Every finding on record at The Manor at Greendale

Based on review of the medical record, interview, and policy review, the facility failed to ensure a care plan with interventions for enhanced barrier precautions (EBP) was initiated. This affected one (#8) of three residents reviewed for care planning. The facility census was 64. Findings include:Review of the medical record for Resident #8 revealed an admission date of 06/29/26. Diagnoses included Type II diabetes mellitus, hypertension, atrial fibrillation, and lumbosacral plexus disorder.Review of the second modification of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment. The resident was frequently incontinent of bowel and bladder. The resident was dependent on staff for toileting, bathing, and transfers. The resident was admitted to the facility with a stage two pressure ulcer. Review of the care plan initiated on 06/30/26 and revised on 07/25/26 for Resident #8 revealed the resident had a stage three pressure ulcer to the sacrum and an unstageable deep tissue injury to the right heel. Further review of the resident's care plan revealed there was no care plan with interventions in place for EBP. Observation on 08/10/26 at 10:35 A.M. of Resident #8 revealed there was a sign posted in the resident's room indicating the resident required EBP during high contact care activities. Further observation on 08/11/26 at 10:20 A.M. of wound care revealed the resident had an unstageable deep tissue injury to the right heel and a stage three pressure ulcer to the coccyx. Interview on 08/10/26 at 2:39 P.M. with the Director of Nursing (DON) verified the resident had no care plan with interventions in place for EBP.Review of the facility policy titled, Care Plan Policy, revised May 2025, revealed the care plan would be reviewed and revised after each assessment. The care plan would describe services furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being.

Based on observation, review of the medical record, interview, and policy review, the facility failed to ensure wound assessments were timely and accurately completed, failed to clarify physician orders, failed to monitor skin breakdown, and failed to ensure interventions to promote wound healing were completed per physician orders. This affected one (#8) of three residents reviewed for pressure ulcers. The facility identified eight residents with pressure ulcers. The facility census was 64.Findings include:Review of the medical record for Resident #8 revealed an admission date of 06/29/26. Diagnoses included lumbosacral plexus disorder, atrial fibrillation, Type II diabetes mellitus, and hypertension. Review of the second modification of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment. The resident was frequently incontinent of bowel and bladder. The resident was dependent on staff for toileting, bathing, and transfers. The resident was admitted to the facility with a stage two pressure ulcer and was at risk for pressure ulcer development. Review of hospital documentation dated 06/24/26 revealed Resident #8 had a small superficial stage two pressure injury (partial thickness skin loss) to the coccyx measuring one centimeter (cm) in length, 0.5 cm in width, and 0.1 cm in depth. The wound base was damp yellow fibrotic tissue with scant serous drainage with flat, defined, irregular attached wound edges. The surrounding skin was intact but fragile. There was a recommendation for hydrocolloid to cover the wound then cover with border foam for additional protection and padding. Review of the care plan dated 06/30/26 and revised on 07/25/26 revealed Resident #8 was at risk for skin breakdown with known areas of skin breakdown related to impaired mobility, incontinence, and poor appetite. Further review of the care plan revealed the resident was admitted with a stage three pressure ulcer to the sacrum. The resident had a deep tissue injury to the right heel. Interventions included administering treatments as ordered and to monitor for effectiveness, monitor/document/report changes in skin condition, and use offloading devices. Review of the clinical admission assessment dated [DATE] at 1:13 A.M. revealed the resident had a wound present on admission. The nurse noted the measurements were not documented because the wound was covered with a dressing. Review of a skilled nursing assessment dated [DATE] at 2:17 A.M. revealed the resident's skin had not been evaluated. Resident #8 was noted with a pressure ulcer to the buttocks that was present since admission.Review of a skin/wound note dated 06/30/26 at 7:22 A.M. revealed the resident was noted with a sacral dressing in place. The dressing was removed to assess the sacral area. No open wound or pressure ulcer was noted. There was mild redness and indentation present over the sacral area with no drainage, swelling, warmth, or other signs of infection. The area was cleansed and a clean dressing was applied. Review of the physician orders for June 2026 revealed no orders for a wound dressing. Further review of the orders revealed a pressure reducing cushion for the chair and a pressure-reduction mattress for the bed were ordered. Review of the skilled nursing evaluations completed 06/30/26 at 12:53 P.M., 07/01/26 at 12:14 P.M., 07/01/26 at 1:26 P.M., 07/01/26 at 9:26 P.M., 07/02/26 at 5:27 A.M., and 07/02/26 at 9:46 A.M. revealed the resident's skin had not been evaluated but each evaluation noted the resident had a pressure ulcer present upon admission. Review of the physician orders dated 06/30/26 through 07/01/26 revealed there were no physician orders for a wound dressing. Review of the Treatment Administration Records (TAR) dated 06/30/26 through 07/02/26 revealed no documentation staff had administered a wound treatment or monitored the wound treatment applied on 06/30/26. Review of a wound assessment dated [DATE] at 2:47 P.M. revealed the resident had an open area to the coccyx. The wound measured 1.4 cm in length, 0.8 cm in width, and 0.2 cm in depth. The wound was described as granulation, no drainage, with a pink periwound. There was no description of the percentage of granulation tissue, and no description of the amount of drainage. The wound type was not specified or staged. Review of a physician order dated 07/02/26 revealed Resident #8 had orders for triad hydrophilic wound paste, apply to coccyx/sacrum topically every shift for open area. The resident had orders for an air mattress every shift for skin integrity, a skin protectant to the bilateral heels was ordered every night shift to maintain skin integrity, and for moisture barrier external cream to the buttocks, apply topically every shift and after each incontinent episode. Review of a physician order dated 07/03/26 revealed an order for blue heel float boots while in bed every shift for skin integrity. Review of a physician order dated 07/06/26 revealed the resident had an order for a protein supplement 30 milliliters (ml) two times per day for wound support. Review of the Medication Administration Record (MAR) dated 07/06/26 through 08/10/26 revealed the amount of the protein supplement the resident had consumed was not documented. Review of a wound care provider initial wound assessment dated [DATE] revealed Resident #8 had a stage three pressure ulcer (full thickness skin loss) to the coccyx. The wound measured 1.5 cm in length, 1.1 cm in width, and 0.3 cm in depth with moderate serous drainage. The wound bed had 40 percent (%) slough, 30% granulation, and 30% subcutaneous tissue with no signs of infection. The resident also had an unstageable deep tissue injury to the right heel. The area measured 1.5 cm in length, 1.5 cm in width, with no measurable depth. The skin was intact with purple/maroon discoloration with no signs of infection. Review of a physician order dated 07/07/26 revealed the resident was ordered triad hydrophilic paste, apply topically to the sacrum every shift and as needed for a stage three pressure ulcer, cover with border dressing and to continue the skin prep daily to the bilateral heels. Review of the weekly wound assessments dated 07/16/26 through 08/04/26 revealed the resident's wounds was assessed weekly with noted improvement. Review of the physician orders and TAR dated 07/16/26 through 08/04/26 revealed wound treatments were documented as completed per physician orders. Observation on 08/10/26 at 10:35 A.M. of Resident #8 revealed the resident was lying in bed on his back. The resident was observed without the soft heel boots. Interview on 08/10/26 at 10:53 A.M. with Licensed Practical Nurse (LPN) #370 verified the resident was not wearing his heel boots. LPN #370 was unable to find the resident's heel boots in his room. LPN #370 then found the resident's unlabeled heels boots at the nurses station. Further observation on 08/10/26 at 10:57 A.M. of Resident #8 revealed LPN #370 removed the resident's sheet and blanket and applied the resident's heel boots. Interview on 08/10/26 at 10:57 A.M. with Resident #8 and his family member revealed staff had not applied the resident's heel boots in a few days. Interview on 08/11/26 at 11:17 A.M. with the Director of Nursing (DON) revealed the resident's skin should have been assessed upon admission. The DON revealed the nurses should document wound measurements and the wound characteristics and contact the physician for wound care orders. The DON verified Resident #8's wound had not been assessed or measured upon admission. The DON also verified the wound assessment completed on 07/02/26 had not specified the type or stage of wound or a thorough assessment of the wound. During follow up interviews, the DON further revealed she was unaware a registered nurse (RN) could stage a pressure ulcer. The DON revealed she had completed the wound assessment on 07/02/26 and found an undated wound dressing in place. The DON verified there were no physician orders for the wound dressing she found on the resident. The DON also verified she was unaware of how long the undated wound dressing had been in place. Interview on 08/11/26 at 7:17 A.M. with RN #214 verified she had not removed the resident's wound dressing upon admission to assess the resident's wound. RN #214 revealed she was unsure if she was allowed to remove the dressing to assess the wound. RN #214 revealed she later spoke with another nurse who told her she could remove the dressing to assess the resident's wound. RN #214 revealed the following morning the wound was assessed, and the resident had intact skin with a large circle area near the coccyx with mild redness and no drainage. RN #214 revealed she cleansed the area and applied a new wound dressing without a physician order. RN #214 revealed the resident had no orders for wound care upon admission and verified she had not contacted the physician to clarify the wound care orders. RN #214 revealed wounds was an area where she lacked education and needed to relearn. Observation on 08/11/26 at 10:20 A.M. of wound care with LPN #360 revealed Resident #8's stage three pressure ulcer to the coccyx was 1.5 cm in length, one cm in width, and 0.2 cm in depth with minimal serosanguineous drainage. The wound had 20% granulation tissue, 20% slough, and 50% subcutaneous tissue with no signs of infection. The surrounding skin was red and intact. The wound treatment was completed per physician orders. A follow-up interview on 08/11/26 at 11:44 A.M. with the DON verified staff were not documenting the amount of the protein supplement the resident had consumed. Review of the facility policy titled, Pressure Ulcer Policy, revised April 2016, revealed a resident with a pressure ulcer would receive interventions and monitoring to promote healing, prevent infection and prevent new ulcers from developing. Should a pressure area present either upon admission or in house, the wound would be monitored at least weekly. Documentation would include the location of the wound and stage, the wound measurements, drainage amount and characteristics, presence of pain and characteristics, and documentation of the wound bed and surrounding tissue.

