleaning cart trash bin sitting outside Resident #16's room. Housekeeping Aide #224, then using gloved hands removed and rag from a bucket on the cleaning cart and a spray bottle of yellow colored solution labeled Neutral Disinfectant Cleaner, sprayed the two black bins for which the yellow trash bags labeled isolation were removed from, sat the spray bottle of disinfectant on the floor and wiped the black bins down using the rag. After wiping down the black bins the rag was placed in bag on the cleaning cart with other used rags and mop heads and the spray bottle of disinfectant was placed on the top of the cleaning cart. Housekeeping Aide #224 removed one yellow and one red bag, both labeled isolation, from the cleaning cart using the same gloved hands used to clean the black isolation bins and placed a yellow liner in one of the black bins and the red liner in the other. Interview on 02/07/24 at 3:15 P.M., with Housekeeping Aide #224 revealed the Neutral Disinfecting Solution is used to clean all surfaces in all rooms and verified the trash and the materials used to clean the C-diff isolation room were placed in and on the cleaning cart, and verified the rag used to clean the black isolation bins was placed with the soiled rag bag with the other rags used throughout the day. Interview on 02/07/24 at 4:43 P.M., with the Director of Environmental Services #297 verified the mop heads and rags go into a bag after each room is cleaned and the bag when full is taken to laundry, the cleaning materials when cleaning a C-diff room are not isolated or separated. Additionally, the Director of Environmental Services #297 verified after reviewing the Neutral Disinfecting Solution directions for use and after checking with the vendor of the product the Neutral Disinfectant Cleaner does not kill C-diff spores and was the improper disinfectant for cleaning residents room in isolation for C-diff. Review of the undated material sheet for Neutral Disinfectant Cleaner instructions for use did not identify as being effective against C-diff. Observation of meal service on 02/08/24 at 8:43 A.M., for Resident #16 was completed. State tested Nursing Aide (STNA) #282 was observed taking Resident #16's tray into her room which was under infection control precautions due to a diagnosis of C-diff. The STNA moved items around on the resident's bedside table with her bare hands and placed the meal tray onto the table. STNA #282 then exited the room, shut the door, and proceeded to take the next resident's tray off of the meal cart. STNA #282 failed to wash her hands with soap and water nor use hand sanitizer. Interview on 02/08/24 at 8:44 A.M., with STNA #282 revealed she failed to wash her hands after leaving Resident #16's room and proceeded to touch other resident meal trays. STNA #282 stated staff was not required to do so in the past. Review of the undated facility policy titled Infection Preventions and Control Program, stated the infection prevention and control program are a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Additionally, important facets of infection prevention include identifying possible infections or potential complications of existing infections, education of staff to ensure adherence to proper techniques and procedures. the facility must also establish policies and procedures regarding infection control including implementation of precautions to prevent individuals from contracting infections and the proper use of personal protective equipment, including checks for its proper use and appropriate means of disposal. 31638 2. Review of the facility Legionella Chlorine Testing Log dated 10/05/22 through 02/05/24 revealed chlorine water testing was completed once weekly in various locations throughout the facility. No negative outcomes were identified. Interview on 02/07/24 at 4:10 P.M., with Maintenance Director #289 verified Legionella chlorine testing was completed once every week and he was unaware of the facility policy. Review of the policy titled Legionnaire's Disease Prevention/Treatment Best Practice dated September 2023, revealed maintenance staff will check the chlorine level of the water three to five times weekly at different locations.

