Every finding on record at Troy Rehabilitation and Healthcare Center

Based on record review, staff interview, and facility policy review, the facility failed to ensure medications were properly stored. This affected one resident, (#14) of three reviewed. The facility census was 136. Findings include:Review of medical record for Resident #14 revealed admission date of 06/01/12. The resident's medical diagnoses included Chronic Obstructive Pulmonary Disease (COPD), schizoaffective disorder depressive type, and unspecified pain.The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She required set up assistance with eating, required touching assistance with toileting hygiene, bed mobility and transfers.Record review of the physician orders revealed an order to apply green pain relieving gel to left hip every four hours as needed with a start date of 04/20/26.Observation on 06/02/26 at 3:39 P.M. with Licensed Practical Nurse (LPN) #101 in the room of Resident #14 revealed a tube of [NAME] Pain Relieving gel located on the bedside nightstand within reach of Resident #14. Interview on 06/02/26 at 3:44 P.M. with LPN #14 verified there was no order for the green pain-relieving gel to be kept at bedside.Review of the undated facility policy, storage of medication documented the facility shall store all drugs and biologics in a secure and orderly manner. This deficiency represents non-compliance investigated under Complaint Number 3000293.

Based on observation, review of medical records, resident and staff interviews, and review of facility policy, the facility failed to ensure residents smoked only in the designated smoking areas and failed to ensure the safety of a vulnerable resident while on leave of absence (LOA). This affected four (#16, #73, #108, and #131) of twenty-eight residents reviewed for smoking and one (#50) of six residents reviewed for accidents. The census was 133.Findings include: 1. Review of Resident #50's medical record revealed an admission date of 09/26/25. Diagnoses included schizophrenia, bipolar disorder, left below the knee amputation, and peripheral vascular disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition and a diagnosis of schizophrenia. Review of the physician orders dated 09/26/25 revealed an order that the resident may go LOA with supervision. Review of application for guardianship Statement of Expert Evaluation (SOEE) documentation dated 12/31/25 revealed Resident #50 had paranoid schizophrenia and bipolar disorder that were not stabilized or reversible. Resident #50 refuses all medications due to believing they were poison, refuses showers, keeps all her belongings by her bed in a bag, and refuses to allow medical providers to examine her. Resident #50 had impairments in thought process, affect, memory, concentration, comprehension, and judgement. A Supplement for Emergency Guardianship of Person was signed 12/31/25 but not completed. Review of the nursing note dated 12/31/25 at 5:13 P.M. revealed Resident #50 told the nurse they were leaving and didn't know if they were coming back. Resident #50 refused to sign an against medical advice (AMA) form because they wanted to come back to the facility but didn't know when they would be back. The facility's upper management was notified. Resident #50 signed the LOA book and left a contact phone number and address. Resident #50's emergency contact was updated. Nurse Practitioner (NP) #564 was notified of Resident #50 leaving LOA. The nursing note dated 01/05/26 revealed the nurse made a call to see how Resident #50 was doing on LOA. Resident #50 did not answer and a voicemail was left. Resident #50's emergency contacts were called and neither of the phone numbers listed were working. The nursing note dated 01/05/26 at 4:56 P.M. revealed Resident #50 called and stated she was stranded in Columbus, Ohio, her rights were being violated, and no one in Ohio likes her because of being an amputee. Resident #50 stated to call her if you have her best interests in mind. The unit manager was notified of the call. Review of the care plan dated 01/07/26 revealed Resident #50 had behaviors related to withdrawn, paranoia, refuses medication and orders, refuses care, refuses showers, delusions, hallucinations, non-compliant, refuses meal trays, refuses to change clothes, refuses to be weighed, hoarding, refuses wound treatments, call emergency services, call businesses and leaves obscene messages, refused to follow LOA policy, and picks at skin. Interview with the Assistant Director of Nursing (ADON) #434 on 04/01/26 at 3:33 P.M. confirmed that facility staff had not checked on Resident #50 from 12/31/25 though 01/05/26 while she was on LOA. ADON #434 confirmed Resident #50 was paranoid and had delusions. Resident #50 had spoken in the past about attempting to go to Los Angeles, California. Interview with Registered Nurse (RN) #521 on 04/01/26 at 3:48 P.M. revealed she was the nurse on duty when Resident #50 left he facility on 12/31/25. She questioned if Resident #50 was allowed to leave the facility. Resident #50 refused to sign an AMA form because she wanted to come back. Resident #50 signed the LOA log. Resident #50 did not give a timeframe for her return to the facility. She told NP #564 that Resident #50 was wanting to leave. Interview with the Administrator on 04/02/26 at 6:54 A.M. confirmed no documentation of staff checking on Resident #50 from 12/31/25 until 01/05/26. Facility staff picked up Resident #50 from Columbus, Ohio on 01/06/26 and returned her to the facility. The Administrator confirmed Resident #50 was ordered LOA with supervision. The Administrator was unable to produce Resident #50's signature on an LOA log. Interview with NP #564 on 04/02/26 at 9:38 A.M. revealed she had completed guardianship paperwork for Resident #50. The facility's former social worker had left the paperwork in her mailbox at the facility. Resident #50 was paranoid and will not speak with NP #564 or allow to be physically assessed. Information from staff was used for the paperwork. Guardianship being established for Resident #50 was a safe decision. Review of the facility's policy titled Leave Of Absence (LOA) dated September 2022 revealed it is the policy of this facility to support a resident's right to leave the facility, including LOA, in accordance with resident rights. Residents have the right to make choices about their care and daily activities, including leaving the facility. The interdisciplinary team (IDT), in collaboration with the resident, will assess the appropriateness of a leave of absence. If the resident is not deemed Incompetent by the court, the resident retains the right to make the decision. If the resident is deemed incompetent by the court, the guardian will participate in decision-making as required by law. Overnight leaves must conform to the requirements of a resident's insurer (payer) if applicable. The resident/family need to sign resident in and out of facility on LOA form. Document a nursing progress note when resident returns and any pertinent information. This is especially important if the resident has an incident while on pass. Review of the facility's policy titled Signing Residents Out dated September 2021 revealed residents leaving should sign out. Each resident leaving the premises (excluding transfers/discharges) should sign out. A sign-out register is located at nursing station. Unless otherwise prohibited by law, medications that must be administered while the resident is out will be given to the resident/person signing the resident out. Written and/or oral instructions on when and how to administer the medication will be provided to the resident or to the person signing the resident out. Only medications that must be administered while the resident is out will be issued. Staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify their supervisor. Restrictions noted on the resident's chart concerning who may not sign the resident out must be honored unless otherwise prohibited by facility policy or state/federal law governing such releases. Residents should sign in upon return to the facility. 2. Observation on 03/30/26 at 2:18 P.M. revealed Residents #16, #73, #108, and #131 were seated in a circle approximately eleven feet from the facility building on facility property and not in the designated smoking area. The residents were observed smoking an unidentified substance rolled in paper, which emitted a strong, pervasive odor. The item was observed being passed from one resident to another. Interview on 03/30/26 at 2:18 P.M. with Resident #131 revealed the unidentified substance rolled in paper, observed being smoke on facility grounds was marijuana. Interview 03/30/26 at 2:23 P.M. with the Administrator verified Residents #16, #73, #108, and #131 were smoking marijuana eleven feet from facility building on facility property and not in the designated smoking area. The Administrator stated education on facility smoking policy was completed on 10/07/25. Residents #73, #108, and #131 were present during education. Residents #16, #73, and #131 signed acknowledgement of the smoking policy, while Resident #108 refused to sign. Review of the facility policy titled Smoking Policy dated September 2022 revealed for those who are deemed safe to smoke independently, per smoking assessment, they may smoke at any time resident chooses in the designated smoking area. This deficiency represents non-compliance investigated under Complaint Number 2587182.

Based on observation and resident and staff interviews, the facility failed to provide a safe and sanitary environment for residents. This affected #1, #29, and #91 and had the potential to affect the 48 residents who utilized the B-hall shower rooms. The facility census was 133.Findings include: 1. Observation on 04/06/25 at 8:21 A.M. of the B-hall shower rooms, left and right shower rooms, revealed in the right shower room, it was observed to have large brown/black spots on the floor around the toilet and into the shower area which appeared to have a wheel pattern streak on the floor. The shower stall had missing tiles near the floor and a hole approximately 12 inches by 12 inches, six inches above the floor in one of the corners of the stall. The grout on the floors and walls of the shower room had dark colored brown and black spots in some areas of the tilework. Interview on 04/06/26 at 8:22 A.M. with Unit Manager (UM) #439 verified the condition of the right shower room. UM #439 verified there was black/brown debris on the floor which appeared to be smears from a wheelchair wheels on the floor. UM #439 verified there was miscolored grout on the tiles and there was a hole in the wall and there were many missing tiles on the floor and walls. Observation and interview on 04/06/26 at 8:28 A.M. of the left shower room on B-hall revealed there was black/brown stained grout throughout the tilework and there were missing tiles on both the walls and throughout the floor. Certified Nursing Assistant (CNA) #505 verified the condition of the left shower room. CNA #505 verified the missing tiles and miscolored grout in the shower room. CNA #505 stated many residents have complained about the condition of the shower rooms during their showers. Interview on 04/06/26 at 8:32 A.M. with Resident #1 stated he does not feel comfortable while he is in either of the shower rooms on the B-hall. Resident #1 stated the shower rooms were always dirty and in disrepair. 2. Observation and interview on 03/30/26 at 11:00 A.M. revealed the wall below the air-conditioning unit mounted in the wall of Resident #29's room had crumbling plaster. The area was approximately two and a half feet wide and one foot tall. Licensed Practical Nurse #495 verified the presence of the crumbling wall in Resident #29's room. 3. Observation and interviews on 03/31/26 at 8:55 A.M. revealed the floor of Resident #91's room had large amounts of debris stuck to the floor. Resident #91 stated they rarely mop or clean his room. Observation and interview on 04/07/26 at 9:15 A.M. revealed the floor of Resident #91's had scattered black substance areas and debris. Certified Nursing Assistant (CNA) #454 verified Resident #91's floor had dark sticky substances and debris. CNA #454 stated housekeeping mops floors every other day, but stated Resident #91's floor looked bad. This deficiency represents non-compliance investigated under Complaint Numbers 1351395 (OH00164633), 2568202, 2587182, 2662726, 2686418, 2963194, and 2971291.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure resident rooms were clean and homelike environment. This affected two (#31 and #64) of six residents reviewed for dignity. The facility census was 133.Findings include:Review of Resident #31's medical record revealed an admission date of 12/15/25. Diagnoses included cerebral palsy and epilepsy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had severely impaired cognition and was dependent on staff for activities of daily living (ADL).Review of Resident #64 medical record revealed an admission date of 07/25/23. Diagnoses included major depressive disorder and Alzheimer's disease.Observation on 03/30/26 at 8:27 A.M. revealed an used incontinence brief on the floor between Resident #31 and Resident #64's beds. The brief was open and feces was visible. A foul odor was apparent. Resident #31 was not in the room. Resident #64 was lying in bed.Interview and observation with Certified Nurse Aide (CNA) #50 on 03/30/26 at 8:29 A.M. confirmed the incontinence brief was on the floor between Resident #31 and Resident #64's beds. CNA #505 confirmed the use incontinence briefs should not be on resident floors. CNA #505 stated nightshift had performed ADL on Resident #31.Review of the facility's policy titled Resident Right dated September 2022 revealed residents have the right of a dignified existence.This deficiency represents non-compliance investigated under Complaint Numbers 1351395 (OH00164633), 2568202, 2587182, 2662726, 2686418, 2963194, and 2971291.

