Every finding on record at West View Healthy Living

Based on observation, interview, and record review, the facility failed to ensure isolation precautions were followed for Resident #7 and #25, and failed to properly monitor Resident #74's stools to ensure proper precautions were in place for Clostridioides Difficile. This affected three residents (Resident #7, Resident #25, and Resident #74) and had the potential to affect all 87 residents residing in the facility. Findings include: 1. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including but not limited to lung cancer, muscle wasting, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had moderately impaired cognition and required partial assistance for activities of daily living. Review of Resident #25's physician's orders for January 2025 revealed on 01/25/25 droplet precautions were ordered to be maintained while COVID positive. Observation on 01/27/24 at 9:28 A.M. revealed Resident #25 had personal protective equipment outside her door. There was no sign on the door to alert staff that Resident #25 was on isolation precautions. Interview at time of observation with Certified Nursing Assistant (CNA) #256 verified Resident #25 did not have a sign on the door about what precautions should be taken and stated Resident #25 just tested positive for COVID recently. 2. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including but not limited to dementia, anxiety disorder, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had intact cognition and required substantial assistance for activities of daily living. Review of Resident #7's physician's orders for January 2025 revealed on 01/24/25 droplet precautions were ordered to be maintained while COVID positive. Observation on 01/27/24 at 12:20 P.M. revealed Certified Nursing Assistant (CNA) #256 delivered a lunch tray to Resident #7. CNA #256 donned (put on) a gown, N95 mask, and gloves, and went into the room without a face shield on. CNA #256 stated she has used a face shield going into Resident #7's room before. An interview on 01/29/25 at 9:57 A.M. with Infection Control Preventionist (ICP) #103 revealed she did not in-service staff on personal protective equipment (PPE) since the new cases of COVID in the facility occurred. ICP #103 revealed [NAME] someone had COVID and were on droplet isolation precautions a sign must be put in place on the door for residents with COVID. Review of the facility policy dated 09/23/20 with a revision date 01/03/24 titled, COVID-19 Testing, Isolation and Masking, revealed all necessary PPE will be required while giving care to a COVID positive resident. Review of the Centers for Disease Control and Prevention (CDC) guidelines dated 06/24/24 titled, Infection Control Guidance: SARS-COV-2, revealed that instruction should be provided before entering room and healthcare personnel who enter a room of a resident with SARS-CoV-2 infection should wear use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 43063 3. Review of the medical record for Resident #74 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, dementia and need for assistance with personal care. Review of the laboratory testing for Resident #74 revealed she was positive for Clostridioides Difficile (C. diff) on 07/26/24, 09/04/24 and 11/01/24. Review of Resident #74's physician's orders revealed she had Vancomycin (antibiotic) for C. diff ordered from 07/27/24 through 08/06/24; 09/06/24 through 10/18/24; and 11/02/24 through 02/07/25. Resident #74 had an order for contact precautions due to C. diff, discontinue if results were negative, dated 11/01/24 and discontinued on 11/12/24. Review of the quarterly 3.0 Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 had impaired cognition, needed substantial-maximum assistance for toileting and was frequently incontinent of bowel. Review of the vitals report for Resident #74's bowel movements dated from 11/01/24 through 01/28/25 revealed the facility staff only documented the size of her bowel movements and not the consistency of bowel movements a total of 84 times. It was noted as optional for staff to document the consistency with every bowel movement. However, Resident #74 was noted to have loose stools on the following dates: -11/13/24, one loose stool -11/14/24, one loose stool -11/21/24, one loose stool -11/24/24, one loose stool -11/25/24, one loose stool -11/26/24, one loose stool -12/13/24, one loose stool -12/20/24, one loose stool -12/22/24, one loose stool -01/04/25, three loose stools -01/15/25, one loose stool -01/19/25, one loose stool Review of the care plan dated 11/03/24 for Resident #74 revealed she had diarrhea related to C. diff. Interventions included contact precautions per protocol. Review of the nursing progress notes revealed on 11/27/24 Resident #74 continued on Vancomycin due to reoccurring C. diff. Review of the physician progress note dated 01/07/25 for Resident #74 revealed she was being seen for her monthly visit. She was noted to be on Vancomycin for recurrent C. diff. There were no significant concern for diarrhea. Observations during the annual survey on 01/27/25 at 9:51 A.M., 01/27/25 at 10:00 A.M, 01/28/25 at 9:05 A.M. and 01/28/25 at 11:06 A.M. of Resident #74 revealed she was sitting by the nurse's station. Her room was across from the nurse's station and it was observed that she did not have personal protective equipment (PPE) outside or inside of the room nor was there a sign stating Resident #74 was on contact isolation. Interview on 01/27/25 at 3:38 P.M. with Registered Nurse (RN) #292 revealed she was an agency nurse and it was the first day she had worked at the facility. She stated she had not received in report Resident #74 was being treated with Vancomycin for C. diff. She stated she did not know if she was on isolation. She verified there was no signage or PPE present at Resident #74's room. Interview on 01/27/25 at 4:10 P.M. with the Director of Nursing (DON) verified Resident #74 had been positive for C. diff in November but had since been cleared. She stated she was not having symptoms since she was discontinued off of isolation on 11/12/24. She stated the physician had Resident #74 on a long-term taper of the antibiotic to ensure she did not get C. diff again. Reviewed the vital tracking of Resident #74's bowel movements and the DON verified it was optional for staff to mark the bowel consistency when charting on a resident's bowel movements. She stated staff should have reported to the nurse if Resident #74 had diarrhea. However, she verified there was the potential of staff not reporting to the nursing on duty and without complete documentation of symptoms, signs and symptoms of C. diff could have been missed. Interview on 01/28/25 at 12:53 P.M. with Licensed Practical Nurse (LPN) #103, who was also the infection preventionist, verified Resident #74 was being treated for C. diff. She stated Resident #74 had not been on contact isolation since 11/12/24. She stated she was unaware that Resident #74 had loose stools since November 2024, including three loose stools on 01/04/25. Interview on 01/28/25 at 1:43 P.M. with Nurse Practitioner (NP) #293 verified she was not updated on Resident #74 having three loose stools on 01/04/25. Review of the facility policy titled, Isolation, Categories of Transmission-Based Precautions, dated 04/01/20, revealed contact precautions would be implemented for residents known or suspected to be infected with microorganisms that could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Review of the facility policy titled, Clostridioides Difficile, revised October 2024, revealed that C. diff was suspected in residents with acute, unexplained onset of diarrhea (three or more unformed stools within 24 hours). Residents with diarrhea and suspected with C. diff would be placed on contact precautions.

Based on record review and staff interview the facility failed to ensure residents received interest on resident funds greater than 100 dollars. This affected seven (Residents #5, #13, #20, #26, #30, #38 and #187) of seven residents reviewed for personal funds with the potential to affect all 16 residents whose funds were managed by the facility. The facility census was 87. Findings include: 1. Review of the medical record for Resident #5 revealed an admitted [DATE] and a readmitted [DATE]. Review of the quarterly statement from 07/01/2 through 09/30/24 revealed a balance of $983.31. No interest was noted credited to Resident #5's account during these three months. Review of the quarterly statement from 10/01/24 through 12/31/24 revealed that Resident #5 was given interest. Interview on 01/27/25 at 5:00 P.M. with Assistant Business Office Manager (ABOM) #193 revealed interest is only given at the end of the year. ABOM #193 verified Resident #5 did not receive interest within the quarter from 07/01/2 through 09/30/24. 2. Review of the medical record for Resident #13 revealed an admitted [DATE] and a readmitted [DATE]. Review of the quarterly statement from 07/01/2 through 09/30/24 revealed a balance of $797.12. No interest was noted credited to Resident #13's account during these three months. Review of the quarterly statement from 10/01/24 through 12/31/24 revealed that Resident #13 was given interest. Interview on 01/27/25 at 5:00 P.M. with ABOM #193 revealed interest is only given at the end of the year. ABOM #193 verified Resident #13 did not receive interest within the quarter from 07/01/2 through 09/30/24. 3. Review of the medical record for Resident #20 revealed an admitted [DATE] and a readmitted [DATE]. Review of the quarterly statement from 07/01/2 through 09/30/24 revealed a balance of $2,078.30. No interest was noted credited to Resident #20's account during these three months. Review of the quarterly statement from 10/01/24 through 12/31/24 revealed that Resident #20 was given interest. Interview on 01/27/25 at 5:00 P.M. with ABOM #193 revealed interest is only given at the end of the year. ABOM #193 verified Resident #20 did not receive interest within the quarter from 07/01/2 through 09/30/24. 4. Review of the medical record for Resident #26 revealed an admitted [DATE] and a readmitted [DATE]. Review of the quarterly statement from 07/01/2 through 09/30/24 revealed a balance of $2,255.20. No interest was noted credited to Resident #26's account during these three months. Review of the quarterly statement from 10/01/24 through 12/31/24 revealed that Resident #26 was given interest. Interview on 01/27/25 at 5:00 P.M. with ABOM #193 revealed interest is only given at the end of the year. ABOM #193 verified Resident #26 did not receive interest within the quarter from 07/01/2 through 09/30/24. 5. Review of the medical record for Resident #30 revealed an admitted [DATE]. Review of the quarterly statement from 07/01/2 through 09/30/24 revealed a balance of $1,939.10. No interest was noted credited to Resident #30's account during these three months. Review of the quarterly statement from 10/01/24 through 12/31/24 revealed that Resident #30 was given interest. Interview on 01/27/25 at 5:00 P.M. with ABOM #193 revealed interest is only given at the end of the year. ABOM #193 verified Resident #30 did not receive interest within the quarter from 07/01/2 through 09/30/24. 6. Review of the medical record for Resident #38 revealed an admitted [DATE]. Review of the quarterly statement from 07/01/2 through 09/30/24 revealed a balance of $250.00. No interest was noted credited to Resident #38's account during these three months. Review of the quarterly statement from 10/01/24 through 12/31/24 revealed that Resident #30 was given interest. Interview on 01/27/25 at 5:00 P.M. with ABOM #193 revealed interest is only given at the end of the year. ABOM #193 verified Resident #38 did not receive interest within the quarter from 07/01/2 through 09/30/24. 7. Review of the medical record for Resident #187 revealed an admitted [DATE] and a discharged date of 10/18/24. Review of the quarterly statement from 07/01/2 through 09/30/24 revealed a balance of $571.00. No interest was noted credited to Resident #187's account during these three months. Review of the quarterly statement from 10/01/24 through 12/31/24 revealed that Resident #26 was given interest. Interview on 01/27/25 at 5:00 P.M. with ABOM #193 revealed Resident #187 did not receive any interest because she left the facility before the end of the year. ABOM #193 stated interest is only given at the end of the year. ABOM #193 verified Resident #187 did not receive interest within the quarter from 07/01/2 through 09/30/24. Review of the undated facility policy titled, Residents Personal Account Policy and Procedure, revealed that interest on the account is prorated among account holders based upon the amount that is being maintained at the end of each month.