Based on observation, staff interview, review of cleaning list, and review of policy, the facility failed to ensure a clean and sanitary kitchen, ensure all food items were dated when opened and contained used by dates. This had the potential to affect all 84 residents who received food from the kitchen. The facility census was 84. Findings include: Observation during the tour of the kitchen on [DATE] between 8:27 A.M. and 9:00 A.M., of the kitchen revealed a buildup of a black substance on around the baseboards of the kitchen, a dirty microwave with a variety of dried color splatter, dried patterns of dried substances on a variety of metal shelving, including a dried white splatter on the cart containing boxes of foil and plastic wraps and an air conditioner in the window next to the grill top with brown/yellow colored debris. Refrigerator with unlabeled and undated bowls (three) of a brown substance, 2 gallons of chocolate milk without open dates, and in the dry storage room revealed an onion on the floor below a wheeled cart that contained a pan of uncovered, undated cornbread. Labeled food items with an open date were absent of use by dates. Interview on [DATE], during the tour of the kitchen, with Cook #219 verified the used by dates were not on the open food items, the brown substances in three bowls were not labeled, two gallon of chocolate milk contained no open date and further verified the cornbread was uncovered and undated. Cook #219 further verified the dirty substance in the microwave, the dried substances on tables and shelves and further verified food items on the floor. Additional interview with Dietary Manager #347 on [DATE] at 10:30 A.M., verified corners and baseboards in kitchen with thick coat of black colored substance, the air conditioner in the window ow to the right of the grill top with brown/yellow colored debris on the front grill. Dietary Manager #347 stated they cannot get the floor clean, and the facility is looking to replace the floor and further stated the air conditioner is cleaned regularly when in use, adding this time of year the air conditioner is not used. Review of the undated policy titled Refrigerators and Freezers, stated the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (date of delivery) will be marked on cases and on individual items removed from the cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and used by dates indicated once the food is opened. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Review of the undated, Daily Cleaning List, revealed food carts, stock rooms, microwave and walls and floors are cleaned on a scheduled basis. Review of the Daily Cleaning List was silent for air conditioner cleaning.

Based on medical record review, observations, policy review, and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments. This affected four (#14, #23, #62 and #241) of twenty-one residents reviewed for assessments. The facility census was 84. Findings include: 1. Review of the medical record for Resident #241 revealed an admitted [DATE], diagnoses included: chronic obstructive pulmonary disease, asthma, oropharyngeal dysphagia, neurocognitive disorder with Lewy bodies, dementia, hypertension, atrial fibrillation, depression, and COVID-19 upon admission. Review of the physician order dated 01/19/24 and timed 1:54 P.M., revealed Resident #241 was ordered a regular diet, pureed with nectar thickened liquids. Review of the care plan dated 01/19/24 identified Resident #241 had an activities of daily living self-care deficit, interventions included one person assist for eating. Resident #241 was also identified as having a dental problem related to missing teeth with interventions in place for staff to provide assistance as needed with oral hygiene, provide medications and treatments as ordered and refer to dental services as needed. Resident #241 was also care planned for an altered nutritional status with chewing and swallowing difficulty with a diagnosis of dysphagia requiring an altered texture diet, interventions included to monitor percentage of intake and changes in eating habits, provide meals, snacks and fluids based on resident food preferences and physician orders and physical therapy and speech therapy evaluations and treatments as needed. Review of the MDS Item set Assessment by patient, dated 01/22/24, completed by Speech Therapist #350 revealed Resident #241 did have difficulty or pain with swallowing and coughed and choked with meals and medications and required a mechanical altered. Review of the admission MDS assessment, dated 01/24/24, revealed Resident #241 had cognitive impairment, required partial assistance for eating and was identified as not having a swallowing disorder or any dental issues. Interview on 02/08/24 at 11:40 A.M. with the MDS Coordinator #318, verified Resident #241's MDS completed on 01/24/24 was inaccurate and did not correctly reflect Resident #241's difficulty with swallowing. Interview on 02/08/24 at 11:47 A.M., with Dietician #351 verified the resident was admitted with orders for pureed meals and nectar thickened liquids, and further verified the assessment completed on 01/22/24 by Speech Therapist #350 revealed the resident was identified as having difficulty with swallowing and was on a mechanical altered diet. Dietician #351 verified the MDS completed on 01/24/24 was inaccurate as it revealed Resident #241 had no issues with swallowing. Dietician #351 also verified; she had signed the MDS on 01/25/24. 