Based on observation, medical record review, interview, and review of the facility policy, the facility failed to ensure physician orders were in place for the care of a suprapubic catheter. This affected one (#12) of one resident identified by the facility as having a suprapubic catheter. The facility census was 64.Findings include:Review of the medical record for Resident #12 revealed an admission date of 06/12/26. Diagnoses included peripheral vascular disease, chronic kidney disease, and obstructive and reflux uropathy. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had intact cognition. Additional review of the MDS revealed Resident #12 had an indwelling catheter. Review of the care plan dated 06/13/26 revealed Resident #12 had a suprapubic and foley catheter. Interventions included providing catheter care per orders and as needed.Review of the physician orders dated 08/04/26 revealed an order for indwelling catheter care every shift, indwelling catheter 16 French (F) 10 cubic centimeter (cc). There were no orders noted for the suprapubic catheter.Observation on 08/10/26 at 2:15 P.M. of Resident #12 revealed a suprapubic catheter with an undated clear protective film over the insertion site.Observation on 08/11/26 at 10:50 A.M. of Resident #12 revealed the suprapubic catheter had an undated clear protective film over the insertion site.Interview on 08/10/26 at 2:15 P.M. with Resident #12 revealed he readmitted to the facility on [DATE] and the facility staff had not cleaned the suprapubic catheter since his readmission.Interview on 08/11/26 at 8:42 A.M. with Registered Nurse (RN) #405 revealed she was unsure of what treatments Resident #12 received because she did not typically work on his hallway. RN #405 verified there were no care orders for Resident #12's suprapubic catheter and no care or treatments documented on the Treatment Administration Record (TAR).Interview on 08/11/26 at 10:34 A.M. with Licensed Practical Nurse (LPN) #360, who was also the facility's Infection Preventionist (IP), confirmed there were no orders for Resident #12's suprapubic catheter and further confirmed there were no orders for suprapubic catheter care.