Based on observation, interview, and record review the facility did not ensure oxygen tubing was dated and changed as required. This affected three residents (Residents #38, #59, and #71) out of five residents on respiratory care. The facility census was 87. Findings include: 1. Resident #59 was admitted to the facility on [DATE] with diagnoses including but not limited to chronic respiratory failure with hypoxia, unspecified dementia with unspecified severity and with other behavioral disturbances and chronic obstructive pulmonary disease (COPD). Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 was cognitively intact. She required substantial and partial assistance for all activities of daily living. Resident #59 had an order dated 11/13/24 and was open ended for oxygen at two liters per minute (lpm) via nasal cannula continuous at bedtime to maintain pulse oxygenation level of 90% or higher at bed time 6:00 P.M. through 11:00 P.M. Review of the care plan dated 11/20/24 revealed Resident #59 has the potential for shortness of breath (SOB), fluid retention, weight gain, stroke, dizziness/lightheadedness, facial flushing, headaches, pallor, wheezing, loss of appetite, pulmonary edema, arrhythmia's, sleep apnea and decreased kidney function related to chronic diastolic congestive heart failure (CHF), atrial fibrillation, hypertension, aortic stenosis, cardiac murmur, tachycardia, hyperlipidemia and peripheral vascular disease. Also, Resident #59 has a care plan for potential arrhythmia's, CHF, pneumonia (PNE), weight loss/malnutrition, decreased oxygen saturation of pulse (SP02), abnormal lung sounds, shortness of breath, anxiety, increased confusion, discoloration of skin/nail beds, elevated heart beat, increased and shallow respirations related to diagnosis of chronic hypoxic respiratory failure, COPD and wheezing. Her goal is to maintain a SPO2 at 90% or greater. Observed for signs of ineffective breathing pattern (dyspnea, tachypnea, cyanosis, use of accessory muscles, change in respiratory rate/pattern and tachycardia. Keep head of bed up as needed. administer oxygen (O2) as ordered. Observe for increased need for O2 and notify physician. Monitor vital signs including pulse oximetry per protocol and as needed (PRN) and report any abnormal findings to the physician. Observation on 01/27/25 at 10:15 A.M. revealed Resident #59's oxygen tubing was not dated. Interview with CNA #123 on 01/27/25 at 10:15 A.M. verified Resident #59's oxygen tubing was not dated. 2. Resident #71 was admitted to the facility on [DATE] with diagnoses including but not limited to chronic respiratory failure with hypoxia, mild persistent asthma and obstructive sleep apnea. Resident #71 had an order dated 06/04/24 for oxygen at two to five lpm via nasal cannula continuous to maintain pulse ox of 90% or higher. Special instructions was to add humidification to the oxygen every shift and PRN day and night. Review of the care plan dated 12/10/24 revealed Resident #71 has the potential for arrhythmia's, CHF, PNE, weight loss/malnutrition, decreased SPO2, abnormal lung sounds, shortness of breath, anxiety, increased confusion, discoloration of skin/nail beds, elevated heart beat, increased and shallow respiration related to diagnosis of chronic respiratory failure with hypoxia, idiopathic pulmonary, obstructive sleep apnea and mild persistent asthma. Her goal was to not have signs of new SOB at rest with SPO2 of less than 90%. One of her goals was to administer O2 as ordered, observe for increased need for O2 and notify physician. Observation on 01/27/25 at 1:22 P.M. revealed Resident #71's oxygen tubing was not dated. Interview with Speech Therapist #295 on 01/27/25 at 1:22 P.M. verified Resident #71's oxygen tubing was not dated. 39333 3. Record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including but not limited to diabetes mellitus, chronic chest pain, and shortness of breath. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 had intact cognition and required substantial assistance for activities of daily living. Review of the physician's orders for January 2025 revealed oxygen at two liters per minute via nasal cannula as needed to maintain pulse Ox 90 percent (%) or higher. Observation on 01/27/25 at 9:47 A.M. revealed that Resident #38's oxygen was not dated. Certified Nursing Assistant (CNA) #166 verified finding during observation.

Based on observation, interview, and review of facility policy, the facility failed to ensure staff implemented proper infection control practices related to hand hygiene. This affected two residents (Resident #14 and Resident #28) who were reviewed for incontinence care. The facility census was 84. Findings include: 1. Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including atherosclerotic heart disease, dementia, wheezing, benign prostatic hyperplasia with urinary tract symptoms, and contractures of bilateral hip, knees, and ankles. Review of the quarterly Minimum Data Set (MDS) assessment completed on 01/02/24 revealed Resident #14 had moderately impaired cognition. Further review revealed Resident #14 was always incontinent of bowel and bladder and was dependent on staff for toileting and bathing. Review of the current care plan revealed Resident #14 needed assistance with activities of daily living (ADLs). Interventions included assisting with ADLs as needed and reporting decline in ability to the physician and therapy department. Observation on 03/19/24 at 8:20 A.M. of Resident #14 revealed he was receiving personal care from State tested Nurse Aide (STNA) #411. Further observation revealed STNA #411 was not wearing gloves while performing a bed bath and incontinence care. STNA #411 was observed removing an incontinence brief containing a small amount of smeared stool from under Resident #14 as she proceeded to wash his rectal area, then genitalia and groin area with ungloved hands. Continued observation revealed STNA #411 donned gloves and applied barrier cream without first performing hand hygiene. STNA #411 then removed her gloves and continued putting on a clean incontinence brief and dressing Resident #14's upper body with no hand hygiene after glove removal or before dressing the resident. Interview on 03/19/24 at 8:45 A.M. with STNA #411 confirmed she did not don gloves to provide the bed bath or incontinence care. Further interview confirmed STNA #411 did not perform hand hygiene before donning gloves prior to the application of barrier cream, dressing Resident #14, or between glove changes. Review of facility policy titled Perineal Care, dated 04/30/19, revealed gloves were to be worn when perineal care was performed. Gloves were to be removed after completing perineal care, and then staff were to perform hand hygiene prior to repositioning the resident and replacing the bed covers. Review of the policy titled Hand Washing/Hand Hygiene, dated 08/30/19, revealed hand hygiene was to be performed before moving from a contaminated area to a clean area during resident care, after potential contact with bodily fluids, and after removing gloves. 2. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including dementia, hypertension, dysphagia, overactive bladder, and functional urinary incontinence. Review of the annual Minimum Data Set (MDS) assessment completed on 03/06/24 revealed Resident #28 had severely impaired cognition. Further review of the annual MDS assessment revealed Resident #28 was always incontinent of bladder and bowel and was dependent on staff for all aspects of personal care. Review of the current care plan revealed Resident #28 had functional urinary incontinence related to dementia, communication deficits, and overactive bladder. Interventions included providing incontinence care as needed, application of moisture barrier to the skin, and reporting signs or symptoms of urinary tract infection or skin breakdown. Observation on 03/20/24 at 9:35 A.M. revealed Resident #28 received incontinence care from STNA #427. The observation revealed STNA #427 did not discard gloves or perform hand hygiene after cleansing loose stool from Resident #28's groin, perineal area, rectal area, buttocks, and coccyx area. Further observation revealed STNA #427 opening the drawer from Resident #28's bedside table, rummaging through the drawer to search for barrier cream and powder, then handling and applying the barrier cream to Resident #28's buttocks with the same soiled gloves used to provide the incontinence care. STNA #427 was observed removing the gloves prior to removing Resident #28's pants (per resident preference), repositioning Resident #28, and applying bed covers. No hand hygiene was performed after glove removal, prior to completing resident care. Interview on 03/20/24 at 9:45 A.M. with STNA #427 confirmed she did not remove her gloves or perform hand hygiene between cleaning Resident #28's bowel movement, obtaining items from her bedside dresser, applying barrier cream, and putting on a clean incontinence brief. Further interview confirmed no hand hygiene was performed after she removed the soiled gloves and proceeded with resident care. STNA #427 further revealed her typical process included wearing the same gloves throughout incontinence care, including applying ordered barrier creams after cleaning the resident's urine and/or stool. Review of facility policy titled Perineal Care, dated 04/30/19, revealed gloves were to be worn when perineal care was performed. Further review revealed gloves were to be removed after completing perineal care, and then staff were to perform hand hygiene prior to repositioning the resident and replacing the bed covers. Review of the policy titled Hand Washing/Hand Hygiene, dated 08/30/19, revealed hand hygiene was to be performed before moving from a contaminated area to a clean area during resident care, after potential contact with bodily fluids, and after removing gloves.