2. Review of the medical record for Resident #14 revealed an admitted [DATE], diagnoses included: multiple sclerosis, quadriplegia, major depressive disorder, foot drop, obstructive and reflux uropathy, protein-calorie malnutrition, end stage renal disease, hypertension, anxiety disorder and contracture's of the left upper arm, left knee, left ankle and right ankle. Review of the annual MDS dated [DATE] revealed Resident #14 was cognitively intact, had no functional limitation in range of motion of either the upper or lower extremities and used a wheelchair. Review of the quarterly MDS dated [DATE] revealed Resident #14 had functional limitations in range of motion with impairment on both sides of the upper extremity and both sides of the lower extremity. Review of the care plan for Resident #14 dated 04/26/22 revealed impaired musculoskeletal status related to contractures. Interview on 02/08/24 at approximately 11:40 A.M., with the MDS Coordinator #318, verified the annual MDS 11/09/23 for Resident #14 was inaccurate and stated Resident #14 had no range of motion limitations. 44815 3. Review of Resident #23's medical record revealed an admitted [DATE], with diagnoses of congestive heart failure, hemiplegia and hemiparesis, and atrial fibrillation. Review of a physician's order dated 08/25/23 revealed an order for oxygen two liters received via nasal cannula every shift. The order was indefinite. Review of the quarterly MDS dated [DATE] revealed the resident did not require oxygen therapy. Review of Resident #23's most recent care plan revealed the resident had impaired cardiovascular status related to angina/chest pain, atrial fibrillation, heart failure, hyperlipidemia, hypocholesterolemia, and hypertension. Interventions were to provide oxygen when needed when the resident exhibited signs/symptoms of difficulty breathing such as shortness of breath, cyanosis, and low oxygen saturation. Review of a physician's order dated 01/24/24 to change oxygen tubing and set up every Wednesday on day shift. This order was indefinite. Observation of Resident #23 on 02/06/23 through 02/08/23, revealed the resident required oxygen therapy at all times via an oxygen concentrator. Interview on 02/07/24 at 4:28 P.M., with MDS Coordinator #318 verified the Resident #23's quarterly MDS dated [DATE] was inaccurate. 4. Review of the medical record for Resident #62 revealed an admitted [DATE], with diagnoses of type 2 diabetes and dementia. Review of the eye doctor progress note dated 11/27/23 revealed Resident #62 required glasses for distance and reading. New glasses were ordered. Review of the quarterly MDS assessment dated [DATE] revealed Resident #62 did not use corrective lenses. Observation on 02/05/24 at 3:29 P.M., revealed Resident #62 wearing glasses. Observation on 02/06/24 at 3:52 P.M., revealed Resident #62's son cleaning Resident #62's glasses and returning them to Resident #62 who put on his glasses. Interview on 02/07/24 at 4:35 P.M., with MDS Coordinator #318 verified the quarterly MDS assessment dated [DATE] was completed inaccurately regarding Resident #62's need for glasses. Review of the policy titled, MDS Completion and Submission Timeframe's, dated September 2021, stated the Assessment Coordinator is responsible for ensuring that resident assessments are submitted in accordance with current federal and state guidelines.

Based on record review and staff interview, the facility failed to timely provide an Notice of Medicare Non-Coverage (NOMNC). This affected one (#188) of three residents reviewed for timely NOMNC's. The facility census was 84. Findings include: Review of the medical record for Resident #188 revealed an admitted [DATE] and a readmitted [DATE] and a discharge date of [DATE]. Resident #188 discharged home with family. Review of the beneficiary notice worksheet provided by the facility during the annual survey revealed Resident #188 was discharged from skilled therapy services while using her Medicare Part A benefit on 01/03/24. Review of the notice provided to Resident #188 upon discontinuation of skilled services revealed the NOMNC notice was provided on 01/02/24. Interview on 02/08/24 at 8:01 A.M., with Director of Social Services #283 verified the NOMNC was not given to Resident #188, 48 hours before the end of coverage. DSS #283 stated the notice should have been given 48 hours before the end of coverage, but was not provided 48 hours ahead of time because 01/01/24 was a holiday.