Based on medical record review, resident interview, staff interview, review of the facilities Self-Reported Incidents (SRIs), review of personnel files, and review of facility policy, the facility failed to report allegations of abuse and misappropriation of narcotic medications to the State Survey Agency and local law enforcement, and staff failed to timely report an allegation of misappropriation to the Administrator. This affected two (#31 and #151) of three residents reviewed for abuse and misappropriation. The facility census was 133.Findings include:1.Review of Resident #31's medical record revealed an admission date of 12/15/25. Diagnoses included cerebral palsy and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had severely impaired cognition and was dependent on staff for activities of daily living (ADL).Review of the facilities SRIs from 03/27/26 to 03/30/26 revealed there was no SRI reported to the State Survey Agency involving Resident #31 and Certified Nurse Aide (CNA) #445.Interview with Resident #12 on 03/30/26 at 2:04 P.M. revealed he heard Resident #31 and CNA #445 in a loud verbal exchange including profanity over the past weekend. Resident #12 went out of his room to see what was going on and saw that Resident #32 was upset. Resident #12 then went to Licensed Practical Nurse (LPN) #516 and reported what he had heard. Resident #12 also reported the incident to Unit Manager #467 the same day. Resident #12 had also reported the incident to LPN #439. Resident #12 had not been interviewed by any facility management about the incident.Telephone interview on 04/01/26 at 8:55 A.M. with LPN #439 revealed Resident #12 reported concerns with CNA #445 caring for Resident #31. LPN #439 did not report the concerns to management because they had already been reported by another staff member but couldn't remember who.Telephone interview on 04/01/26 9:05 A.M with LPN #467 denied Resident #12 reported any concerns with CNA #445's care of Resident #31 to her. Interview on 04/01/26 at 9:12 A.M. with LPN #421 revealed on Monday (03/30/26), Resident #12 was venting about CNA #445's care of Resident #31. Resident #12 reported profanity was being used by CNA #445 and Resident #31. LPN #421 stated Resident #12 was truthful and protects Resident #31. LPN #421 was not interviewed by management about the incident.Telephone interview on 04/01/26 at 2:57 P.M. with LPN #516 revealed Resident #12 came to her and reported a concern with the way CNA #445 was taking care of Resident #31. Resident #12 reported Resident #31 using profanity and wasn't being taken care of properly. LPN #516 went to Resident #31's room and watched CNA #445 complete Resident #12's care and did not witness any concerns. LPN #516 did not report the incident to management because she felt it did not witness anything that would warrant any more investigation. Interview on 04/02/26 at 7:20 A.M. with the Administrator confirmed the incident Resident #12 reported to staff about CNA #445's care of Resident #31 was not investigated or reported to the State Survey Agency. Telephone interview on 04/07/26 at 9:52 A.M. revealed CNA #445 denied any abuse of Resident #31. Resident #12 had reported to the nurse that she was using profanity or something. CNA #445 did not know why Resident #12 said that. A nurse told her that she can no longer take care of Resident #31. CNA #445 was unable to name any nurses. CNA #445 was not asked by facility management about the incident until last week when someone called her.2. Review of Resident #151's closed medical record revealed an admission date of 03/04/24. Diagnoses included convulsions and osteomyelitis. Resident #151 passed away at the facility on 08/14/25. Review the physician orders revealed an order dated 08/01/25 to administer oxycodone hydrochloride (narcotic) five milligrams (mg) three times for chronic pain. An order dated 07/06/26 was for give oxycodone hydrochloride five mg one tablet as needed for chronic pain. Review of facility investigation documents revealed Licensed Practical Nurse (LPN) #565 was accused of misappropriation of Resident #151's oxycodone hydrochloride on 11/06/25. CNA #406 reported that on 08/15/25, LPN #565 told him she was going steal Resident #151 oxycodone hydrochloride. On 08/16/25 while in LPN #151's vehicle he found a medication card of Resident #151's oxycodone hydrochloride that was approximately half full in the glove compartment. CNA #406 reported being threatened by LPN #565 after he told her he found it. Review of LPN #565 personnel file revealed she was suspended on 11/06/25 and returned to work on 11/10/25. LPN #565 was then terminated on 12/17/25 when it was discovered she was not truthful during the investigation into the alleged misappropriation of Resident #151's oxycodone hydrochloride. Review of the facilities SRIs from 08/14/25 to 03/30/26 revealed there was no SRI reported to the State Survey Agency regarding the allegation of misappropriation of Resident #151's oxycodone hydrochloride. Interview on 04/02/26 at 3:20 P.M. with the Administrator confirmed the allegation of Resident #151's narcotic medications by Licensed Practical Nurse (LPN) #565 was not reported to the State Survey Agency nor to the State Board of Nursing. The Administrator stated facility corporate staff advised not to report the allegations. Follow-up interview on 04/06/26 at 8:24 A.M. with the Administrator revealed he was first made aware of the alleged misappropriation of Resident #151's oxycodone hydrochloride in November 2025. LPN #565 was suspended immediately. LPN #565 returned to work on 11/10/25 but then was terminated after she was not truthful during investigation interviews and was found to be enrolled in a drug treatment program. Investigators form the State Board of Health and State Board of Nursing had been in the facility to investigate. LPN #565 gave up her nursing license voluntarily. Interview on 04/06/26 at 9:45 A.M. with CNA #406 revealed he found a resident's narcotic medication in LPN #565's car while on lunch in August or September 2025. CNA #406 reported the Director of Nursing (DON) in November 2026. CNA #406 confirmed he should have reported sooner.Review of the facility's policy titled Abuse Investigation and Reporting dated September 2021 revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and the findings of abuse investigations will also be reported.Review of the facility's policy titled Drug Diversion Policy dated September 2024 revealed the facility will contact appropriate agencies (Board of Nursing, etc.) as appropriate.This deficiency represents non-compliance investigated under Complaint Numbers 2683813, 2697534, 2715021, 2748588, and 2963194.

Based on medical record review, resident interview, staff interview, review of the facilities investigations, review of personnel files, and review of facility policy, the facility failed to thoroughly investigate allegations of abuse and misappropriation of medications. This affected two (#31 and #151) of three residents reviewed for abuse and misappropriation. The facility census was 133.Findings include:1.Review of Resident #31's medical record revealed an admission date of 12/15/25. Diagnoses included cerebral palsy and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had severely impaired cognition and was dependent on staff for activities of daily living (ADL).The facility was unable to provide any investigation documents regarding the allegation of CNA #445 verbally abusing Resident #32.Interview with Resident #12 on 03/30/26 at 2:04 P.M. revealed he heard Resident #31 and CNA #445 in a loud verbal exchange including profanity over the past weekend. Resident #12 went out of his room to see what was going on and saw that Resident #32 was upset. Resident #12 then went to Licensed Practical Nurse (LPN) #516 and reported what he had heard. Resident #12 also reported the incident to Unit Manager #467 the same day. Resident #12 had also reported the incident to LPN #439. Resident #12 had not been interviewed by any facility management about the incident.Telephone interview on 04/01/26 at 8:55 A.M. with LPN #439 revealed Resident #12 reported concerns with CNA #445 caring for Resident #31. LPN #439 did not report the concerns to management because they had already been reported by another staff member but couldn't remember who.Interview on 04/01/26 at 9:12 A.M. with LPN #421 revealed on Monday (03/30/26), Resident #12 was venting about CNA #445's care of Resident #31. Resident #12 reported profanity was being used by CNA #445 and Resident #31. LPN #421 stated Resident #12 was truthful and protects Resident #31. LPN #421 was not interviewed by management about the incident.Telephone interview on 04/01/26 at 2:57 P.M. with LPN #516 revealed Resident #12 came to her and reported a concern with the way CNA #445 was taking care of Resident #31. Resident #12 reported Resident #31 using profanity and wasn't being taken care of properly. LPN #516 went to Resident #31's room and watched CNA #445 complete Resident #12's care and did not witness any concerns. LPN #516 did not report the incident to management because she felt it did not witness anything that would warrant any more investigation. Interview on 04/02/26 at 7:20 A.M. with the Administrator confirmed the facility did not complete an investigation into the allegation of abuse reported by Resident #12 involving CNA #445's care of Resident #31. Telephone interview on 04/07/26 at 9:52 A.M. revealed CNA #445 denied any abuse of Resident #31. Resident #12 had reported to the nurse that she was using profanity or something. CNA #445 did not know why Resident #12 said that. A nurse told her that she can no longer take care of Resident #31. CNA #445 was unable to name any nurses. CNA #445 was not asked by facility management about the incident until last week when someone called her.2. Review of Resident #151's closed medical record revealed an admission date of 03/04/24. Diagnoses included convulsions and osteomyelitis. Resident #151 passed away at the facility on 08/14/25. Review the physician orders revealed an order dated 08/01/25 to administer oxycodone hydrochloride (narcotic) five milligrams (mg) three times for chronic pain. An order dated 07/06/26 was for give oxycodone hydrochloride five mg one tablet as needed for chronic pain. Review of facility investigation documents revealed Licensed Practical Nurse (LPN) #565 was accused of misappropriation of Resident #151's oxycodone hydrochloride on 11/06/25. Certified Nursing Assistant (CNA) #406 reported that on 08/15/25, LPN #565 told him she was going steal Resident #151's oxycodone hydrochloride. On 08/16/25 while in LPN #151's vehicle, CNA #406 found a medication card of Resident #151's oxycodone hydrochloride that was approximately half full in the glove compartment. CNA #406 reported being threatened by LPN #565 after the CNA told the nurse he found it. LPN #565, LPN #438, and CNA #406 were the only staff interviewed about the allegation. No residents were documented as being interviewed. There was no documentation of any other resident's medical record being reviewed for misappropriation until after a state health investigator and a state board of nursing investigator were at the facility on 12/04/25. Review of LPN #565 personnel file revealed she was suspended on 11/06/25 and returned to work on 11/10/25. LPN #565 was then terminated on 12/17/25 when it was discovered she was not truthful during the investigation into the alleged misappropriation of Resident #151's oxycodone hydrochloride. Interview on 04/06/26 at 8:24 A.M. with the Administrator revealed he was first made aware of the alleged misappropriation of Resident #151's oxycodone hydrochloride in November 2025. LPN #565 was suspended immediately. LPN #565 returned to work on 11/10/25 but then was terminated after she was not truthful during investigation interviews and was found to be enrolled in a drug treatment program. Investigators form the state board of health and state board of nursing had been in the facility to investigate. LPN #565 gave up her nursing license voluntarily. The Administrator confirmed the facility did not interview other residents and did not review other like residents who LPN #565 had access to their medications until after the board of health was in the facility.Review of the facility's policy titled Abuse Investigation and Reporting dated September 2021 revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be thoroughly investigated by facility management. Review of the facility's policy titled Drug Diversion Policy dated September 2024 revealed all potential drug diversions will be thoroughly investigated. This deficiency represents non-compliance investigated under Complaint Numbers 2683813, 2697534, 2715021, 2748588, and 2963194.

Based on observation, staff interview, policy review, and medical record review, the facility failed to ensure a resident received provide proper wound care treatment as physician ordered. This affected one (Resident #29) of seven reviewed for wound care. The facility census was 133.Findings include:Review of Resident #29's medical record revealed an admission date of 10/30/22. Diagnoses included malignant neoplasm of prostate and bone and metabolic encephalopathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively impaired.Review of the care plan dated 01/03/26 revealed Resident #29 was at risk for impaired skin integrity due to decreased mobility, incontinence, weakness, diabetes mellitus, and history of previous areas/moisture-associated skin damage (MASD). Interventions included medication(s)/treatment(s) per physician, nurse practitioner, and/or physician assistant orders.Review of the physician orders dated 03/04/26 revealed an order to apply house barrier cream, zinc, or Triad to buttock every shift. On 03/25/26, there was an additional order to cleanse left buttock with wound cleanser, pat dry, and apply Triad paste to wound bed and cover with silicone bordered gauze dressing. Change daily and as needed. Observation and interview on 03/30/26 at 2:35 P.M. of wound care performed by Licensed Practical Nurse (LPN) #495 revealed there was no dressing in place to the left buttock of Resident #29 when the area was first exposed. LPN #495 confirmed this finding upon completion of the wound care. LPN #495 confirmed there was no evidence that house barrier cream had been applied to the buttocks following incontinence care and none appeared to be present upon exposing the area.Review of the wound nurse note dated 04/01/26 revealed the wound on left buttocks was MASD and wound was improving and very minimally open. No changes to current treatment. Review of the facility policy titled Wound Care dated September 2021 revealed the purpose of the procedure is to provide guidelines for the care of wounds to promote healing. A step in the procedure included to clean wound and apply treatments as ordered by the physician.This deficiency represents non-compliance investigated under Complaint Numbers 1351395 (OH00164633), 2664481, and 2686418.

Based on record review, staff interviews, observation, and facility policy review, the facility failed to ensure a resident received provide proper wound care treatment as physician ordered. This affected one (Resident #13) of seven residents reviewed for pressure ulcers. The facility census was 133. Findings include:Review of Resident #13's medical records revealed the resident was admitted on [DATE]. Diagnoses included type two diabetes mellitus, obesity, Parkinson's disease, neoplasm of behavior of bone, dementia, and peripheral vascular disease.Review of the hospital Discharge summary dated [DATE] revealed Resident #13 had a pressure injury to right buttocks measured 3.0 centimeters (cm) in length and 2.5 cm in width with 0.2 cm depth. No slough or tunneling was present.Review of the care plan dated 02/26/26 revealed Resident #13 was at risk for impaired skin integrity as evidence by an area to right sacrum and a surgical area to abdomen. Interventions included to complete treatments per physician orders and wound consult as needed.Review of Wound Nurse Practitioner #566's wound assessment dated [DATE] revealed Resident #13 was being seen for an initial consultation for wound care services. Resident #13 had a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.) to the right buttocks and it was present on admission. The wound measured 3.0 cm in length and 1.7 cm in width by 0.2 cm in depth. There was no tunneling and granulation tissue found. Recommendations were reduction mattress per facility protocol, reposition per facility protocol, and nutritional consultation. Review of the physician's order dated 03/25/26 to 04/01/26 revealed an order for wound care to sacrum, cleanse with wound cleanser then pat dry, apply calcium alginate to wound bed, and cover with silicone super absorbent dressing change daily or as needed. On 04/01/26, an order for the wound care to the sacrum to be changed to cleanse with wound cleanser, pat dry, apply collagen plus alginate to wound bed, and cover with silicone super absorbent dressing or a clean dry dressing change daily and as needed. Observation and interview on 04/06/26 beginning at 1:57 P.M. revealed Certified Nursing Assistant (CNA) and Unit Manager #542 were going to provide wound care to Resident #13's sacrum. There was no dressing in place to the resident's sacrum. The pressure ulcer was pink with a red center and it was open. At 2:04 P.M., Unit Manager #542 verified Resident #13 did not have a dressing on her sacrum when they began wound care. Review of the facility policy titled Wound Care dated September 2021 revealed the purpose of the procedure is to provide guidelines for the care of wounds to promote healing. A step in the procedure included to clean wound and apply treatments as ordered by the physician.This deficiency represents non-compliance investigated under Complaint Numbers 1351395 (OH00164633), 2664481, and 2686418.