Based on record review, self-reported incident (SRI) review, policy review and interview, the facility failed to ensure residents were free from verbal abuse. This affected two residents (#213 and #259) of three residents reviewed for abuse. The facility census was 79. Findings included: 1. Review of the medical record review for Resident #259 revealed an admitted [DATE]. Diagnoses included but were not limited to Neurocognitive disorder with Lewy bodies, Parkinson's disease, dysphagia, and stage III chronic kidney disease. Review of 04/03/23 quarterly Minimum Data Set (MDS) 3.0 for Resident #259 revealed a Brief Interview of Mental Status (BIMS) score of 03 out of 15 which indicated severe cognitive impairment. Review of activities of daily living (ADLs) for Resident #259 revealed he required extensive assist of two staff for bed mobility, dressing, personal hygiene, total dependence of two staff for transfer, locomotion on and off the unit, toileting, total dependence of one staff for bathing and supervision for eating meals. Review of Resident #259's care plan revealed he needed assistance with ADL's. Interventions included transfer and toileting with a mechanical lift with blue sling with assistance of two staff. Review of Resident #259's nursing progress notes dated 05/06/23 revealed a staff member pulled the sling to the mechanical lift up while Resident #259 was in it and pinched his arm. Resident #259 was noted to have a 3.5 x 1 x <.1 cm reddened area on his right forearm with intact skin. Resident #259 stated a lady was rough with me in the mechanical lift, and I was yelling at her to stop. Interview on 05/18/23 at 9:11 A.M. with Resident #259 revealed he got his arm pinched during a transfer, he asked the aide to stop, but she did not and said to him; Are you bleeding, then cry about it. 2. Medical record review for Resident #213 revealed an admitted [DATE]. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia, and abnormal posture. Resident code status is DNRCC. Review of 02/20/23 quarterly MDS 3.0 for Resident #213 revealed a BIMS score of 04 out of 15 which indicated severe cognitive impairment. Review of activities of daily living (ADLs) revealed resident requires extensive assist of two staff for bed mobility, toileting, transfer, walk in room, locomotion on/off unit, extensive assist of one for dressing, supervision for eating, and total dependence of one for bathing. Review of the nursing progress note dated 5/06/23 at 1:49 P.M. for Resident #213 revealed STNA #418 was rough and loud with Resident #213. Resident #213 did not recall the incident, felt safe at the facility, did not have any noted skin issues, and did not voice any other concerns. Review of the 05/06/23 facility self-reported incident report revealed State tested Nurse Aide (STNA) #411 observed STNA #418 being rough and loud with Resident #213 and STNA #411 told STNA #418 not to be so rough with him. STNA #411 proceeded to assist STNA #418 with a mechanical lift transfer of Resident #259. During the transfer of Resident #259, his arm became pinched, and he requested STNA #418 to stop. STNA #418 told Resident #259, Are you bleeding, if not cry about it. Interview on 05/18/23 at 8:55 A.M. with STNA #411 revealed on 05/06/23 she heard Resident #213 yelling and went to his room. She stated STNA #418 was being loud and aggressive towards Resident #213. STNA #411 stated she told STNA #418 to be gentler. About five minutes later, STNA #411 was assisting STNA #418 with the mechanical lift for Resident #259 and he got pinched. Resident #259 asked STNA #418 to stop and STNA #418 did not listen. STNA #411 stated she told STNA #418 to stop. STNA #418 looked at Resident #259 and told him, Are you bleeding, then cry about it. STNA #411 confirmed she had not told the nurse about the incident with Resident #213 until after Resident #259 got injured. Interview on 05/18/23 at 12:54 P.M. with Licensed Practical Nurse (LPN) #420 revealed after being made aware of the incidents involving Resident #213 and Resident #259, she interviewed Resident #213 who stated he did not recall the incident and Resident #259 stated the aide was rough during his transfer while using the mechanical lift and his arm became pinched. Resident #259 stated he asked STNA #418 to stop but she did not until STNA #411 told her to stop. STNA #418 then told Resident #259, Are you bleeding, then cry about it. Interview on 05/18/23 at 1:36 P.M. with the Administrator revealed he was not at the facility when the incident involving Residents #213 and #259, was made aware of it, and advised the supervisor to initiate the abuse investigation. The Administrator stated the facility takes allegations of abuse very seriously to ensure safety. Review of the 09/01/19 revised facility policy called: Resident Rights revealed employees shall treat all residents with kindness, respect, and dignity. These rights include the resident's right to be treated with respect, kindness, and dignity and be free from abuse. Review of the 01/21/20 revised facility policy called: Abuse, Neglect, Exploitation, Mistreatment of a Resident and Misappropriation of Resident Property revealed the facility will not tolerate any type of abuse. This deficiency represents non-compliance investigated under Complaint Number OH00142712.

Based on record review, self-reported incident (SRI) review, policy review and interview, the facility failed to ensure a report of alleged abuse was reported timely. This affected two residents (#213 and #259) of three residents reviewed for abuse. The facility census was 79. Findings included: 1. Review of the medical record review for Resident #259 revealed an admitted [DATE]. Diagnoses included but were not limited to Neurocognitive disorder with Lewy bodies, Parkinson's disease, dysphagia, and stage III chronic kidney disease. Review of 04/03/23 quarterly Minimum Data Set (MDS) 3.0 for Resident #259 revealed a Brief Interview of Mental Status (BIMS) score of 03 out of 15 which indicated severe cognitive impairment. Review of activities of daily living (ADLs) for Resident #259 revealed he required extensive assist of two staff for bed mobility, dressing, personal hygiene, total dependence of two staff for transfer, locomotion on and off the unit, toileting, total dependence of one staff for bathing and supervision for eating meals. Review of Resident #259's care plan revealed he needed assistance with ADL's. Interventions included transfer and toileting with a mechanical lift with blue sling with assistance of two staff. Review of Resident #259's nursing progress notes dated 05/06/23 revealed a staff member pulled the sling to the mechanical lift up while Resident #259 was in it and pinched his arm. Resident #259 was noted to have a 3.5 x 1 x <.1 cm reddened area on his right forearm with intact skin. Resident #259 stated a lady was rough with me in the mechanical lift, and I was yelling at her to stop. Interview on 05/18/23 at 9:11 A.M. with Resident #259 revealed he got his arm pinched during a transfer, he asked the aide to stop, but she did not and said to him; Are you bleeding, then cry about it. 2. Medical record review for Resident #213 revealed an admitted [DATE]. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia, and abnormal posture. Resident code status is DNRCC. Review of 02/20/23 quarterly MDS 3.0 for Resident #213 revealed a Brief Interview of Mental Status (BIMS) score of 04 out of 15 which indicated severe cognitive impairment. Review of activities of daily living (ADLs) revealed resident requires extensive assist of two staff for bed mobility, toileting, transfer, walk in room, locomotion on/off unit, extensive assist of one for dressing, supervision for eating, and total dependence of one for bathing. Review of the nursing progress note dated 5/06/23 at 1:49 P.M. for Resident #213 revealed STNA #418 was rough and loud with Resident #213. Resident #213 indicated he did not recall the incident, felt safe at the facility, did not have any noted skin issues, and did not voice any other concerns. Review of the 05/06/23 facility self-reported incident report revealed State tested Nurse Aide (STNA) #411 observed STNA #418 being rough and loud with Resident #213 and STNA #411 told STNA #418 not to be so rough with him. STNA #411 proceeded to assist STNA #418 with a mechanical lift transfer of Resident #259. During the transfer of Resident #259, his arm became pinched, and he requested STNA #418 to stop. STNA #418 told Resident #259, Are you bleeding, if not cry about it. Interview on 05/18/23 at 8:55 A.M. with STNA #411 revealed on 05/06/23 she heard Resident #213 yelling and went to his room. She stated STNA #418 was being loud and aggressive towards Resident #213. STNA #411 stated she told STNA #418 to be gentler. About five minutes later, STNA #411 was assisting STNA #418 with the mechanical lift for Resident #259 and he got pinched. Resident #259 asked STNA #418 to stop and STNA #418 did not listen. STNA #411 stated she told STNA #418 to stop. STNA #418 looked at Resident #259 and told him, Are you bleeding, then cry about it. STNA #411 confirmed she had not told the nurse about the incident with Resident #213 until after Resident #259 got injured. Interview on 05/18/23 at 12:54 P.M. with Licensed Practical Nurse (LPN) #420 revealed after being made aware of the incidents involving Resident #213 and Resident #259, she interviewed Resident #213 and Resident #259 and conducted skin assessments on them both. LPN #420 stated she provided an in-service on abuse to both LPN #419 and STNA #411 related to the importance of timely reporting and proper procedures and indicated she did not provide abuse in-services to any additional staff following the incident. Interview on 05/18/23 at 1:15 P.M. with the Director of Nursing (DON) confirmed all incidents of alleged abuse are to be reported immediately. Interview on 05/18/23 at 1:36 P.M. with the Administrator confirmed any type of alleged abuse is to be reported immediately. Review of the 01/21/20 revised facility policy called: Abuse, Neglect, Exploitation, Mistreatment of a Resident and Misappropriation of Resident Property revealed the facility staff should immediately report all allegations of abuse to the Administrator and to the Ohio Department of Health in accordance with the procedures in this policy. This deficiency represents non-compliance investigated under Complaint Number OH00142712.