Based on observation, medical record review, interview, and review of the facility policy, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented during high contact resident care activities for Resident #12 and Resident #8. Additionally, the facility failed to ensure Resident #12's indwelling urinary catheter drainage bag was maintained in a sanitary manner. This affected two (#12 and #8) of three residents reviewed for EBP. The facility identified nine residents on EBP and eight residents with indwelling urinary catheters. The facility census was 64.Findings include: 1. Review of the medical records for Resident #12 revealed an admission date of 06/12/26. Diagnoses included peripheral vascular disease, chronic kidney disease, and obstructive and reflux uropathy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition. Additional review of the MDS revealed Resident #12 had an indwelling catheter and wounds. Review of the care plan dated 06/13/26 revealed Resident #12 had an indwelling medical device and the resident may be in EBP while residing in the facility. Interventions included education for resident, family, and staff on EBP and answer questions they may have. Observation on 08/10/26 at 2:00 P.M. revealed Resident #12's door closed. Upon entering Resident #12's room, Licensed Practical Nurse (LPN) #370 was observed providing wound care for the resident. LPN #370 was not wearing PPE. Continued observation revealed Resident #12's foley catheter bag was lying on the floor, without a barrier between the catheter bad and the floor. Interview on 08/10/26 at 2:10 P.M. with LPN #370 confirmed she did not wear personal protective equipment (PPE) while completing wound care for Resident #12. LPN #370 further confirmed the catheter bag was lying on the floor. 2. Review of the medical record for Resident #8 revealed an admission date of 06/29/26. Diagnoses included Type II diabetes mellitus, hypertension, atrial fibrillation, and lumbosacral plexus disorder. Review of the second modification of the admission MDS assessment dated [DATE] revealed the resident had mild cognitive impairment. The resident was frequently incontinent of bowel and bladder. The resident was dependent on staff for toileting, bathing, and transfers. The resident was admitted to the facility with a stage two pressure ulcer. Review of the care plan initiated on 06/30/26 and revised on 07/25/26 revealed Resident #8 had a stage three pressure ulcer to the sacrum and an unstageable deep tissue injury to the right heel. Further review of the resident's care plan revealed there was no care plan with interventions in place for EBP. Review of a physician order dated 07/03/26 revealed an order for blue heel float boots while in bed every shift for skin integrity. Further review of the physician orders revealed there were no orders for EBP. Observation on 08/10/26 at 10:35 A.M. revealed a sign posted in the resident's room indicating the resident required EBP during high contact care activities. Observation on 08/10/26 at 10:57 A.M. of Resident #8 revealed LPN #370 removed the resident's sheet and blanket and applied the resident's heel boots. LPN #370 was not wearing gloves or a protective gown. Interview on 08/10/26 at 11:01 A.M. with Infection Preventionist (IP) #360 verified staff were required to wear a gown and gloves when applying heel boots for residents with EBP. Interview on 08/10/26 at 2:39 P.M. with the Director of Nursing (DON) revealed the facility typically had not used physician orders for EBP. The DON revealed there would be a sign posted inside the resident's room if a resident was on EBP. The DON also revealed a notice would be posted on the resident's care profile in the electronic medical record. The DON verified there was no notice regarding EBP in Resident #8's care profile in the electronic medical record. The DON also verified the resident had no care plan in place for EBP. Review of the facility policy titled, Enhanced Barrier Precautions, dated August 2022, revealed the facility would implement EBP in addition to standard precaution for residents to prevent transmission of multi-drug resistant organisms in the facility. All staff would wear gloves and gown during high-contact resident care activities. High contact resident care activities included dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinence care/toileting assistance, device care or use, and during wound care.

35031 Based on observation, medical record review, resident interview, and staff interview the facility failed to ensure residents seated at the same table were served meals together. This directly affected four residents, #08, #20, #33, and #55, in the main dining room and one resident, #64, in the memory care dining room. The facility census was 73. Findings include: 1. Observation on 02/24/25 at 12:35 P.M. revealed two Residents, #33 and #49, seated at one table, three residents, #08, #37, and #58, seated at another, and three residents, #20, #52, and #55, seated at a third table. Meals were delivered on a cart from the adjacent kitchen and delivered to Residents #49, #37, #58, and #52, leaving at least one resident at the three tables without being served. The time lapse was no greater than 10 minutes. Interview at 12:40 P.M. with Certified Nursing Assistants #400 and #422 provided verification of residents #08, #20, #33 and #55 not being served. Additional interview with CNA #424 stated she had stacked the meal tickets together but was unsure as to why the meals were not served simultaneously. Review of the medical record of Resident #08 revealed an admitted [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #08 was cognitively intact and required set-up assistance for eating. Interview on 02/24/25 at 12:45 P.M. with Resident #08 revealed she would prefer to be served at the same time as her tablemates. Review of the medical record of Resident #20 revealed an admitted [DATE]. Review of the quarterly MDS dated [DATE] revealed Resident #20 was cognitively intact and required only set-up assistance for eating. Interview on 02/24/25 at 12:40 P.M. with Resident #20 revealed she did not like to watch others eat while waiting for her food. Review of the medical record of Resident #33 revealed an admitted [DATE]. Review of the quarterly MDS dated [DATE] revealed Resident #33 was cognitively intact and required only supervision for eating. Interview on 02/24/25 at 12:40 P.M. with Resident #33 revealed he would rather eat at the same time as his tablemate. Review of the medical record of Resident #55 revealed an admitted [DATE]. Review of the quarterly 01/28/25 revealed Resident #55 was cognitively intact and was independent for eating. Interview on 02/24/25 at 12:40 P.M. revealed she feels as if all residents at the table should be served at the same time. 2. Observation of dining services in the memory care unit on 02/24/25 at 11:56 A.M. revealed meal trays arrived and were served to all residents except Resident #122. Resident #122 was sitting at a table with Resident #64 who was served her meal and eating. Observation on 02/24/25 at 12:04 P.M. revealed Resident #122 asked where her meal was and stated she was hungry. Observation on 02/24/25 at 12:18 P.M. revealed Resident #122's meal tray arrived after Certified Nursing Assistant (CNA) #479 went to the kitchen and retrieved an additional cart of meal trays. Interview with CNA #479 on 02/24/25 at 12:19 P.M. verified Resident #122 waited 22 minutes for her meal tray while her tablemate consumed her lunch.