Based on record review, observation, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance, and facility policy review, the facility failed to ensure staff wore the appropriate proper personal protective equipment (PPE) during high contact resident care activity for a resident under enhanced barrier precautions (EBP) and staff utilized the appropriate hand hygiene during incontinence care and personal hygiene. This affected two residents (Residents #52 and #94) reviewed for infection control. The facility identified 71 residents who were under EBP. The facility census was 133. Findings include: 1. Record review for Resident #94 revealed the resident was admitted to the facility on [DATE]. Diagnoses included encephalopathy, acute respiratory failure with hypoxia, quadriplegia, anoxic brain damage, hepatitis B, hepatitis C and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had impaired cognition and had EBP in place. Review of the current physician orders for 03/30/26 revealed Resident #94 had orders for tube feed administration through the percutaneous endoscopic gastrostomy (PEG) tube. Observation and interview on 03/30/26 at 8:30 A.M. revealed Certified Nursing Assistant (CNA) #485 provided incontinence care to Resident #94 while wearing gloves only and was not wearing a gown during the high contact resident care activity. There was a sign above Resident #94's bed for EBP stating everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and gown for the following high-contact resident care activities: dressing bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care such as central lines, urinary catheter, feeding tube, and tracheostomy. Wound care: and skin opening requiring a dressing. CNA #485 verified she did not wear a gown to provide incontinence care to Resident #94 and should have due to the resident was under EBP. Review of the care plan dated 04/04/26 revealed Resident #94 was at risk for infection due to tube feeding. Review of the facility policy titled Enhanced Barrier Precautions dated January 2024 revealed EBP refers to the use of gown and gloves during high-contact care activities for resident. The high-contact resident care activities are typical bundled care activities that are provided either during the morning and evening care and include: transferring and changing briefs. Review of the CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. 2. Review of Resident #52's medical record revealed the resident was admitted on [DATE]. Diagnoses included type two diabetes mellitus, enterocolitis due to Clostridioides difficile (C-diff) (03/25/26). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was severely cognitively impaired. Review of the skin assessment dated [DATE] revealed Resident #52 had stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.) on the coccyx. Resident #52 had a order for contact isolation precaution due to Resident #52 had active C. diff in stool. Resident #52 had an order for indwelling urinary catheter care every shift, and as needed. Observation and interview on 04/06/26 from 1:37 P.M. through 1:55 P.M. revealed Unit Manager (UM) #542 and Certified Nurse Aid (CNA) #482 were going to provide incontinence care and indwelling urinary catheter care for Resident #53. UM #542 verified Resident #52 had C-diff in stool. CNA #482 and UM #542 performed hand hygiene at door, placed personal protective equipment on appropriately before entering the room. CNA #482 had double gloves on both her hands. CNA #482 had her supplies on the bedside table, covered with clean linen. CNA #482 positioned Resident #52 in bed with UM #542. CNA #482 took Resident #52 dirty incontinent brief off, then cleaned Resident #52 front side with soap and water and dried at end. Resident #52's perineum area was bright red. CNA #482 then took off one pair of gloves and leaving one glove on each hand. CNA #482 did not perform hand hygiene. CNA #482 and UM #542 positioned Resident #52 to her other side to perform care on back side. CNA #482 finished washing, and drying Resident #52's backs side, and never took off her gloves, or performed hand hygiene. CNA #482 verified there was dried feces on her back side. CNA #482 continued to provide care, by placing her incontinent brief on, fixing her gown, touching her leg to roll and repositioning Resident #52, and laying her linens on top of her. CNA #482 verified she did not perform hand hygiene when providing care. CNA #482 verified she had her dirty gloves on when finishing Resident #52's care. Interview on 04/06/26 at 4:00 P.M. with Assisted Director of Nursing (ADON) #490 stated she expected staff to follow the hand hygiene policy and infection control policy when providing incontinence care, personal hygiene, and when residents were in contact precautions for C-diff. Review of the facility's undated policy titled Isolation-Initiating Transmission-Based Precaution revealed if a resident was suspected of, or identified as, or having a communicable infectious disease, the charge nurse or nursing supervisor shall notify the Infection Preventionist and the resident's attending physicians for orders. Review of the facility policy titled Hand Hygiene revealed the hand hygiene will be properly performed to assist in the prevention of spreading infections. Review of CDC guidance titled Clinical Safety: Hand Hygiene for Healthcare Workers found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html and dated 02/27/24 revealed hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of deadly germs to patients. Recommendations included on know when to wear (and change) gloves stated gloves are not a substitute for hand hygiene. If your tasks requires gloves, perform hand hygiene before donning gloves and touching the patient or the patients surroundings; always clean your hands after removing gloves. When to change gloves and clean hands included if gloves become soiled with blood or body fluids after a task, if moving from work on a soiled body site to a clean body site on the same patient or if clinical indication for hand hygiene occurs, and before exiting a patient room. This deficiency represents non-compliance investigated under Complaint Numbers 1351395 (OH00164633) and 1351400 (OH00165900).

Based on record review and interviews with staff, hospital staff and medical transport staff, the facility failed to permit a resident to return to the facility after the resident was hospitalized . This affected one (#137) out of three residents reviewed for bed holds. The facility census was 134. Findings include: Review of the medical record revealed an admission date of 02/21/25 with diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbance, epilepsy, unspecified, not intractable, without status epilepticus, and bipolar disorder. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #137 had moderate cognitive impairment. Resident #137 had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) every one to three days. Resident #137 required supervision assistance with eating, oral hygiene, bed mobility, transfers, and ambulation. Resident #137 required substantial assistance with toileting hygiene, bathing, and dressing. Review of the care plan dated 02/24/25 revealed Resident #137 has behaviors related to withdrawn, refused assessments, anxiousness paranoia, delusions/hallucinations, throwing medications, refusing medications, speaking to voices in head, pacing, pushed nurse, refused tuberculosis (TB) testing, exit seeking, removed mattress from bed, refused shower, sprinting up and down hall, attempting to hit staff, hit staff, kicking staff, refused blood draw with interventions of administer medications per physician order. Interventions included to monitor for effectiveness and side-effects. Approach resident in a calm manner to avoid frustration and behavior escalation; If resident becomes agitated and shows signs of escalation, reapproach later. Attempt to redirect resident when exhibiting behaviors; re-approach when resident has deescalated. Review of the progress noted dated 02/24/25 at 12:00 A.M. from Physician #500 revealed Resident #137 with increased behavioral agitation, he is seemingly a threat to himself and others at this time and for this reason he is going to be transferred to a tertiary mental facility for full stabilization. Resident #137 had been pink slipped. Review of Resident #137's Face Sheet revealed resident discharged to the hospital on [DATE]. Review of Resident #137's medical record revealed there was no other documentation regarding the resident returning to the facility. Interview on 03/19/25 at 8:19 A.M. with Hospital Licensed Social Worker (LSW) #504 confirmed on 03/10/25, unsure of time of conversation she spoke with Admissions Coordinator #293 directly and was advised Resident #137 would be returning to the facility on Wednesday, 03/12/25. Interview with Hospital LSW #504 confirmed Admissions Coordinator #293 did not request an update on Resident #137 during the conversation. Hospital LSW #504 confirmed she called Admissions Coordinator #293 on 03/11/25 and left a voice message with the time Resident #137 would be transported back to the facility. Interview on 03/19/25 at 1:47 P.M. with Hospital LSW #504 confirmed she talked to Admissions Coordinator #293 on 03/12/25 around 1:30 P.M. she spoke with Admissions Coordinator #293 and confirmed that Resident #137 was at the facility. Hospital LSW #504 confirmed Admissions Coordinator #293 refused to let Resident #137 remain at the facility. Hospital LSW #504 confirmed she offered to send an update to Admissions Coordinator #293 at the time, and Admissions Coordinator #293 refused and sent Resident #137 back to the hospital. Hospital LSW #504 stated Resident #137 is currently in the hospital. Telephone call on 03/19/25 at 1:51 P.M. with Director of Transport at Medical Transport #501 confirmed the transport report revealed on 03/12/25 around 1:30 P.M. transport was made to [NAME] Rehabilitation and Healthcare Center for non-emergently from Hospital #2. Director of Transport confirmed the transport personnel received the paperwork from the nurse at Hospital #2 to be delivered to the nurse at [NAME] Rehabilitation and Healthcare Center. Resident #137 was alert and oriented times one (self). Resident #137 was able to stand and pivot onto the stretcher and drove to the facility. The crew unloaded Resident #137 and took the resident to his room. Resident #137 was sheet lifted via two person sheet draw onto his bed. The facilities admission coordinator informed the crew that he can't stay here, we won't take him. The admission coordinator informed the crew that Resident #137 was supposed to go to Hospital #3 and not the facility. After an excess of unproductive deliberation, the crew decided to depart the scene and take Resident #137 back to Hospital #2, as the facility was refusing to accept Resident #137 back at the facility. Resident #137 was sheet lifted via two person sheet draw back onto the stretcher and secured. Resident #137 was taken back to the ambulance and loaded in. Telephone call on 03/20/25 at 10:33 A.M. with Director of Transport at Medical Transport #501 confirmed the release of the documentation on the transport of Resident #137 to [NAME] Rehabilitation with signed consent sent from ODH. Interview on 03/24/25 at 7:47 A.M. with Admissions Coordinator #293 confirmed Resident #137 was sent out to a hospital for behaviors and was then sent to another hospital. Admissions Coordinator #293 stated there were several hospitals involved in the care of Resident #137 after the resident was transferred out on 03/12/25. Admissions Coordinator #293 stated that the facility planned to bring the resident back. Interview also confirmed on 03/12/25 when Resident #137 returned, she went and talked to the transport personnel and told them she didn't know the resident was coming back and that no one called report, and no referral was received. Interview stated Resident #137 was on the cot the whole time she was speaking with the transport personnel. Interview confirmed she called the hospital social worker and was told they didn't have to send an update since the facility was the admitting facility. Interview also confirmed the Emergency Medical Technician (EMT) would not give her the paperwork to review since the facility was not accepting the resident back. Interview also confirmed she talked to the hospital social worker about the admission process of getting an updated report before the hospital sends a resident back. Interview also confirmed facility was sending referrals to two other nursing facilities for Resident #137. When asked why she sent referrals if resident was allowed to return and who gave the authorization to send referrals to other facilities, interview confirmed the referrals were sent due to resident's prior behaviors and the facility not being able to manage the resident and she was unsure who gave the authorization to send the referrals. When asked about the hospital call on Monday, 03/10/25 about Resident #137 returning, interview confirmed she did speak to someone but thought it was someone from Hospital #3. Interview also confirmed that she did receive a voice mail from someone that Resident #137 was returning but doesn't remember who it was that left the message or when they left it. Admissions Coordinator #293 confirmed Resident #137 was not provided with a discharge notice that the facility would not accept him back. Telephone call on 03/24/25 at 9:37 A.M. with EMT #503 with Medical Transport #501 confirmed on 03/12/25 around 1:30 P.M. Resident #137 was transported from Hospital #2 to [NAME] Rehabilitation and Healthcare Center. Interview confirmed the transport personnel received the paperwork from the nurse at Hospital #2 to be delivered to the nurse at [NAME] Rehabilitation and Healthcare Center. Interview confirmed Resident #137 was alert and oriented times one (self), and was able to stand and pivot onto the stretcher. Interview also confirmed Resident #137 was unloaded and was taken to his room. Resident #137 was then sheet lifted via two person sheet draw onto the bed. Interview also confirmed the facilities admission Coordinator #293 came, as we were exiting the room, and informed us that he can't stay here, we won't take him. admission Coordinator #293 informed crew that Resident #137 was supposed to go to Hospital #3 and not the facility. After an excess of unproductive deliberating, the crew decided to depart the scene and take Resident #137 back to Hospital #2, as the facility was refusing to accept the resident back. Interview confirmed Resident #137 was sheet lifted via two person sheet draw back onto the stretcher and secured. Interview also confirmed the Resident #137 was taken back to the ambulance and transported back to Hospital #2. Telephone call on 03/24/25 at 9:42 A.M. with Medic/Registered Nurse (RN) #502 with Medical Transport #501 confirmed on 03/12/25 around 1:30 P.M. Resident #137 was transported from Hospital #2 to [NAME] Rehabilitation and Healthcare Center. Interview confirmed the transport personnel received the paperwork from the nurse at Hospital #2 to be delivered to the nurse at [NAME] Rehabilitation and Healthcare Center. Interview confirmed Resident #137 was alert and oriented times one (self), and was able to stand and pivot onto the stretcher. Interview also confirmed Resident #137 was unloaded and took to his room. Resident #137 was then sheet lifted via two person sheet draw onto his bed. Interview also confirmed the facilities admission Coordinator #293 came, as we were exiting the room, and informed us that he can't stay here, we won't take him. admission Coordinator #293 informed crew that Resident #137 was supposed to go to Hospital #3. After an excess of unproductive deliberating, the crew decided to depart the scene and took Resident #137 back to Hospital #2, as the facility was refusing to accept the resident back. Interview confirmed Resident #137 was sheet lifted via two person sheet draw back onto the stretcher and secured. Interview also confirmed Resident #137 was taken back to the ambulance and transported back to Hospital #2. Interview also confirmed he asked admission Coordinator #293 if there was a path to acceptance of the resident and she said absolutely not. Telephone call on 03/24/25 at 9:46 A.M. with Licensed Practical Nurse (LPN) #351 confirmed on 03/12/25 around 1:30 P.M. when she was on break when Resident #137 returned from the hospital. When she arrived to the floor the Admissions Coordinator #293 and the EMT were going back and forth due to not being notified of the re-admission ahead of time. Interview also confirmed she does not remember if resident was in the room or still on the EMT's cot. Interview on 03/24/25 at 1:45 P.M. with the Administrator confirmed they plan on accepting Resident #137 back when he is ready and that they never denied his re-admission. Interview confirmed when Resident #137 was brought back on 03/12/25 and the facility was not notified he was returning, they have to protect other residents due to his aggressive behaviors and the resident was over medicated when they arrived and zonked out. When asked why they didn't let the resident stay on 03/12/25 since they couldn't tell if he was having behaviors or not after he was brought back, interview confirmed because the facility did not receive an update. When asked about the paperwork transport had being acceptable, interview confirmed transport wouldn't give them the paperwork. When reminded transport wouldn't give them the paperwork due to Health Insurance Portability and Accountability Act (HIPAA) violation if the facility was not going to re-admit the resident, interview confirmed the facility needed an update prior to the resident returning. When asked why the facility didn't re-admit the resident and accept the paperwork from transport and then if the resident had behaviors again that was a danger to others they could send the resident out to a behavior facility, interview confirmed the facility needed an update prior to resident returning. Interview also confirmed the facility billed from Medicaid bed hold days from 02/25/25 through 03/12/25, at which time resident was discharged . The Administrator confirmed Resident #137 has not been provided a discharge notice that he would not be accepted back. The Administrator confirmed they have not contacted the hospital to inquire about Resident #137's return or readiness for discharge since 03/12/25. Interview on 03/24/25 at 2:15 P.M. with the Administrator confirmed the facility does not have an admission / re-admission policy. This deficiency represents non-compliance investigated under Complaint Number OH00163702.