Based on record review, self-reported incident (SRI) review, policy review and interview, the facility failed to complete a thorough abuse investigation. This affected two residents (#213 and #259) of three residents reviewed for abuse. The facility census was 79. Findings included: 1. Review of the medical record review for Resident #259 revealed an admitted [DATE]. Diagnoses included but were not limited to Neurocognitive disorder with Lewy bodies, Parkinson's disease, dysphagia, and stage III chronic kidney disease. Review of 04/03/23 quarterly Minimum Data Set (MDS) 3.0 for Resident #259 revealed a Brief Interview of Mental Status (BIMS) score of 03 out of 15 which indicated severe cognitive impairment. Review of activities of daily living (ADLs) for Resident #259 revealed he required extensive assist of two staff for bed mobility, dressing, personal hygiene, total dependence of two staff for transfer, locomotion on and off the unit, toileting, total dependence of one staff for bathing and supervision for eating meals. Review of Resident #259's care plan revealed he needed assistance with ADL's. Interventions included transfer and toileting with a mechanical lift with blue sling with assistance of two staff. Review of Resident #259's nursing progress notes dated 05/06/23 revealed a staff member pulled the sling to the mechanical lift up while Resident #259 was in it and pinched his arm. Resident #259 was noted to have a 3.5 x 1 x <.1 cm reddened area on his right forearm with intact skin. 2. Medical record review for Resident #213 revealed an admitted [DATE]. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia, and abnormal posture. Resident code status is DNRCC. Review of 02/20/23 quarterly MDS 3.0 for Resident #213 revealed a Brief Interview of Mental Status (BIMS) score of 04 out of 15 which indicated severe cognitive impairment. Review of activities of daily living (ADLs) revealed resident requires extensive assist of two staff for bed mobility, toileting, transfer, walk in room, locomotion on/off unit, extensive assist of one for dressing, supervision for eating, and total dependence of one for bathing. A nursing progress note dated 5/06/23 at 1:49 P.M. for Resident #213 revealed State tested Nurse Aide (STNA) #418 was reported being rough and loud with Resident #213. Resident #213 did not recall the incident, felt safe at the facility, did not have any noted skin issues, and did not voice any other concerns. Review of the facility incident investigation report revealed STNA #411 observed STNA #418 being rough and loud with Resident #213 and STNA #411 told STNA #418 not to be so rough with him. STNA #411 then assisted STNA #418 with a mechanical lift transfer of Resident #259 in which STNA #418 spoke loudly and rudely to Resident #259. STNA #411 reported the two incidents of verbal abuse involving STNA #418 with Resident #213 and Resident #259. The investigation report included witness statements from STNA #411, Licensed Practical Nurse (LPN #419), LPN #420 and resident interviews and skin assessments for Resident #213 and #259. No additional resident interviews or skin assessments were provided for review. STNA #418 was noted to have been removed from the facility, but a witness statement was not obtained. Review of the 05/06/23 facility self-reported incident report (SRI) reported to the state agency revealed State tested Nurse Aide (STNA) #411 observed STNA #418 being rough and loud with Resident #213. STNA #411 proceeded to assist STNA #418 with a mechanical lift transfer of Resident #259. During the transfer of Resident #259, his arm became pinched, and he requested STNA #418 to stop. STNA #418 told Resident #259, Are you bleeding, if not cry about it. Interview on 05/18/23 at 8:55 A.M. with STNA #411 revealed on 05/06/23 she heard Resident #213 yelling and went to his room. STNA #411 stated STNA #418 was being loud and aggressive towards Resident #213. STNA #411 stated she told STNA #418 to be gentler. About five minutes later, STNA #411 assisted STNA #418 with the mechanical lift for Resident #259 and he got pinched. Resident #259 asked STNA #418 to stop and STNA #418 did not listen. STNA #411 stated she told STNA #418 to stop. STNA #418 looked at Resident #259 and told him, Are you bleeding, then cry about it. STNA #411 confirmed she had not told the nurse about the incident with Resident #213 until after Resident #259 got injured. Interview on 05/18/23 at 9:11 A.M. with Resident #259 revealed he got his arm pinched during a transfer, he asked the aide to stop, but she did not and said to him; Are you bleeding, then cry about it. Interview on 05/18/23 at 12:54 P.M. with Licensed Practical Nurse (LPN) #420 revealed after being made aware of the incidents involving Resident #213 and Resident #259, she interviewed Resident #213 and Resident #259 and conducted skin assessments on them both. LPN #420 indicated she did not do any interviews or skin assessments of other residents on the unit. LPN #420 stated she provided an in-service on abuse to both LPN #419 and STNA #411 related to the importance of timely reporting and proper procedures and indicated she did not provide abuse in-services to any additional staff following the incident. Interview on 05/18/23 at 12:45 P.M. with the Administrator confirmed following the incidents involving Resident #213 and #259, staff in-services were only provided to LPN #419 and STNA #411 and he did not have any additional information to provide for review regarding SRI # 234752. The Administrator also confirmed a thorough investigation would include ensuring safety of the resident, following up the investigation with statements from staff and residents and skin assessments of all potentially affected residents. Interview on 05/18/23 at 1:15 P.M. with the Director of Nursing (DON) confirmed the facility did not have additional interviews of skin assessments to provide related to the incident involving Resident #213 and #259. The DON revealed all incidences of potential alleged abuse are to be reported immediately and conduct interviews and skin assessments on all residents who were potentially involved in the incident. Review of the 01/21/20 revised facility policy called: Abuse, Neglect, Exploitation, Mistreatment of a Resident and Misappropriation of Resident Property revealed the facility will investigate all alleged violations of abuse. The facility will conduct a thorough, evidence-based investigation in which the investigator may interview the additional residents with information, conduct skin evaluations of those with cognitive impairment. The investigator will thoroughly collect evidence, observations, interviews, and record review and corroborate information about the incident. Staff training would be completed as determined by the results of the investigation. This deficiency represents non-compliance investigated under Complaint Number OH00142712.

Based on record review, interview, and policy review, the facility failed to administer pain medication as scheduled to Resident #5. This affected one resident (#5) out of three residents reviewed for pain medication administration. The facility census was 77. Findings include: Review of the medical record revealed Resident #5 was admitted on [DATE] with diagnoses including Alzheimer's disease, delusional disorder, anxiety disorder, insomnia, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had moderately impaired cognition. Review of the quarterly pain assessment dated [DATE] revealed Resident #5 received scheduled pain medication. Resident #5 revealed they had frequent pain and rated the pain a four on a scale of zero to ten with ten as the worst pain imaginable. Review of the plan of care dated 04/15/23 revealed Resident #5 had complaints of pain. Interventions included to administer pain medication as ordered and notify physician of unrelieved pain. Review of physician orders for April and May 2023 included but not limited to tramadol (narcotic for moderate to severe pain) 50 milligram (mg) three times a day, acetaminophen (analgesic for minor aches and pains) 650 mg every six hours as needed, and pain management scale every shift. Review of the controlled drug receipt proof-of-use/disposition form revealed Resident #5 was administered the last tablet in the card of tramadol 50 mg on 04/20/23 at 9:30 P.M. Review of medication administration records (MAR) for April 2023 revealed Resident #5 did not receive tramadol 50 mg on 04/21/23 scheduled for 6:00 A.M. to 10:00 A.M. A reason for not administering the scheduled tramadol was listed as Not administered: Drug/item not available. Resident #5 did not receive tramadol 50 mg on 04/21/23 scheduled for 1:00 P.M. to 4:00 P.M. A reason for not administering the scheduled tramadol was listed as Not administered: Drug/item not available. Review of the MAR revealed Resident #5 was administered acetaminophen 650 mg on 04/21/23 at 4:46 P.M. for eight out of ten on the pain scale. An authorization to pull controlled substance from Omnicell (medication dispensing system) dated 04/21/23 at 8:20 P.M. revealed tramadol 50 mg was pulled for Resident #5. Review of the progress note dated 04/22/23 at 2:13 A.M. revealed tramadol 50 mg was pulled with authorization on 04/21/23 at 8:20 P.M. Review of the MAR revealed Resident #5 was administered tramadol 50 mg scheduled for 6:00 P.M. to 10:00 P.M. Interviews on 05/01/23 from 10:56 A.M. to 11:39 A.M. Licensed Practical Nurse (LPN) #100, LPN #101, and LPN #102 revealed if a controlled medication was needed, authorization could be obtained, and the medication could be pulled from the Omnicell. Interview on 05/01/23 at 4:40 P.M. Assistant Director of Nursing (ADON) verified Resident #5 did not receive scheduled tramadol twice on 04/21/23. Review of the facility policy titled Administering Medications, dated 06/01/19, revealed medications must be administered in accordance with the orders, including any required time frame. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. This deficiency represents non-compliance investigated under Complaint Number OH00142004.

Based on review of the infection control tracking log and staff interview the facility failed to ensure monthly completion of the infection control tracking log. This had the potential to affect all 72 residents residing in the facility. Findings include: Review of the Antibiotic Stewardship program revealed the facility would complete monthly tracking of resident antibiotic use/infection. However, the monthly antibiotic use tracking log form did not contain any evidence of location/room/unit of resident, signs and symptoms, x-ray and/or culture and results, healthcare acquired or community acquired infection, if the infection met antibiotic treatment criteria, resident isolation status if required and resolution date. In addition, review of the facility infection control tracking log revealed the last month recorded/completed was January 2020. The facility failed to provide any additional evidence of infection control tracking. On 09/29/22 at 11:20 A.M. interview with the Director of Nursing verified the facility was not completing a monthly infection log/tracking form with the name of the resident, location of resident, signs and symptoms, type of infection, x-ray and/or culture and results, healthcare acquired or community acquired, if an antibiotic used met treatment criteria, resident isolation status if required and resolution date.

Based on record review and staff interview the facility failed to ensure advance directives matched in the electronic health record and paper medical record. This affected one resident (#65) of 18 residents reviewed for advance directives. Findings include: Review of Resident #65's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the electronic health record (EHR) revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the paper medical record found no evidence of any advance directives in place and a Full Code identification paper was in place under the Advance Directives section of the paper medical record. On 09/26/22 at 3:00 P.M. Licensed Practical Nurse (LPN) #543 verified Advance Directives for Resident #65 did not match in the EHR and paper medical record. LPN #543 indicated Resident #65 should have a DNRCC-A form signed by the physician and the resident in the paper medical record, which was not there.

Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #177's physician and the dietitian were notified of significant weight changes. This affected one resident (#177) of three residents reviewed for nutrition. Findings include: Review of Resident #177's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/16/22 revealed the resident had intact cognition. Review of Resident #177's weighs revealed: On 09/14/22 weight of 169.7 pounds On 09/15/22 weight of 168.4 pounds On 09/17/22 weight of 172.8 pounds On 09/20/22 weight of 193.3 pounds On 09/22/22 weight of 174.1 pounds On 09/24/11 weight of 191.5 pounds On 09/27/22 weight of 192.0 pounds Review of Resident #177's nutrition note, dated 09/23/22 revealed no documentation related to the resident's recent weight fluctuations. Review of Resident #177's nursing notes revealed no evidence the physician or dietitian were notified or addressed the resident's weight fluctuations until 09/27/22. On 09/29/22 at 12:02 P.M. interview with the Director of Nursing confirmed there was no evidence the physician or dietitian were timely notified and addressed Resident #177's weight fluctuations until 09/27/22. Review of the facility policy titled Weight Assessment and Intervention, dated 05/15/19 revealed any weight change of five percent or more since the last weight assessment would be retaken the day for confirmation. If the weight was verified, nursing would immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. A dietitian would respond within 24 hours of receipt of written notification. Review of the facility polity titled Nutrition (Impaired)/Unplanned Wight loss, dated 05/01/19 revealed the staff would report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake.