Based on medical record review, staff interview, and resident interview, the facility failed to update resident care plans in a timely manner to reflect the resident's current needs. This affected two (#14 and #44) of 21 residents reviewed for accuracy of the care plan. This had the ability to affect all residents. The facility census was 84. Findings included: 1. Review of Resident #44's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's, diabetes mellitus, chronic kidney disease, sciatica, and transient ischemia accident (TIA). Review of Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had no broken or loose-fitting teeth. Review of Resident #44's most recent care plan revealed she was at risk for a dental problem related to age. The plan was silent to being edematous and only having top dentures. Review of Resident #44's dietary notes dated 08/22/23 through 02/01/24 the dietician failed to refer to the fact that the resident was edematous. Interview on 02/06/24 at 2:43 P.M., with Resident #44 revealed she was edematous, but did wear upper dentures. The resident did not own bottom dentures. Interview on 02/07/24 at 4:28 P.M., with MDS Coordinator #331 verified that Resident #44's care plan was inaccurate and failed to address her dental issues. 2. Review of the medical record for Resident #62 revealed an admitted [DATE], with diagnoses of right femur fracture (10/09/23) and left femur fracture (11/08/23). Review of the quarterly MDS assessment dated [DATE] revealed Resident #62 had impaired cognition and ambulated with a wheelchair. Resident #62 required substantial/maximal assistance when transferring from sitting to standing and from the chair to bed and to the toilet. Ambulation was not attempted due to medical condition or safety concerns. Review of the current care plan for Resident #62 revealed the resident had an activities of daily life (ADL) self-care performance deficit due to a right femur fracture. Interventions included two-person assistance for transfers and toileting. Review of the physical therapy progress report dated 01/10/24 revealed Resident #62 required partial/moderate assistance for sitting to standing. Observation on 02/07/24 at approximately 8:15 A.M., revealed Resident #62 in the dining room. Resident #62 stated he needed to use the restroom. Continued observation revealed State tested Nurse Aide (STNA) #298 assisting Resident #62 into his room. Interview on 02/07/24 at 8:31 A.M, with STNA #298 revealed Resident #62 required only one person assistance for transfers and toileting since he had recovered from his fractures. Interview on 02/08/24 at 7:53 A.M., with Physical Therapist (PT) #354 revealed Resident #62 received physical therapy since 12/31/23. PT #354 stated on 01/10/24, Resident #62 improved and required partial/moderate assistance for sitting to standing transfers. PT #354 stated Resident #62 only required one person to assist for transfers and toileting since 01/10/24. Interview on 02/08/24 at 1:33 P.M., with MDS Coordinator #318 confirmed Resident #62's ADL care plan was not updated to reflect his need for assistance of only one person for transfers and toileting. MDS Coordinator #318 stated she was not aware of the change to Resident #62's assistance needs and therefore did not update the care plan.

