Every finding on record at Whitehouse Country Manor

Based on medical record review, staff interview, review of the facility's Self-Reported Incident (SRI), review of the facility's investigation, and policy review, the facility failed to timely report an incident of potential sexual abuse. This affected two (#11 and #12) of three residents reviewed for abuse. The facility census was 81. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 08/12/15 with diagnoses of bipolar disorder, schizophrenia and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/20/25, revealed Resident #11 had intact cognition. Further review of the record revealed Resident #11 had a guardian. Review of the current care plan, updated August 2023, revealed Resident #11 displayed behaviors of showing interest in physical affection/intimacy with male peers. Review of a nursing progress note dated 05/11/25 at 2:38 A.M. revealed Resident #11 was found by staff in her room performing oral sex on a male resident. The two residents were separated. 2. Review of the medical record for Resident #12 revealed an admission date of 04/15/22 with diagnoses of schizoaffective disorder, bipolar disorder and hallucinations. Review of the comprehensive annual MDS assessment completed 04/16/25 revealed Resident #12 had impaired cognition. Review of a nursing progress note dated 05/11/25 at 2:39 A.M. revealed Resident #12 was found by staff in another resident's room receiving oral sex from a female resident. Residents were separated. Review of SRI #260263 revealed the facility initiated the investigation on 05/12/25 at 9:30 A.M. Review of the facility's investigation into SRI 260263 revealed witness statements were obtained on 05/10/25 from Certified Nursing Assistant (CNA) #101 and Registered Nurse (RN) #203. Interview on 06/04/25 at 10:04 A.M. with the Director of Nursing (DON) confirmed she initiated the investigation on 05/12/25. The DON stated the incident occurred on third shift on 05/11/25. Interview on 06/04/25 at 10:55 A.M. with RN #203, and concurrent observation of her cell phone text messages revealed she notified the Assistant Director of Nursing (ADON) via text of the incident between Resident #11 and Resident #12 on 05/11/25 at 12:01 A.M. Further interview with RN #203 confirmed the incident happened before midnight on 05/10/25 and RN #203 confirmed she and CNA #101 completed witness statements on 05/10/25. Interview on 06/04/25 at 11:21 A.M. with the ADON confirmed she received a text from RN #203 on 05/11/25 at 12:01 A.M. The ADON stated she did not see the message until later in the morning when she notified the DON of the incident. Concurrent observation of the ADON's cell phone text messages revealed she notified the DON on 05/11/25 at 10:05 A.M. Two attempts to contact the DON via telephone at the facility were unsuccessful on 06/04/25 at 4:37 P.M. and 4:52 P.M. regarding her receipt of the text message from the ADON on 05/11/25 at 10:05 A.M. and her initiation of the SRI on 05/12/25 at 9:30 A.M., reflecting a 33.5 hour time span between the incident and the initiation of an investigation. Review of the policy titled, Abuse Policy, revised 01/27/23, revealed if abuse or serious bodily injury is alleged, it should be reported to the State Agency immediately, but not later than two hours after the allegation is made. Further review revealed the Administrator or designee will notify the State Agency of all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property and Injuries of Unknown Source as soon as possible but no later than 24 hours. The was an incidental finding during the course of the complaint investigation/ self-reported incdent investigation completed 06/04/25.

Based on observation, staff interview, and policy review, the facility failed to store food in a safe and sanitary manner. This had the potential to affect all but five (#16, #32, #48, #50, and #64) residents who eat food from the kitchen. The facility census was 84. Findings included: Observation of of the kitchen reach in refrigerator on 02/10/25 at 6:48 P.M. revealed a clear plastic bag of 12 chicken strips was found to not be dated nor labeled. An additional bag of nine hamburger patties were found to be undated. Further observation of the reach in freezer found a bag of mixed vegetables which failed to be securely closed and the contents were open to air. Interview with Dietary Manager #366 on 02/10/25 at 6:57 P.M. verified the chicken and beef patties were not labeled and the mixed vegetables were improperly stored. Review of the undated facility policy titled, Food and Supply Storage Procedures, revealed food should be covered, labeled, and dated. Further review revealed staff were to wrap food tightly to prevent freezer burn.