Based on record review and staff interview the facility failed to ensure a Preadmission Screening and Review Review (PASARR) assessment was resubmitted for review after a new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of Resident #14's medical record revealed an admitted [DATE] with admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed on 03/30/20 and 04/24/20 a PASARR review was completed which indicated the resident had no serious mental illness. Review of Resident #14's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/28/22 a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of the medical record found no evidence of a PASARR being submitted after the new serious mental health diagnoses, [CONDITION(S)] with hallucinations and dementia with behaviors were added. Interview with Social Services Designee (SSD) #534 on 09/28/22 at 10:50 A.M. revealed a new PASARR should be completed after a new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An additional interview with SSD #534 on 09/28/22 at 11:55 A.M. verified there was no evidence of any new PASARR completed for Resident #14 after the new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure proper infection control practices were followed during Resident #53's dressing change to prevent a wound infection. This affected one resident (#53) of four residents reviewed for pressure ulcers. Findings include: Review of Resident #53's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #53's September 2022 physician's orders revealed an order to cleanse the resident's left buttock open area with house cleanser, pat dry, apply a nickel thick amount of Santyl (medicated ointment) topically to the wound bed, cover with Mesalt (wound dressing), place four by four gauze over area and secure with [MEDICATION(S)] tape. The dressing was to be changed daily. On 09/27/22 at 2:12 P.M. Licensed Practical Nurse (LPN) #419 was observed to complete Resident #53's dressing/wound care. LPN #419 placed a barrier down on the resident's bedside table and placed supplies on the barrier, she then washed her hands and applied gloves. Using her gloved right hand, LPN #419 grabbed the resident's half full trash can and pulled it closer to the bed. LPN #419 then used her right hand to remove the resident's old dressing and removed the Mesalt from the wound. LPN #419 then obtained wound cleanser and sprayed the wound cleaner on the sponge and used the sponge to clean the wound. LPN #419 used a clean sponge to dry the wound and surrounding area, removed her gloves, and washed hands. She then obtained new gloves, placed a nickel size amount of Santyl on sterile Q-Tip and placed the ointment on the residents wound. She then cut a small square of Mesalt and placed it over wound, covered the area with four by four gauze and secured with tape. After tape was on resident, she used a marker to write the date, time and her initials on the tape. On 09/27/22 at 2:24 P.M. interview with LPN #419 confirmed the above observation and verified proper hand washing and infection control was not followed during Resident #53's dressing change when she used the same gloved hands to touch the trash can and then remove the resident's dressing and clean the area/wound. Review of the facility policy, Hand washing/ Hand Hygiene, dated 08/20/19 revealed the use of soap and water or alcohol-based hand rub should be used after after handling used dressings.

Based on record review and staff interview the facility failed to ensure Resident #65, who had a gastrostomy tube with enteral feeding, was provided water flushes as ordered by the physician. This affected one resident (#65) of one resident reviewed for enteral feedings. Findings include: Review of Resident #65's medical record revealed an admitted [DATE] with admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed on 08/26/22, the enteral feeding order was clarified. The enteral feeding remained the same of [MEDICATION(S)] 1.5 237 ml QID, but the water flush was not re-ordered into the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Registered Licensed Dietician (RDLD) #556 on 09/27/22 at 3:15 P.M. verified Resident #65 had not received any water flushes by gastrostomy tube since 08/26/22 when the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, record review, facility policy and procedure review and interview the facility failed to obtain physician's orders for hemodialysis treatments for Resident #177 and failed to ensure the resident's hemodialysis access site was monitored/assessed for patency and/or complications. This affected one resident (#177) of one resident reviewed for hemodialysis. Findings include: Review of Resident #177's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/16/22 revealed the resident had intact cognition. Review of Resident #177's care plan, dated 09/23/22 revealed the resident was at risk for air embolism, [CONDITION(S)], muscle cramps, nausea, vomiting, headache, chest pain, fever, chills, and itching related to dependence on hemodialysis. Interventions included observe the resident's graft or fistula site every shift for presence of thrill and bruit, signs and symptoms of infection, and bleeding/bruising, and report any abnormal findings to physician and [CONDITION(S)] center. Review of Resident #177's September 2022 physician's orders revealed the resident's did not have an order to go hemodialysis and did not have an order to assess or monitor his [CONDITION(S)] access site (fistula). Review of Resident #177's September 2022 nursing notes revealed no evidence the facility was assessing the resident's [CONDITION(S)] access site every shift as noted in the 09/23/22 care plan. Review of Resident #177's Hemodialysis Communication forms revealed the resident's [CONDITION(S)] access site was only assessed on 09/14/22, 09/15/22, 09/17/22, 9/20/22 and 09/27/22 prior to leaving for [CONDITION(S)]. On 09/26/22 at 11:45 A.M. Resident #177 was observed to have a fistula to his left arm with a dressing covering. Interview with the resident at the time of the observation revealed he goes to [CONDITION(S)] three times a week on Tuesday, Thursday, and Saturday. The resident denied facility staff assessing his fistula site but stated the staff at [CONDITION(S)] did assess it when he was there. On 09/28/22 at 11:52 A.M. interview with Licensed Practical Nurse (LPN) #537 confirmed Resident #177 did not have hemodialysis orders or orders to assess his [CONDITION(S)] access site. The LPN confirmed there was no evidence of the resident's fistula being assessed each shift as it was care planned to do. LPN #537 denied assessing the site during her shift. On 09/28/22 at 12:12 P.M. interview with the Director of Nursing confirmed the above findings and revealed she would reach out to the physician to obtain orders. Review of the facility policy Care of a Resident with End-Stage Renal Disease, dated 09/2010 revealed residents with end-stage renal disease would be cared for according to currently reconized standards of care including the care of grafts and fistulas.

Based on observation, facility policy and procedure review and interview the facility failed to properly dispose of garbage and refuse in outside dumpsters. This had the potential to affect all 72 residents residing in the facility. Findings include: On 09/28/22 at 8:00 A.M. observation of the outside dumpsters revealed there was debris laying on the ground outside of the second dumpster and a garbage bag laying next to the third dumpster. On 09/28/22 at 8:03 A.M. interview with Maintenance #455 and Maintenance #548 confirmed the above findings. Review of the facility policy Food-related Garbage and Refuse Disposal,dated 06/30/19 revealed outside dumpsters would be kept free of surrounding litter.

Based on observations, record review, interviews and policy review, the facility failed to ensure all health care personnel (HCP) utilized personal protective equipment (PPE) properly to attempt to prevent and/or contain the spread of infection related to the global pandemic of [DIAGNOSES REDACTED]-CoV-2 infection (COVID-19). This had the potential to affect all 61 residents. Findings include: Review of the medical record revealed Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing progress note dated 11/23/20 revealed the resident had temperatures of 99.6 and 100.8 degrees Fahrenheit. Her baseline temperature was noted to be 97.7 degrees Fahrenheit. A new order was received on 11/23/20 for droplet isolation until COVID-19 testing results were received. Observation during the tour of the facility on 11/24/20 at 8:45 A.M. with the Director of Nursing revealed disposable isolation gowns hanging on hooks on the residents' doors as well as isolation carts with PPE outside of their rooms. The Director of Nursing verified all staff utilized the same disposable isolation gown to provide care to the resident in that specific room. She stated she was concerned the facility would have a shortage of the disposable isolation gowns; therefore, the facility was attempting to conserve PPE. An observation of the supply room revealed there boxes of unused PPE. Observation on 11/24/20 at 10:11 A.M. of Resident #101's room with Registered Nurse (RN) #118 revealed an isolation cart by her room with signs lying on top of the cart stating droplet precautions. There were no signs on the door instructing staff, residents or visitors of what isolation precautions were in use. RN #118 verified the resident was on droplet precautions as she had an increased temperature and was being tested for COVID-19. She stated the disposable isolation gown on the left hook on the door was for bed one (Resident #101), and the disposable isolation gown on the right hook was for bed two. She stated the staff was not wearing the same gown to take care of both residents in this room though staff were still sharing the disposable isolation gowns. Observation on 11/24/20 at 10:14 A.M. revealed Maintenance Employee #111 go into Resident #101's room after donning the disposable isolation gown hanging on the left hook on the resident's door as well as gloves from the isolation cart. He was noted to have a surgical mask on with safety glasses while in the resident's room. After Maintenance Employee #111 finished checking water temperatures in the room, he came out of the room and removed the gloves and removed the disposable gown and hung it on the left hook on the resident's door. He did verify all staff wear the same isolation gown in the resident's room. He stated there were no residents currently on isolation outside of the COVID-19 isolation unit. He had not removed or changed his surgical mask. Observation on 11/24/20 at 10:25 A.M. of Housekeeper #112 wearing PPE including a N95 mask, face shield and a disposable isolation gown while cleaning a resident's room. She stated she was wearing an isolation gown that she had taken from the hook on the door and when she was finished in the room, she would return the isolation gown back to the hook on the resident's door. Interview on 11/24/20 at 9:18 A.M. with Supply Clerk #105 revealed the facility had a stock of 5,283 disposable isolation gowns in the supply room, and there were more gowns the units. She stated if they become low on the disposable isolation gowns she would be able to order more, and there had been no issues getting PPE since July 2020. Interview on 11/24/20 at 9:30 A.M. with Housekeeper #107 verified staff had been sharing disposable isolation gowns to go into the residents' rooms. Interview with State tested Nursing Assistant (STNA) #110 on 11/24/20 at 10:01 A.M. verified staff was sharing disposable isolation gowns that were hanging the residents' doors. She stated the isolation gowns were for the staff to wear in that particular resident's room, and new disposable isolation gowns were only placed once a shift. Review of the policy Infection Prevention and Control Program, dated 04/01/20, stated important facets of prevention infection include implementing appropriate isolation precautions and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). Guidance from the CDC, updated on 11/20/20, Infection Control for Nursing Homes stated residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves and gown. This information is located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. Guidance from the Centers for Disease Control (CDC), updated on 10/09/20, Strategies for Optimizing the Supply of Isolation Gowns indicated that once PPE supplies and availability return to normal, healthcare facilities should promptly resume conventional practices. During crisis capacity strategies from the CDC include extended use of isolation gowns (disposable or reusable) to be worn by the same HCP when interacting with more than one patient housed in the same location and known to be infected with the same infectious disease. This information is located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html. This deficiency substantiates Complaint Number OH 455.