49742 Based on observation, staff interview, resident interview, review of the medical record, and review of facility policy, the facility failed to ensure staff used appropriate hand hygiene while distributing meal trays to residents. This affected seven residents (#1, #2, #4, #5, #17, #32 and #33) served meal trays on the C-Hall, with the potential to affect all 14 residents (#1, #2, #4, #5, #7, #11, #17, #22, #32, #33, #37, #52, #58, and #222) residing on C-Hall who receive meal trays. The facility also failed to ensure staff wore appropriate personal protective equipment (PPE) when entering a resident room who was in droplet precaution. This affected one resident (#2) of one resident reviewed for transmission-based precautions (TBP). Additionally, the facility failed to ensure resident's catheter collection bags were maintained off the floor and in a safe and sanitary manner. This affected one resident (#123) of one resident reviewed for indwelling catheters. The facility identified four residents (#12, #48, #123, and #177) with indwelling catheters. The facility census was 73. Findings include: 1. Observation on 02/24/25 at 12:55 P.M. of lunch tray distribution to the C-Hall revealed Certified Nursing Assistant (CNA) #479 delivered a lunch tray to Resident #32 without first performing hand hygiene. Concurrent observation by two Ohio Department of Health (ODH) Surveyors on 02/24/25 at 12:56 P.M. of lunch tray distribution to the C-Hall revealed Licensed Practical Nurse (LPN) #415 delivered a lunch tray to Resident #5 without performing hand hygiene before or after tray delivery. Concurrent observation by two Ohio Department of Health (ODH) Surveyors on 02/24/25 at 12:56 P.M. of lunch tray distribution to the C-Hall revealed Licensed Practical Nurse (LPN) #415 delivered a lunch tray to Resident #1 without performing hand hygiene before or after tray delivery. Observation on 02/24/25 at 12:57 P.M. of CNA #479 delivered a lunch tray to Resident #33 delivered a lunch tray to Resident #4 without performing hand hygiene before or after tray delivery. Concurrent observation by two Ohio Department of Health (ODH) Surveyors on 02/24/25 at 12:58 P.M. of lunch tray distribution to the C-Hall revealed LPN #415 bringing a tray out of Resident #2's room, stating Resident #2 stated she did not want to eat due to her nausea. LPN #415 offered Resident #2 alternate lunch options and Resident #2 declined. Further observation of this interaction revealed LPN #415 did not perform hand hygiene upon exiting Resident #2's room with the refused lunch tray. Concurrent observation by two Ohio Department of Health (ODH) Surveyors on 02/24/25 at 12:58 P.M. of lunch tray distribution to the C-Hall revealed LPN #415 delivered a lunch tray to Resident #17 without performing hand hygiene before or after tray delivery. In an interview on 02/24/25 at 1:02 P.M. with LPN #415, LPN #415 denied not performing hand hygiene, but it was observed by two ODH Surveyors that she did not perform hand hygiene in the above interactions. Interview on 02/24/25 at 1:05 P.M. with CNA #497 verified she did not perform hand hygiene when delivering lunch meal trays to Resident #4 and Resident #32. 2. Review of the medical record for Resident #2 revealed an admitted [DATE], with diagnoses of dementia, chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, stage 3A chronic kidney disease (CKD3A), extended-spectrum beta-lactamase (ESBL) resistance, chronic migraine, bipolar disorder, cervicalgia, depression, chronic pain syndrome, atherosclerotic heart disease, carrier/suspected carrier of methicillin-resistant Staphylococcus aureus (MRSA), insomnia, hypertension (HTN), anxiety, osteoarthritis, acquired absence of left leg above the knee, gastro-esophageal reflux disease (GERD), hyperlipidemia, personality disorder, and fibromyalgia. Review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #2, dated 12/17/24, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #2 was cognitively intact. Review of the current physician orders for Resident #2 revealed a physician order, dated 02/24/25 at 2:17 P.M., for droplet precautions. Observation on 02/26/25 at 9:00 A.M. of the signage by Resident #2's door revealed prior to entering the room, everyone must clean their hands, including before entering and when leaving the room and make sure their eyes, nose and mouth are covered before room entry. Observation on 02/26/25 at 9:03 A.M. revealed CNA #492 entering Resident #2's room without donning any personal protective equipment (PPE). Observation on 02/26/25 at 10:57 A.M. of CNA #479 revealed CNA #497 entering Resident #2's room without donning any PPE. Interview on 02/26/25 at 9:05 A.M. with CNA #492 verified she did not wear PPE when she entered Resident #2's room. Interview on 02/26/25 10:59 A.M. with CNA #497 verified she did not wear PPE when she entered Resident #2's room. Review of the facility policy titled, Transmission Based Precautions - Droplet, dated 08/22, revealed it is the intent of this facility to use droplet precautions in addition to standard precautions to decrease the risk of droplet transmission of infectious agents. A mask should be worn upon entry into the the resident's room. Gloves are indicated for all persons entering the room. 3. Review of Resident #123's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's, congestive heart failure, and urinary retention. Review of Resident #123's care plan revealed the resident suffered from bladder incontinence. Observation on 02/24/25 at 11:43 A.M. revealed Resident #123 was being transported from her room to the dining room in a wheelchair by Certified Nursing Assistant (CNA) #480. Further observation revealed the urinary catheter bag was covered in a pillow case and was tied to the bottom of the resident's wheelchair. The urinary catheter bag was dragging on the floor under the wheelchair. Interview with CNA #480 on 02/24/25 at 11:45 A.M. verified Resident #123's urinary catheter bag was dragging on the floor which was an infection control issue. Interview with the Administrator on 02/27/25 at 10:03 A.M. revealed the facility did not have a policy regarding catheter infection control.

Based on medical record review, observations, staff interviews, and review of facility policy the facility failed to ensure a resident's bed was in the lowest position. This affected one resident (Resident #222) of two residents reviewed for accidents. The facility census was 73. Findings include: Review of medical record for Resident #222 revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease, asthma, and sleep apnea. The Multiple Data Set assessment was in progress and not available for review due to the admitted [DATE]. The admission assessment indicated Resident #222 was alert and oriented, able to communicate clearly, continent of bowel and bladder, had a history of falls, and had a moderate risk for skin breakdown based on Braden score of 17. Review of the care plan for Resident #222 revealed an intervention for the bed to be in the lowest position to reduce the risk of falls. Observation on 02/24/25 at 9:07 A.M. revealed Resident #222's bed was in the highest position. Observation on 02/25/25 at 6:50 A.M. revealed Resident #222's bed was in the highest position. Observation on 02/26/25 at 2:44 P.M. revealed Resident #222's bed was in the highest position. Observation on 02/27/25 at 11:45 A.M. revealed Resident #222's bed was not in the lowest position. Interview on 02/25/25 at 6:50 A.M. with Certified Nursing Assistant (CNA) #446 verified Resident #222's bed was in the highest position. Interview on 02/26/25 at 2:44 P.M. with Licensed Practical Nurse (LPN) #415 verified Resident #222's bed was in the highest position. Interview on 02/27/25 at 11:45 A.M. with LPN #441 verified Resident #222's bed was in the highest position. Review of the facility policy, titled Fall Reduction Policy, dated 04/29/16, indicated a fall risk assessment would be completed on admission. Further review indicated outcomes of the fall risk assessment would be incorporated into the resident's plan of care.

Based on medical record review, observation, staff interview, resident interview, and review of facility policy the facility failed to ensure oxygen was administered as ordered. This affected one Resident (#222) of 19 Residents reviewed for the use of oxygen. The facility identified 19 resident on oxygen therapy (#7, #14, #16, #17, #18, #22, #23, #24 #30, #32, #37, #39, #43, #51, #55, #63, #176, #178, #222). The facility census was 73. Findings include: Review of medical record for Resident #222 revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease, asthma, and sleep apnea. The Multiple Data Set assessment was in progress and not available for review due to the admitted [DATE]. The admission assessment dated [DATE] indicated Resident #222 was alert and oriented, able to communicate clearly, and had an oxygen saturation of 91 percent (%) with oxygen being delivered via nasal cannula. Review of the physician orders for Resident #222 revealed an order dated 02/21/25 to administer oxygen at five liters per minute (L/m) via nasal cannula to maintain oxygen saturation greater than 90% and may titrate up to 10 L/m for mobility needs. Review of the care plan for Resident #222 revealed she is dependent on oxygen with interventions to give medications as ordered by the physician and to monitor for lethargy, confusion, and skin color. Observation on 02/24/25 at 9:07 A.M. revealed Resident #222 sitting in bed with eyes closed, pale coloring, and a nasal cannula resting on her chest. The nasal cannula was connected to the oxygen concentrator that was set to 8 L/m. Resident #222 was not responsive to voice. Interview on 02/24/25 at 9:13 A.M. revealed Certified Nurse Assistant (CNA) #451 knew Resident #222 was admitted recently but was not aware of the oxygen orders for this resident. Interview on 02/24/25 9:16 A.M. with Licensed Practical Nurse (LPN) #415 confirmed Resident #222's nasal cannula was on the her chest and her level of consciousness was decreased. Further interview revealed LPN #415 was unsure of the oxygen orders. Continued observation on 02/24/25 at 9:18 AM of LPN #415 providing care for Resident #222 revealed LPN #415 was attempting to arouse this resident with her voice but this resident would not fully awaken. LPN #415 placed the nasal cannula into Resident #222's nose. LPN #415 did not have a pulse oximeter with her and attempted to obtain one from the medication cart but none was available; she then left the floor to get a pulse oximeter. Continued observation on 02/24/25 at 9:20 A.M. revealed Resident #222's oxygen saturation was reading 82% via the pulse oximeter obtained by LPN #415. LPN #415 then went to get the respiratory therapist. Interview on 02/24/25 at 9:23 A.M. with LPN #415 confirmed Resident #222's oxygen saturation was 82% and it should be greater than 90%. Observation on 02/24/25 at 9:26 A.M. revealed Resident #222 was awake and interacting with staff. Her oxygen saturation was now 87%. Continued observation through 9:30 A.M. revealed Respiratory Therapist #419 arriving to Resident #222's room, adjusting the oxygen flow rate to 10 L/m, and obtaining an oxygen level of 90% via pulse oximeter. Resident #222 was conversing appropriately with Respiratory Therapist #419. Interview on 02/24/25 at 9:54 A.M. with Resident #222 revealed she did not remember taking off her nasal cannula and recalled it has fallen off in the past. Review of the facility policy titled Medication Administration - General Guidelines, dated 09/21/17 indicated medications were to be administered according to physician orders.

