Every finding on record at Vancrest of Hicksville

Based on record review and staff interview, the facility failed to ensure residents received appropriate interest dividends based on the balance of their resident trust accounts. This affected five (#1, #2, #10, #16, and #34) of five residents reviewed for resident trust accounts. The facility identified 37 (#1, #2, #4, #5, #6, #7, #8, #9, #10, #12, #16, #17, #19, #20, #22, #23, #24, #25, #26, #27, #28, #30, #31, #32, #34, #36, #37, #38, #40, #41, #42, #44, #45, #47, #50, #51, and #52) residents with a resident trust account. The facility census was 51.Findings include:1. Review of the monthly resident trust statement for Resident #1, dated 04/01/26 through 04/30/26, revealed an ending account balance of $0.36 with an interest payment on 04/30/26 of $0.11. 2. Review of the monthly resident trust statement for Resident #2, dated 04/01/26 through 04/30/26, revealed an ending account balance of $1,335.17 with an interest payment on 04/30/26 of $0.11. 3. Review of the monthly resident trust statement for Resident #10, dated 04/01/26 through 04/30/26, revealed an ending account balance of $1,567.22 with an interest payment on 04/30/26 of $0.11. 4. Review of the monthly resident trust statement for Resident #16, dated 04/01/26 through 04/30/26, revealed an ending account balance of $1,776.02 with an interest payment on 04/30/26 of $0.05. 5. Review of the monthly resident trust statement for Resident #34, dated 04/01/26 through 04/30/26, revealed an ending account balance of $1,162.39 with an interest payment on 04/30/26 of $0.11. Interview on 05/06/26 at 10:45 A.M. with Business Office Manager (BOM) #279 revealed she was in the position for a year and managed resident trust accounts. BOM #279 stated the bank sent a bulk interest payment monthly and BOM #279 was trained to allocate interest payments evenly between all residents in the Skilled Nursing Facility (SNF) and the Assisted Living Facility (ALF). BOM #279 stated she did not consider the individual account balances when applying interest to the account. A follow-up interview on 05/07/26 at 12:29 P.M. with BOM #279 revealed she could not provide a reason why some residents received interest payments of $0.05 and others received $0.11 when she previously stated the bulk interest payment received from the bank was split evenly among all residents.

Based on observation, staff interview and review of the menu spreadsheet, the facility failed to ensure residents on a mechanical soft diet received appropriate protein portions. This affected seven (#4, #7, #23, #42, #44, #48, and #50) residents who received mechanical soft textured protein. Additionally, the facility failed to ensure residents on a pureed diet received all components of the meal. This affected three (#5, #10, and #52) residents who received a pureed meal. The facility census was 51.Findings include:Observation during meal service on 05/06/26 at 12:07 P.M. revealed [NAME] #212 plating mechanical soft and pureed meals. Concurrent interview with [NAME] #212 confirmed she used a two-ounce scoop to serve mechanical soft meatloaf and she provided two scoops, for a total of a four-ounce portion. Further interview confirmed residents on a pureed diet received meatloaf, lima beans, and mashed potatoes.Interview on 05/06/26 at 12:32 P.M. with Dietary Manager #280 and concurrent review of the menu spreadsheet confirmed residents on a mechanical soft diet should receive a five-and-one-third ounce portion of meatloaf. Further review and interview confirmed residents on a pureed diet should receive pureed bread.Interview on 05/06/26 at 12:35 P.M. with [NAME] #212 confirmed pureed bread was not prepared or served with the noon meal.

Based on observation and staff interview, the facility failed to ensure common bathrooms, accessible to residents in the facility, had emergency call lights. This had the potential to affect 36 (#1, #2, #4, #6, #7, #8, #9, #12, #13, #16, #17, #19, #21, #22, #23, #24, #25, #26, #27, #28, #30, #31, #32, #34, #37, #38, #40, #41, #44, #45, #46, #47, #51, #52, #54, and #60) residents identified by the facility as independently ambulatory. The facility census was 51. Findings include: Observations on 05/04/26 at 9:30 A.M., 11:35 A.M., 2:15 P.M. and 4:45 P.M. revealed two public restrooms were kept unlocked when not in use, with the doors standing open. The two restrooms were located near the entrance lobby of the facility.Interview on 05/04/26 at 3:56 P.M. with Registered Nurse (RN) #272 confirmed the two public restrooms off the main lobby were unlocked and accessible at all times.Interview on 05/04/26 at 4:05 P.M. with Assistant Director of Nursing (ADON) #226 confirmed the two public restrooms off the main lobby were accessible to residents and had no call lights for residents to use in case of emergency.Observation on 05/05/26 at approximately 6:20 P.M. revealed the bathroom doors remained opened and unlocked.Observation on 05/06/26 at approximately 3:30 P.M. revealed the bathroom doors remained opened and unlocked.Observation on 05/07/26 at approximately 10:00 A.M. revealed the bathroom doors remained opened and unlocked.

Based on observation, staff interview and review of the user manual, the facility failed to ensure insulin pens were primed correctly prior to administration. This affected one (#33) of two residents reviewed for insulin administration. The facility identified six (#09, #33, #43, #46, #47, and #56) residents who received insulin. The facility census was 51.Findings include: Observation on 05/06/26 at 7:58 A.M. revealed Licensed Practical Nurse (LPN) #247 obtained an insulin Lispro injection pen for Resident #33 from the medication cart and dialed the pen to two units and activated the injector. LPN #247 then applied the needle to the pen and dialed the pen to two units and injected Resident #33 with the insulin. LPN #247 did not prime the insulin pen prior to administration to Resident #33. Concurrent interview with LPN #247 verified the incorrect manner of priming the insulin pen prior to administration to Resident #33.Review of the educational material titled, Lilly Disposable Insulin Delivery Device User Manual, revised 05/02/05, revealed to ensure a needle was completely attached to the pen before priming, setting (dialing) the dose, and injecting the insulin.