Based on review of personnel files, review of the facility new hire list, review of the facility abuse policy, and staff interview, the facility failed to effectively implement their abuse policy and procedure to ensure all potential staff hires were checked against the Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. This affected 15 dietary personnel, three Housekeeping personnel, one Maintenance personnel, one Life Enrichment Director, one Medical Records Coordinator and one Director of Dietary Services and had the potential to affect all 69 residents residing in the facility. Findings Include: Review of the new hire list dated 06/20/18 to 08/27/19 and review of employee personnel file revealed Dietary Personnel #620, #721, #647, #673, #757, #680, #630, #679, #746, #770, #670, #731, #729, #612 and #686, Housekeeping Personnel #738, #768 and #740, Maintenance Personnel #678, Life Enrichment Director #773, Medical Records Coordinator #636 and Director of Dietary Services #727 had not been checked against the Nurse Aide Registry prior to hire. An interview on 09/17/19 at 1:20 P.M. with Administrative Personnel #626 revealed the facility had found out they were supposed to be checking all new hires on the nurse aide registry last week on 09/11/19. She verified she did not have the physical evidence to show the Nurse Aide Registry had been checked for Dietary Personnel #620, #721, #647, #673, #757, #680, #630, #679, #746, #770, #670, #731, #729, #612 and #686, Housekeeping Personnel #738, #768 and #740, Maintenance Personnel #678, Life Enrichment Director #773, Medical Records Coordinator #636 or Director of Dietary Services #727. Review of the facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 01/24/17 revealed the facility would not tolerate Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident Property. It was the facility policy to investigate all alleged violations involving Abuse, Neglect , Exploitation, Mistreatment of [REDACTED]. It was the policy of the facility to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks. The facility would do the following prior to hiring a new employee: a. Check with the Ohio Nurse Assistant Registry and any other nurse assistant registries that the facility had reason to believe contained information on an individual, prior to using the individual as a nurse assistant. b. Check with all applicable licensing and certification authorities to ensure employees held the requisite license and/or certification status to perform their job functions and did not have a disciplinary action in effect against his or her professional license by a State licensure agency as a result of a finding of abuse, neglect, exploitation or misappropriation of resident property; c. Conduct a criminal background check in accordance with Ohio law and the facility's policy. d. Verify the applicant was not excluded from any Federally-funded health care programs.

Based on observation, record review and interview the facility failed to provide a dignified dining experience for Resident #2, Resident #6 and Resident #49. This affected three residents (#2, #6 and #49) of 11 residents who were identified to eat in the Tuscan dining room. Findings Include: An observation on 09/16/19 at 5:20 P.M. revealed State tested Nursing Assistant (STNA) #758 was assisting Resident #2, Resident #6 and Resident #49 with the dinner meal. STNA #758 was standing at the table, walking around the table giving each resident a bite of food then moving on the next resident. STNA #758 never sat down to feed a specific resident. During an interview on 09/16/19 at 5:30 P.M. STNA #785 verified she had been standing while feeding Resident #2, Resident #6 and Resident #49. An interview on 09/16/19 at 5:40 P.M. with the Vice President of Clinical Operations revealed staff were expected to sit while they fed residents. Review of the facility policy titled Assistance with Meals, dated 07/2017 revealed the residents would receive assistance with meals in a manner that meets the individual needs of each resident. Residents who could not feed themselves would be fed with attention to safety, comfort and dignity for example: not standing over residents while assisting them to with meals, keeping interaction with other staff to a minimum while assisting residents with meals, avoiding the use of label when referring to residents; and and the use of bibs or clothing protectors instead of napkins, unless requested by the resident.

Based on observation, record review and interview the facility failed to ensure Resident #48 was comprehensively assessed for the use of a seatbelt restraint in a motorized wheelchair. This affected one resident (#48) of one resident reviewed for restraints. Findings Include: Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had moderately impaired cognition, required staff extensive assistance with bed mobility and toilet use and required total assistance from staff for transfer. The assessment revealed the resident did not have a restraint. Observations on 09/17/19 at 9:15 [NAME]M., 1:45 P.M., 4:20 P.M. and on 09/18/19 at 9:00 [NAME]M. revealed Resident # 48 was in a motorized wheelchair with a seatbelt restraint fastened around his waist. An interview on 09/17/19 at 9:15 [NAME]M. Resident #48 revealed he did not need the seat belt but it came with the wheelchair and if you did not fasten it then it would drag on the ground. He indicated no one had attempted to remove it from the wheelchair. An observation on 09/19/19 at 12:03 P.M. revealed State tested Nursing Assistant (STNA) #661 asked Resident #48 to release his seatbelt and the resident stated he was not able to release it on his own. STNA # 661 verified Resident #48 was unable to release his seatbelt restraint at that time. An interview on 09/19/19 at 3:08 P.M. with Registered Nurse (RN) #639 revealed Resident #48 had waned the seatbelt fastened. However, she verified there was not a restraint assessment or a plan of care completed to indicate the resident preferred the seatbelt fastened.

Based on observation, interview and record review the facility failed to ensure Resident #3 was transferred and toileted according to her individualized plan of care resulting in a left hip fracture and a right femur fracture. This affected one of three residents reviewed for falls. Actual harm occurred on 12/14/16 when State tested Nursing Assistant (STNA) #20 provided incontinence care without assistance while Resident #3 was on the toilet. Resident #3 fell off of the toilet resulting in a left hip fracture and a right femur fracture requiring hospitalization and surgical repair. The resident was assessed to require extensive assistance of two staff for transfers and toileting, including incontinence care. Findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current fall care plan initiated on 12/25/14 included interventions for staff to ensure proper footwear was worn during transfers and ambulation. Review of the quarterly minimum data set (MDS) 3.0 assessment revealed Resident #3 was severely cognitively impaired. Resident #3 required extensive assistance of two or more staff for physical assistance with transfers and toileting. Toileting was defined as how the resident used the toilet room, transfers on and off the toilet, cleanses after elimination and adjusts clothing. The assessment indicated Resident #3 used a wheelchair and was frequently incontinent of bowel and bladder. Review of physician's orders [REDACTED]. Review of the physical therapy (PT) screen dated 09/14/16 revealed the staff reported Resident #3 had increased difficulty with standing and use of the pivot disc for transfers. Resident #3 received skilled PT until she was discharged on [DATE]. At that time, Resident #3 still required the physical assistance of two staff utilizing the pivot disc for transfers, including to the toilet. They also recommended Resident #3 resume restorative therapy for lower extremity exercises and use of the omnicycle. Review of the STNA information Kardex dated 12/08/16 revealed the resident needed physical assistance of two staff for ADL's and required a pivot disc for transfers. Review of the nursing note dated 12/14/16 revealed Registered Nurse (RN) #10 was called to Resident #3's room and observed the resident laying on the floor on her back with her knees bent and laying off to the right side. STNA #20 reported to RN #10 that Resident #3 was leaning forward while in the restroom and fell to the floor. The resident complained of pain and had pain on palpation. RN #10 observed a raised lump on Resident #3's right outer mid-thigh area. Resident #3 was sent to the hospital for evaluation. Review of the fall investigation report dated 12/14/16 revealed no evidence the pivot disc was used with Resident #3 during the transfer to the toilet, no evidence she had on proper foot wear (non-skid), and no evidence two staff were with her during the transfer or while providing personal care while on the toilet. The only witness statement was written by STNA #20, and indicated she assisted Resident #3 to the toilet using a gait belt. STNA #20 stated Resident #3 was having a bowel movement and was leaning forward and began to vomit and slipped off toilet. STNA #20 said she lowered Resident #3 to the floor to prevent her from hitting her head and her legs remained to the right of the toilet. Review of the hospital exam report dated 12/14/16 revealed Resident #3 was not able to indicate what happened to her. The resident presented with leg pain. X-rays revealed she sustained a left hip displaced intertrochanteric (in the ball joint) femur (thigh bone) fracture and a right femur fracture, which was displaced or broken apart in the middle. Review of the comprehensive re-admission skin assessment dated [DATE] revealed Resident #3's hip was surgically repaired and had three sections of sutures and/or staples including eight sutures, four sutures and four staples with scant yellow drainage and some swelling. The right femur had also been surgically repaired and had 30 staples to the incision with scant drainage but no swelling. On 12/29/16 at 4:25 P.M., interview with RN #11 revealed he thought Resident #3 required one person assist with transfers and toileting. Upon record review, RN #11 verified the STNA Kardex indicated Resident #3 required two staff for assistance and staff was to use the pivot disc for transfers. On 12/29/16 at 4:30 P.M., RN #10, the unit manager, verified Resident #3 needed two staff for transfers and with care during toileting such as incontinence care and adjusting clothing. RN #10 verified she was the nurse who was called to the room and observed Resident #3 on the floor after her fall off the toilet on 12/14/16. RN #10 verified STNA #20 indicated she was the only staff with Resident #3 for the transfer and the only staff in the restroom when providing personal/incontinence care. RN #10 verified she completed the facility fall investigation report and that there was no evidence the planned fall interventions were utilized including two staff for transfers and care after toileting, use of the pivot disc for transfers and use of proper foot wear. RN #10 verified Resident #3 was yelling out and had severe pain with palpation but was not able to indicate what happened. RN #10 verified the resident vomit was observed on the floor near the resident. On 12/29/16 at 4:45 P.M., STNA #20 was interview via telephone. She indicated Resident #3 was not able to voice her needs and she was on a scheduled toileting program. STNA #20 verified she was not usually assigned to Resident #3 but said she was mobile in a wheelchair but not able to participate in pivot transfers. STNA #20 stated Resident #3 needed the assistance of one or two staff depending on her strength and availability of staff each day. STNA #20 indicated on 12/14/16, she pushed Resident #3 in her wheelchair into the restroom, applied the gait belt and assisted her to stand. She said the resident was able to use the wheelchair arms to assist to stand but she was not able to stand on her own. STNA #20 said she grabbed Resident #3 around her upper half with both arms and used her leg to push the resident's hips toward the toilet and then had to lower the resident onto the toilet. STNA #20 stated Resident #3 was not able to participate in the pivot transfer at all. STNA #20 said Resident #3 used to use the pivot disc for transfers but said it had not been used in a while because the resident was not able to stand on it. STNA #20 verified Resident #3 was having a bowel movement. She stated she moved the resident's upper body forward on the toilet and scooted the resident toward the left side of the toilet in order to provide personal care. STNA #20 said the resident started to look clammy and ashy in color and she thought she was going to be sick so she lowered the resident to the floor. STNA #20 said the resident landed on her buttock and both of her legs were bent and going off to her right in front of the toilet. STNA #20 stated the resident started to vomit so she rolled the resident to her left side so she would not aspirate (choke). STNA #20 stated she then pushed the call light for assistance. On 12/29/16 at 5:45 P.M., interview with the Director of Nursing (DON), RN #10, and Licensed Practical Nurse (LPN) #22 verified Resident #3 should have been transferred with two staff utilizing the pivot disc and should have had two staff when providing personal care while she was on the toilet including cleansing, incontinence care or adjusting her clothing. The DON verified STNA #20 transferred Resident #3 to the toilet and provided care to the resident on 12/14/16 by herself. The DON verified no discipline or education had been provided to STNA #20. On 12/29/16 at 6:30 P.M., the DON verified STNA #20 did not transfer and provide care to Resident #3 according to her plan of care and did not request assistance from other staff while providing incontinence care. This resulted in the resident falling off the toilet and sustaining two fractures which required surgical repair. This deficiency substantiates Master Complaint Number OH 739 and Complaint Number OH 639.