Based on record review, observation and staff interviews, the facility failed to implement a pressure redistribution device or cushion to the resident's chair according to the care plan to treat a pressure ulcer. This affected one (#36) out of three residents reviewed for wound care. The facility census was 134. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnosis of peripheral vascular disease, type 2 diabetes mellitus with diabetic neuropathy, and unspecified combined systolic (congestive) and diastolic (congestive) heart failure. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident with severe cognitive impairment. Resident #36 required set-up assistance with eating, required supervision assistance with oral hygiene, required partial assistance with personal hygiene, required substantial assistance with bed mobility, transfers, ambulating, and wheelchair mobility, and was dependent on staff assistance with toileting hygiene, bathing, and dressing. Resident was at risk for developing pressure injuries. Review of the care plan dated 02/26/25 revealed resident has impaired skin integrity as evidenced by: pressure ulcer to right and left buttock. With interventions of assist resident with turning and repositioning as needed, wound consult as needed, provide incontinence care as needed. On 03/12/25 an intervention for air mattress and pressure redistribution device in chair were added to the care plan. Review of the wounds revealed one open area to left buttocks measuring approximately 1.6 centimeters (cm) x 3.6 cm x 0.3 cm, and an open area to the right buttock measuring approximately 3.1 cm x 5.1 cm x 0.3 cm. Both areas stage 3 with peri wound pink and wound bed with 100% beefy red granulation tissue present. Staff performed proper handwashing and applied personal protective equipment properly. Observation on 03/19/25 at 4:08 P.M. of Resident #36's pressure wounds to bilateral buttocks with Registered Nurse (RN) #203 revealed the resident returned from dialysis in dialysis chair at this time, transferred to bed. Dialysis chair noted without a pressure redistribution cushion in place. Interview at this time of observation with RN #203 confirmed there was not a pressure redistribution device or cushion in the dialysis chair. RN #203 asked the surveyor if you could use a cushion in the dialysis care. Interview with RN #203 confirmed Resident #36 was care planned to have a pressure redistribution cushion to the chair. Interview on 03/19/25 at 4:15 P.M. with Certified Nursing Assistant (CNA) #204 confirmed Resident #36 has never had a cushion available to use in her chair. Interview on 03/19/25 at 4:19 P.M. with CNA #300 confirmed Resident #36 does not have a cushion available to use in her chair. Interview on 03/19/25 at 4:25 P.M. with Licensed Practical Nurse (LPN) #217 stated To be completely honest, I don't know if Resident #36 is supposed to have a cushion or not. This deficiency represents non-compliance investigated under Complaint Number OH00163535.

Based on record review, review of hospital documentation, staff interview, local health department interview, review of Legionella water testing, review of electronic mail (email) correspondence, and policy review, the facility failed to implement their water management policy and respond to the local health department (LHD) recommendations to remediate their water system to reduce the presence of microorganisms including Legionella. This affected one (#129) of three residents reviewed for Legionella and had the potential to affect all 128 residents residing in the facility. The facility census was 128. Findings include: Review of medical record for Resident #129 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included but not limited to acute kidney failure, gastrointestinal hemorrhage, hypovolemic shock, Legionnaire's disease, atrial fibrillation, cocaine abuse, dermatitis, dependence on renal dialysis, and other pericardial effusion (noninflammatory). Review of Minimum Data Set (MDS) assessment for Resident #129 revealed the resident was cognitively intact. Resident #129 required extensive assistance for activities of daily living with the exception of eating and oral care which required set up or clean-up assistance. Resident #129 used a non-invasive mechanical ventilator and was on dialysis. Review of Pulmonary and Critical Care notes from the hospital dated 11/22/24 revealed the resident was admitted for acute gastrointestinal bleed, hemorrhagic shock, acute blood loss anemia, acute hypoxemic respiratory failure as evidenced by oxygen saturations less than 89 percent on room air, in addition to requiring greater than or equal to five liters of oxygen, and end stage renal disease on in house dialysis with evidence of volume overload. Plan was to admit to intensive care unit, continue ventilator support, wean per protocol, obtain arterial blood gases and chest x-ray, may require bronchoscopy, and repeat chemistries. Resident #129 was transferred to this hospital on 11/22/24 from the local hospital. Review of hospital documentation from the local hospital dated 11/20/24 for Resident #129 revealed retrocardiac opacity on x-ray etiology not certain however in view of leukocytosis will consider pneumonia as a differential and treat. Cultures will be drawn to check strep and Legionella antigen. Labs were not drawn as the resident was transferred to another hospital on 11/22/24 for the GI bleed. Review of lab result for Legionella dated 11/28/24 revealed the specimen was collected on 11/28/24 and reported as positive on 11/29/24. Interview on 12/23/24 at 10:18 A.M. with the Administrator and Director of Nursing (DON) revealed the LHD notified them Resident #129 in the hospital had tested positive for Legionnaire's disease. The Administrator stated they had spoken to the LHD several times since then. The DON stated the LHD asked questions such as how they cleaned their CPAP/BiPAP tubing, what water they used for them, dialysis information, and questions regarding any construction or water leaks. Interview on 12/23/24 at 1:11 P.M. with Maintenance Director (MD) #530 revealed on 12/23/24 was the first day he had been notified of a presumptive case of Legionella. MD #530 stated the facility did chlorine testing three times a week. MD #530 stated that was how he was told to test for Legionella in the water. MD #530 verified he had not done any other testing for Legionella. MD #530 verified he had not installed any filters on water outlets on the hot water distribution loop where the resident resided. Interview on 12/23/24 at 2:31 P.M. with the Administrator verified the facility did not test the water for Legionella after they were made aware of the suspected case. The Administrator verified they did not follow the facility policy for suspected Legionella. Interview on 12/23/24 at 2:57 P.M. with Environmental Health Director (EHD) #326 from the LHD revealed they sent an email on 12/17/24 to the facility regarding the information they needed to go forward with the investigation. EHD #326 stated the facility had not yet done what the LHD asked them to do. EHD #326 stated the facility had been ignoring them by not returning calls, emails, or calls being dropped when transferred. Interview on 12/23/24 at 3:17 P.M. with the Administrator revealed she denied getting an email until 12/18/24 when she was out of the building. The Administrator verified the email was sent to her on 12/17/24. The Administrator stated that she did not see the section regarding sending information. The Administrator stated she had only seen the section where they were going to schedule a call with the Ohio Department of Health (ODH), the LHD, and the administration of the facility. The Administrator stated they had a call with Water Management #09 today at 4:00 P.M. to come and test the water. The Administrator verified the LHD had resent her an email on 12/23/24 requesting information and when they received the information they would set up the call. The Administrator stated she would send the same information provided to the ODH. Interview on 12/24/24 at 2:00 P.M. with Infection Preventionist/Assistant Director of Nursing (IP/ADON) #682 revealed she was the one who spoke with the LHD first. IP/ADON #682 verified she was notified on 12/02/24 of the presumptive case of Legionella. IP/ADON #682 verified the LHD inquired on whether Resident #129 had been out for any appointments or outings for the past two weeks, how the facility cleaned BiPAP/CPAP tubing, and if the resident had any respiratory symptoms. IP/ADON #682 stated the LHD contacted them again on 12/05/24 and asked about water testing. IP/ADON #682 stated she was unsure about water testing as she was not maintenance. IP/ADON #682 stated she had reach out to the LHD on 12/16/24 regarding the results she received from maintenance regarding the water testing. Interview on 12/26/24 at 8:40 A.M. via phone with EHD #326 revealed that Communicable Disease Nurse (CDN) #327 is who contacted the facility first. CDN #327 stated she first contacted the facility on 12/02/24. CDN #327 stated she inquired about whether the resident had been out of the facility within the last two weeks, had any respiratory symptoms, facility process on CPAP/BiPAP cleaning and water used for those, dialysis process, and any construction or water issues. CDN #327 stated they asked the facility to keep an eye on anybody that showed signs of pneumonia, and they may need to test for Legionella if there are respiratory symptoms since there was only one case. CDN #327 stated she talked to the facility on [DATE], 12/06/24, and 12/09/24 and always spoke to the ADON/IP for follow-up. CDN #327 verified that was the last time she spoke with the facility. CDN #327 stated there have been no other reported cases of Legionella since she has worked for the LHD. Interview on 01/02/25 at 2:36 P.M. with the Administrator revealed if the water comes back positive, the facility has a plan in place with the consultant that will let them know what needs to be done next. The Administrator stated that the dialysis machines have a microfilter and the consultant from the water company stated that those machines would stop all of the germs. The Administrator stated they would continue to do what they are doing until the water testing came back. Review of the water testing report reported on 01/03/25 revealed hot water tank on Transitional Care Unit three (TCU3) tested positive for Legionella. The room Resident #129 resided in tested negative for Legionella. Review of email sent from the LHD to the facility on [DATE] revealed that the health department stated that whenever there is a presumptive healthcare-associated case of Legionnaire's disease, they ask that the facility follow the Center for Disease Control (CDC) guidance for a full investigation. As part of this investigation, we would like to set up a call to discuss the next steps and requirements with the ODH. We would ask that the administrator and any facility maintenance workers be included as well. These steps will allow the facility to immediately eliminate risk of exposure by implementing restrictions, remediate their water system to reduce the presence of microorganisms (including Legionella), and improve ongoing prevention efforts by updating the water management program. Prior to the call between your administration, ODH, local health department, several materials from the facility are needed. Documents include the most recent version of the facility's water management program, any environmental Legionella samples collected within a year, a floor plan of the facility, temperature and chlorine monitoring logs for your facility, any maintenance or monitoring logs of the facilities secondary disinfection system if available, and maintenance and monitoring logs for any additional water features at the facility such as cooling towers. This is an urgent matter. Review of policy titled, Legionnaire's Disease Prevention/Treatment Best Practices, dated September 2019 revealed the facility will employ the following measures if Legionnaire's disease is detected and/or suspected: confirm the diagnosis of resident within the facility through urine antigen test or sputum test, notify the Director of Integrated Support of outbreak: Quick Response Protocol will be enacted, begin course of treatment as ordered by the physician, test water system to determine source of outbreak, implement immediate procedures to eliminate presence of Legionella bacteria and prevent further outbreak, and notify residents, families, responsible parties, employees, Department of Health, other State Agencies, and local authorities of presence of Legionnaire's Disease to await further instruction and follow-up. This deficiency represents non-compliance investigated under Complaint Number OH00160885 and continued non-compliance from the survey dated 12/16/24.