Based on observation, record review, staff interview and review of facility policy, the facility failed to accurately provide, monitor, and document fluid intake for residents on a fluid restriction. This affected one (#4) of one resident reviewed for a fluid restriction. The facility identified three (#4, #17, and #60) residents on a fluid restriction. The facility census was 51.Findings include:Review of the medical record for Resident #4 revealed an admission date of 12/22/25 with diagnoses of congestive heart failure (CHF), hypo-osmolality and hyponatremia, and hypertension.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/12/26, revealed Resident #4 had intact cognition, had a significant weight gain, was not on a physician-prescribed regimen, and was on a therapeutic diet.Review of the current care plan, initiated 12/23/25 and updated 05/07/26, revealed Resident #4 had the potential for/at risk for an alteration in cardiac output/arrhythmia (irregular heart rate/rhythm/cardiorespiratory distress) related to CHF, hypertension and nonrheumatic aortic insufficiency. Interventions included assessing for edema (dated 12/23/25) and fluid restriction as ordered. Further interview revealed interventions added on 05/07/26 included may refuse to be compliant with fluid restriction. Additional review revealed a care area initiated 05/07/26 indicating Resident #4 had acute kidney injury and was diagnosed with hyponatremia. Resident #4 was on a fluid restriction and at times had been known to be non-compliant. Education was provided on the importance of following a fluid restriction. Review of a current physician order dated 02/17/26 revealed Resident #4 was on an 1800 milliliter (ml) fluid restriction related to hypo-osmolality and hyponatremia.Review of the nurses' paper charting, kept at the nurses' station, dated 02/17/26 through 05/06/26, revealed Resident #4's daily fluid intake ranged from 1560 ml to 2000 ml. Further review of the charting revealed the total daily intake included fluids from meals and fluids provided by nursing staff.Review of the nurse aide charting of daily fluid intake dated 04/07/26 to 05/07/26 revealed Resident #4's fluid intake varied from 540 ml per day (04/08/26) to 1450 ml per day (05/05/26).Review of the undated kitchen's posted fluid restriction allocation for Resident #4 revealed he received 360 ml of fluid at each meal. Observation on 05/04/26 at 10:10 A.M. revealed Resident #4 in his room sitting in a recliner. Resident #4 had no beverages in front of him. Further observation revealed Registered Nurse (RN) #272 entered the room and asked Resident #4 if he would like some water and where his water pitcher was. RN #272 stated it was unusual Resident #4 did not have a pitcher and said, at times, residents on a fluid restriction did not have water pitchers, but she did not believe Resident #4 was on a fluid restriction.Observation on 05/04/26 at 12:02 P.M. revealed Resident #4 in the dining room for the noon meal. Resident #4 had a glass of clear liquid beverage and a glass of orange juice. The glasses were approximately the same size. Observation on 05/05/26 at 1:17 P.M. revealed Resident #4 was in his room drinking a bowl of soup. A water pitcher was observed on the resident's overbed table. Concurrent interview with Resident #4 revealed he was having soup and crackers for lunch. Resident #4 confirmed he had a water pitcher filled with water on his overbed table. Resident #4 stated he was on a fluid restriction but he did not know why and had no further information regarding the fluid restriction.Interview on 05/05/26 at 2:58 P.M. with Licensed Practical Nurse (LPN) #227 revealed she documented fluid intake for Resident #4 on paper attached to a clipboard. Continued interview revealed LPN #227 stated Resident #4 was allowed 360 ml per meal and, therefore, LPN #227 charted he received 360 ml per meal. LPN #227 stated Resident #4 did not usually consume all the fluids he was allowed.Observation on 05/05/26 at 5:09 P.M. revealed Resident #4 seated at a table in the dining room. Resident #4 had a large cup of clear liquid and a cup of orange juice. Concurrent interview with Resident #4 revealed he requested soup for dinner. Observation on 05/06/26 at 8:10 A.M. revealed Resident #4 was in the dining room with a glass of orange juice, an empty glass of prune juice, and a cup of coffee. Concurrent interview with Dietary Aide (DA) #207 confirmed the glass of orange juice and the empty glass of prune juice were the same size glass and provided the surveyor with a duplicate sized glass.Interview on 05/06/26 at 4:15 P.M. with Dietary Manager (DM) #280, and concurrent observation of the glass provided by DA #207, revealed the glass held 240 ml of fluid. DM #280 confirmed Resident #4 should receive one 240 ml glass and one 120 ml glass of fluid at each meal. DM #280 further confirmed the coffee cups held 240 ml, for a total of 720 ml of fluids provided to Resident #4 during the breakfast meal. Interview on 05/07/26 at 7:48 A.M. with the Director of Nursing (DON) revealed Resident #4 was on a fluid restriction due to a history of fluid overload requiring hospitalization when the resident resided in the facility's Assisted Living (AL), prior to his admission to the long-term care facility.Interview on 05/07/26 at 8:12 A.M. with Certified Nursing Assistant (CNA) #264 confirmed she documented the amount of fluids residents consumed at meals. Concurrent observation revealed Resident #4 consuming beverages in the dining room. Continued interview with CNA #264 revealed CNA #264 could not estimate the amount of fluids Resident #4 consumed. CNA #264 stated she would document 100 (percent) if residents consumed all the fluids during their meal. CNA #264 further stated she sometimes documented 720 because that was how she was trained. Interview on 05/07/26 at 8:17 A.M. with CNA #245, and concurrent observation of two glasses of fluid in front of Resident #4 revealed CNA #245 could not estimate the amount of fluids in the glasses. CNA #245 identified a cup in front of Resident #4 and stated the covered, spill-proof, single-handled cup held 240 ml. Interview on 05/07/26 at 8:20 A.M. with LPN #227 revealed she did not know the volume of the cup in front of Resident #4 and LPN #227 therefore went to the kitchen and returned with a new cup and the written description for the cup. Continued interview and review of the cup's description revealed the cup, when filled to a specific level, contained seven ounces (approximately 210 ml). LPN #227 confirmed Resident #4's cup was filled above the line and confirmed the cup's instructions provided no guidance for estimating the volume of the cup when filled above the designated level.A follow-up interview on 05/07/26 at 8:51 A.M. with the DON revealed Resident #4 was not compliant with the fluid restriction at times and staff provided education. The DON confirmed no progress notes were documented regarding noncompliance or the provision of staff education.Interview on 05/07/26 at 2:00 P.M. with Registered Dietitian (RD) #300 revealed he was present in the facility one day every other week. RD #300 stated he verbally checked with staff regarding Resident #4's compliance with the fluid restriction. RD #300 stated he was not aware Resident #4 drank coffee with breakfast in addition to two types of juice. RD #300 stated he could not recall talking with Resident #4 about his preferences regarding beverages at meals.Review of the undated policy Fluid Restriction Policy revealed fluid restrictions must be initiated only with a physician/provider order specifying the total daily fluid allowance and any related dietary instructions or monitoring requirements. Additionally, fluid intake shall be monitored and documented according to physician orders and facility policy. Intake and output records shall be completed when ordered or clinically indicated. Further, resident refusals or noncompliance with fluid restrictions shall be documented. The physician/provider and responsible party shall be notified as appropriate based on clinical significance. Also, dietary services shall provide meal plans and beverages consistent with physician/provider orders and communicate any concerns regarding compliance or hydration status to nursing. Additionally, residents on fluid restrictions shall have individualized care plan interventions addressing monitoring, education, risks, resident preferences and compliance strategies as appropriate. Finally, the facility shall monitor compliance with fluid restrictions practices through audits, documentation review, and staff education to support resident safety and regulatory compliance.