Based on observation, interview and record review the facility failed to ensure adequate direct care staff were available to timely meet the needs of eleven residents (Resident's #1, #3, #4, #7, #8, #9, #10, #11, #12, #13 and #14) who required staff assistance with activities of daily living (ADL's) including incontinence care, bathing and transfers. This resulted in Resident #3 being assisted with one staff member and sustaining a fall with two fractures. This had the potential to affect any of the 76 residents identified as needing staff assistance for activities of daily living (ADL's). Actual harm occurred when Resident #3 was transferred for toileting and was provided personal care while toileting with one staff member. Resident #3 required two staff members for these ADL's. The resident sustained [REDACTED]. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She resided on the [MEDICATION NAME] unit. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed severe memory impairment and the need for extensive assistance with two or more staff providing physical assistance for transfers and toileting. Review of the care conference note dated 12/09/16 revealed the family's concerns with the resident's increased need for help towards the afternoon and evening time. Review of the nursing note dated 12/14/16 revealed Registered Nurse (RN) #10 was called to Resident #3's room and she was observed lying on the floor on her back with her knees bent and outwards to the right. State tested Nursing Assistant (STNA) #20 told her Resident #3 was leaning forward with her in the restroom and the resident fell off the toilet to the floor. The resident complained of pain and had pain when touched. The nurse observed a raised lump to the resident's right outer mid-thigh area. The resident was sent to the hospital for evaluation and was found to have both right and left femur (thigh) fractures. Review of the hospital exam report dated 12/14/16 revealed Resident #3 was not able to indicate what happened to her. The resident presented with leg pain. X-rays revealed she sustained a left hip displaced intertrochanteric (in the hip joint) femur fracture and a right femur fracture, which was displaced or broken apart in the middle. Review of the comprehensive re-admission skin assessment dated [DATE] revealed Resident #3's hip was surgically repaired and had three sections of sutures and/or staples including eight sutures, four sutures and four staples with scant yellow drainage and some swelling. The right femur had also been surgically repaired and had 30 staples to the incision with scant drainage but no swelling. On 12/29/16 at 4:45 P.M., phone interview with STNA #20 verified she transferred Resident #3 onto the toilet and was providing care by herself at the time when the resident fell off the toilet. STNA #20 verified there were no other staff available to assist her with the transfer or her personal/incontinence care. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #1 was alert and oriented with intact memory. This assessment indicated the resident required extensive assistance of two or more staff for ADL's. Review of the current plan of care revealed the resident required two staff for transfers. On 12/29/16 at 1:30 P.M., interview with Resident #1 revealed sometimes in the evenings it takes a long time to get assistance. He/She said a couple nights ago it took staff over 30 minutes to respond to a request to be toileted for a bowel movement. Resident #1 said he/she could not hold it that long resulting in him/her being incontinent of bowel. Resident #1 said it was very upsetting but there was nothing he/she could do and had to wait on staff for help. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He resided on the [MEDICATION NAME] unit. As of 09/10/16, the resident had a physician's orders [REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed he was alert and oriented with an intact memory. He was assessed to be totally dependent on two or more staff for transfers and needed extensive assistance with two or more staff for toileting. Review of the care conference documentation dated 01/04/17 revealed the family requested a meeting because of concerns. The specific concerns and any outcomes were not documented. On 01/06/17 at 6:00 P.M., Social Service Assistant (SSA) #51 verified she was responsible for the [MEDICATION NAME] unit and held the care conferences. She verified she was aware of the family's concerns with the resident laying with his call light on and no staff responding to his care needs. SSA #51 stated sometimes their perception of time is very different than reality. SSA #51 verified RN #10 was in the meeting and would have handled the concern and SSA #51 was not involved in handling the concerns just having the meetings. SSA #51 verified she also had many emails of concerns from Resident #7's son which she passed along to RN #10 and the Director of Nursing (DON). She said she was not able to provide these emails because they were internal documents. 4. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He resided on the [MEDICATION NAME] unit. He was mobile in an electric wheelchair. Review of the quarterly MDS assessment dated [DATE] revealed he was alert and oriented with an intact memory. This assessment indicated he was totally dependent on two or more staff for transfers and needed the extensive assistance of two or more staff for toileting. On 01/05/17 at 5:55 P.M., Resident #13 was in his room trying to reach the call light which was on the floor. The resident stated he needed assistance to go to bed and knew staff were busy and it might take awhile. On 01/06/17 at 1:35 P.M., the resident was in his room trying to reach the call light. He stated he asked STNA #61 after lunch, about 12:30 P.M., to change his soiled brief and she said she would as soon as she could. He knew this STNA was busy but may have forgot so he wanted to activate the call light as a reminder. The surveyor found STNA #31 and she stated she was aware of Resident #13's needs and that he had been waiting for an hour but had not been able to get to him yet. STNA #31 came to the room and Resident #13 stated, I need my brief changed. STNA #31 verified he had been waiting over an hour to get his brief changed but he needed two staff to assist him and she said they would get to him soon but no one was available to assist her right now. STNA #31 verified there were three STNA's working the unit at the time, herself, STNA #32 and STNA #61. 5. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She resided on the [MEDICATION NAME] unit. Review of the quarterly MDS assessment dated [DATE] revealed she was alert and oriented with an intact memory. This assessment indicated Resident #10 required extensive assistance with two or more staff for transfers and toileting. Review of the care conference dated 10/27/16 revealed no concerns were noted. Further review of the medical record did not indicate the resident had any concerns related to staffing. On 01/05/17 at 3:50 P.M., Resident #10 stated she needed two staff for transfers and the facility did not have enough staff to timely meet the needs of the residents especially on the weekends. She said she frequently had to wait 30 minutes or more for assistance for transfers, incontinence care and getting in and out of bed. The resident stated she liked to get up in the morning at 5:30 A.M., get dressed and be ready for breakfast but there was frequently not enough staff on nights to get her up. She said she had to eat breakfast in bed and she usually did not get the assistance she needed to get out of bed until about 9:00 A.M. She said a couple of months ago she requested a meeting and it was held. It included the resident, her representative, the Administrator, Assistant Administrator #50, SSA #51 and RN #10. She said they discussed her staffing concerns but staffing had not improved and they did not indicate they were going to make any changes to address her concerns. She said no one had followed up to see about her expressed concerns. On 01/05/17 at 6:40 P.M., Resident #10's call light was observed already activated and it was observed turned off by 6:46 P.M. At 6:48 P.M., the surveyor entered the resident's room and asked if the staff met her needs when she activated the call light. The resident was observed sitting in her chair and stated she asked to go back to bed because she was very tired. She said the STNA came in, turned off the call light and said they were busy assisting other residents and would return as soon as possible to assist her. At 7:15 P.M., Resident #10 still not been assisted back to bed. At 7:18 P.M., STNA #35 went into the resident's room and told her as soon as another staff person comes they would get her into bed. On 01/05/17 at 7:18 P.M., interview with STNA #35 verified the resident had been waiting at least 40 minutes to be assisted back into bed. He stated they have a lot of residents who need two staff for care/assistance and they get to them as fast as they can. 6. Resident #12 was re-admitted to the facility on [DATE] with a ulnar fracture and a history of dementia and spinal stenosis. She resided on the [MEDICATION NAME] unit. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 had severe cognitive impairment. This assessment indicated she required the use of a mechanical lift for transfers and needed extensive assistance with two or more people for transfers and toileting. Review of the care conferences dated 09/01/16 and 12/08/16 revealed no indication of any care concerns or any indication Resident #12's husband was demanding or interfering with the resident's care. On 01/05/17 at 5:45 P.M., Resident #12 was assisted out of the dining room and at 5:50 P.M., the resident's call light was observed already activated. The call light was turned off by 5:55 P.M. At 6:16 P.M., the call light was reactivated and at 6:19 P.M., RN #10 entered the room and turned off the call light and told the resident not to take off her shirt, it was not night time yet. Resident #1's call light sounded, this room was near Resident #12's room. State tested Nursing Assistants (STNA's) #62 and #35 responded to Resident #1's call light and closed the door. RN #10 knocked on Resident #1's door and told STNA #62 to come and toilet Resident #12 because she was disrobing. At 6:20 P.M., Resident #12's call light was reactivated again and RN #10 and STNA #62 entered the room. After care was provided, RN #10 was interviewed and verified Resident #12 had been waiting for assistance for at least 30 minutes. RN #10 attempted to wheel Resident #12 out of the room and the resident became very upset and did not want to leave her husband. The surveyor verified the care plan indicated Resident #12 was to be placed in bed and a bed pan used when needed. Then RN #10 returned Resident #12 to their room and the resident immediately calmed. RN #10 had STNA #62 stay in the room with Resident #12 and assist her with her night gown until additional staff were available to assist the resident back to bed to be changed. Interview with RN #10 revealed the husband was very demanding and expected everything to be done now and then RN #10 left the area. Interview with STNA #62 verified the resident needed to be mechanically lifted and transferred back into bed for incontinence care and to use the bed pan when requested. STNA #62 said she had to wait for another staff person to come and assist her with a transfer of this type and to provide care. She said Resident #1 was on the toilet and was with STNA #35 and also needed two staff assistance to get off of the toilet. Both STNA's had to wait, one with each resident, Resident #1 and Resident #12, to get additional assistance to provide their personal care. STNA #62 said Resident #12 started to get agitated and was attempting to transfer herself back into bed and this still continued at 6:40 P.M., as the resident was still in the wheelchair waiting for another staff person to assist in the transfer. Resident #12 waited at least 55 minutes and still had not received assistance with her toileting needs. On 01/05/17 at 6:40 P.M., interview with the Resident #12's husband stated it usually took about an hour to have his wife, Resident #12's, care needs met and had expressed his concerns to RN #10 but nothing had been done. 7. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident required a mechanical lift for transfers. Review of the quarterly MDS assessment dated [DATE] revealed Resident #4 had severe cognitive impairment and was totally dependent on two or more staff for transfers and needed extensive assistance of one staff person for incontinence care. On 01/06/17 at 2:50 P.M., Resident #4, with his wife in room, stated he hadn't received a shower in three weeks. He said staff told him they did not have enough help to give him a shower. He stated he liked at least one shower a week and was upset he had not received a shower. Review of the shower schedule and the skin monitoring sheets revealed Resident #4 was to receive a shower every Wednesday on day shift. This is about 4 showers a month. There was no evidence the resident refused his showers. Further review of the state tested nursing assistant (STNA) bath detail report revealed showers were not given as scheduled for the months of October, November and December 2016 and January 2017. Resident #4 only received two showers in October (10/12/16 and 10/19/16), three showers in November (11/09/16, 11/22/16 and 11/30/16), two showers in December (12/07/16 and 12/21/16) and no showers in January 2017. On 01/06/17 at 5:10 P.M., RN #10 verified Resident #4 did not receive his showers as planned because there was not enough staff available. 8. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He resided on the [MEDICATION NAME] unit. He was mobile in a wheelchair. Review of the quarterly MDS assessment dated [DATE] revealed he had moderate cognitive impairment and was totally dependent on two or more staff for transfers and needed extensive assistance with one staff for toileting. On 01/05/17 at 5:50 P.M., Resident #11's wife verified she was wheeling him back to his room from dining because he needed to use the restroom. The resident stated he had to wait too long sometimes and was incontinent because he had to wait. On 01/06/17 at 6:00 P.M., interview with SSA #51 verified she was aware of the Resident #11's family's concerns about staff not timely meeting his care needs because the wife came to her with these concerns. She said they had a care conference with RN #10 and the DON but did not know what was done. SSA #51 verified at times families and/or residents come to her in passing and tell her about concerns related to a lack of staff to timely meet their care needs but she does not document them but she would report them to RN #10. 9. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She resided on the [MEDICATION NAME] unit. The resident was mobile in a wheelchair. The quarterly MDS assessment dated [DATE] revealed she was alert and oriented and had an intact memory. She required physical assistance of one person for bathing. On 01/06/17 at 1:45 P.M., Resident #14 verified she liked her showers in the morning before breakfast and wanted showers twice a week. She said some weeks she only got one shower and she usually did not get her showers until 10:00 A.M. or after lunch. Staff told her they do not have time to do her showers in the morning and as preferred because they are too busy and do not have time. Review of the shower schedule and the skin monitoring sheets revealed Resident #14 was to receive a shower twice a week on Tuesdays and Saturdays, on day shift. This would be about eight showers per month. There was no evidence Resident #14 refused her showers. Further review of the STNA bath detail report revealed Resident #14 did not receive her showers as scheduled for the months of October, November and December 2016 and January 2017. Resident #14 received four showers in October (10/11/16, 10/15/16, 10/18/16 and 10/29/16), five showers in November (11/05/16, 11/08/16, 11/14/16, 11/22/16 and 11/29/16), six showers in December (12/03/16, 12/06/16, 12/13/16, 12/17/16, 12/20/16 and 12/27/16) and one shower for January as of 01/06/17 (01/03/17). On 01/06/17 at 5:10 P.M., RN #10 verified Resident #14 did not receive her showers as planned because there was not enough staff available. 10. Review of the [MEDICATION NAME] unit census dated 12/29/16 to 01/06/17 revealed a daily census of 33 residents. Seven of the residents on this unit required the assistance of two staff persons with a mechanical lift for transfers and toileting. Seven residents required two staff persons for transfers and 13 residents required the assistance of one staff for transfers. All 33 residents required assistance for their ADL's. The capacity of the unit was 34 residents. Review of the staffing schedules from 12/13/16 to 12/15/16 and 12/23/16 to 12/31/16 revealed the [MEDICATION NAME] unit was to have four STNA's on day shift and three STNA's on afternoon shift and night shift. There was to be one floor nurse on the unit for all shifts. The following was the actual number of STNA's who worked on each day for each shift and revealed the facility was short staffed on a number of shifts: On 12/13/16, three on day shift, 2.8 on afternoon shift and 2.5 on night shift. On 12/14/16, four on day shift, three on afternoon shift and 2.5 on night shift. On 12/15/16, three on day shift , 2.5 on afternoon shift, and 2.5 on night shift. On 12/23/16, 3.6 on day shift, three on afternoon shift, and two on night shift. On 12/24/16, three on day shift, 2.5 on afternoon shift and 2.5 on night shift. On 12/25/16, three on day shift, 2.6 on afternoon shift, and two on night shift. On 12/26/16, three on day shift, 2.5 on afternoon shift and 1.5 on night shift. On 12/27/16, 3.5 on day shift, three on afternoon shift, and 2.5 on night shift. On 12/28/16, 3.5 on day shift, three on second shift, and two on night shift. On 12/29/16, four on day shift, three on second shift, and 1.5 two on night shift. On 12/30/16, three on day shift, 2.5 on second shift and 1.5 two on night shift. On 12/31/16, 3.5 on day shift, three on second shift, and two two on night shift. On 12/29/16 at 2:40 P.M., a confidential interview with Employee #100 verified there were many residents who needed a lot of assistance with two staff and indicated staff were not able to timely respond to all the residents needs. Employee #100 said they needed four STNA's on days and afternoons to timely meet the needs of the residents. Employee #100 also said afternoon was only scheduled with three STNA's and may only have two STNA's working at times if someone reports off and they can't find a replacement. On 12/29/16 at 4:45 P.M., a confidential interview with Employee #101 verified there were a lot of residents who needed two person assistance and there was not always enough staff. Employee #101 indicated STNA's then had to provide care for a resident by themselves, even if the resident should have two staff for assistance. On 01/05/17 at 3:15 P.M., interview with Resident #8 stated she did not need much assistance from staff but had to frequently put on call light for her roommate. She said her roommate frequently had to wait about 30 minutes to have her care needs met. On 01/05/17 at 3:20 P.M., interview with Resident #9 verified sometimes it took a while for staff to respond to her request for assistance but she was not able to give any additional information. 01/05/17 at 3:25 P.M., a confidential interview with a family member who did not want their name used, Family #103, verified their family member who was a resident at the facility needed two staff to assist with transfers and toileting. Family #103 said it was hard to find staff to assist with the resident's needs timely and said they are very busy and there is not enough help resulting in falls, sitting in soiled incontinence briefs and behaviors. Family #103 said the resident could express when his/her brief was soiled and if they requested staff assistance after dinner, the resident was mechanically transferred into bed to change the soiled brief or placed on a bed pan. Family #103 said the resident may lay on the bed pan for 45 minutes until staff return. Staff have said they don't have time to get the resident back out of bed and the resident then has to stay in bed for the rest of the evening. Family #103 said care needs are met timely when there are four STNA's but frequently there are only two or three STNA's on day and afternoon shifts. Family #103 indicated he/she had talked with RN #10, the unit manager, about these concerns but nothing changed. On 01/05/17 at 4:00 P.M., a confidential interview with a family member of a resident, Family #102, verified the resident was not able to do things without staff assistance and needed one to two staff for ADL's. Family #102 said the resident usually had to wait at least 30 minutes to have care needs met including incontinence care and personal hygiene. Family #102 said the wait time was longer for transfers because the resident required two staff assistance. This family member said over the holidays there were frequently only two STNA's on day shift and afternoon shift and some residents could not get out of bed when they wanted because there was not enough help. This family said he/she had talked to the facility management, including RN #10, multiple times but no one seems to want to listen. Family #102 said RN #10 tells him/her that is how it is and they are trying their best. On 01/05/17 at 5:15 P.M., interview with licensed practical nurse (LPN) #52 verified if the unit was staffed with four STNA's on days and afternoon shifts they would be able to timely meet the needs of the residents. LPN #52 verified the facility only staffed three STNA's on afternoons and at times there were only two STNA's on the unit. On 01/05/17 at 5:30 P.M., interview with STNA #35 verified they could timely meet the needs of the residents with four STNA's on day shift and afternoon shift, but not with less. Afternoon shifts were only staffed with three STNA's. On 01/05/17 at 5:45 P.M., a confidential interview with Employee #104 verified the unit had many residents who needed two staff to assist them with their ADL's and there were only three STNA's scheduled for the afternoon shift. Employee #104 said there were many times when there were only two STNA's on the unit on afternoon shift and all management would leave by 5:00 P.M. before dining was over and thus did not assist them. This employee said staff were afraid to provide this information because they were fearful of RN #10, the unit manager, who was hovering around during the interview. Employee #104 verified some residents may wait an hour or more to get their care needs met because of the high acuity of the residents including incontinence care, personal hygiene, toileting and transfers. He/She said they answer the call lights and let the residents know they will be back as soon as they can. On 01/05/17 at 5:50 P.M., confidential interview with a resident's family member, Family #60, verified she has had to assist other residents with reaching for cups and utensils and cutting up foods during meal times because there was not enough staff in the dining room to assist everyone. Family #60 verified her family member needed assistance with transfers and toileting and frequently had to wait too long for toileting and would be incontinent as a result. This was also verified by the resident themselves. Family #60 verified she had expressed her concerns to RN #10 but nothing changed. On 01/05/17 at 6:02 P.M., interview with STNA #33 verified she was working as fast as she could to get to each resident but it was difficult especially after meals. Many residents needed to be toileted and/or have incontinence care provided and wanted to lay down and many of them needed two staff. STNA #33 said they usually only have three STNA's scheduled on afternoon shift but sometimes they have to work with only two STNA's. On 01/06/17 at 4:00 P.M., an interview was conducted with Scheduler #65. The working schedules for 12/13/16 to 12/16/16 and 12/23/16 to 12/31/16 were reviewed and revealed the [MEDICATION NAME] unit regularly did not have the minimum staff as scheduled. The scheduler said the DON was the one who determined how many direct care staff were to be on each unit for each shift. This deficiency substantiates Master Complaint Number OH 739 and Complaint Number OH 639.