Based on observation, medical record review, staff interview, review of the Centers for Disease Control and Prevention (CDC) website, and review of an infection control facility assessment document, the facility failed to ensure staff members wore appropriate personal protective equipment (PPE) while handling soiled laundry and failed to wear, dispose of, and perform adequate hand hygiene after removing PPE while in resident rooms who were on infection control precautions due to COVID-19 infection. This had the potential to affect all 84 residents in the facility. The census was 84. Findings include: 1. Observation on 02/12/25 at 1:49 P.M. revealed Housekeeping Supervisor (HS) #397 in the laundry room not wearing any personal protective equipment (PPE). Further observation revealed a laundry basket of dry clothes beneath a washing machine with some dry items loaded into the washing machine. Concurrent interview with HS #397 confirmed she was in the middle of loading the washing machine with soiled items and was not wearing PPE. HS #397 further confirmed she should be wearing PPE while handling soiled clothing or linens. HS #397 further stated the items she was loading in the washing machine were not from rooms where residents were in isolation for infections. Review of a document titled, Infection Control Facility Assessment, revised 08/2019, revealed environmental staff should follow standard practice when handling linen, including avoiding direct body contact with soiled items. 51513 2. Review of the medical record for Resident #36 revealed an admitted [DATE] with a diagnosis of cerebrovascular accident. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact and required staff assistance for all activities of daily living (ADLs). Review a physicians order dated 02/10/25 revealed Resident #36 was in contact/droplet precautions every shift for COVID-19 for ten days. Observation on 02/11/25 at 7:33 A.M. revealed signage on Resident #36's door indicating the resident was on droplet precautions that required everyone must wash hands before entering and exiting the room. Further observation revealed additional signage indicating proper steps for putting on (donning) PPE before entering the room and taking off (doffing) PPE upon exiting the room. Observation of the steps for doffing the PPE included first removing gloves and discarding, then remove goggles or face shield, then remove gown, followed by removing mask or respirator, and last step was to wash hands or use an alcohol based hand sanitizer immediately after removing PPE. Observation on 02/11/25 at 7:33 A.M. revealed Certified Nurse Aide (CNA) #396 delivered a food tray into Resident #36's room without an N95 mask on. CNA #396 wore two surgical masks along with a gown and gloves into the room. Observation on 02/11/25 at 7:35 revealed CNA #396 exiting the room then she removed her left glove before she removed the gown then removed the right glove and placed the rolled up, used PPE on the floor. CNA #396 then failed to perform hand hygiene after exiting room. CNA #396 then walked down the entire hall past resident rooms, into a staff office, then down another corridor never performing hand hygiene. Interview on 02/11/25 at 7:42 A.M. with CNA #396 confirmed she did not wear an N95 mask as it was her understanding two surgical masks would be appropriate for droplet precautions. Further, CNA #396 confirmed she did not appropriate hand hygiene, and stated she placed the used PPE on the floor outside Resident #36's room because there was no garbage can inside the room and she was going to retrieve a garbage can for the room. 49742 3. Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses of dementia, depression, hypercholesterolemia, type two diabetes mellitus, osteoarthritis, vitamin D deficiency, vitamin B deficiency, and epilepsy. Review of the modified quarterly MDS assessment, dated 12/18/24, revealed Resident #33 was moderately cognitively impaired. Review of Resident #33's physician orders revealed an order dated 02/10/25 for the resident to be on contact/droplet isolation every shift for COVID-19. Observation on 02/11/25 at 7:36 A.M. revealed CNA #330 delivered a meal tray to Resident #33 donning only a gown and a surgical mask. Interview on 02/11/25 at 7:41 A.M. with CNA #330 verified while delivering a tray to Resident #33 she did not wear a face shield or goggles, did not donned gloves in Resident #33's room after entry, and did not take off the surgical mask she wore prior to leaving Resident #33's room. 4. Review of Resident #29's medical record revealed an admitted [DATE] with diagnoses including dementia, schizoaffective disorder, paranoid schizophrenia, heart disease, anxiety, dysphagia, COVID-19, cognitive communication deficit, and abnormalities of gait and mobility. Review of the most recent quarterly MDS assessment for Resident #29, dated 01/31/25, revealed the resident was cognitively intact. Review of Resident #29's physician orders revealed an order dated 02/10/25 for the resident to be on contact/droplet isolation precautions every shift for COVID-19. 5. Review of Resident #34's medical record revealed an admitted [DATE] with diagnoses including dementia, muscle wasting and atrophy, anxiety, COVID-19, generalized muscle weakness, depression, and chronic obstructive pulmonary disease. Review of Resident #34's medical record revealed an order dated 02/10/25 for the resident to be on contact/droplet isolation precautions every shift for COVID-19. Observation on 02/11/25 at 10:19 A.M. revealed Housekeeper #402 he was cleaning inside the room shared by Resident #29 and Resident #34 wearing no PPE other than a surgical mask. Interview on 02/11/25 at 10:20 A.M. with Housekeeper #402 verified he did not wear any PPE other than a surgical mask while cleaning the room shared by Resident #29 and Resident #34. Review of the CDC website at https://www.cdc.gov/covid/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html under the section titled, Infection Control Guidance: SARS-CoV-2, dated 06/24/24, revealed healthcare personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 (COVID-19) infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (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). Review of the the CDC website at https://www.cdc.gov/niosh/learning/safetyculturehc/module-3/8.html, under the section titled, Donning and Doffing PPE: Proper Wearing, Removal, and Disposal, dated 10/03/22, revealed donning means to put on and use PPE properly to achieve the intended protection and minimize the risk of exposure and doffing means removing PPE in a way that avoids self-contamination. Further review revealed individuals wearing PPE should remove the PPE before entering any non-clinical areas including restrooms, breakrooms, and administrative areas, always wash hands with soap and water before wearing and after removal of PPE, and dispose of all PPE in appropriate waste containers.