Based on observation, medical record review and staff interview, the facility failed to ensure residents received meal textures as physician ordered. This affected two (#37 and #38) of three residents reviewed for altered food textures. The facility census was 56. Findings include: 1. Review of the medical record for Resident #37 revealed an admitted [DATE] with a diagnosis of dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/14/25, revealed Resident #37 had impaired cognition and required set-up or clean-up assistance for eating. Review of a physician order, dated 10/31/24, revealed Resident #37 received a regular diet with mechanical soft textures and ground meats, with regular texture liquids. Also noted in the physician's order was Resident #37 should receive gravy or sauce on all foods, and should receive no skins, seeds, or nuts. Observation on 04/02/25 at 12:10 P.M. revealed Resident #37 seated in the dining room during the noon meal. Resident #37 received ground Salisbury steak, mashed potatoes, and whole peas with diced carrots on his plate. Resident #37 ate his meal without assistance. Observation and interview on 04/02/25 at 12:12 P.M. with Certified Nursing Assistant (CNA) #101 confirmed Resident #37 received peas and was eating them. 2. Review of the medical record for Resident #38 revealed an admitted [DATE] with diagnoses of dementia and dysphagia (difficulty swallowing). Review of the quarterly MDS assessment, dated 02/13/25, revealed Resident #38 was rarely/never understood and required set-up or clean-up assistance for eating. Review of a physician order, dated 11/11/24, revealed Resident #38 received a regular diet with mechanical soft textures and ground meats, with regular texture liquids. Also noted in the physician's order was Resident #38 should receive gravy or sauce on all foods, and should receive no skins, seeds, or nuts. Observation on 04/02/25 at 12:18 P.M., in the dining room, revealed Resident #38 was served a plate with ground Salisbury steak, mashed potatoes, and whole peas and carrots. Concurrent interview with Dietary Aide (DA) #301 confirmed Resident #38 received peas on her tray and confirmed Resident #38's diet ticket stated she should not receive skins, seeds, or nuts. DA #301 stated items with skins would include foods such as grapes or other fruit with skins. Interview on 04/02/25 at 12:37 P.M. with Dietary Manager (DM) #300 revealed food items with skins included corn and dried beans. DM #300 further stated she had no defined list of items to be excluded for residents who should not receive skins, seeds, or nuts with their meals. A telephone interview on 04/02/25 at 12:47 P.M. with Speech Therapist (ST) #200 verified peas would be included as a food item with skin. Further, ST #200 confirmed Resident #37 and Resident #38 should not receive peas. This deficiency represents non-compliance investigated under Complaint Number OH00161460.