Based on medical record review, staff, Nurse Practitioner (NP) #447, Physician #448 and Neurologist #449 interviews, review of medication information from Medscape, and policy review, the facility failed to appropriately reconcile medications following a hospital re-admission resulting in a significant medication error. This resulted in Actual Harm when Resident #96 was readmitted from the hospital on 10/03/24 and the facility failed to appropriately reconcile the resident's transfer orders resulting in the resident's anticonvulsant medication being abruptly stopped on 11/06/24 and Resident #96 subsequently began having seizure activity on 11/11/24 which resulted in re-hospitalization . This affected one (#96) of one resident reviewed for hospitalization . The facility census was 131. Findings include: Review of the medical record of Resident #96 revealed an original admitted [DATE]. Diagnoses include metabolic encephalopathy, epilepsy without status epilepticus, transient ischemic attack and cerebral infarction. Review of the hospital admission orders dated 10/03/24 revealed an order for Keppra (anticonvulsant) 750 milligrams (mg) to be administered twice daily for 30 days. A follow-up appointment was scheduled for 11/19/24 with a neurologist Advanced Practice Registered Nurse. Review of the Resident #96's Assessment and Plan, documented by a Hospitalist, dated 10/03/24, revealed a routine electroencephalogram (EEG), completed on 08/30/24, revealed consistent with epileptogenic right hemisphere structural lesion which is prone to focal seizures. Intravenous Keppra load with Keppra was ordered. The plan included to continue Keppra. This form was not printed at the facility at the time of re-admission on 10/03/24. The form was printed by the facility upon the surveyor's request on 12/11/24. Review of Resident #96's progress notes revealed no indication the physician was called to clarify the Keppra stop date. Review of the physician note dated 10/07/24, documented by Physician #448, revealed Resident #96 was seen for readmission from hospital with urinary tract infection, and sepsis with metabolic encephalopathy. Review of the Medication Administration Record for the month of 11/24 revealed Resident #96's Keppra was last given on 11/06/24 at 7:00 A.M. Review of a progress note, documented by NP #563, dated 11/11/24 revealed Resident #96's wife was stating his eyes were doing something weird. The nurse had explained the wife reported eyes were twitching or jerking, but this was not witnessed by the nurse. NP #563 agreed to send him to the emergency room (ER). Review of Resident #96's progress note dated 11/11/24 at 10:17 P.M. revealed the resident was sent to the ER at 9:45 P.M. Review of Resident #96's hospital Discharge Summary, documented by a hospital physician, dated 11/14/24 revealed reason for admission on 11/11/24 principal diagnosis seizure in the setting of missed doses of Keppra. The Hospital Course and Treatment revealed Resident #96 had missed his Keppra dosing as there was some miscommunication in the nursing home regarding the continuation of Keppra dosing and was admitted with seizure activity. Review of the hospital Neurology consult note, dated 11/12/24, revealed an assessment of provoked seizure in setting of noncompliance with Keppra (not continued at extended care facility) for unknown reasons. Interview on 12/11/24 at 8:46 A.M. with NP #447 and the Director of Nursing (DON) revealed they were unaware of the diagnosis of epilepsy and the 30-day order of Keppra for Resident #96. The DON confirmed Resident #96's Keppra was abruptly stopped without consulting neurology. The DON and NP #447 both stated they were not able to view the Hospitalist Progress Note dated 10/03/24 by a hospital physician as they did not have access to the hospital records but were able to print them upon the surveyor's request. The DON stated it would be her expectation for nurses to question any order they see fit and notify the provider of the questions for clarification. NP #447 stated she thought the half-life of Keppra was eight to 12 hours. The DON stated, We just follow the orders. Interview on 12/11/24 at 10:55 A.M. with Licensed Practical Nurse (LPN) #454 revealed she did not notice the stop date for the Keppra but would have questioned it. Interview on 12/11/24 at 1:24 P.M. with Physician #448, NP #447, and the DON revealed Physician #448 stated the Keppra regimen depends on the patient. When a resident experiences a cardiovascular accident and then has seizures, the Keppra can be stopped abruptly. Physician #448 stated Resident #96 was experiencing acute post stroke seizure, and these are treated differently. Most neurologists treat seizures differently. Physician #448 stated during treatment it would be normal to check a patient to see if they are still having seizures. Physician #448 stated Keppra can be continued for up to two months but would depend on whether or not any seizures occurred during that time. If no seizure activity is experienced the medication may be stopped abruptly. Physician #448 stated he had not been aware of the 30-day stop order but it would not have made a difference in his treatment. If any seizure activity had been reported during treatment, he would have continued the Keppra. Physician #448 confirmed he had received no notifications of any seizure activity, shaking, eye twitching, mouth flopping, incontinence, or tongue biting. Physician #448 stated a diagnosis of epilepsy would indicate to continue Keppra for the rest of your life. A telephone interview on 12/12/24 at 11:17 A.M. with Neurologist #449 revealed seizures following a stroke are rare. Neurologist #449 stated he would have expected Resident #96's Keppra to be continued until the resident followed up with neurology, when an electroencephalogram would have been completed to determine the need or not of medication continuation. Neurologist #449 stated Keppra has very little side effects and is very safe to take. Review of medication information from Medscape at https://reference.medscape.com/drug/keppra-spritam-levetiracetam-343013#0 revealed Keppra is used to treat seizure disorder. Do not stop taking this medication without consulting your doctor. Your seizures may become worse when the drug is suddenly stopped. You should avoid abrupt withdrawal of Keppra to reduce the risk of increased seizure frequency and status epilepticus. Review of an undated facility policy titled Administering Medications revealed medications shall be administered in a safe and timely manner.

Based on observations and resident and staff interviews, the facility failed to ensure resident rooms were clean and in good repair. This affected four (#15, #36, #43, and #116) of seven resident rooms reviewed for environment. The census was 131. Findings include: 1. Observation of Resident #116's room on 12/09/24 at 11:36 A.M. revealed and adhesive fly paper strip hanging on the wall behind the head of the bed. The fly paper had dead flies and gnats on it. Interview with Resident #116 on 12/10/24 at 7:34 A.M. revealed the fly paper strip had was in the room when she moved into it. Observation revealed the fly paper strip remained on the wall. Interview with Maintenance Director (MD) #445 on 12/16/24 at 11:14 A.M. revealed a private company handles pest control for the facility. That company does not put any fly strips in resident rooms. MD #445 was unaware that a fly strip was in Resident #116's room. MD #445 confirmed fly strips should not be hung up in resident rooms and removed the fly strip. 34745 2. Observation in Resident #36's room on 12/10/24 at 8:36 A.M. revealed a pillow lying on a broken heater on the floor. The heater did not feel hot. The Activity Aide verified the pillow should not be on the heater and the vent cover looked like it was broken. Observation on 12/10/24 at 8:45 A.M. of the vent cover in Resident #36's room with MD #445 verified the vent cover for the heater was in disrepair and had not received a notification of it being broken. MD #445 revealed the heater does work along with the air conditioner and or heater which is mounted in the wall and it is unsafe. 3. Interview with Resident #15 on 12/09/24 at 11:05 A.M. revealed there was a hole under the air conditioner which allowed bugs to come into the room. Observation of the air conditioner on 12/09/24 at 11:05 A.M. revealed a large area under the air conditioner which was three fourth of the underside and there was also some insulation viewable. There was also a one and half inch gap between the air conditioner and seal which could be seen all the way outside. 4. Observation of Resident #43's room on 12/16/24 at 11:20 A.M. with MD #445 revealed a large piece of the dry wall with notes some insulation sticking out under the wall mounted air conditioner and heating unit. There was also a one and half inch gap on the left side of the unit which went all the through to the outside. Interview with MD #445 on 12/16/24 at 11:24 A.M. verified there was not a notification made of this issue to the unit in Resident #43's room which included missing drywall under three fourths of the unit and the gap between the window seal and unit. MD #445 also verified the facility is in the middle of updating the facility and is unsure when the second floor will be updated.

Based on record review, observations, staff interviews, and policy review, the facility failed to ensure a resident was provided privacy when toileting. This affected one (#54) out of one residents reviewed for privacy. The facility census was 131. Findings include: Review of the medical records for Resident #54 revealed an admitted [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and chronic obstructive pulmonary disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had range of motion impairment on one side of bilateral upper and lower extremities, required toileting hygiene, dressing, and personal hygiene, and required substantial assistance for bathing. Observation on 12/09/24 at 2:07 P.M. Resident #54 went into the shower room to use the bathroom, due to the bathroom in his room does not work. Observation of the shower room door revealed it does not shut and does not provide privacy. Interview on 12/09/24 at 2:07 P.M. with Certified Nursing Assistant (CNA) #482 confirmed Resident #54's toilet in his room is broken and has been broke for a long time and has not worked for months. Observation on 12/09/24 at 2:10 P.M. with CNA #482 confirmed Resident #54's toilet in his room is broke, by flushing the toileting which caused water to spray across the bathroom and flood onto the floor. Interview on 12/09/24 at 2:41 P.M. with Licensed Practical Nurse (LPN)/Unit Manager (UM) #426 confirmed Resident #54 does use the shower room for toileting needs due to his bathroom not working. Interview with LPN/UM #426 confirmed the shower room door is hard to close but will close when pulled forcefully. Review of the undated facility policy titled Dignity revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level satisfaction with life, and feelings of self-esteem. Residents are treated with dignity and respect.

Based on medical record review, observations, resident and staff interviews and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded. This affected three (#67, #289 and #125) out of 26 residents reviewed during the survey. The facility census was 131. Findings include: 1. Review of the medical record for Resident #289 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Review of the admission MDS assessment dated [DATE] revealed Resident #289 was cognitively intact. The MDS assessment coded Resident #289 does not use oxygen. Observation on 12/09/24 at 10:52 A.M. revealed Resident #289 reclining in bed with an auto-adjusting positive airway pressure (APAP) device delivering oxygen via a nose piece. Resident #289 stated the device is constantly on as he his doctors have told him he needs a lung transplant. Interview on 12/16/24 at 2:18 P.M. with Unit Manager #482 confirmed Resident #289 uses oxygen and the MDS dated [DATE] was not accurately coded. 48570 2. Review of the medical records for Resident #67 revealed an admitted [DATE] with diagnoses of acute pulmonary edema, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of the quarterly MDS assessment dated [DATE] revealed resident was cognitively intact. Resident #67 required set-up assistance with eating and oral hygiene, required supervision for with personal hygiene, required substantial assistance with bathing, bed mobility, and wheelchair mobility, and was dependent on staff assistance toileting hygiene, dressing, and transfers. Review also revealed resident did not receive oxygen therapy while a resident. Review of the Physician Order dated 08/26/24 revealed an order for oxygen at four (4) liters via nasal cannula (NC) may titrate as needed. Review of the Treatment Administration Record (TAR) for 11/2024 revealed resident received oxygen therapy at 4 liters via nasal cannula daily. Interview on 12/16/24 at 8:03 A.M. with Resident #67 revealed he wears his oxygen when he is sleeping. Interview on 12/16/24 at 8:27 A.M. with Licensed Practical Nurse (LPN)/MDS Coordinator #421 confirmed she did not mark on the quarterly MDS dated [DATE] that Resident #67 had oxygen therapy received during the look back period. Interview with LPN/MDS Coordinator #421 also confirmed Resident #67 did receive oxygen therapy daily during the look back period. 3. Review of the medical records for Resident #125 revealed an admitted [DATE], a discharge date of [DATE] to the hospital, and a re-admitted [DATE], with diagnoses of post laminectomy syndrome, pressure ulcer of sacral region, stage 2, pressure ulcer of left buttock, stage 2, and pressure ulcer of right buttock, stage 2. Review if the quarterly MDS assessment dated [DATE] revealed resident was cognitively intact, required supervision with oral hygiene, required partial assistance with eating and personal hygiene, required substantial assistance with bathing and wheelchair mobility, and was dependent on staff assistance with toileting hygiene, dressing, bed mobility, and transfers. Further review revealed resident was at risk for pressure ulcers, had one unstageable pressure ulcer, had a pressure reducing device to her bed, did not have a pressure reducing device to her chair. Review of Resident #125's Encore Wound note dated 10/09/24 revealed recommendations of wheelchair pressure reduction cushion per facility protocol. Observation on 12/11/24 at 10:00 A.M. revealed a Roho style cushion in Resident #125's wheelchair. Interview on 12/11/24 at 10:34 A.M. with LPN/MDS Coordinator #421 confirmed she did not mark on the quarterly MDS assessment dated [DATE] that Resident #125 care a pressure reduction cushion in place and the MDS is coded inaccurately. Review of the MDS Completion and Submission Timeframe's policy, dated September 2021 revealed the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframe's.

Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure the care plan was revised to accurately reflect resident care. This affected two (#16 and #125) out of 26 residents reviewed for care plans. The facility census was 131. Findings include: 1. Review of the medical records for Resident #16 revealed an admitted [DATE] with diagnoses of quadriplegia, unspecified open wound of left buttock, subsequent encounter, contracture of muscle, left hand, and contracture of muscle, right hand. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact, had impairment on bilateral upper and lower extremities. Resident #16 required set-up assistance with eating, oral hygiene, and wheelchair mobility, and required substantial assistance with toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and transfers. Review of the physician orders revealed an order for showers scheduled on Tuesday, Thursday, and Saturdays on day shift. Review of Resident #16 Care Plan with a revision date of 10/22/24 revealed resident had an Activities of Daily Living (ADL) self-care performance deficit related to requires assist with ADL's, incomplete quad, neuropathy. Resident #16 will only ambulate with therapy staff not with the nursing staff with a goal to maintain current level of function with ADL's through the review date. Resident required assist with activities of daily living (i.e.: dressing, grooming, personal hygiene, locomotion, oral care, etc.) as needed. Resident uses motorized wheelchair for locomotion related to diagnoses of Quadriplegia, requires one (1) person assistance with toileting and transfers. Further review of the care plan revealed no documentation related to assistance needed with bathing. Observation on 12/10/24 at 8:47 A.M. Resident t#16 noted in shower room by himself. Interview with Certified Nursing Assistant (CNA) #434 confirmed Resident #16 takes three (3) hour showers every Monday, Wednesday, and Friday and that she assists him with washing his hair. Interview with CNA #434 also confirmed Resident #16 has repetitive needs, he feels he must wash his body three times, and staff washes his hair three times with each shower. Interview with CNA #434 confirmed she does not stay with him for the full shower time, she knows he is a fall risk, but this is how it has been done. Observation on 12/10/24 at 8:49 A.M. revealed CNA #434 entered shower room. Observation on 12/10/24 at 8:57 A.M. revealed CNA #434 exited shower room, reports she washed Resident #16's hair twice already. Observation on 12/10/24 at 9:07 A.M. revealed CNA #434 entered shower room. Observation on 12/10/24 at 9:08 A.M. revealed CNA #434 exited shower room. Observation on 12/10/24 at 9:16 A.M. revealed shower room call light flashing red. Observation on 12/10/24 at 9:19 A.M. revealed CNA #434 entered the shower room. Observation on 12/10/24 at 9:42 A.M. revealed CNA #434 exited shower room with Resident #16 in a shower chair, covered with towels and bath blanket. Interview on 12/10/24 at 9:55 A.M. with Registered Nurse (RN) #532 confirmed Resident #16 uses a slide board for transfers, can brush his teeth himself, and he uses his call light and calls for assistance when needed. Interview on 12/12/24 at 7:32 A.M. with RN/MDS Coordinator #412 and Licensed Practical Nurse (LPN)/MDS Coordinator #421 confirmed Resident #16 was not care planned for bathing and the assistance needed while bathing. 2. Review of the medical records for Resident #125 revealed an admitted [DATE], a discharge date of [DATE] to the hospital, and a re-admitted [DATE], with diagnoses of post laminectomy syndrome, pressure ulcer of sacral region, stage 2, pressure ulcer of left buttock, stage 2, and pressure ulcer of right buttock, stage 2. Review if the quarterly MDS assessment dated [DATE] revealed resident was cognitively intact, required supervision with oral hygiene, required partial assistance with eating and personal hygiene, required substantial assistance with bathing and wheelchair mobility, and was dependent on staff assistance with toileting hygiene, dressing, bed mobility, and transfers. Further review revealed resident was at risk for pressure ulcers, had one unstageable pressure ulcer, had a pressure reducing device to her bed, did not have a pressure reducing device to her chair. Review of Resident #125's Encore Wound note dated 10/09/24 revealed recommendations of wheelchair pressure reduction cushion per facility protocol. Review of the Care Plan for Resident #125 revealed no documentation related to a pressure reduction cushion. Observation on 12/11/24 at 10:00 A.M. revealed a Roho style cushion in Resident #125's wheelchair. Interview on 12/11/24 at 10:34 A.M. with LPN/MDS Coordinator #421 confirmed the intervention of pressure reducing cushion to chair that Wound Nurse Practitioner #446 ordered on 10/09/24 was not on Resident #125's care plan and should have been. Review of the Wound Care policy dated September 2021 revealed the purpose is to ensure care is provided in a way to promote healing. Review of the Care Plans, Comprehensive Person-Centered policy, dated September 2021 revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also revealed that the care plan will include identified problems, goals and interventions to enhance the optimal functioning of the resident.