Based on observation, staff interview, review of the medical record, and review of the facility policy, the facility failed to ensure medication was stored appropriately. This affected one resident (#173) of the 16 residents (#6, #10, #12, #14, #19, #20, #21, #26, #36, #45, #173, #174, #176, #177, #178, and #179) who received medication from the E-Hall medication cart. The facility census was 73. Findings include: Review of the medical record for Resident #173 revealed an admitted [DATE], with diagnoses that included, malignant neoplasm of pancreas, secondary malignant neoplasm of bone, malnutrition, chronic obstructive pulmonary disease (COPD), chronic obstructive pulmonary disease, asthma, lumbar radiculopathy, hypertension (HTN), depression, insomnia, gastro-esophageal reflux disease (GERD), hyperlipidemia, anemia, and neuropathy. Resident #173''s Minimum Data Set (MDS) assessment was in-process and not available due to an admitted [DATE]. Review of the current physician orders for Resident #173 revealed a physician order, dated 02/21/25, for Zenpep Oral Capsule Delayed Release Particles 40000-126000 unit, give two capsules by mouth with means related to malignant neoplasm of pancreas and give one capsule by mouth as needed for pancreatic cancer. Observation on 02/25/25 at 11:41 A.M. of the top drawer E-Hall medication cart revealed two capsules that were one-half orange and one-half white with 40 and Aptalis inscribed in black on each capsule. Interview on 02/25/25 at 11:42 A.M. with the Director of Nursing (DON) verified the medication was stored inappropriately in the top drawer of the medication cart for E-Hall. Further interview with the DON revealed these capsules were Resident #173's Zenpep Oral Capsule Delayed Release Particles 40000-126000 unit. Review of the facility policy titled, Medication Storage in the Facility, dated 02/11/21, revealed medications and biological's are stored safely , securely, and properly.

Based on medical record review, staff interview and policy review, the facility failed to ensure accurate and complete documentation in resident records. This directly affected one resident, #178, of 18 records reviewed for complete documentation. The facility census was 73. Findings include: Review of the medical record of Resident #178 revealed an admitted [DATE]. Diagnoses include infection and inflammatory reaction due to internal fixation device or other site, subluxation of left ankle, asthma, type II diabetes mellitus, systemic lupus erythematosus, protein-calorie malnutrition, palmar fascial fibromatosis, herpesviral infection, hepatitis A, chronic peripheral venous insufficiency, and vitamin D deficiency. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #178 to be cognitively intact and to require partial to moderate assistance for toileting and lower body dressing. The assessment included surgical wounds but no moisture associated skin damage. Review of the progress note titled Clinical Admission, dated 02/14/25 at 5:13 P.M. revealed Resident #178 had the following wounds present upon admission: wound #1, on the intergluteal cleft identified as excoriation with no description and no measurements. Wound #2, on the genital identified as excoriation without description or size. Wound #3, identified on the left lateral ankle as a surgical wound with approximated edges, 14 sutures and measured 11.4 centimeters (cm) wide and 1.2 cm in length, no other description. Wound #4, identified on the left lateral shin as a surgical wound. The incision was approximated and dehiscence. Six sutures in place and measured one cm in length, 1.4 cm in depth, and 0.8 cm in depth. Wound #5, on left shin four areas of rod insertion sites, two on lateral and two medial, no other description noted. Review of a progress note dated 02/14/25 at 5:13 P.M., documented as a late entry on 02/26/25 at 10:28 A.M. by Registered Nurse (RN) #431, revealed the presence of wound #6. The wound was documented as a surgical wound to the left medial ankle. A wet to dry dressing was removed with scant drainage. The wound measured 2.4 cm in length, 3 cm in width and 0.8 cm in depth. The surrounding tissue had a small amount of redness around the wound with normal temperature. A negative pressure wound treatment was applied as ordered. Review of a wound doctor note dated 02/25/25 revealed a wound to the left medial ankle post-surgical wound. The wound measured two cm in length, 2.5 cm in width, and 0.8 cm in depth with moderate serous exudate, 40 percent granulation tissue and 60 percent (%) other viable tissue (tendon, fascia, muscle). A new treatment order to apply Vaseline gauze to the base of the wound to cover the tendon three times a week and then apply the negative pressure wound dressing therapy three times a week for 30 days at 125 millimeters of mercury continuous. Review of the progress note dated 02/26/25 at 11:18 A.M., documented by Registered Nurse (RN) #431, revealed wound #1 on middle intergluteal cleft excoriation, redness, measuring 0.8 cm in length, 0.3 cm in width with no depth. Wound #2 on the genital excoriation, redness, measuring 1.2 cm in length and 0.5 in width without depth. Wound #3 on the left lateral ankle was identified as a surgical wound measuring 11.3 cm in length, 1.2 cm in width with 14 sutures and approximated edges. Wound #4 on the lateral left shin as a surgical wound. The description had conflicting data. The wound measured one cm in length, 1.4 cm in width, and 0.8 cm in depth. RN #431 documented incision approximated and dehiscence. The incision had six sutures and no dressing was applied. Wound #5 on the left medial shin as a surgical wound with four rod insertion sites, two lateral ankle and two medial shin. This wound identified as painful with pain medications effective. A non-woven drain sponge was applied. Wound #6 identified on the left medial ankle as a surgical wound, not approximated. The wound was dressed with a negative pressure wound therapy. The length was two cm, width was 2.5 cm, and depth of 0.8 cm. The wound had 40 percent (%) granulation tissue with moderate serous (clear, watery fluid) exudate. Review of a progress note dated 02/27/25 at 11:36 A.M., documented by RN #431, revealed a clarification of wound #4. The entire wound measured one cm in length and 1.4 cm in width with a small area of dehiscence measuring 0.3 cm in length by 0.3 cm in width by 0.8 cm in depth at the medial end of the wound. The wound was without redness, drainage, or odor. Interview on 02/26/25 at 9:35 A.M. with Registered Nurse (RN) 431 and Clinical Support RN #439 revealed RN #431 admitted to having falsely documented a wound evaluation but not completing the evaluation. RN #431 stated the documentation was incomplete. Review of the policy titled Documentation Policy dated 03/17 revealed the facility will provide a complete and accurate account of the resident's signs and symptoms, as well as the progress of care.