Based on observation, record review, review of fall investigations, staff interview, and review of policy, the facility failed to facility failed to complete a thorough root cause analysis into why a resident continued to fall. In addition, the facility failed to implement effective fall interventions to prevent falls. This affected two (#62 and #65) of three residents reviewed for falls. The facility census was 84. Findings include: 1. Review of the medical record for Resident #62 revealed an admitted [DATE] with diagnoses of Alzheimer's, dementia, hypertension, right femur fracture (10/09/23) and left femur fracture (11/08/23). Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #62 had impaired cognition and ambulated with a wheelchair. Resident #62 required substantial/maximal assistance when transferring from sitting to standing and from the chair to bed and to the toilet. Ambulation was not attempted due to medical condition or safety concerns. Resident #62 had two or more falls since the previous assessment. Review of the current care plan on 02/07/24 revealed Resident #62 was at risk for falls due to Alzheimer's, dementia, and hypertension. Interventions included non-skid strips in front of the toilet, non-skid strips next to the bed, a raised toilet seat, anti-rollback bars to the wheelchair, and a dump wheelchair (a wheelchair with a seat positioned so the rear of the seat is lower to the ground than the front). Review of the facility's incident log revealed Resident #62 fell on [DATE], 11/06/23, 11/21/23, and 12/25/23. Review of the facility's fall investigations revealed Resident #62 was found in the bathroom after he fell on [DATE] at 1:15 A.M. The root cause was identified as ambulating without assistance. The facility added non-skid strips to the bathroom floor. Review of the fall investigation dated 11/06/23 at 4:15 A.M. revealed Resident #62 was found on the floor of his bedroom when attempting to take himself to the bathroom. The facility implemented non-skid strips next to the bed. Review of the fall investigation dated 11/21/23 at 4:50 P.M. revealed Resident #62 was found in the bathroom. The facility implemented anti-rollback bars to Resident #62's wheelchair. Review of the fall investigation dated 12/25/23 at 12:15 A.M. revealed Resident #62 was found on the floor next to his bed, leaning on his wheelchair. Resident #62 stated he was attempting to use the bathroom. The facility implemented a dump wheelchair. Interview on 02/07/24 at 10:29 A.M., with Regional Support Staff (RSS) #349 revealed he attended morning meetings at the facility for approximately the previous two months. RSS #349 stated the interdisciplinary team (IDT) reviewed falls during the morning meetings. RSS #349 stated the root cause of the falls for Resident #62 was ambulating without assistance and interventions were developed to address the physical situation Resident #62 was in at the time of the fall. RSS #349 stated Resident #62 was walking, or attempting to walk, at the time of the fall, and the IDT implemented interventions to increase walking safety. Continued interview with RSS #349 revealed the IDT did not recognize in each of Resident #62's falls he was attempting to use the restroom. RSS #349 confirmed a dump chair addressed positioning and did not address Resident #62's need or desire to use the bathroom safely. RSS #349 further stated, after recognizing a trend in falls related to bathroom use, an intervention of assisting to the toilet in the middle of the night may have been a more relevant intervention. Observation on 02/07/24 at 8:40 A.M. revealed Resident #62's toilet did not have a raised seat. Interview on 02/07/24 at 8:41 A.M., with Licensed Practical Nurse (LPN) #325 revealed no residents on the secured unit, where Resident #62 was located, had raised toilet seats. Continued interview on 02/07/24 at 8:41 A.M., with LPN #325 and concurrent observation of Resident #62 in the dining room confirmed Resident #62 was in a standard wheelchair, not a dump wheelchair. Interview on 02/08/24 at 1:37 P.M., with RSS #349 confirmed Resident #62 did not have a raised toilet seat until RSS #349 directed staff to provide one after our previous conversation on 02/07/24. Further interview confirmed the intervention for a dump wheelchair for Resident #62 was removed from his care plan. 45445 2. Review of the medical record for Resident #65 revealed an admitted [DATE], with diagnoses including: chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, hypothyroidism, and schizoaffective disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #65 was cognitively intact and required moderate assistance for showers, upper body and lower body dressing, and mobility, used a wheelchair and walker, was incontinent of bowel and bladder and had one fall with no injury during assessment period. Review of the care plan dated 01/26/23 revealed Resident #65 had impaired muscle skeletal status