Based on observation, resident and staff interviews, medical record review, and policy review, the facility failed to ensure residents were afforded the ability to smoke during designated smoking times. This affected one (#69) of one residents reviewed for smoking. The facility census was 84. Findings include: Review of the medical record for Resident #69 revealed an admitted [DATE] with diagnoses of heart failure and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/13/24, revealed Resident #69 had intact cognition. Review of the smoking assessment, completed 02/12/25, revealed Resident #69 smoked five (5) to 10 times per day. Interview on 02/10/25 at 8:30 P.M. with Resident #69 revealed he was frustrated because he was not allowed to smoke on three occasions because he was told he showed up too late for the scheduled smoking time. Resident #69 stated he had a clock in his room and was on time for the scheduled smoking break. Observation on 02/12/25 at 1:58 P.M. revealed Resident #69 in his wheelchair in the common area asking for a cigarette. Interview on 02/12/25 at 1:58 P.M. with Registered Nurse (RN) #367 stated Resident #69's smoke time was 1:45 P.M. and residents were allowed a ten minute grace period. RN #367 stated residents could arrive until 1:55 P.M. and still be allowed to smoke during the scheduled smoke time. Interview on 02/12/25 at 1:59 P.M. with Certified Nurse Aide (CNA) #348 stated she did not take residents out for the 1:45 P.M. smoke break. CNA #348 further stated residents had a 10 minute grace period to arrive for the assigned smoking time. Interview on 02/12/25 at 2:00 P.M. with CNA #330 revealed she was responsible for the 1:45 P.M. smoking break. CNA #330 repeatedly stated Resident #69 arrived at 1:52 P.M. and was not allowed to smoke because CNA #330 understood residents had to be present by 1:50 P.M. to be allowed to smoke during the break. CNA #330 could not clarify if residents were allowed a ten minute grace period. CNA #330 repeated residents had to be present by ten minutes before the hour to be allowed to smoke during the 1:45 P.M. smoke break. Interview on 02/12/25 at 2:02 P.M. with the Director of Nursing (DON) confirmed residents were allowed a ten minute grace period to arrive for the assigned smoke break. The DON stated if Resident #69 arrived at 1:52 P.M. he should have been allowed to smoke. The DON stated she would ensure Resident #69 was taken out to smoke to make up for the missed smoke time. Further interview with the DON revealed the smoking policy does not include guidance for a ten minute grace period but stated it was something the staff were trained to accommodate. Review of the smoking policy, dated 08/26/24, revealed the facility will make every best effort to establish and maintain safe resident smoking practices that accommodate the resident's needs. This deficiency represents non-compliance investigated under Complaint Number OH00162567.