Based on resident interview, staff interview, review of admission agreement, and facility policy the facility failed to honor a resident's choice to smoke. This affected one (Resident #27) of five residents reviewed for choices regarding smoking. The facility census was 70. Findings include: Medical record review of Resident #27 revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. Per the record, the resident was readmitted on [DATE]. Diagnoses included dysphagia, anxiety disorder, memory deficit and cerebrovascular disease. Review of Resident #27's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mildly impaired cognition and was not receiving supplemental oxygen. Review of Resident #27's care plan dated 11/18/22 revealed no focus for smoking cessation (quitting smoking) or safe smoking. Review of Resident #27's acknowledgement of documents and admission agreement, signed per the resident's Power of Attorney (POA), dated 11/18/22 revealed the POA and the resident were informed of the facility's smoking policy. Review of the facility admission agreement dated 05/2022 revealed under the section, 'Smoke-Free Environment,' stated the facility instructed all residents and visitors who smoked may do so under the following circumstances: under staff supervision or family/guardian supervision and only in designated areas. There was no mention of newly admitted residents being unable to smoke. Review of the facility policy titled, Smoking Policy, dated 10/2022 revealed for facilities who permit smoking, must provide a safe environment to those residents who wish to smoke. If the facility changes its policy to prohibit smoking, it should allow current residents who smoke to continue in designated areas. Further requests for an updated no smoking policy revealed the facility did not have a policy stating the facility was smoke-free. Interview on 06/11/23 at 10:02 A.M. with Resident #27 revealed the resident was alert and oriented and able to be interviewed. Resident #27 stated she had no concerns with her care except she was not allowed to smoke. Resident #27 stated she had seen other residents smoking outside but she was told the facility was a smoke-free facility. Resident #27 stated she knew she had not smoked for a long time but she still had the desire to go outside and smoke and was being told she was not allowed to by staff. Interview on 06/14/23 at 2:15 P.M. with the Administrator revealed during the COVID-19 pandemic, the facility decided to become a smoke-free facility. Per the Administrator all new admissions would no longer be allowed to smoke. The Administrator verified the admission document labeled 'Smoke-Free Environment' did not state the facility was a smoke-free facility nor did it say only previous admitted residents would be permitted to smoke. The Administrator verified Resident #27 did smoke prior to admission and was no longer allowed to smoke after her 2022 admission. Interview on 06/14/23 at 8:10 A.M. with Resident #27 stated chose to come to this facility because she was allowed to smoke in 2019 with her last admission. Resident #27 stated she had no idea she would be prevented from smoking when she was admitted to the facility. Resident #27 stated she knew the hazards of smoking but stated she still chose to smoke and felt she was being denied her choice. Interview on 06/14/23 at 8:15 A.M. with Licensed Practical Nurse (LPN) #400 revealed the staff was aware of Resident #27's desire to smoke. LPN #400 stated the facility was to be smoke-free and only certain residents were allowed to smoke.

Based on medical record review, observation, and staff interview, the facility failed to ensure residents nonverbal communication of hunger was responded to. This affected one (#53) of four residents observed on the secured unit who received meals in their rooms. The facility census was 65. Findings include: Review of Resident #53's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #53's care plan, revised 03/30/21, revealed an intervention for a communication problem which included supports to anticipate and meet Resident #53's needs. An additional intervention was found for increased nutritional risk. Supports included saving Resident #53's meals for later consumption if Resident #53 did not eat. Observation on 04/13/21 at 12:25 P.M. found Resident #53 pacing in his room. Resident #53 was observed sitting on the bed, getting up and walking to the door, looking at the meal tray cart, going back in his room, sitting on the bed and positioning the gray side table in front of him. Resident #53 was observed repeating this process four times in three minutes. Observation on 04/13/21 at 12:28 P.M. of the meal trays on the hall cart found Resident #53's lunch tray was on the cart. The lunch tray was covered and appeared untouched. Interview on 04/13/21 at 12:29 P.M. with State tested Nursing Assistant (STNA) #157 verified the untouched lunch tray on the meal cart was Resident #53's. STNA #157 reported Resident #53 placed the lunch tray in the hallway after it was initially delivered. STNA #157 verified she picked up the untouched tray and put it back on the cart. STNA #157 stated Resident #53 must have not wanted it. Coinciding observation of Resident #53 found him sitting on his bed with his side table in front of him, looking at the meal cart and his tray as it went by. STNA #157 did not stop and ask Resident #53 if he was hungry or if he wanted his meal. STNA #157 was observed pushing the meal cart down the hallway and adding other resident's used lunch trays to the cart to be taken back to the kitchen. Observation on 04/15/21 at 8:05 A.M. of Resident #53 found Resident #53 seated on his bed with his breakfast meal on the gray side table positioned in front of him. Resident #53 was observed eating and drinking independently. Interview on 04/15/21 at 8:07 A.M. with STNA #165 revealed Resident #53 was not able to verbally communicate if he was hungry. STNA #165 reported they knew he was hungry by his nonverbal communication. STNA #165 explained Resident #53 took his meals in his room and he would get fidgety when he was hungry. STNA #165 stated Resident #53 would pace and move his gray table around when he was hungry and wanted to eat. STNA #165 reported if Resident #53 refused his food they were to make additional attempts to offer his meal to him and/or offer an alternate.

Based on review of resident funds records, staff interview, and review of facility policy, the facility failed to return resident funds to the resident's responsible party within 30 days of the resident's death. This affected one resident (#165) of one resident reviewed for discharge funds. The facility census was 65. Findings include: Review of Resident #165's medical record revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of medical record revealed the resident was private pay. Review of copy of check dated 02/04/21 addressed to the estate of Resident #165's revealed the amount of $1,417.48. Interview on 04/19/21 at 11:27 A.M. with Business Office Manager #177 verified Resident #165's funds were not returned within 30 days of the resident's death. Review of facility policy titled Resident Personal Funds dated November 2016, revealed within 30 days of a resident's death, the Manor will transfer funds in their personal account to their estate.