Based on observation, interview, and policy review, the facility failed to ensure medications stored in the medication room were not expired. This had the potential to affect all residents who resided in facility. The facility census was 43. Findings include: Observation on [DATE] at 11:09 A.M. of medication storage room revealed 17 bottles of Milk of Magnesia with expiration date of ,d+[DATE], and two bottles of polyethylene glycol with expiration date of ,d+[DATE] in a cupboard hanging on the wall. Observation on [DATE] at 11:15 A.M. and 11:38 A.M. of both medication carts revealed no outdated Milk of Magnesia or polyethylene glycol. Medication cart on the C hall had no Milk of Magnesia. Interview on [DATE] at 11:11 A.M. with Licensed Practical Nurse (LPN #167) verified 17 bottles of Milk of Magnesia were expired as of [DATE], and two bottles of polyethylene glycol were expired as of ,d+[DATE]. Interview on [DATE] at 11:57 A.M. with Registered Nurse (RN #166) verified if the cart did not have Milk of Magnesia they would get it from the medication storage room if available or call the pharmacy if none available in the medication storage room. Interview on [DATE] at approximately 3:45 P.M. with Director of Nursing (DON) verified that every resident had an order for bowel protocol which included if no bowel movement in three days administer Milk of Magnesia per order. Review of policy titled, Storage of Medications revised [DATE] revealed the facility shall not use outdated, discontinued, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on medical record review and staff interview the facility failed to ensure resident assessments were accurately completed. This affected two (#15 and #31) of two residents reviewed for accurate resident assessments. The facility census was 43. Findings include: 1. Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure, hemiplegia affecting left nondominant side, essential hypertension, Alzheimer's disease, major depressive disorder, and acute respiratory failure with hypoxia. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #15 was cognitively intact. The assessment documented Resident #15 was taking an anticoagulant. Review of current physician orders revealed an order dated 09/15/22 for aspirin chewable tablet 81 milligram (mg) with directions to give one tablet by mouth one time a day. 2. Review of the medical record revealed Resident #31 was admitted on [DATE]. Diagnoses included poly-osteoarthritis, unspecified dementia, unspecified osteoarthritis, essential hypertension, type two diabetes mellitus without complications, muscle weakness, fibromyalgia, unspecified dementia, hyperlipidemia, anxiety disorder, and depression. Review of the MDS assessment dated [DATE] revealed Resident #31 was severely cognitively impaired. The assessment documented Resident #31 was taking an anticoagulant. Review of physician orders dated 01/26/23 revealed an order for aspirin tablet delayed release 81 milligram (mg) with directions to give one tablet by mouth at bedtime. Review of physician orders from 01/25/23 to 01/18/24 revealed no medications classified as a anticoagulant were prescribed for Resident #31. Interview on 01/18/24 at 8:33 A.M. with MDS Coordinator #150 verified Resident #15 and #31's physician order for aspirin were miscoded as an anticoagulant.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure resident rooms were maintained in a safe manner. This affected one resident (#2) of three residents reviewed for electrical safety concerns. The facility census was 37. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included weakness, [CONDITION(S)], diabetes mellitus type II, [CONDITION(S)], heart failure, bilateral hearing loss, repeated falls, overactive bladder, dementia with behavioral disturbance, restlessness and agitation, hypertension, asthma and [CONDITION(S)]. Review of a quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident had severe cognitive deficits with no abnormal behaviors. The resident required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene with limited assistance with eating. Observation of each resident room on 03/29/22 between 8:55 A.M. and 9:20 A.M., with Maintenance Director #30 revealed the electric plug was pulled away from the wall by the bed of Resident #2 and had wires exposed. Interview on 03/29/22 at 9:10 A.M. Maintenance Director #30 revealed he had not been informed of the outlet coming away from the wall in Resident #2's room. He stated he checked his maintenance log, but nothing had been documented. He stated staff used his logbook to document any issues he needed to address. He stated this same issue had occurred with Resident #1 about 10 days ago, and it was found the beds were hitting the outlets, which stuck out about three inches and had knocked two loose. Review of facility policy, Preventative Maintenance, dated 04/01/21 revealed staff were to document any maintenance needs in the maintenance log which was kept at the nurses station. Maintenance was to do spot checks on rooms and equipment to assure proper working order. This deficiency substantiates Complaint Number OH 037.

Based on review of the facility trust account statement, review of the facility surety bond and staff interview and record review, the facility failed to have a surety bond sufficient in coverage to protect resident trust account balances. This had the potential to affect all residents, except Residents #1, #12, #25, #27, #134 and #236. The facility census was 37. Findings include: Review of the resident trust account balance statement, dated 04/30/21, revealed the total amount held in trust accounts by the facility totaled $58,744.61. Review of the facility's surety bond, effective 04/01/21, revealed the value of the bond to be $50,000.00. Interview on 05/05/21 at 3:30 P.M. of the Business Office Manager (BOM) #100 verified the facility's surety bond did not provide sufficient coverage for the total in resident trust accounts. She further stated residents received stimulus checks in April 2021, resulting in resident accounts exceeding the surety bond. BOM #100 confirmed 31 out of the 37 residents residing in the facility had personal funds accounts and that Residents #1, #12, #25, #27, #134 and #236 did not have a personal funds account with the facility.

Based on medical record review, staff interview and facility policy review, the facility failed to monitor a residents laboratory levels per the physician orders. This affected one (#20) of five residents reviewed for unnecessary medications. The facility census was 37. Findings include: Review of the medical record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed the annual TSH levels ordered to be completed in April every year was not completed by the facility. Interview on 05/05/21 at 10:48 A.M. the Director of Nursing (DON) verified there was no TSH level completed as per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the undated facility policy titled Medication Monitoring and Management revealed in order to optimize the therapeutic benefit of medication therapy and minimize or prevent adverse consequences the facility and the physician will perform ongoing monitoring for appropriate, effective and safe medication use.

Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to administer insulin as ordered by a physician. This affected one (#18) of five residents reviewed for unnecessary medications. The facility identified four residents with orders for insulin. The census was 37. Findings include: Review of Resident #18's medical record revealed an admitted [DATE]. Diagnoses included [CONDITION(S)] without behavioral disturbances, anxiety disorder, psychotic disorders, diabetes mellitus type I, cardiac arrhythmia, and essential hypertension. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had severely impaired cognitive skills for daily decision making and received insulin injections seven days during the seven day look back period. Review of a diabetic care plan date 03/17/20 revealed Resident #18 was at risk for hyper/hypoglycemic episodes episodes with and intervention dated 06/29/20 to monitor blood sugars and given insulin per sliding scale as ordered by the physician. Review of a physician order dated 01/10/21 revealed Resident #18 was ordered insulin [MEDICATION(S)] via sliding scale subcutaneously three times daily scheduled for 8:00 A.M., 12:00 P.M., and 5:00 P.M. Resident #18 sliding scale was ordered for blood glucose levels between zero and 200 milligrams per deciliter (mg/dL) administer four units of insulin; for blood glucose levels between 201 and 300 mg/dL given six units of insulin; and for blood glucose levels 301 and above given eight units of insulin and repeat blood glucose check in two hours and repeat sliding scale if the blood glucose level was above 200 mg/dL. Review of the January 2021 medication administration record (MAR) revealed on 01/11/21 at 12:00 P.M. Resident #18's blood glucose level was 395 mg/dL. Review of Resident #18's vital signs in the electronic health record (EHR) revealed Resident #18's blood glucose level was rechecked on 01/11/21 at 2:09 P.M. and was 315 mg/dL. There was no documentation on the MAR of Resident #18 receiving any additional insulin with a rechecked blood glucose level above 200 mg/dL per the physician order. Review of the February 2021 MAR revealed on 02/13/21 at 8:00 A.M. Resident #18's blood glucose level was 307 mg/dL. Review of Resident #18's vital signs in the EHR revealed Resident #18's blood glucose level was rechecked at 10:00 A.M. and was 316 mg/dL. There was no documentation of additional units of insulin given to Resident #18 at this time. Further review of the February 2021 MAR revealed Resident #18's blood glucose level on 02/14/21 at 12:00 P.M. was 357 mg/dL. Review of Resident #18's vital signs in the EHR revealed Resident #18's blood glucose level was recheck at 1:30 P.M. and was 237 mg/dL. There was no documentation of Resident #18 receiving any additional units of insulin at this time as ordered. Review of the March 2021 MAR revealed on 03/04/21 at 12:00 P.M. Resident #18's blood glucose level was 331 mg/dL. Review of Resident #18's vital signs in the EHR revealed Resident #18's blood glucose level was rechecked at 1:45 P.M. and was 239 mg/dL. There was no documentation of additional units of insulin given to Resident #18 at this time. Review of the nursing progress notes dated between 01/01/21 and 03/31/21 revealed no documentation of Resident #18 receiving any additional units of insulin on 01/11/21, 02/13/21, 02/14/21, or 03/04/21 after Resident #18's initial blood glucose levels were 301 mg/dL or above, and after it was rechecked as ordered, Resident #18's blood glucose level was above 200 mg/dL. Resident #18 experienced no acute changes in condition and required no additional medical interventions during this time frame. Observation on 05/04/21 at 10:58 A.M., 1:23 P.M., and 4:17 P.M., and on 05/05/21 at 8:47 A.M., 11:40 A.M., and 2:03 P.M. revealed Resident #18 was free from any distress or discomfort. Resident #18 was not observed experiencing any outward signs or symptoms of [CONDITION(S)]. Interview on 05/05/21 at 2:29 P.M. with Licensed Practical Nurse (LPN) #490 verified Resident #18's insulin [MEDICATION(S)] sliding scale order contained instructions if Resident #18's blood glucose level was 301 mg/dL or above the nurse was to recheck her blood glucose level two hours later and if the recheck blood glucose level was 200 mg/dL or above to restart the sliding scale. LPN #490 stated nurse usually documented the blood glucose levels on the MAR's but could also document them in a progress note or in the vital signs tab in the electronic health record. LPN #490 verified there was no documentation on the January, February, or March 2021 MAR's or in nursing progress of Resident #18 receiving any additional insulin as ordered on 01/11/21, 02/13/21, 02/14/21, and 03/04/21 when her initial blood glucose levels were at or above 301 mg/dL and recheck blood glucose levels were above 200 mg/dL. Interview on 05/06/21 at 8:14 A.M. with Director of Nursing (DON) #1 verified there was no place for nurses to document on Resident #18's January, February, or March 2021 MAR's when the blood glucose levels were rechecked, and if the level was above 200 mg/dL, there was no place to document additional insulin doses given. DON #1 verified there was no documentation of additional insulin doses given per the physician ordered sliding scale when Resident #18's rechecked blood glucose levels were above 200 mg/dL on 01/11/21, 02/13/21, 02/14/21, and 03/04/21. Review of an undated facility policy titled, Insulin Administration, revealed the type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's orders. Staff should check blood glucose per physician order or facility policy and document the resident's blood glucose result as ordered and also document the dose of the insulin injection.

Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure fall interventions were in place as care planned and as ordered by a physician. This affected one (#234) of three residents reviewed for accidents. The facility identified four residents with orders for personal alarms. The census was 37. Findings include: Review of Resident #234's medical record revealed an admitted [DATE]. Diagnoses included unspecified severe protein malnutrition, chronic [CONDITION(S)], chronic kidney disease, anxiety, and [CONDITION(S)]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #234 was cognitively impaired and required an extensive two-plus persons physical assistance for bed mobility and transfers. Review of an admission nursing assessment dated [DATE] revealed Resident #234 had an unsteady gait and poor balance and required staff assistance with bed mobility and transfers. Review of an admission fall risk assessment revealed Resident #234 was assessed at high risk for falls. Review of a fall risk care plan dated 04/30/21 revealed Resident #234 had a potential for falls related to a history of falling and a balance deficit. There was an intervention implemented on 05/04/21 for Resident #234 to have a clip alarm on when up in a chair. Review of a physician order dated 05/04/21 revealed Resident #234 was ordered a clip alarm when in a chair to alert staff of unassisted attempts to transfer. Observation on 05/04/21 at 2:43 P.M. revealed Resident #234 sitting in a wheelchair in the common area near the dining room on the Memory Lane hall. There was no clip alarm noted to Resident #234's body, clothing, or wheelchair. Further observation revealed two staff members sitting at a table in the common area within ten feet of Resident #234. Observation on 05/04/21 at approximately 2:55 P.M. revealed both staff members sitting at the table got up from the area and walked down the Memory Lane hall leaving Resident #234 unattended with no clip alarm on. There were no other staff members in the immediate area and Resident #234 was not visible to other staff members working further down the Memory Lane hall or on other halls of the facility. Observation on 05/04/21 at approximately 3:00 P.M. revealed a stated tested nurses aide (STNA) passing ice and water to residents on the Memory Lane further down the hallway away from Resident #234's location. From where the STNA was located in the hallway Resident #234 could not be seen. Interview on 05/04/21 at 3:02 P.M. with STNA #378 verified Resident #234 should have an alarm on when she was up in her wheelchair, and after walking down the hallway toward Resident #234's location, STNA #378 verified Resident #234 did not have an alarm on her body, clothing, or wheelchair. Review of an undated policy titled, Managing Falls and Fall Risk, 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 try to minimize complications from falling. The staff with input of the attending physician will identify appropriate interventions to reduce the risk of falls. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to obtain a resident's blood glucose levels as ordered by a physician. This affected one (#18) of five residents reviewed for unnecessary medications. The facility identified four residents with orders for blood glucose monitoring. The census was 37. Findings include: Review of Resident #18's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had severely impaired cognitive skills for daily decision making and received insulin injections seven days during the seven day look back period. Review of a diabetic care plan date 03/17/20 revealed Resident #18 was at risk for hyper/hypoglycemic episodes episodes with and intervention dated 06/29/20 to monitor blood sugars and given insulin per sliding scale as ordered by the physician. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 12:00 P.M., and 5:00 P.M. Resident #18 sliding scale was ordered for blood glucose levels between zero and 200 milligrams per deciliter (mg/dL) administer four units of insulin; for blood glucose levels between 201 and 300 mg/dL given six units of insulin; and for blood glucose levels 301 and above given eight units of insulin and repeat blood glucose check in two hours and repeat sliding scale if the blood glucose level was above 200 mg/dL. Review of the January 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Resident #18's blood glucose level was 346 mg/dL; on 01/21/21 at 12:00 P.M. Resident #18's blood glucose levels was 308 mg/dL; and on 01/22/21 at 12:00 P.M. Resident #18's blood glucose level was 343 mg/dL. There was no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Resident #18's blood glucose level was 322 mg/dL; on 02/03/21 at 12:00 P.M. Resident #18's blood glucose level was 339 mg/dL and on 02/13/21 at 12:00 P.M. Resident #18's blood glucose level was 346 mg/dL. There was no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's nursing progress notes and blood glucose levels documented in the electronic health record under vital signs dated between 01/01/21 and 02/28/21 revealed no documentation of Resident #18's blood glucose levels being rechecked as ordered by the physician on 01/16/21, 01/21/21, 01/22/21, on 02/01/21, on 02/03/21, and on 02/13/21 after Resident #18's blood glucose levels were 301 mg/dL or above. Further review of the nursing progress notes revealed Resident #18 did not experience any changes in condition during this time frame and no additional medical interventions were implemented. Observation on 05/04/21 at 10:58 A.M., 1:23 P.M., and 4:17 P.M., and on 05/05/21 at 8:47 A.M., 11:40 A.M., and 2:03 P.M. revealed Resident #18 was free from any distress or discomfort. Resident #18 was not observed experiencing any outward signs or symptoms of [CONDITION(S)]. Interview on 05/05/21 at 2:29 P.M. with Licensed Practical Nurse (LPN) #490 verified Resident #18's insulin [MEDICATION(S)] sliding scale order contained instructions if Resident #18's blood glucose level was 301 mg/dL or above the nurse was to recheck her blood glucose level two hours later and if the recheck blood glucose level was 200 mg/dL or above to restart the sliding scale. LPN #490 stated nurse usually documented the blood glucose levels on the MAR's but could also document them in a progress note or in the vital signs tab in the electronic health record. LPN #490 verified there was no documentation on the January or February 2021 MAR's or in nursing progress of Resident #18's blood glucose level being rechecked as ordered on 01/16/21, 01/21/21, 01/22/21, on 02/01/21, on 02/03/21, and on 02/13/21 after Resident #18's blood glucose levels were 301 mg/dL or above. Interview on 05/06/21 at 8:14 A.M. with Director of Nursing (DON) #1 verified there was no place for nurses to document on Resident #18's January and February 2021 MAR's when the blood glucose levels were to be rechecked if the level was 301 mg/dl or above. DON #1 verified there was no documentation for blood glucose level rechecks as ordered for Resident #1 on 01/16/21, 01/21/21, 01/22/21, on 02/01/21, on 02/03/21, and on 02/13/21. Review of an undated facility policy titled, Insulin Administration, revealed staff should check blood glucose per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on document review, staff interview and facility policy review, the facility failed to have a Quality Assessment and Assurance Committee (QAA) meeting at least quarterly in the last 12 months. This had the potential to affect 37 of 37 facility residents. The facility census was 37. Findings include: Review of the a document titled Class Attendance Record for Quality Assurance and Performance Improvement (QA/QAPI) dated 04/30/21 revealed the facility did hold one QAA meeting in the last 12 months. Interview on 05/05/21 at 11:44 A.M. with Director of Nursing (DON) she stated the facility held QAA meetings over the last year however the the prior Administrator never had anyone sign in. DON verified there were no QAA meeting sign in sheets and no evidence the facility had held the required minimum meetings. Interview on 05/06/21 at 11:54 A.M. with the current Administrator stated she was hired at the facility on 04/15/21. Administrator verified she held a QAA on 04/30/21. Administrator verified she was not able to locate any signature logs for staff who attended QAA/QAPI meetings held in the last year. Review of the facility policy titled Quality Assurance Performance Improvement Plan dated April 2021 revealed the QAA committee meets quarterly.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, review of a hospital report, review of an employee personnel file, review of employee education and in-service records, review of facility audits of resident transfers, review of facility audits of mechanical lift functional components, and review of the facility policy, the facility failed to safely transfer a resident as care planned and per facility policy. This resulted in actual harm when Resident #5 suffered a fracture to her right radius, a possible fracture of her left wrist, a laceration to her forehead requiring staples, and large skin tears to her left and right forearms following an improper transfer by facility staff. This affected one (#5) of three residents reviewed for accidents. The facility identified 11 residents who required a mechanical lift for transfers. The total facility census was 30. Findings include: Review of Resident #5's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #5 was discharged on [DATE]. Review of the most recently completed Minimum Data Set (MDS) assessment completed 08/14/20, revealed Resident #5 had severely impaired cognition, required extensive two-plus person physical assistance with transfers, and had one fall with major injury since admission or prior assessment. Review of fall risk assessments completed on 05/29/20, 08/03/20, and 08/10/20, revealed Resident #5 was a high risk for falling. Review of a fall care plan dated 03/21/18, revealed Resident #5 had a history of [REDACTED]. The care plan was updated on 08/03/20, to include two staff members were required when transferring Resident #5 with a hoyer lift. Review of a nursing progress note dated 08/01/20, revealed Resident #5 fell forward and to the right out of the hoyer lift during a transfer. Two large skin tears were observed on both of Resident #5's arm and a bleeding laceration was noted to her right temple. Resident #5 moaned when her right arm was moved and Resident #5 was taken to the hospital Review of hospital documentation dated 08/01/20, revealed Resident #5 fractured her right radius and possibly fractured her left wrist. Resident #5 had a laceration to her right forehead with well approximated staples. Resident #5 sustained a skin tear to her left forearm measuring 5.5 centimeters (cm) long by 5.7 cm wide with a large bruise from her elbow to her fingers on the dorsal side of the left forearm. Resident #5 sustained a skin tear to her right forearm measuring 8 cm long by 3.5 cm wide with a 5 cm long by 1.5 cm wide area to the proximal aspect of the wound. There was also a 7.5 cm long by 1 cm wide area at the distal end of the right forearm that wrapped around the forearm. Review of a nursing progress note dated 08/01/20, revealed Resident #5 returned to the facility with right and left wrist fractures with splints applied and nine staples on her face. Review of Licensed Practical Nurse (LPN) #100's personnel file revealed a hire date of 05/31/18, as a State tested Nurse Aide (STNA). LPN #100 was moved from an STNA to a LPN on 11/22/20. Review of an employee discipline document revealed LPN #100 performed a serious violation of safety rules when on 08/01/20, she utilized a mechanical lift by herself to transfer Resident #5. The mechanical lift was to be used by two people and the outcome of the unsafe practice resulted in Resident #5 fracturing both wrists. Interview on 01/04/20 at 10:04 A.M. with Director of Nursing (DON) #1, stated two staff were needed in order to transfer a resident using a mechanical lift. Interview on 01/04/20 at 10:44 A.M. with LPN #100, verified she transferred Resident #5 by herself on 08/01/20, with a mechanical lift when Resident #5 fell . Review of a facility policy titled, Hoyer lift (Mechanical Lift), dated June 2006, revealed all resident transfers completed by means of a mechanical lift will be done with two nursing staff members (nursing assistants or nurses) in attendance at all times As a result of the incident, the facility took the following action to correct the deficient practice by 08/14/20: 1. On 08/01/20, review of the personnel file for LPN #100, revealed she received written discipline, was immediately suspended during the investigation, and received education regarding using two staff members for all mechanical lift transfers. 2. On 08/01/20, review of inservice records revealed all staff members were in-serviced on using two staff members at all times for mechanical lift transfers. Staff were also educated to check hoyer slings for frays and holes and secure all hoyer sling loops and double check the connection before transferring a resident. 3. On 08/03/20, review of a post-fall hoyer lift inspection was completed by the facility with no concerns. All facility mechanical lifts continued on monthly inspections by the facility on 08/10/20, 09/03/20, 10/14/20, 11/06/20, and 12/09/20 with no concerns. 4. Review of audits of residents transfers for 08/02/20, 08/03/20, 08/05/20, 08/07/20, 08/11/20, and 08/14/20, revealed all transfers completed using the appropriate level of assistance with no resident injuries noted. There were no other residents who sustained a fall from a mechanical lift since 08/01/20. This deficiency substantiated Complaint Number OH 807.