Based on medical record review, observations and resident and staff interviews, the facility failed to assist residents with needed activities of daily living (ADL) care. This affected two (#16 and #31) out of six residents reviewed for ADL care. The facility census was 131. Findings include: 1. Review of the medical records for Resident #16 revealed an admitted [DATE] with diagnoses of quadriplegia, unspecified open wound of left buttock, subsequent encounter, contracture of muscle, left hand, and contracture of muscle, right hand. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact, had impairment on bilateral upper and lower extremities. Resident #16 required set-up assistance with eating, oral hygiene, and wheelchair mobility, and required substantial assistance with toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and transfers. Review of the physician orders revealed an order for showers scheduled on Tuesday, Thursday, and Saturdays on day shift. Review of Resident #16 Care Plan with a revision date of 10/22/24 revealed resident had an Activities of Daily Living (ADL) self-care performance deficit related to requires assist with ADL's, incomplete quad, neuropathy. Resident will only ambulate with therapy staff not with the nursing staff with a goal to maintain current level of function with ADL's through the review date. Resident required assist with activities of daily living (i.e.: dressing, grooming, personal hygiene, locomotion, oral care, etc.) as needed. Resident uses motorized wheelchair for locomotion related to diagnosis Quadriplegia, requires one (1) person assistance with toileting and transfers. Further review of the care plan revealed no documentation related to assistance needed with bathing. Review of the Point of Care (POC) Response History for Scheduled Bathing on 11/30/24 at 6:59 P.M. revealed resident required physical help limited to transfer only with bathing activity, on 12/05/24 at 5:03 P.M. resident required physical help in part of bathing activity, and on 12/07/2024 at 12:31 P.M. resident required physical help in part of bathing activity. Observation on 12/10/24 at 8:47 A.M. Resident #16 noted in shower room by himself. Interview with Certified Nursing Assistant (CNA) #434 at this time confirmed Resident #16 takes three (3) hour showers every Monday, Wednesday, and Friday and that she assists him with washing his hair. Interview with CNA #434 also confirmed resident has repetitive needs, he feels he must wash his body three times, and staff washes his hair three times with each shower. Interview with CNA #434 confirmed she does not stay with him for the full shower time, she knows he is a fall risk, but this is how it has been done. Interview also confirmed resident is at risk for falls due to diagnoses, can not transfer himself, and cannot stand without assistance. Observation on 12/10/24 at 8:49 A.M. revealed CNA #434 entered shower room. Observation on 12/10/24 at 8:57 A.M. revealed CNA #434 exited shower room, reports she washed resident's hair twice already. Observation on 12/10/24 at 9:07 A.M. revealed CNA #434 entered shower room. Observation on 12/10/24 at 9:08 A.M. revealed CNA #434 exited shower room. Observation on 12/10/24 at 9:16 A.M. revealed shower room call light flashing red. Observation on 12/10/24 at 9:19 A.M. revealed CNA #434 entered the shower room. Observation on 12/10/24 at 9:42 A.M. revealed CNA #434 exited shower room with Resident #434 in a shower chair, covered with towels and bath blanket. Interview on 12/10/24 at 9:55 A.M. with Registered Nurse (RN) #532 confirmed Resident #16 uses a slide board for transfers, can brush his teeth himself, and he uses his call light and calls for assistance when needed. Interview on 12/12/24 at 7:32 A.M. with RN/MDS Coordinator #412 and Licensed Practical Nurse (LPN) MDS Coordinator #421 confirmed resident was not care planned for bathing and the assistance needed while bathing. Interview on 12/09/24 at 2:41 P.M. with Licensed Practical Nurse (LPN)/Unit Manager #426 confirmed Resident #16 requires assistance with all ADL;s, and the resident tends to do what he wants. Interview with LPN/Unit Manager #426 confirmed his expectations for staff is to assist Resident #16 during his shower and the resident should not be left alone in the shower room. 2. Review of the medical records for Resident #31 revealed an admitted [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and down syndrome. Review of the quarterly MDS assessment dated [DATE] revealed Resident #31 was cognitively intact, had no impairment to bilateral upper or lower extremities. Resident #31 required set-up assistance with eating, required supervision with oral hygiene, and required substantial assistance with toileting hygiene, bathing, dressing, personal hygiene, bed mobility, transfers, ambulation and wheelchair mobility. Review of the physician orders revealed an order dated 01/15/23 to use Hoyer lift as needed, and an order dated 08/12/24 for showers on Monday and Friday on day shift. Review of the Care Plan with a revision date of 06/22/23 revealed Resident #31 required two person assistance with toileting and transfers. Review of the Quarterly Nursing Evaluation dated 11/15/24 revealed Resident #31 was at high risk for falls. Observation on 12/09/24 at 2:12 P.M. revealed Resident #31 in the shower room, alone and attempting to open the door to get out of the shower room, while in her wheelchair. Another fell ow resident assisted with opening the door so Resident #31 could get out. Interview with Resident #31, revealed she was using the toilet in the shower room. Interview on 12/09/24 at 2:07 P.M. with Certified Nursing Assistant (CNA) #482 confirmed Resident #31 was in the facility shower room alone. Interview with CNA #482 also confirmed Resident #31 should not be in the shower room alone because she needs assistance with toileting and should not be going in the shower room by herself. Interview on 12/09/24 at 2:41 P.M. with Licensed Practical Nurse (LPN)/Unit Manager #426 confirmed Resident #31 should not be using the shower room for toileting due to needing assistance with toileting needs. Interview with LPN/Unit Manager #426 confirmed the shower room door is partially open, it is hard to close but will close when pulled forcefully.

Based on medical record review, staff interviews, and policy review, the facility failed to ensure pressure sore treatments were complete as ordered. This affected one (#125) out of five resident reviewed for pressure ulcer care. The facility census was 131. Findings include: Review of the medical records for Resident #125 revealed an admitted [DATE], a discharge date of [DATE] to the hospital, and a re-admitted [DATE]. Diagnoses of post laminectomy syndrome, pressure ulcer of sacral region, stage 2, pressure ulcer of left buttock, stage 2, and pressure ulcer of right buttock, stage 2. Review if the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #125 was cognitively intact, required supervision with oral hygiene, required partial assistance with eating and personal hygiene, required substantial assistance with bathing and wheelchair mobility, and was dependent on staff assistance with toileting hygiene, dressing, bed mobility, and transfers. Further review revealed Resident #125 was at risk for pressure ulcers, had one unstageable pressure ulcer, had a pressure reducing device to her bed, did not have a pressure reducing device to her chair. Review of Resident #125's Treatment Administration Record (TAR) for October 2024 revealed on 10/16/24 the following treatments were not completed as ordered: Wound Care: Coccyx. Cleanse with NS and pat dry. Apply Silvadene to wound bed followed by Calcium Alginate. Cover with Composite (comfortell) dressing. Wound Care: Right Buttock. Cleanse with NS and pat dry. Apply Triad to wound bed and cover with Composite dressing (Comfortell). Wound care: right buttocks cleanse with wound cleanser, pat dry, apply triad and cover with bordered foam. Further review of the TAR revealed on 10/30/24 the follow treatments were not completed as ordered: Wound Care: Coccyx. Cleanse with 0.25% Dakins and pat dry. Apply Silvadene to wound bed and pack wound with Calcium Alginate Rope. Cover with sacral bordered foam dressing (or other foam dressing available). Wound Care: Right Buttock. Cleanse with NS and pat dry. Apply Triad to wound bed and cover with bordered foam dressing (may use sacral bordered foam if also covering sacral wound). Interview on 12/11/24 at 10:34 A.M. with Licensed Practical Nurse (LPN)/MDS Coordinator #421 confirmed Resident #125's pressure ulcer treatments were not completed as ordered on 10/16/24 and 10/30/24. 12/16/24 at 10:34 A.M. with LPN #442 confirmed Resident #125's treatments on 10/16/24 and 10/30/24 for day shift was her responsibility, and that she always signs off when she completes a treatment. Interview with LPN #442 confirmed she did not complete all treatments on 10/16/24 and 10/30/24 and that some days she just does not have time to get everything done. Review of the Wound Care policy, dated September 2021 revealed the purpose is to ensure care is provided in a way to promote healing.

Based on medical record review, observation, staff interviews, and review of facility policy, the facility failed to ensure interventions were in place for a resident at risk for falls. This affected one (#53) of two residents reviewed for accidents. The census was 131. Findings include: Review of Resident #53's medical record revealed an admitted [DATE]. Diagnoses included dementia with behavioral disturbance, low back pain, major depression disorder, hypertension, and Alzheimer's disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact. Review of a care plan initiated 01/07/22 revealed Resident #53 was at risk for falls related to peripheral vascular disease, dementia with impaired cognition, and decreased mobility. Interventions listed included, keep bed in lowest position initiated on 09/14/24 and low bed initiated on 09/16/24. Review of progress notes revealed Resident #53 fell from the bed onto the floor on 09/14/24. Hospice added and intervention of fall mats to the floor of each side of Resident #53's bed. Observation of 12/11/24 at 8:50 A.M. revealed Resident #53 bed was raised and not in the lowest position. A fall mat was not on the floor to the right side of Resident #53's bed. The fall matt was folded and at the end of Resident #53's bed. Interview with Licensed Practical Nurse (LPN) #426 on 12/11/24 at 9:02 A.M. confirmed Resident #53's bed was not in the lowest position and a fall mat was not in place to the right side of the bed. LPN #426 had to move a bedside table to permit Resident #53's to be lowered to the floor and place the fall mat to the right side of the bed. Interview with the Director of Nursing (DON) on 12/11/24 at 9:16 A.M. confirmed Resident #53's bed should be in the lowest position. The DON stated the facility did not have low beds. Review of the facility's policy titled Falls 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 falling.