Based on medical record review and staff and resident interviews, the facility failed to ensure residents received adequate bathing. This affected one resident (#3) of five reviewed for activities of daily living (ADL). The facility identified 89 residents who required assistance with bathing. The facility census was 109. Findings include: Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a five-day Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficits, verbal and other behavioral symptoms. The resident required extensive assistance for bed mobility, toileting, limited assistance with transfers and personal hygiene and physical assistance for bathing. Review of computerized charting in the task section for State tested Nursing Assistant (STNA) charting, dated 06/24/19 through 07/15/19 revealed the resident had received one bath on 06/27/19. Review of the tasks for showers in the past 30 days revealed the shower had been refused on 07/11/19 and 07/14/19. Review of Occupational therapy notes dated 07/11/19 and 07/14/19 revealed the resident refused therapy including bathing on those days. Review of shower list for D hall revealed Resident #3 was not listed on the shower sheet. The shower sheet for C hall was updated as of 7/12/19 and would not have included the resident as she was transferred to the other hall on 7/11/19. Observation of and interview with Resident #3 on 07/15/19 at 10:30 A.M. revealed she was talking loudly with therapy staff regarding not receiving a shower for three weeks, the therapy staff assured her she would get a shower today and left the room. Interview with Resident #3 at that time revealed she stated she was very upset. She stated it had been three weeks since she had received a shower, she felt dirty and she wanted one today. The resident's hair was slightly greasy. There was no odor and her clothes were clean. Interview with STNA #16 on 07/15/19 at 10:45 A.M. revealed the resident had recently moved to the D hall and was not added on the shower list. She verified she had not given the resident a shower. Interview with Unit Manager #20 on 07/15/19 at 10:50 A.M. revealed the resident had only one bath charted between 06/24/19 and 07/15/19 and that was on 06/27/19. She verified there was no documentation of showers being given on 06/30/19, 07/04/19 or 07/07/19. Interviews with STNAs #15, #19, and #21 on 07/15/19 between 10:55 A.M. and 11:45 A.M. revealed they had not given the resident a shower. Interviews with the above STNAs #15, #16, #19, #21 revealed they went by the paper shower sheet to determine which residents were to receive shower on what days. They stated it was listed on their task sections in the computer, but they did not go by the computer. Follow up interview with Unit manager #20 on 07/15/19 at 11:00 A.M. revealed she had taken the old shower sheet for C hall to the shredder and was unable to verify if the resident had been added to the shower schedule or not. Interview with the Director of Nursing on 07/15/19 at 12:15 P.M. revealed she had spoken with all the STNA's who would have cared for the resident on her shower days. STNA #18 had offered a shower yesterday, but no other STNA's had provided the resident a shower. She verified the STNA's did not chart if the resident was offered or refused a shower. She verified STNA's were to document the residents acceptance or refusals and inform the nurse of any refusal. She verified the progress notes from the time of admission did not reflect and refusals of any showers. There was no policy available for showers.

Based on record review, review of facility policy and staff interview, the facility failed to issue written notice of the reasoning for a resident's transfer to the hospital to the resident and/or resident representative. This affected one (#16) of three residents reviewed for hospitalization s. The facility census was 103. Findings include: Review of Resident #16's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as having severe cognitive impairment. Review of the change in condition progress note dated 12/17/18 at 8:30 A.M. revealed the respiratory therapist was asked to see/assess the resident due to change in condition. Upon entering room the respiration rate was 40-50, shallow and labored with course rhonchi throughout. The resident refused to allow to obtain a pulse ox reading and was later obtained by Registered Nurse at 90-91% on two liters per nasal cannula. The resident has a urinary tract infection, blood colored urine and a temperature. He was transferred out to the emergency room at 9:33 A.M. Review of the resident's progress notes dated 12/21/18 at 3:05 P.M. revealed the resident returned to the facility from the hospital that day. Review of Resident #16's medical record revealed there was no evidence the resident and/or residents representative was notified in writing of the reasoning for transfer to the hospital. Interview with the Licensed Nursing Home Administrator (LNHA) on 01/10/19 at 8:50 A.M. confirmed there was no evidence a written transfer notice was provided to the resident/and or resident representative regarding Resident #16 being transferred to the hospital. Review of the facility policy titled Transfer, Discharge and Room Change dated 02/06/18 revealed that notice of a transfer/discharge will be given to the resident and sent certified mail, return receipt requested, to the resident's guardian, responsible party, sponsor, or family member.

Based on record review and staff interview, the facility failed to issue a written notice of the bed hold policy to a resident/resident's representative . This affected one (#16) of three reviewed for hospitalization s. The facility census was 103. Findings include: Review of Resident #16's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as having severe cognitive impairment. Review of the change in condition progress note dated 12/17/18 at 8:30 A.M. revealed the respiratory therapist asked to see/assess the resident due to a change in condition. Upon entering room the respiration rate was 40-50, shallow and labored with course rhonchi throughout. The resident refused to allow to obtain a pulse ox reading and was later obtained by Registered Nurse at 90-91% on two liters per nasal cannula. The resident has a urinary tract infection, blood colored urine and a temperature. He was transferred out to the emergency room at 9:33 A.M. Review of the resident's progress notes dated 12/21/18 at 3:05 P.M. revealed the resident returned to the facility from the hospital. Review of Resident #16's medical record revealed there was no evidence the resident and/or residents representative was notified in writing of the facility bed hold policy or bed hold days. Interview with the Licensed Nursing Home Administrator (LNHA) on 01/10/19 at 8:50 A.M. confirmed there was no evidence that a bed hold notification was issued for Resident #21.

Based on medical record review and staff interview, the facility failed to accurately code Minimum Data Set (MDS) assessments. This affected two (#9 and #84) of 24 MDS assessments reviewed during the annual survey. The facility census was 103. Findings include: 1. Review of medical record review for Resident #84 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the pre-admission screen and resident review (PASRR) level two determination dated 09/01/18 documented the Resident #84 had serious mental illness, was appropriate for a nursing facility and did not require and special services were no required. Review of admission MDS assessment dated [DATE] assessed the Resident #84 as not having a PASRR level two screen identifying her as having a serious mental illness. On 01/08/19 at 12:59 P.M., an interview with MDS Nurse #200 verified Resident #84's admission MDS assessment was coded inaccurately at Section A 1500 and section A 1510. She further verified Resident #84 was identified as having a serious mental illness during PASRR level two screening determination. 2. Review of medical record for Resident #9 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] documented Resident #9 was assessed as being 68 inches and 130 pounds. Further review documented he had a significant weight loss and weight gain during the assessment period. On 01/08/19 at 12:46 P.M. interview with Nutrition Assistant #210 verified the quarterly MDS assessment, dated 10/08/18 was coded inaccurately and Resident #9 did not have a significant increase in his weight. She further revealed he had a significant weight loss due to his weight being 164 pounds on 04/11/18 which was a 20.73 percent weight loss in the past six months.