Based on observation, resident and staff interview, and policy review, the facility failed to repair or replace broken window blinds. This affected two (#15 and #68) of three residents reviewed for environmental concerns. The facility census was 84. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses of schizoaffective disorder and hemiplegia and hemiparesis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/24/25, revealed Resident #15 had intact cognition. Observation on 02/11/25 at 6:59 A.M. in Resident #15's room revealed the vertical blinds had missing slats and a blanket covering up half of the window blinds. Concurrent interview with Resident #15 confirmed the missing slats bothered her and she used the blanket to further block sunlight. Interview and observation on 02/12/25 at 2:26 P.M. with Registered Nurse (RN) #367 confirmed there were five missing blind slats and an additional missing slat under the blanket. RN #367 confirmed she was aware the blinds were missing but did not report it because she thought somebody else had reported it. Interview on 02/18/25 at 4:00 P.M. with Maintenance Director #400 revealed he was unaware of the missing vertical slats in Resident #15's room. 51513 2. Review of the medical record for Resident #68 revealed an admitted [DATE] with diagnoses of Huntington's disease, major depressive disorder, and anxiety. Review of quarterly MDS assessment dated [DATE] revealed Resident #68 had impaired cognition and was receiving hospice care. Observation on 02/10/25 at approximately 7:30 P.M. revealed Resident #68 had horizontal blinds covering window next to bed. Further observation revealed approximately six to ten blind slats broken or missing. Interview on 02/12/25 at 11:41 A.M. with Certified Nurse Aide (CNA) #311 confirmed the missing or broken blind slats in Resident #68's room. CNA #311 stated she was aware the blinds were broken and there was a maintenance request form to fill out for facility repairs but had not filled out a request form for the blinds. Review of the policy titled, Quality of Life - Homelike Environment, revised 05/2017, revealed the facility will maximize a clean, sanitary and orderly environment and comfortable (minimum glare) yet adequate lighting.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure fall interventions were in place as ordered and care planned. This affected two (#27 and #33) of three residents reviewed for falls. The facility census was 84. Findings Include: 1. Review of the medical record for Resident #27 revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, atrial fibrillation, history of COVID-19, atherosclerotic heart disease, generalized muscle weakness, neurosyphilis, seizures, bipolar disorder, unspecified abnormalities of gait and abnormalities, schizophrenia, hypothyroidism, and dementia. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 01/21/25, revealed Resident #27 was cognitively intact. Review of Resident #27's current physician orders revealed an order for this resident to utilize a reacher/grabber when items are out of reach. Review of Resident #27's current comprehensive care plan revealed the resident was at risk for falls with interventions including a mat on floor next to the bed on both sides and utilize a reacher/grabber when items are out of reach. Observation on 02/18/25 at 7:48 A.M. of Resident #27's room revealed no fall mat on either side of his bed and no reacher/grabber to utilize when items are out of reach. An interview on 02/18/25 at 7:50 A.M. with Resident #27 revealed he does not have a reacher/grabber or fall mats. Further interview with Resident #27 revealed he had no knowledge of these items. An interview on 02/18/25 at 7:53 A.M. with Licensed Practical Nurse (LPN) # 365 verified there was no reacher/grabber or floor mats on either side of the bed. 44815 2. Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses of dementia and epilepsy. Review of the modified quarterly MDS assessment, dated 12/18/24, revealed Resident #33 had impaired cognition and was mobile with a walker and/or wheelchair. Resident #33 required supervision or touching assistance for personal hygiene and dressing and bed mobility. Further review revealed Resident #33 had no falls since the previous assessment. Review of the fall risk assessment, completed 01/05/25, revealed Resident #33 was at high risk for falls. Review of a current physician order initiated 05/02/23 revealed Resident #33 should have a motion sensor alarm above the bathroom door for fall prevention. Review of a current physician order initiated 07/03/23 revealed Resident #33 should have non-skid strips on floor in front of the closet. Review of a current physician order initiated 08/15/23 revealed Resident #33 should have non-skid strips in front of the bed for fall prevention. Observation and interview on 02/18/25 at approximately 7:45 A.M. with Certified Nurse Aide (CNA) #348 in Resident #33's room revealed no non-skid strips were on the floor near the bed or in front of the closet. CNA #348 stated Resident #33 had not moved rooms recently. Interview on 02/18/25 at 8:34 A.M. with the Director of Nursing (DON) stated Resident #33 was recently moved from another room after Resident #33 tested positive for COVID-19. Observation in Resident #33's previous room revealed non-skid strips in front of her closet. The DON confirmed fall interventions were not in place in Resident #33's current room. Observation and interview on 02/18/25 at 8:37 A.M. revealed Unit Manager (UM) #365 placing non-skid strips in front of the closet in Resident #33's room. UM #365 confirmed no door alarm was on the bathroom door in Resident #33's room. Further observation revealed a door alarm on the bathroom door in Resident #33's old room. Review of the falls policy, dated 01/01/2016, revealed it is the policy of the facility to insure the safety and well-being of residents who are at risk for falls. Additional review revealed the facility would implement interventions to guard against another fall of the same type. This deficiency represents non-compliance investigated under Complaint Number OH00162567.