related to arthritis. Interventions included for pain medications to be administered as ordered, encourage resident to ask for assistance, keep call light within reach, monitor for fatigue, encourage resident to take time with activities, treatments as ordered, provide assistance with turning and repositioning as needed and physical therapy and occupational therapy as needed. Review of Resident #65's fall history revealed falls had occurred on 01/26/23, 02/07/23 02/09/23, 02/24/23, 05/12/23, 07/26/23, 09/14/23, 12/12/23 and 12/28/23. Review of the interdisciplinary team review on 09/15/23 of the fall that occurred on 09/14/23 at 11:00 A.M. revealed Resident #65 became dizzy and lightheaded when getting out of the chair. A new intervention was put into place to use extended oxygen tubing so when ambulating to the bathroom Resident #65 did not have to go without required oxygen. Review of the interdisciplinary team review dated 12/12/23 of the fall that occurred on 12/12/23 at 6:00 A.M. when Resident #65 was found sitting on the floor after the resident slid out of bed revealed nonskid strips at bedside and on the bathroom floor. Review of the interdisciplinary team review dated 12/18/23 of the fall that occurred on 12/17/23 at 1:34 P.M. revealed Resident #65 was trying to sit on the toilet and was unable to move foot revealed the following fall interventions were in place: Educate resident and family to call for assistance before transferring; Education resident not to stand without assistance; Extended oxygen tubing; Food/fluids within reach; Maintain call light within reach; Nonskid strips; Nonskid strips in the bathroom; Nonskid footwear; Reacher; Resident education on safety interventions; and a Toilet riser. Observations on 02/06/24 at 10:48 A.M., 4:38 P.M. and on 12/07/24 at 8:40 A.M., revealed Resident #65 did not have extension tubing, nonskid strips were not in place at bedside or in bathroom and no toilet riser was present. Observation on 02/07/24 at 10:50 A.M., of State tested Nursing Assistant (STNA) #302 assisting Resident #65 to the bathroom revealed the nasal cannula was removed from Resident #65 prior to the resident being assisted to the bathroom. Interview with STNA #302 at the time of the observation revealed the oxygen tubing is not long enough for Resident #65 to keep on when in the bathroom. Additional interview with STNA #302 at 11:00 A.M., verified Resident #65 did not have nonskid strips on the floor of the bathroom or next to the bed and further verified no toilet riser was in place. Interview on 02/07/24 at 11:05 A.M., with Regional Support #349 confirmed the interventions identified by the multidisciplinary team upon the fall reviews for Resident #65 had not been implemented and further verified the care plan for Resident #65 had not been updated to the reflect the identified interventions. Review of the undated policy titled Falls, stated the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Appropriate interventions will be identified to reduce the risk of falls. Interventions, if successful in preventing falls the interventions will continue and if unsuccessful and the resident continues to fall the staff will re-evaluate the situation and determine whether interventions are appropriate to continue or if current interventions need to be changed. Review of the policy titled, Care Plans, Comprehensive Person-Center, dated September 2021, stated a comprehensive, person-centered care plan that includes measurable objectives and timetables to the resident's physical, psychosocial and functional needs is developed and implemented for each resident with ongoing assessment and care plan revisions as information about the resident and the resident condition change.

Based on medical record review, staff interview, review of Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to address and implement interventions for a resident (#75) with physical behaviors directed towards staff and residents. Resident #75 admitted to the facility on [DATE] with a history of physical behaviors directed towards others. On 05/20/22, Resident #75 punched a staff member in the chest. No care plan or interventions were implemented, and behaviors continued. This resulted in resident-to-resident physical abuse on 05/23/22 when Resident #75 hit Resident #22 on the back of her head for an unknown reason. Shortly after the incident with Resident #22, Resident #75 than pushed Resident #20, causing her to fall and hit her head. This resulted in actual harm when Resident #20 suffered from a head laceration requiring emergency care and six staples. This affected two (#22 and #20) of three residents reviewed for abuse. The census was 64. Findings include: Review of the closed medical record for Resident #75 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital discharge paperwork dated 05/17/22, revealed Resident #75 had an inpatient stay from 05/02/22 to 05/19/22 due to difficulties