Based on observations, medical record review, review of the facility's investigation, interviews with facility staff, and review of the facility's policy on elopement, the facility failed to ensure staff provided adequate supervision to prevent a resident, with a history of exit seeking behavior, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#64) was placed at potential risk for serious life-threatening harm and injury when she eloped from the facility without staff knowledge. Resident #64 was missing for approximately 30 minutes and was found by the local police approximately 0.2 miles from the facility at an apartment complex, knocking on the door of a residence asking to be let in. This affected one (#64) of four residents reviewed for risk of elopement. The facility identified 26 current residents at risk for elopement. The facility census was 122. On 09/09/22 at 4:06 P.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 09/07/22 at approximately 3:00 A.M. when Resident #64 exited the secured unit without staff knowledge. Resident #64 was previously assessed as being at risk for elopement, exhibited exit-seeking behaviors almost daily, and resided on a secured unit to ensure the resident's safety. On 09/07/22 at 3:22 A.M., Resident #64 was found by the local police after receiving a nine-one-one (911) call by a homeowner who lived close to the facility. The homeowner reported an unknown female was knocking on the door of a residence asking to be let in. The local police arrived at the homeowner's location at 3:22 A.M. and found Resident #64 without shoes. The local police suspected Resident #64 was from the facility. The facility was unaware Resident #64 was missing until 3:34 A.M. when the local police officer arrived at the facility. Resident #64 returned to the facility at 4:00 A.M. and Resident #64 was noted to have abrasions (top layer of skin removed) on her bilateral knees and the right side of her back. The Immediate Jeopardy was removed on 09/07/22 when the facility implemented the following corrective actions: On 09/07/22 at 4:00 A.M., Resident #64 was safely returned to the facility after being informed by the local police of her whereabouts. Resident #64 was placed on one-on-one supervision until Resident #64 was sent for a psychiatric evaluation on 09/07/22 at 10:00 A.M. Resident #64 was admitted to the psychiatric hospital. On 09/07/22 at 4:28 A.M., the facility staff completed a facility head count and found no other missing residents. On 09/07/22 at 6:30 A.M., Maintenance Director #140 placed a screw in Resident #64's room window to prevent it from opening more than three inches. Maintenance Director #140 then placed a device to prevent the windows from opening more than three inches in all the residents' rooms. This was completed on 09/07/22. On 09/07/22 at 7:00 A.M., Maintenance Director #140 checked all doors and secure care bracelets (a bracelet type device worn to alert staff of unauthorized exits through doors equipped with an alarming system) to ensure they were working. On 09/07/22, the Administrator, DON and Designee in-serviced all the staff on the elopement policy and procedure. On 09/07/22, the DON completed audits on all residents with secure care bracelets to ensure they were being checked for expiration and proper function. On 09/07/22, the Administrator and Maintenance Director #140 completed elopement drills on all shifts. On 09/07/22, weekly audits for four weeks were put in to place to be completed by Maintenance Director #140 or Designee to make sure all windows open no further than three inches. Any negative findings will be addressed immediately to the Administrator and reported to the Quality Assurance (QA) committee for tracking and trending. On 09/07/22 at 7:00 A.M., the DON, and Social Worker #72 checked all residents who were at risk for elopement to ensure current pictures and face sheets were in place. The DON also checked all care plans and assessments for residents at high risk for elopement. There were 26 residents identified to be at risk for elopement. Observations on 09/09/22 at 1:00 P.M. with Maintenance Director #140 revealed all residents' rooms in the facility had bolts in the windows. This included ten rooms on the memory care unit, ten rooms on unit A-1, ten rooms on unit A-2, ten rooms on B-1, ten rooms on B-2, ten rooms on TCU-1 and TCU-2, and ten rooms on TCU-3. On 09/12/22, the medical records for Residents #24, ##36, #39, #44, and #126, identified at risk for elopement, were reviewed with appropriate assessments and plans of care in place. There were no other identified elopement events. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and are monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #64 revealed an initial admitted [DATE]. Diagnoses included dementia, anxiety, and high blood pressure. Review of the wandering risk assessment, dated 08/10/22, revealed Resident #64 was a high elopement risk due to behaviors of exit seeking. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/22/22, revealed Resident #64 had moderate cognitive impairment, and required supervision with ambulation and personal care. Review of the care plan, dated 08/10/22, revealed Resident #64 had impaired safety awareness, and exhibited exit seeking behaviors. Resident #64 resided on a locked dementia unit for safety. Resident #64 required staff assistance to exit the unit. Staff were to assist Resident #64 with developing more appropriate coping methods, offering diversions, structured activities, food, conversation, television, and opportunities for positive interaction. Resident #64 also had a secure care bracelet in place to alert staff if Resident #64 left via the alarmed doors. Review of the census record revealed Resident #64 was transferred to the memory care unit on 08/22/22 due to exit seeking behaviors. Review of the nursing progress notes from 08/10/22 through 09/06/22 revealed Resident #64 often went from exit door to exit door. Resident #64 was often seen sitting by the exit doors with her belongings. Resident #64 was not easily redirected. A progress note, dated 09/06/22 at 7:25 P.M., revealed Resident #64 was exhibiting signs of exit seeking behavior and becoming physically aggressive with redirection. Review of the Local Police Report dated 09/07/22 at 3:22 A.M. revealed an elderly woman was reported knocking on doors at apartments. Resident #64 did not know her name and was not wearing shoes. Resident #64 asked the local police officer to not take her back to the facility and stated, 'they were holding her hostage'. The report noted Resident #64 had no injuries seen. According to witnesses from the apartment, Resident #64 had been in the parking lot at least ten minutes prior to the local police arriving. Review of the nursing progress note, dated 09/07/22 at 3:30 A.M., revealed nursing staff were notified by a local police officer that Resident #64 was across the street in the parking lot of apartment buildings. The local police stated Resident #64 would not come with them and requested a staff member to come and get Resident #64. The local police officer noted Resident #64 stated she went out the window. A head-to-toe assessment was completed which revealed Resident #64 had abrasions on her bilateral knees and on the right side of her back. Following the assessment of Resident #64, the note documented she was placed on one-to-one monitoring, there was a head count completed of all residents on the unit, and all exit doors and alarms were tested and found to be in working condition. Review of the facility's investigation revealed the investigation was initiated on 09/07/22. State tested Nursing Aide (STNA) #18 and Licensed Practical Nurse (LPN) #87 observed Resident #64 in her room on 09/07/22 at 2:30 A.M. The staff did not know Resident #64 had left the facility until the local police arrived and told them. LPN #87 sent another nurse to get Resident #64 and began a whole facility search and head count. On 09/09/22 at 9:30 A.M., an interview with the Administrator and the DON verified Resident #64 left their facility without staff knowledge on 09/07/22 at 3:00 A.M. Resident #64 had left the facility via the first-floor window in her room. A facility staff member returned Resident #64 to the facility without incident. The DON stated on 04/11/22, another unidentified resident left the facility through a window. Screws were placed in the windows at an eight-inch width to prevent residents from leaving the facility through the windows. The Administrator and DON confirmed all the residents' windows now had screws at a three-inch width after Resident #64's elopement through the residents' window on 09/07/22. On 09/09/22 at 2:15 P.M., an interview with Maintenance Director #140 revealed the first thing on the morning after Resident #64 eloped, he checked all the door alarms, and found them to be functioning. He reported all windows on the dementia unit were checked and found them to open a maximum of eight inches. Maintenance Director #140 stated screws were placed on all residents' windows to prevent them from opening more than three inches. On 09/09/22 at 4:30 P.M., an interview with STNA #18 revealed Resident #64 engaged in exit seeking regularly and staff immediately intervened and redirected her to other activities. STNA #18 stated on 09/07/22, she last saw Resident #64 at approximately 2:30 A.M. STNA #18 stated Resident #64 was sitting on the side of her bed in her room holding her stuffed animal. STNA #18 stated she had never seen Resident #64 near a window trying to open it. On 09/09/22 at 5:15 P.M., an interview with LPN #87 revealed Resident #64 would frequently exit seek or state she wanted to go home. LPN #87 noted Resident #64 was hard to redirect at times. LPN #87 revealed she sent the male nurse on duty over to the apartments to get Resident #64 after Resident #64 had eloped. Review of the facility's policy on elopement protocol and procedure, last reviewed on 09/2022, revealed staff should promptly report to the charge nurse or DON when it was suspected any resident was missing. If it was discovered the resident left the facility, a search should be initiated of the building and the premises and if the resident was not located, law enforcement should be contacted. When the resident returned to the facility, nursing should examine for injuries and the family and doctor should be notified and updated throughout the process. This deficiency substantiates Complaint Number OH 653.