Based on observation, staff interview, medical record review, review of facility policy, and review of manufacturers instructions, the facility failed to ensure Novolog insulin was properly removed from use after it was opened past 28 days. This affected one (#10) of 21 residents with orders for insulin. The facility census was 84. Findings Include: Review of Resident #10's medical record revealed an admitted [DATE] with diagnoses including hemiplegia, vitamin D deficiency, bipolar disorder, type two diabetes mellitus, hypertension, and schizoaffective disorder. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Observation on 02/12/25 at 9:42 A.M. of a medication storage cart revealed a Novolog Flex Pen for Resident #10 was opened, contained approximately 210 units of insulin, and was labeled with an open date of 12/25/24. Interview on 02/12/25 at 9:44 A.M. with the Director of Nursing (DON) confirmed the Novolog Flex Pen for Resident #10 contained approximately 210 units and was labeled with an open date of 12/25/24. The DON stated the facility policy indicated for staff to discard Novolog Flex Pens 28 days after the date they are opened. Review of the manufacturers package insert for Novolog Flex Pen revealed when the pen was stored at room temperature after opening it should be thrown away after 28 days. Review of the facility policy titled, PCA (Pharmacy Care Associates) Expiration Dates, dated November 2018, revealed Novolog Flex Pen should be discarded 28 days after opening.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure information contained in a resident's medical record was accurate. This affected one (#33) of three residents reviewed for falls. The facility census was 84. Findings Include: Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses of dementia and epilepsy. Review of the modified quarterly Minimum Data Set (MDS) assessment, dated 12/18/24, revealed Resident #33 had impaired cognition and was mobile with a walker and/or wheelchair. Further review revealed Resident #33 had no falls since the previous assessment. Review of a current physician order initiated 05/02/23 revealed Resident #33 should have a motion sensor alarm above bathroom door for fall prevention. Review of a current physician order initiated 07/03/23 revealed Resident #33 should have non-skid strips on floor in front of the closet. Review of a current physician order initiated 08/15/23 revealed Resident #33 should have non-skid strips in front of the bed for fall prevention. Observation and interview on 02/18/25 at approximately 7:45 A.M. with Certified Nurse Aide (CNA) #348 in Resident #33's room revealed no non-skid strips were on the floor near the bed or in front of the closet. CNA #348 stated Resident #33 had not moved rooms recently. Interview on 02/18/25 at 8:34 A.M. with the Director of Nursing (DON) stated Resident #33 was recently moved from another room after Resident #33 tested positive for COVID-19. Observation in Resident #33's previous room revealed non-skid strips in front of her closet. The DON confirmed fall interventions were not in place in Resident #33's current room. Further interview, along with concurrent review of Resident #33's electronic medical record (EMR), revealed staff charted the non-skid strips were in place in Resident #33's room. The DON confirmed the charting was inaccurate. Observation and interview on 02/18/25 at 8:37 A.M. revealed Unit Manager (UM) #365 placing non-skid strips in front of the closet in Resident #33's room. UM #365 confirmed no door alarm was on the bathroom door in Resident #33's room. Further observation revealed a door alarm on the bathroom door in Resident #33's old room. Interview on 02/18/25 at 8:47 A.M. with Licensed Practical Nurse (LPN) #331, and concurrent review of Resident #33's EMR, revealed LPN #331 charted fall interventions were in place on 02/17/25 for Resident #33. LPN #331 stated she was aware the door alarm was not in the room with Resident #33, and further stated the door alarm was nonfunctional and required new batteries. LPN # further confirmed she documented on 02/17/25 in the EMR Resident #33's placement and function of the door alarm with a y to indicate it was in place and functional. LPN #331 again confirmed the door alarm was nonfunctional and the charting was not accurate. Observation and interview on 02/18/25 at approximately 9:00 A.M. with the DON confirmed the door alarm on the bathroom door in Resident #33's old room was not working. Additionally, the DON confirmed charting in the resident's EMR reflected the door alarm was in place in Resident #33's room and was in functional, and verified the door alarm was not actually in Resident #33's room and was not functional. Review of the facility policy titled, Charting and Documentation, with a revision date of 07/17, revealed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 44815