Based on record review, staff interview, review of self-reported incidents, review of an employee personnel file, and review of a facility policy, the facility failed to report an allegation of neglect involving Resident #5 to the State Survey Agency. This affected one (Resident #5) of three residents reviewed for accidents. The total facility census was 30. Findings include: Review of Resident #5's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #5 was discharged on [DATE]. Review of the most recently completed Minimum Data Set (MDS) assessment completed 08/14/20, revealed Resident #5 had severely impaired cognition, required extensive two-plus person physical assistance with transfers, and had one fall with major injury since admission or prior assessment. Review of fall risk assessments completed on 05/29/20, 08/03/20, and 08/10/20, revealed Resident #5 was a high risk for falling. Review of a fall care plan dated 03/21/18, revealed Resident #5 had a history of [REDACTED]. The care plan was updated on 08/03/20 to include two staff members were required when transferring Resident #5 with a hoyer lift. Review of a nursing progress note dated 08/01/20, revealed Resident #5 fell forward and to the right out of the hoyer lift during a transfer. Two large skin tears were observed on both of Resident #5's arm and a bleeding laceration was noted to her right temple. Resident #5 moaned when her right arm was moved and Resident #5 was taken to the hospital Review of hospital documentation dated 08/01/20, revealed Resident #5 fractured her right radius and possibly fractured her left wrist. Resident #5 had a laceration to her right forehead with well approximated staples. Resident #5 sustained a skin tear to her left forearm measuring 5.5 centimeters (cm) long by 5.7 cm wide with a large bruise from her elbow to her fingers on the dorsal side of the left forearm. Resident #5 sustained a skin tear to her right forearm measuring 8 cm long by 3.5 cm wide with a 5 cm long by 1.5 cm wide area to the proximal aspect of the wound. There was also a 7.5 cm long by 1 cm wide area at the distal end of the right forearm that wrapped around the forearm. Review of a nursing progress note dated 08/01/20, revealed Resident #5 returned to the facility with right and left wrist fractures with splints applied and nine staples on her face. Review of Licensed Practical Nurse (LPN) #100's personnel file revealed a hire date of 05/31/18, as a State tested nurse aide (STNA). LPN #100 was moved from an STNA to a LPN on 11/22/20. Review of an employee discipline document revealed LPN #100 performed a serious violation of safety rules when on 08/01/20, she utilized a mechanical lift by herself to transfer Resident #5. The mechanical lift was to be used by two people and the outcome of the unsafe practice resulted in Resident #5 fracturing both wrists. Interview on 01/04/20 at 10:04 A.M. with Director of Nursing (DON) #,1 stated two staff were needed in order to transfer a resident using a mechanical lift. Interview on 01/04/20 at 10:44 A.M. with LPN #100, verified she transferred Resident #5 by herself on 08/01/20 with a mechanical lift when Resident #5 fell . Review of facility self-reported incidents submitted by the facility between 05/07/20 and 08/24/20, revealed the facility did not submit the investigation of LPN #100 transferring Resident #5 with a hoyer lift by herself resulting in serious injuries. Interview on 01/04/20 at 2:27 P.M. with the Administrator, verified the facility did not submit the investigation to the state agency related to Resident #5's fall with injuries as a result of LPN #100 transferring her in a mechanical lift by herself. Review of a facility policy titled, Resident Mistreatment, Neglect, Abuse, and Misappropriation of Property, dated June 2018, revealed it was the policy of the facility that each resident will be free from abuse. Abuse can include mistreatment, neglect, misappropriation of resident funds and property, exploitation, verbal, mental, sexual or physical abuse, corporal punishment, or involuntary seclusion, and any physical or chemical restraint not required to treat the resident's symptoms. All reported incidents of alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported to the Administrator immediately, investigated and reported per state and federal law (typically within 24 hours of witness/identification). Written results of investigations (including criminal, abuse, neglect, injuries of unknown etiology and misappropriation of resident property) are reported by the administrator to other officials in accordance with local, state, and federal law (including the state survey and certification agency, adult protective services (APS), etc.) within five (5) working days of the incident. This deficiency was an incidental finding discovered during the course of this complaint investigation.