Based on medical record review, observation, and staff interview, the facility failed to ensure a waffle mattress was in place per physician's orders. This affected one (Resident #21) of three residents reviewed for appropriate skin interventions. The facility census was 103. Findings include: Review of Resident #21's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as being cognitively intact. It identified the resident as requiring an extensive two person assist with bed mobility, total dependence two person assist with transfers, and extensive two person assist with toilet use. Review of Resident #21's care plan, last revised on 01/25/18, indicated the resident was at risk for ill effects related to incontinence. It indicated the resident has excoriation of the bilateral thighs, groins and large abdominal fold and continue to get treatment for [REDACTED]. An intervention included to provide a waffle mattress to her bed. Review of the physicians order dated 07/25/18 revealed an order for [REDACTED]. Review of the (MONTH) 2019 treatment administration record (TAR) revealed for a waffle mattress to the bed and to check for proper inflation every shift; this was to be completed on each shift from 7:00 A.M. to 7:00 P.M. and from 7:00 P.M. to 7:00 A.M. Further review of the TAR from 01/01/19 until 01/08/19 revealed staff were signing off that the waffle mattress was in place with proper inflation. Observation on 01/08/19 at 3:17 P.M., 01/09/19 at 10:05 A.M., and 01/09/19 at 3:43 P.M. revealed Resident #21 did not have a waffle mattress on her bed. Interview with Registered Nurse (RN) #300 on 01/09/19 at 3:58 P.M. confirmed Resident #21 had an order for [REDACTED].#300 confirmed there was not a waffle mattress on her bed and verified staff had been signing off that the waffle mattress was on her bed.

Based on observations, staff interview, review of a facility list, review of the facility policy on chemical storage and review of the Safety Data Sheets (SDS), the facility failed to ensure potentially hazardous chemicals were kept in a locked area on the secured behavior unit. In addition, the facility also failed to secure a food temperature probe that consisted of a digital unit and a very sharp metal probe. These failed practices had the potential to affect all 42 Residents (#3, #5, #7, #9, #11, #15, #19, #21, #23, #24, #25, #26, #27, #29, #30, #31, #32, #33, #34, #42, #43, #44, #45, #46, #48, #50, #53, #54, #60, #68, #70, #71, #72, #73, #74, #75, #76, #81, #85, #101, #103 and #108) identified as confused and independently mobile that resided on the secured behavior unit. The facility census was 109. Findings include: Observation during the initial tour on 11/28/17 at 10:50 A.M. revealed a bottle labeled Super HDQL10. Further investigation on the bottle revealed a warning that the contents of the bottle was hazardous to humans. In addition, a second container labeled BarMaid Sani Maid Tablet Sanitizer with a label warning the contents of the container was to be kept out of reach of children, and if swallowed to call poison control. The label also stated the contents caused irreversible eye damage. Both containers were found in an un-locked cabinet in the dining room on Hall A of the secured behavior unit. During the same observation, a red food temperature probe was discovered in an un-locked drawer. The food probe, when the cover was removed, revealed a very sharp pointed probe end approximately two and a half inches long. An interview was conducted with Licensed Practical Nurse (LPN) #310 on 11/28/17 at 11:05 A.M. She confirmed that the two containers were found in an unsecured cabinet, in the dining room of the secured behavior unit. She also verified the two containers were not supposed to be unsecured. LPN #310 locked the two chemical containers in the cabinet during the interview. Unit Manager Registered Nurse (RN) #360 was interviewed on 12/01/17 at 11:05 A.M. and verified she had been notified on 11/28/17 that two containers of potentially hazardous cleaning products and a temperature probe were discovered in an unlocked cabinet in the dining room of the secured behavior unit. State tested Nursing Assistant (STNA) #320 was interviewed on 11/28/17 at 11:10 A.M. confirmed the unsecured food temp probe, and removed it from the drawer. The Dietary Manager (DM) #370 was interviewed on 12/01/17 at 1:20 P.M. and verified he had been notified on 11/28/17 that a temperature probe was discovered in an unlocked drawer in the dining room of the secured behavior unit. He stated he gave his staff an in-service on 11/28/17 on the proper storage of temperature probes and they were not to leave any temperature probes on the secured behavior unit. On 12/01/17 at 1:30 P.M. RN #380 provided a list of 42 Residents (#3, #5, #7, #9, #11, #15, #19, #21, #23, #24, #25, #26, #27, #29, #30, #31, #32, #33, #34, #42, #43, #44, #45, #46, #48, #50, #53, #54, #60, #68, #70, #71, #72, #73, #74, #75, #76, #81, #85, #101, #103 and #108) that resided on the secured behavior unit that were mobile and cognitively impaired. Review of the SDS titled HDQ Neutral, dated 08/14/15, revealed HDQ Neutral disinfectant was harmful if swallowed. It further revealed the chemical caused severe [MEDICAL CONDITION] serious eye damage. Review of the facility's policy numbered 114.140.3 dated 02/01/05 revealed under point three, cleaning supplies shall be stored in locked areas separate from food storage rooms and shall be stored as instructed on the labels of such products.

Based on medical record review, staff interview, review of facility Self-Reported Incidents (SRI's) and review of a facility policy, the facility failed to timely report to the state survey agency an allegation of physical abuse involving two (#200 and #300) out of three residents reviewed for abuse, and out of eleven facility investigated SRIs reviewed. The facility identified 16 SRI's reported to the state survey agency in the past two month. The facility census was 105. Findings include: Review of the medical record of Resident #300 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the nurses notes dated 09/05/16 at 7:00 P.M. revealed staff witnessed Resident #300 standing in the doorway of her room. Resident #200, the roommate of Resident #300, was observed to shut the door on the left arm of Resident #300 three times. No injury was documented. Resident #300 was documented as feeling scared and crying. Resident #300 was immediately assisted to a private room on another hallway, away from Resident #200. Review of the medical record of Resident #200 revealed the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of nurses notes dated 09/05/16 at 7:00 P.M. revealed Resident #200 was observed to shut the door on Resident #300's arm three times, hitting Resident #300 with the door. Review of the facility SRI dated 09/06/16 revealed on 09/06/16 Resident #300 was showing staff a bruise to the right forearm and stating another resident had beaten her up. Upon investigation it was noted on 09/05/16 Resident #200 was witnessed hitting Resident #300's left arm with the door to the room. The SRI was not submitted to the state survey agency until 09/07/16. Interview on 11/16/16 at 10:50 A.M., the Administrator verified he was made aware of Resident #200 shutting the door three times on the left arm of Resident #300 on 09/05/16. The Administrator stated the altercation between Resident #200 and Resident #300 was a result of a dispute over the temperature of the room. The Administrator verified the incident was not reported to the state survey agency until 09/07/16. Review of the facility policy titled Abuse, Neglect, Injuries of Unknown Source, and/or Misappropriation of Resident Property Policy, revised 06/2011, revealed the facility was to report allegations of abuse, neglect, injuries of unknown source and misappropriation to the state survey agency immediately, but not to exceed 24 hours after the discovery of the incident. This is an incidental finding discovered at the time of the investigation of Complaint Number OH 800.