Based on observation, staff interview, and review of facility policy, the facility failed to ensure the resident call light system was functioning appropriately and relaying the calls to a centralized staff work area or to a staff member. This affected two (#204 and #207) of 24 rooms located on the 200 Hall. The census was 84. Findings Include: Observation on 02/18/25 at 9:05 A.M. revealed the call lights for room [ROOM NUMBER] and room [ROOM NUMBER] were illuminated in the hall above the doors entering the room. Continued observation revealed both call lights were not relaying the call to a staff member or a monitoring system located at the centralized staff work area. Interview on 02/18/25 at 9:08 A.M. with Housekeeper #397 verified revealed the call lights for room [ROOM NUMBER] and room [ROOM NUMBER] were illuminated in the hall above the doors entering the room, but were not relayed to the centralized monitoring system located in the staff work area. Interview on 02/18/25 at 9:15 A.M. with Licensed Practical Nurse (LPN) #365 revealed the centralized monitoring system located in the staff work area had received call light signals for approximately a week and one-half. LPN #365 revealed she was unsure of when the call lights would be repaired or what actions the maintenance department had taken to fix the call lights. Interview on 02/18/25 at 11:14 A.M. with Maintenance Director (MD) #400 verified the call light monitoring system located in the staff work area where room [ROOM NUMBER] and room [ROOM NUMBER] were located had not been functional for approximately two and one-half weeks. MD #400 stated he had not had someone evaluate the call light system to determine what was needed to repair the communication system located in the staff work area. Review of the facility policy titled, Call Light Policy and Procedure, dated December 2020, revealed the call light was used by a resident to notify staff of the nursing facility that the resident has a need that they would like addressed. This deficiency represents non-compliance investigated under Complaint Number OH00162567.

Based on observation, medical record review, staff interview, and clean dressing change policy review, the facility failed to prevent cross- contamination between soiled elimination containers, clean wound dressings, food, and beverages. This affected one (#1) of three residents reviewed for infection control interventions in a facility census of 80. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE], with the diagnoses including: type II diabetes mellitus with foot ulcer, urinary tract infection, non-pressure chronic ulcer of right heel and midfoot, atrial fibrillation, hemiplegia, aortocoronary bypass graph, heart failure, hypertension, benign prostatic hyperplasia, and major depression. Review of the most current minimum data set assessment dated [DATE], revealed Resident #1 was assessed with intact cognition (BIMS-15), ability to make needs known, required substantial to maximal assistance with activities of daily living, incontinent of bowel and bladder, at risk for pressure ulcer development with presence of diabetic foot ulcer and associated application of wound treatment (dressing). Review of the medical record noted on 03/18/24, a physician orders were implemented for the treatment of diabetic ulcers to Resident #1 right plantar heel and right posterior heel. Treatments were ordered as follows: Right plantar heel, cleanse with wound cleanser. Pat dry. Pack collagen in area at 10 o'clock and place on wound bed. Cover with abdominal dressing (ABD) pad. Wrap with kerlix. Secure with tape. Complete every day shift for diabetic ulcer and as needed for Diabetic ulcer. Right posterior heel, cleanse with wound cleanser. Pat dry. Apply Collagen to wound bed. Cover with ABD pad. Wrap with kerlix. Secure with tape. Complete every day shift for Diabetic ulcer and as needed for diabetic ulcer. Observation on 04/11/24 at 7:11 A.M., noted Resident #1 resting in bed. A urinal was placed on the overbed table and located four inches from an empty cup and water pitcher. At 7:17 A.M., a State tested Nurse Aide (STNA) #200 was observed to place the residents breakfast tray on the overbed table and proceeded to empty the urinal. No cleansing of the overbed table occurred. At 10:26 A.M., Registered Nurse (RN) #300 placed clean dressing supplies on the overbed table within one inch of a soiled urinal. RN #300 proceeded to open and apply the dressing to the residents wound. No cleansing of the table or clean field was attempted. Interview on 04/11/24 at 10:40 A.M., with RN #300 confirmed the soiled urinal was setting on the bedside table next to clean dressing supplies. RN #300 stated the overbed table was not cleaned or sanitized prior to dressing application. Interview on 04/11/24 at 10:45 A.M., with Director of Nursing verified Resident #1 frequently places urinal on overbed table. The table is also used for personal effects, water pitcher, beverage cup, meals, and dressing changes. Prior to placing clean items on bedside table, the surface should be cleansed. Observations on 04/11/24 at 11:47 A.M., noted Resident #1 in bed eating lunch. The residents meal tray with food contents were positioned on the overbed table. Located within one inch was a urinal containing approximately 300 cubic centimeters of yellow urine. Resident #1 was consuming the lunch meal while seated in bed. Interview on 04/11/24 at 11:54 A.M., with Licensed Practical Nurse (LPN) #400 revealed she delivered the meal tray to the resident and placed the meal tray on the overbed table. LPN #200 indicated the urinal was not located on the table when the meal tray was delivered. LPN #200 confirmed no additional location was provided to Resident #1 regarding the placement of the urinal when in bed other than the overbed table. Interview on 04/11/24 at 12:10 P.M., with the Director of Nursing confirmed all potentially soiled continence collection equipment is to be stored away from food, clean wound dressing supplies or beverages. Review of the undated policy titled, Clean Dressing Change stated when completing a dressing change establish a clean field, place equipment on clean field. This deficiency represents non-compliance investigated under Complaint Number OH00152257.