Based on record review, review of hospital documentation, staff interview, review of self-reported incidents, review of an employee personnel file, and review of a facility policy, the facility failed to implement their abuse policy when they did not report an allegation of neglect involving Resident #5 to the State Agency. This affected one (#5) of three residents reviewed for accidents. The total facility census was 30. Findings include: Review of Resident #5's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #5 was discharged on [DATE]. Review of the most recently completed Minimum Data Set (MDS) assessment completed 08/14/20, revealed Resident #5 had severely impaired cognition, required extensive two-plus person physical assistance with transfers, and had one fall with major injury since admission or prior assessment. Review of fall risk assessments completed on 05/29/20, 08/03/20, and 08/10/20, revealed Resident #5 was a high risk for falling. Review of a fall care plan dated 03/21/18, revealed Resident #5 had a history of [REDACTED]. The care plan was updated on 08/03/20, to include two staff members were required when transferring Resident #5 with a hoyer lift. Review of a nursing progress note dated 08/01/20, revealed Resident #5 fell forward and to the right out of the hoyer lift during a transfer. Two large skin tears were observed on both of Resident #5's arm and a bleeding laceration was noted to her right temple. Resident #5 moaned when her right arm was moved and Resident #5 was taken to the hospital Review of hospital documentation dated 08/01/20, revealed Resident #5 fractured her right radius and possibly fractured her left wrist. Resident #5 had a laceration to her right forehead with well approximated staples. Resident #5 sustained a skin tear to her left forearm measuring 5.5 centimeters (cm) long by 5.7 cm wide with a large bruise from her elbow to her fingers on the dorsal side of the left forearm. Resident #5 sustained a skin tear to her right forearm measuring 8 cm long by 3.5 cm wide with a 5 cm long by 1.5 cm wide area to the proximal aspect of the wound. There was also a 7.5 cm long by 1 cm wide area at the distal end of the right forearm that wrapped around the forearm. Review of a nursing progress note dated 08/01/20, revealed Resident #5 returned to the facility with right and left wrist fractures with splints applied and nine staples on her face. Review of Licensed Practical Nurse (LPN) #100's personnel file revealed a hire date of 05/31/18, as a State tested Nurse Aide (STNA). LPN #100 was moved from an STNA to a LPN on 11/22/20. Review of an employee discipline document revealed LPN #100, performed a serious violation of safety rules when on 08/01/20, she utilized a mechanical lift by herself to transfer Resident #5. The mechanical lift was to be used by two people and the outcome of the unsafe practice resulted in Resident #5 fracturing both wrists. Interview on 01/04/20 at 10:04 A.M. with Director of Nursing (DON) #1, stated two staff were needed in order to transfer a resident using a mechanical lift. Interview on 01/04/20 at 10:44 A.M. with LPN #100, verified she transferred Resident #5 by herself on 08/01/20 with a mechanical lift when Resident #5 fell . Review of the facility self-reported incidents submitted by the facility between 05/07/20 and 08/24/20, revealed the facility did not submit the investigation of LPN #100 transferring Resident #5 with a hoyer lift by herself resulting in serious injuries. Interview on 01/04/20 at 2:27 P.M. with the Administrator, verified the facility did not submit the investigation to the State Agency related to Resident #5's fall with injuries as a result of LPN #100 transferring her in a mechanical lift by herself. Review of a facility policy titled, Resident Mistreatment, Neglect, Abuse, and Misappropriation of Property, dated June 2018, revealed it was the policy of the facility that each resident will be free from abuse. Abuse can include mistreatment, neglect, misappropriation of resident funds and property, exploitation, verbal, mental, sexual or physical abuse, corporal punishment, or involuntary seclusion, and any physical or chemical restraint not required to treat the resident's symptoms. All reported incidents of alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported to the Administrator immediately, investigated and reported per state and federal law (typically within 24 hours of witness/identification). Written results of investigations (including criminal, abuse, neglect, injuries of unknown etiology and misappropriation of resident property) are reported by the administrator to other officials in accordance with local, state, and federal law (including the state survey and certification agency, adult protective services (APS), etc.) within five (5) working days of the incident. This deficiency was an incidental finding discovered during the course of this complaint investigation.

Based on review of a facility policy and staff interview, the facility failed to implement a risk assessment and water management program for the prevention and spread of Legionella. This had the potential to affect all residents. The facility census was 44. Findings include: Review of the facility policy titled Water Management Program, dated 11/17, revealed the facility water management program will include, at a minimum, an initial evaluation of the building water system, and based on that analysis, will complete a water system infection control risk assessment. The program may include disinfectant level controls and specify testing protocols and acceptable ranges for control measures. The facility failed to provide evidence of a risk assessment or water management program. Interview on 09/05/19 at 11:00 [NAME]M. with the Administrator revealed the facility did not have a water management program in place to monitor for Legionella. He further verified the facility did not have a risk assessment completed. He verified the facility did not have a flow sheet to identify potential areas of concern and the facility and was not completing any water testing protocols.

Based on review of the Quality Assessment and Assurance meeting sign-in sheets and staff interview, the facility failed to ensure the medical director attended the Quality Assessment and Assurance meeting on a quarterly basis. This had the potential to effect all 44 residents residing in the facility. Findings include: Review of the Quality Assessment and Assurance meeting sign-in sheets for July, August, September, November, and (MONTH) 2019 revealed no medical director signature. The (MONTH) 2019 meeting was not held due to Administrator illness. Interview on 09/05/19 at 11:00 [NAME]M., the Administrator verified the Medical Director had not attended the required quarterly meetings.