managing behavior and medication management for aggressive and combative behaviors associated with dementia. Resident #75 was admitted to inpatient from another long-term care facility due to combative behaviors toward staff and safety concerns of elopement. While Resident #75 was receiving inpatient care, several team responses were called (assistance from more than one staff member) due to combative behavior toward nursing staff. Review of Resident #75's Minimum Data Set (MDS) assessment history revealed an entry assessment was completed with minimum information on 05/19/22. Review of the Admission Evaluation dated 05/19/22, revealed Resident #75 was admitted on [DATE] at 7:31 P.M. due to altered mental status. Resident #75 had a/or multiple psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #75 was alert and oriented to person and time and had memory problems. Resident #75 was independently mobile and was identified as a wandering risk or having a history of wandering. Review of Resident #75's care plan history revealed a care plan had not been initiated until 05/24/22. Review of the care plan dated 05/24/22 revealed Resident #75 was physically aggressive towards others, resistive to care, and verbally aggressive towards others due to dementia with behavioral disturbance, major depressive disorder, and [CONDITION(S)]. Interventions included administer medications per order and monitor for effectiveness/side effects, approach resident in a calm manner to avoid further frustration and behavior escalation, if resident becomes agitated and shows signs of escalation re-approach later, attempt to redirect resident when exhibiting behaviors, re-approach when resident has de-escalated, encourage resident to ask questions when concerned with their medical condition to reduce anxiety, encourage resident to participate in care, give non-judgmental support, keep residents safe during episodes of behaviors and attempt to redirect, monitor and document episodes of inappropriate behaviors, notify the physician when behaviors persist or unable to de-escalate, monitor behavior episodes and attempt to determine underlying cause, observe and report any changes in mental status caused by situational stressors, offer assistance to identify problems that cannot be controlled, offer psychological/psychiatrist services as needed, offer resident choices when possible to promote feeling of self-worth and control, offer activities of interest, provide a calm safe environment, provide structured schedule for daily care when possible, and provide positive feedback to resident when behavior is appropriate. Review of the nursing progress note dated 05/20/22, revealed Resident #75 punched an aide in the chest two times and attempted to hit a nurse. Resident #75 was re-directed to lay in bed. Review of the SRI completed on 05/26/22, revealed Resident #75 was observed smacking Resident #22 in the back of the head. Resident #75 was taken to his room to calm down and Resident #22 was taken to her room and was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #22 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's MDS assessment dated [DATE], revealed the resident was moderately cognitively impaired, there was no history of behaviors, and the resident used a walker and required limited staff assistance for Activities of Daily Living (ADLs). Review of the nursing progress note dated 05/23/22, revealed Resident #22 was walking out of the dining room after eating dinner and was approached by another resident (Resident #75). Resident #75 struck Resident #22 in the back of the head. Resident #22 was immediately assessed for injury and vitals were completed with no negative findings. Review of the SRI completed on 05/26/22, revealed Resident #75 shoved Resident #20, causing her to fall back and sustain a laceration to the back of her head. Resident #75 was immediately removed from all other residents while staff attended to Resident #20. Emergency services were called and both residents were transported to the hospital. Resident #20 returned with six staples to the back of her head. Resident #75 returned to the facility and was placed on one-on-one supervision. An investigation was completed. Review of the medical record for Resident #20 revealed an admitted d of 10/11/19. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's MDS assessment, dated 05/24/22, revealed the resident was rarely understood, was not steady and required one-person extensive assistance with ambulating. Review of the nursing progress note dated 05/23/22 at 5:55 P.M., revealed Licensed Practical Nurse (LPN) #219 observed Resident #75 walk up to another resident and smack her on the back of the head (Resident #22) as she was exiting the dining room. LPN #219 approached Resident #75 and told him that was not acceptable, and he apologized to the resident. Resident #75 was walked to his room where it was quiet and calm. Resident #75 returned to the dining room within minutes and pushed another resident to the ground (Resident #20), grabbed a staff member, and started physically hitting the staff member with a closed fist. Upon hearing his name, Resident #75 stopped hitting the staff member and sat down in the chair. The on-call unit manager and the Director of Nursing (DON) were contacted. Review of the nursing progress note dated 05/23/22 at 8:48 P.M., revealed Unit Manager LPN #215 was the on-call manager. LPN #215 was notified by the DON that Resident #75 was combative with other residents and staff and LPN #215 needed to go to the facility. Facility staff reported Resident #75 knocked down Resident #20, resulting in her falling and hitting the back of her head. Emergency services were called. Resident #75 also hit Resident #22 as she was walking with her walker in the hallway. Resident #75 was also combative with nursing staff. Resident #75 was upset and agitated, and an order was received for [MEDICATION(S)] (sedative). Resident #75 was transported by emergency services for evaluation and treatment. Review of the emergency room documentation dated 05/23/22 at 8:56 P.M., revealed Resident #20 arrived via emergency services from a long-term care facility after an altercation with another resident. Resident #20 was pushed, fell backwards, and hit her head on the floor. Resident #20 had a small vertical scalp laceration, which was cleansed and closed with staples. A Computerized Tomography (CT) scan of the brain and C-spine were completed with no negative findings. Resident #20 was discharged back to the long-term care facility. Interview on 05/26/22 at 10:49 A.M. State tested Nursing Assistant (STNA) #209 verified working on the memory care unit and providing care to Resident #75 on 05/20/22 and 05/21/22. STNA #209 reported Resident #75 was easily agitated, wandered in other resident rooms, and would yank staff when guided to the restroom. STNA #209 further reported Resident #75 was verbally aggressive and would tell her to, Shut the hell up, and told her she sounded stupid. STNA #209 reported she heard Resident #75 swung at a nurse but did not make contact. Interview on 05/26/22 at 8:20 A.M. the DON verified she had completed an investigation for SRIs completed on 05/26/22. The DON reported Resident #75 was admitted to the facility on Thursday 05/19/22 and over the weekend had been aggressive toward staff. The DON reported on 05/23/22 at dinner time, Resident #75 pushed Resident #22 on the back of the head. Staff were present in the dining room and witnessed the incident. Resident #75 was escorted back to his room but returned to the dining room and pushed Resident #20. Resident #20 fell backward and hit her head. The DON reported the two incidents were about 25 minutes apart from each other. Resident #75 and Resident #20 were sent to the hospital for evaluation and treatment. Resident #20 had a laceration to her head, which required staples. Resident #75 returned to the facility and one-on-one supervision was provided. Resident #75 discharged on [DATE] to a senior inpatient psychiatric care facility. Interview on 05/26/22 at 11:25 A.M. with STNA #210 revealed on 05/23/22 at approximately 5:15 P.M. Resident #75 was sitting in the dining room and was provided coffee and a snack. Resident #22 was also in the dining room and began to walk out of the doorway when Resident #75 got behind her. Resident #75 was reminded to be patient as Resident #22 walked slow. As both residents approached the door, Resident #75 slapped Resident #22 on the back of the head. While assisting other residents, STNA #210 heard screaming. Upon entering the dining room, STNA #210 observed Resident #20 being assisted to a chair and Resident #75 was asked to sit down. STNA #210 approached Resident #75 when he grabbed her hair and punched her. Throughout the interview, STNA #210 was tearful and upset. Interview on 05/26/22 at 1:06 P.M., the DON verified Resident #75 did not have a care plan developed until 05/24/22. The facility did not have interventions in place for Resident #75's behaviors. Interview on 05/31/22 at 8:15 A.M., Unit Manager LPN #215 reported she was responsible for the hall Resident #75 resided on. LPN #215 reported she was unaware Resident #75 had any behavioral issues prior to admission and reported no staff reported any behavioral issues prior to the incident on 05/23/22. Review of facility undated policy titled, Abuse Prevention, Intervention, Investigation, and Crime Reporting, revealed residents had the right to be free from verbal, sexual, physical, and mental abuse, neglect, corporal punishment, and involuntary seclusion. Any form of mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility would provide adequate assessment and care-planning of behaviors, including but not limited to verbal/physical aggression, wandering, and high care needs. This deficiency substantiates Complaint Number OH 921.