Based on observation, resident interview, family interview, and staff interview, the facility failed to maintain a clean and homelike environment. This affected five (#9, #10, #11, #41, and #51) of five residents reviewed for environment. The facility census was 87. Findings include: 1. Observation on 10/04/23 at 9:10 A.M., revealed the blinds covering the window over Resident #41's were torn and broken a quarter of the way up the window on the right side of the window. Resident #41's bed was against the wall below the window with the head of the bed below the area where the blinds were torn, broken, and not covering the window. A black substance that smeared with touch was observed on the walls in Resident #41's room. Interview at the time of the observation on 10/04/23 at 9:10 A.M., with Resident #41, stated the window covering had been like that since Resident #41 moved in. Resident #41 stated I hate it because the sun shines in my eyes and at night gets the lights from the cars pulling in and out of the parking lot that shine in. Resident #41 stated, no good to say anything because nothing gets done, I have tried. 2. Interview and observation on 10/04/23 at 9:50 A.M., with Resident #9 revealed he was concerned about the black substance on the in the three walls alongside the dresser. Observation of the walls surrounding the dresser revealed rough walls with peeling and torn plaster and drywall, with the flooring missing from under the dresser. The dresser sat on a concrete floor and along the base of the floor and approximately 4 inches off the floor on the three walls surrounding the dresser were various patches of a black substance that smeared when touched. 3. Interview and observation on 10/04/23 at 9:55 A.M., with Resident #10 stated no one cares, we have to look at the mold (black substance) all day, every day (referring to Resident #9's wall). Missing and broken white trim pieces along the half walls were observed in the room of Residents #9 and #10, with exposed bare wood. 4. Interview and observation on 10/04/23 at 10:00 A.M., with Resident #11 revealed a missing piece of wall under the sink in the bathroom, the hole measuring approximately two feet by two feet with pipes exposed. Resident #11 stated it has been that way for some time, I do not like sitting on the toilet looking at a hole in the wall. Missing and broken white trim pieces along the half walls was observed in the room of Residents #11, with exposed bare wood. 5. Interview on 10/04/23 at 11:00 A.M., with the family member of Resident #51 revealed concerns regarding the physical condition of Resident #51's room. Resident #51's family member stated when they moved Resident #51, they were told the facility is being renovated, and the family member has yet to see anything done. Resident #51's family member stated concerns were brought forward about the dust on the vent above Resident #51's bed and the black substance on the walls, not to mention the odor and nothing has been done. Observation at the time of the interview revealed the vent in the right side of the room, above the bed of Resident #51 contained a thick layer of dust that covered the openings of vent and a black substance at the base of the wall surrounding the recessed dresser. The black substance smeared when touched. Interview on 10/04/23 at 11:40 A.M., with Maintenance Supervisor #208 revealed the facility had started to renovate the first week in June 2023, however, there have been issues that have prevented the renovations to occur as originally scheduled. Observations on 10/04/23 beginning at 12:00 P.M., with Maintenance Supervisor #208 confirmed blinds and window coverings were broken and torn, the hole in the wall of Resident #11's bathroom, a substance on the walls of resident rooms, peeling and cracked drywall, dust, and odors in the facility especially on the east wing of the building. Maintenance Supervisor #208 verified the conditions were unacceptable for the residents. This deficiency represents non-compliance investigated under Master Complaint Number OH00146847 and Complaint Number OH00146411.