Based on observation, review of the dishwasher temperature log, review of facility policies, review of dishwasher service run sheets, staff interview, interview with the dishwasher service technician and review of a facility's infection tracking log, the facility failed to ensure the high temperature dishwasher was functioning properly and reaching temperatures high enough to effectively sanitize dish ware. This failure of the dishwasher to reach the required sanitation temperature of 180 degrees Fahrenheit (F) resulted in Immediate Jeopardy with the potential for serious harm for 124 of 128 residents that received meals trays from the kitchen. The facility identified four Residents (#19, #20, #21 and #22) as not receiving meal trays from the kitchen. Facility census was 128. Furthermore, based on observations, staff interviews, review of refrigerator temperature logs and the facility's policy, the facility also failed to ensure refrigerators were maintained at the proper temperatures and opened foods were stored appropriately for use and discard dates to prevent the spread of foodborne illness. Improper sanitization of food contact surfaces, improper food storage and improper food holding temperatures can contribute to the spread of foodborne illness. Since June 2017, the facility identified 20 residents (#2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #30, #31, #32, #15, #33, #16, #17 and #18) who have been affected by Salmonella, a foodborne illness, which causes diarrhea, fever and abdominal cramping. On 08/04/17 at 4:55 P.M., the Administrator was notified that Immediate Jeopardy began on 06/07/17 when the dishwasher recorded a final rinse temperature of 140 degrees F at the breakfast meal and continuing with the lunch final rinse temperature check of 140 degrees F, without any remedial action initiated by the facility. The Immediate Jeopardy continued on 08/04/17 at 8:50 A.M. when staff was operating the dishwasher and washing pots and pans with a final rinse temperature of only 150 degrees F. The Immediate Jeopardy was removed on 08/04/17 at 10:00 A.M. when the facility implemented the following corrective actions. · On 08/04/17 at 10:00 A.M. the facility switched to serving resident meals on paper products and utilized the three compartment sink method to sanitize the dishes used in food preparation. · On 08/04/17, Director of Dietary Services #1 and the Administrator began in-service training with all dietary employees to ensure the final rinse temperature for the dishwasher reached the required 180 degrees F to appropriately sanitize the dishes. If the dishwasher did not meet the appropriate final rinse temperature, the dietary staff were trained to initiate the three compartment sink method to sanitize the dishes. The training was completed on 08/05/17. · On 08/04/17 at 5:15 P.M. the dishwasher was serviced by a dishwasher service technician to ensure proper functioning. · On 08/05/17 and 08/06/17 during each meal, the administrator monitored the dishwasher for correct functioning. The dishwasher was working properly. · The Administrator or designee will continue to perform dishwasher equipment functionality checks daily for two weeks, then three times a week for two weeks, and then one time a week for four weeks. · The Director of Dietary Services #1 or designee will monitor the dishwasher temperatures at all times of operation and assures temperatures are within appropriate range and are recorded. Immediate follow up with maintenance department and/or the dishwasher technician will occur if temperatures do not reach the acceptable range. · Ongoing monitoring will occur by the Director of Dietary Services #1 or designee when the machine is in use. Temperature sticks (T-sticks) will be used to confirm temperature readings of each meal. The dishwasher equipment temperatures will be checked three times a day and equipment function three times a day. · Observation of the dishwasher operation on 08/07/17 at 11:00 A.M. revealed the dishwasher was not reaching appropriate rinse temperatures to sanitize dish ware, and the facility staff instituted the three compartment sink method to sanitize all dishes in conjunction with serving meals on paper products. · During interviews with Dietary Workers #5 and #10 on 08/07/17 between 11:20 A.M. and 11:40 A.M., it was verified that they had received training on 08/04/17 and 08/05/17, regarding the dishwasher and the proper temperature readings for sanitization of the dishes and the procedures to follow if the dishwasher did not reach the correct temperature. Dietary worker #10 stated today she was monitoring the dishwasher and it was reading correctly and then the temperature dropped and she stopped the machine, let her supervisor know, and they started using the three compartment sink for sanitation. · An interview with the Administrator on 08/07/17 at 11:45 A.M. revealed the facility had the booster fuse within the dishwasher booster heater replaced this morning and the facility had also chosen to have all three boosters within the booster heater replaced. Additionally, per the Administrator, the facility is having the heating coil in the hot water heater which is used for the dishwasher replaced as well. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance Findings Include: 1. During an initial tour of the kitchen on 08/04/17 at 8:50 A.M., the dishwasher was observed with Dietary Worker #10. Dietary Worker #10 stated that the Dietary Manager was not in the facility yet and when asked to observe the dishwasher, Dietary Worker #10, stated good and went on to say she didn't know what happened to it but it won't shut off, it just keeps running. Dietary Worker #10 stated the dishwasher worked fine yesterday but today it keeps running maybe you know how to fix it. The dishwasher was observed with a wash temperature reading 150 degrees F and the final rinse temperature reading 150 degrees F. Dietary Worker #10 was asked about the temperatures and she stated when it doesn't work right they call that one guy, not naming who the one guy is. Dietary Worker #10 proceeded to put pots and pans through the dishwasher and as the pots had air dried from coming out of the dishwasher, she was observed re-shelving the pots and pans for future use. During the observation Dietary Worker #10 made no attempt to inform any other staff or management that the dishwasher was running continually or that the final rinse temperature was not adequate to appropriately sanitize the dishes being washed. Dietary Worker #10 was asked about the machine not reaching temperature and she verified that the temperatures were reading 150 degrees F, for both the wash and the final rinse cycle, and continued about her work. Dietary Worker #10 did not exhibit any concerns and/or did not alert any other individual about the dishwasher. During the observation on 08/04/17 at 9:00 A.M., Dietary Worker #15, who was in another part of the kitchen by the prep table/prep sink, was asked to test the three compartment sink. Dietary Worker #15 stated that the sanitizer solution was not in the sink as they only use the three compartment sink for sanitation purposes when the dishwasher is not operational and not working properly. Dietary Worker #15 was informed the dishwasher was reading 150 degrees F on the wash and final rinse cycle. Dietary Worker #15 turned to Dietary Worker #10 at that time and asked if the dishwasher was running all the time and not shutting off and Dietary Worker #10 stated yes. Dietary Worker #15 then stated that is why the machine is not getting to temperature. Dietary Worker #15 was asked what the dietary staff was going to do about the dishes that had already been washed and she stated the dish carts had just been brought down and they had not started washing them yet. Dietary Worker #15 was informed that Dietary Worker #10 had been re-shelving pots and pans that had been washed by the dishwasher. Dietary Worker #15 then told Dietary Worker #10 that if she had put any pans or pots back on the shelf that they need to be sanitized in the three compartment sink and Dietary Worker #10 proceeded to remove pans and pots from the shelves. Dietary Worker #15 instructed Dietary Worker #10 to fill the three compartment sink and put the sanitizer solution in the sink so that they could sanitize all the dishes properly. An interview with the Administrator on 08/04/17 at 9:15 A.M. revealed that he was aware that the dishwasher was not up to temperature this morning when the surveyor toured the kitchen. The Administrator stated the Maintenance Director was working on the dishwasher currently and the facility was using the three compartment sink to sanitize all the dishes until the dishwasher was operational and correctly working. Additional observations and tour of the kitchen with Director of Dietary Services #1 on 08/04/17 at 9:45 A.M. revealed the dietary staff were utilizing the three compartment sink to sanitize all dishes after the dishes were run through the dishwasher for washing purposes to get the food off of them. The three sink method was at the appropriate sanitizing level. Director of Dietary Services #1 showed the surveyor the part of the dishwasher that was malfunctioning and stated it was a metal roller at the end of the machine that moved up and down and when working properly would turn the temperature booster on and off for the rinse water. The dishwasher part was not moving up and down properly and thus not turning the booster on and off correctly. Director of Dietary Services #1 ran the dishwasher during the observation and the wash temperature was over 160 degrees F and the final rinse temp was over 180 degrees F. Director of Dietary Services #1 verified that a dishwasher service technician was coming to the facility today to fix the part as they had called him this morning when it was discovered that the part was malfunctioning causing the dishwasher to not reach the proper final rinse temperature for sanitation. Director of Dietary Services #1 stated until that time the facility will use the sanitizer sink for sanitizing all dishes. The dishwasher temperature log was reviewed for June 2017. The review revealed on 06/07/17 for breakfast and lunch the final rinse temperature read 140 degrees F. The form indicated the final rinse temperature was required to be 180 degrees F. During an interview with Director of Dietary Services #1 and the Administrator on 08/04/17 at 1:30 P.M., it was verified the dishwasher temperature log on 06/07/17 read 140 degrees F for the final rinse temperature for the breakfast and lunch and not the minimum 180 degrees F required for sanitation. Director of Dietary Services #1 denied having any knowledge of the low readings on 06/07/17 and denied knowing how his staff ensured the dishes were sanitized on 06/07/17. Review of the dishwasher temperature log sheet revealed the supervisor is to be notified immediately of abnormal temperatures. Director of Dietary Services #1 further stated there is no documentation required or available that would confirm the actions the staff took on 06/07/17 to ensure the dishes and dishware were properly sanitized. Director of Dietary Services #1 verified there was no formal documentation of in-servicing with dietary staff documenting the staff had received education on what steps to take if the dishwasher was not operating correctly. During an interview with the Administrator on 08/04/17 at 1:40 P.M. it was verified Director of Dietary Services #1 should have knowledge of the low temperature dishwasher readings, and should have known what occurred on the day in question when the dishwasher was not reading the correct temperature. During an interview on 08/04/17 at 2:03 P.M. with Dietary Worker #20, the dietary staff member who recorded the low wash and final rinse temperature reading on 06/07/17, revealed her process for recording wash and rinse temperatures is she runs a rack through the dishwasher and documents the temperature of the water for wash and the rinse cycle. Dietary Worker #20 verified if she had a wash temperature reading below 160 degrees F she would fill up the three compartment sink with sanitizer and use that to sanitize the dishes. Dietary Worker #20 denied knowing if there is a specific temperature required for the final rinse water. Dietary Worker #20 was asked if she remembers having to fill up the three compartment sink for sanitizing the dishes recently and she stated she has had to do that in the past but it has been three or four months ago, and not recently. Dietary Worker #20 additionally stated that when the temperatures do not read correctly the staff member must let the dietary manager know at that time. Dietary Worker #20 stated the time she had to use the three compartment sink because the water did not reach the correct temperature her the manager was in the facility and was aware of the situation and the use of the three compartment sink for dish sanitation. During a telephone interview with Dishwasher Service Technician #75 on 08/04/17 at 2:20 P.M. he stated he made two service calls to the facility during the month of June. At the time of the interview Dishwasher Service Technician #75 was driving and stated later he would text the surveyor the dates of the service calls. Dishwasher Service Technician #75 did indicate that one of the calls was to update equipment and the other was to service the dishwasher as it was reading 110 degrees F on the rinse cycle. A text message was received and the service calls to the facility were made on 06/16/17 and 06/28/17. Review of dishwasher service run sheets for the month of June 2017 revealed the technician had serviced the dishwasher on 06/16/17 due to the machine not reaching the correct temperature on the wash cycle. The dishwasher service technician was at the facility on 06/28/17 to install a new dispensing system on the three compartment sink, labeled bottles for chemical use, provided a mop sink, and provided the facility with half a case of solid powder XL. There were no service run sheets regarding the low final temperature readings for 06/07/17. Review of a facility policy titled Food and Nutrition Services Policies and Procedures, 4.4 Machine Warewashing and Sanitizing with a revision date 03/16/15, documented the dishwasher is used for machine warewashing for high temperature machine the wash cycle temperature ranges between 150 degrees F and 165 degrees F and the final rinse temperature is a minimum of 180 degrees F. The policy further documented if the temperature fall below the standard for either the wash or final rinse or the chemical sanitizer does not test at the appropriate concentration the director of dining services of maintenance department should be notified immediately. Further review of a facility infection tracking log revealed 20 (#2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #30, #31, #32, #15, #33, #16, #17 and #18) residents have tested positive for Salmonella from 06/10/17 through present. 2. Observation and tour of the kitchen with Director of Dietary Services #1 on 08/04/17 at 9:45 A.M. revealed the refrigerator by the prep sink had a plastic container with an orange liquid in it that did not have a label on the container of what it was. Additionally, the container was not dated for when the liquid was put in the container and when it was to be used by. The Director of Dietary Services #1 verified the container was not labeled as to what was in the container nor was it dated on when it was opened or when it should be used by. Director of Dietary Services #1 removed the container and dumped it down the sink at this time. An observation of the reach in refrigerator next to the ice machine on 08/04/17 at 10:00 A.M. with the Director of Dietary Services #1 revealed there were drinks including white milk, chocolate milk, cranberry juice, apple juice, orange juice, lemonade and fruit punch in the refrigerator. Additionally, there was ketchup and mayonnaise in the refrigerator. The thermometer inside the refrigerator read 44 degrees F at 10:00 A.M.; the reading was verified with the Director of Dietary Services #1 during the observation and the temperature log on the outside of the refrigerator had a recorded temperature for 08/04/17 at 7:30 A.M. with a reading of 47 degrees F. The Director of Dietary Services #1 stated the staff are in and out of the refrigerator often as it is the drink refrigerator and that is why the temperatures are slightly over where they should be. During the tour of the kitchen on 08/04/17 the dietary staff was observed to be working on cleansing the dishes from breakfast and there was no food preparation or food storage/re-stocking occurring where the doors of the refrigerator were opened and reopened repeatedly. An observation of the C2 lounge refrigerator on 08/04/17 at 10:55 A.M. revealed two gallons of sweet tea, one gallon of un-sweeten tea and a box of prune juice that all had been opened but were not labeled with the date they were initially opened for use or the date when they should be discarded. The refrigerator temperature additionally read 44 degrees F. During an interview on 08/04/17 at 10:55 A.M. with State tested Nursing Assistant (STNA) #200 verified the three containers of tea and the box of prune juice all had been opened and had liquid missing out of their containers. STNA #200 verified the items were not labeled with a date of when they were opened or when they should be discarded by. Additionally, STNA #200 verified the refrigerator temperature was 44 degrees F. During an observation of the reach in drink refrigerator on 08/07/17 at 11:30 A.M. with Director of Dietary Services #2, the internal thermometer read 46 degrees F, and the external thermometer of the refrigerator read 46 degrees F. Director of Dietary Services #2 verified the thermometer readings at this time. The food items within the refrigerator included milk, juice, ketchup and mayonnaise. Director of Dietary Services #2 tested the temperature of both the milk and the mayonnaise in the refrigerator and both tested at 45 degrees F, above the recommended 41 degrees F for safe handling. Director of Dietary Services #2 verified the temperature readings and verified the items would be discarded and the refrigerator would be serviced to ensure proper operational status of the refrigerator. Review of the policy titled Refrigerator/Frozen Food Storage with a revision date of 10/06/13 and a review date of 10/01/15, documented all foods are labeled with the name of the product and date received by and use by date once opened. Manufacturer use by dates are used until opened. This deficiency substantiates Complaint Number OH 735.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on closed medical record review, review of hospital records, and physician and staff interviews, the facility failed to ensure a resident was administered physician ordered medications. This affected one (#161) sampled resident whose Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident subsequently developed [MEDICAL CONDITION] and was hospitalized . Findings include: Review of the closed medical record for Resident #161 revealed she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident had been hospitalized from [DATE] through 04/21/11 for significant co-morbidities that required mechanical ventilation as well as vasopressors intravenously to sustain her blood pressure. Upon admission to the facility, the nurse assessed the resident with two plus [MEDICAL CONDITION] in her legs. She was alert and oriented and her lungs were clear with no cough. On 04/21/11, the facility physician also assessed the resident. His documentation stated that the resident had clear lung sounds on auscultation. Nursing notes dated 04/30/11 at 7:45 P.M., documented the nurse was called to Resident #161's room. The resident was gray, sweaty, had shallow respirations and was barely able to respond . The resident's vitals signs were taken and her blood pressure was 137/71, pulse 68 beats per minute, respirations 12 breaths per minute and shallow and temperature 94.6 degrees Fahrenheit. Her blood oxygen level was 90 percent on three liters of oxygen per a nasal cannula. (Normal blood oxygen level is 90 to 100 percent). The oxygen was increased to four liters per minute and the nursing supervisor was immediately notified of the change in the resident's condition. At 8:00 P.M., nursing notes documented the resident had severely diminished lung sounds on the right side, rales (sounds indicating fluid in the lungs) on the left side and was becoming more lethargic. At 8:30 P.M., the physician was paged. At 8:50 P.M., the physician called back and was updated on the resident's declining condition. The physician ordered a stat chest x-ray and if the resident's condition worsened, to sent her out to the hospital. At 8:51 P.M., the facility made the decision to send the resident out to the hospital as the x-ray was unable to be done stat. Review of the resident's history and physical report from the emergency room dated 05/01/11, revealed a physical assessment, blood work and a chest x-ray was completed. The results from the test and assessment showed Resident #161 had bilateral crackles in her lungs, swelling of the feet, a rectal temperature of 95.1 degrees Fahrenheit and elevated cardiac enzymes (blood work which can identify damage to the heart). The resident was diagnosed with [REDACTED]. She was subsequently released from the hospital to another nursing facility. Review of the facility's written investigation of the incident dated 05/04/11, revealed on 04/30/11 at 9:30 A.M. registered nurse (RN) #2 discovered the resident's medications had been omitted from 04/26/11 through 04/29/11. The medications omitted were an anti-arrhythmic heart medication (Amidoarone 200 milligrams) ordered daily; an anti-arrhythmic heart medication ([MEDICATION NAME] 0.125 milligrams) ordered daily; a potassium supplement (Mirco K 20 milliequivalent) ordered daily; a steroid medication to decrease lung inflammation ([MEDICATION NAME] 0.1 milligrams) ordered daily; a diuretic to remove excess fluid from the body ([MEDICATION NAME] 20 milligrams) ordered every other day; a laxative ([MEDICATION NAME] 17 grams) order twice a day; an antibiotic (Keflex 500 milligrams) ordered three times per day and an antifungal medication ([MEDICATION NAME] 100 milligrams) ordered daily. After discovering the omitted medications, RN #2 notified the supervisor, RN #35 who soon after 9:30 A.M. assessed the resident. RN #35 awoke the resident and had a discussion with her. The resident denied feeling bad. Her lungs were diminished at that time and she was breathing regularly with no distress. At 11:15 A.M., the resident's physician was notified. The physician gave an order to administer the resident's medications at that time and resume the doses as ordered prior to the omission. At 4:00 P.M., the resident was given her afternoon medications. No changes in the resident's condition were noted. At 6:30 P.M., RN #2 completed the resident's treatments. She was arousable and repositioned in bed. At 7:45 P.M., the resident was found gray in color, sweating, barely able to respond and had abnormal lung sounds. The physician was called at 8:30 P.M. She returned the call at 8:50 P.M. and ordered a stat chest x-ray. The chest x-ray was not able to be done stat, so the resident was sent to the emergency room . During interview on 05/11/11 at 2:15 P.M., the Assistant Director of Nursing (ADON) verified Resident #161's medications were omitted from 04/26/11 through 04/29/11. The ADON stated RN #2 noted there where extra boxes of medications in the medication cart for Resident #161 on 04/30/11 at 9:30 A.M. He then compared the electronic medication sheet with the hard copy of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. RN #2 notified RN #35 and RN #35 assessed the resident. RN #35 then notified the ADON and the physician of the omitted medications. During interview on 05/11/11 at 2:15 P.M., licensed practical nurse (LPN) #1 stated while she was working on the monthly change over process of the resident's April 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated she was not aware of what she had done until 04/30/11, when RN #2 found the extra medications in the medication cart. Interview with the Director of Nursing (DON) on 05/12/11 at 10:00 A.M. revealed after the incident the facility took the following actions: On 05/02/11, the ADON and Unit Managers held a mandatory inservice training to educate the licensed nurses on the monthly change over process. Steps included to double check when filing the MAR indicated [REDACTED]. LPN #1 was suspended on 05/02/11 during the investigation. LPN #1 was inserviced regarding the monthly change over process. On 05/02/11, the ADON and Unit Managers audited the resident's charts on every unit to assure that no other residents were affected. No concerns were found during the audit. The ADON and Unit Managers continue to audit five resident records a week to ensure appropriate transcription of medications. Review of facility's documentation revealed on 05/02/11, the interdisciplinary team reviewed this incident and corrective action during the facility's monthly performance improvement meeting. According to the facility's documentation, the facility's monthly performance improvement meetings are planned to review monitoring documentation to ensure continue compliance regarding medication errors. On 05/11/11, a medication pass was observed and no medication errors were found. The medication administration records for the ten residents observed during medication pass were reviewed and were accurate and complete. This certification deficiency substantiates Complaint Control Number OH 748.