Based on observation and staff interview, the facility failed to maintain a clean, functional, sanitary, and homelike environment for its residents. This had the potential to affect all 43 (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85 and #86) residents residing on the east wing of the building and affected seven residents (#3, #4, and #12) of 43 residents residing on the west wing of building. The facility censuses were 86. Findings include: Observations during tour of the facility on 10/04/23 between 9:10 A.M. and 10:15 A.M., revealed on the east wing, there was a strong foul odor noted as soon as one passed through the secure double doors. In the activity room/dining room, a cupboard door above sink, was hanging loosely off the cupboard by the right lower hinge; a missing front panel on the top drawer to the left of the sink; and sticky floors. Across from the nurse's station, the corner of the wall was cracked and crumbling with exposed drywall, with a jagged broken metal corner piece exposed to the hallway. The screen on window at the end of hall outside rooms [ROOM NUMBERS] was torn and hanging a quarter way down off the window closet to the emergency exit door. Ceiling tiles are not seeded in the tracks with several tiles stained brown and yellow in hallway outside Resident #70 and #71's room. A missing right closed door with the left closet door off the track with cracked and crumbling drywall and an exposed bent metal stripping hanging off the corner of the wall just outside the closet of Resident #75 and #76's room. A black substance that extended from the floor to waist high on the three walls surrounding the dresser in the room of Residents #62 and #63. The black substance smeared when touched. Continued tour on the west wing of the building revealed bowed, cracked, and yellow stained ceiling tiles outside room [ROOM NUMBER], missing blinds and curtain with a bath blanket hanging over the left window and three exposed rods for hanging curtain, sticking straight off wall, over the bed of Resident #4's bed, walls along the wall next to Resident #4's bed had two visible holes with white tape covering. Missing and broken white trim pieces along the half walls in the rooms of Residents #3, #4, and #12 with exposed bare wood was observed. Interview on 10/04/23 at 10:04 A.M., with Licensed Practical Nurse (LPN) #148 verified the foul odor on the east wing and did not know what it was. Interview on 10/04/23 at 10:30 A.M. with Certified Nursing Assistants (CAN) #116 and #136 verified the black substance on the walls of Residents #4's room. CNA #116 stated the black substance has been on the walls for several months. CNA #116 and #136 both verified they have submitted work orders to have the issue addressed and further stated no one does anything about it. Interview on 10/04/23 at 11:40 A.M., with Maintenance Supervisor #208 revealed the facility had started to renovate the first week in June 2023, however, there have been issues that have prevented the renovations to occur as originally scheduled. Observations on 10/04/23 at 12:00 P.M., with Maintenance Supervisor #208 confirmed the foul odor on the east wing, the torn screen, verified broken and missing cupboard doors, blinds and window coverings were broken and torn, there were a substance on the walls of resident rooms, peeling and cracked drywall and exposed metal striping. Maintenance Supervisor #208 was observed seeding ceiling tiles into the track during the tour and agreed the conditions were unacceptable for the residents. This deficiency represents non-compliance investigated under Master Complaint Number OH00146847 and Complaint Number OH00146411.

Based on observation, staff interview, and review of the facility policy, the facility failed to practice appropriate hand hygiene and wear appropriate hair restraints while preparing and distributing food. This had the potential to affect all residents in the facility except Resident #55 who received no food from the kitchen. The facility census was 86. Findings include: 1. Observation on 05/10/23 at 12:15 P.M. revealed Dietary Aide #302 scooped ice from the ice machine and a piece of ice fell on the floor. Dietary Aide #302 picked the ice up off the floor with her bare left hand while wearing a glove on her right hand. Dietary Aide #302 then took the glove off her right hand and threw it in the trash. Dietary Aide #302 then picked up a coffee mug by the handle with her left hand and delivered it to Resident #97. Resident #97 then picked up the mug by the handle and drank from it. Interview at the time of the observation with Dietary Aide #302 confirmed she did not wash her hands after picking ice up off the floor with her bare hand and before handling Resident #97's coffee mug by the handle. 2. Observation on 05/10/23 at 3:15 P.M. revealed Dietary Aide #304 pouring drinks and stirring drinks for the evening meal. Dietary Aide #304 had curly dark hair all over his head and was not wearing a hair net. Interview at the time of the observation with Dietary Aide #304 stated he had never been told he had to wear a hairnet. Interim Dietary Manager #303, who was present during the observation and interview, verified Dietary Aide #304 was not wearing a hairnet and handed a hairnet to Dietary Aide #304. Review of the undated facility policy, Personal Hygiene, revealed staff should wash their hands after touching soiled dishes, foods, or trash, and before putting on gloves or after removing them. Further review revealed hair must be kept clean and kept restrained with a hairnet or cap covering all hair. This deficiency represents non-compliance investigated under Master Complaint Number OH00142692.

Based on observation, resident interview, and staff interview, the facility failed to maintain a clean and homelike environment. This affected 14 (#17, #18, #25, #26, #37, #38, #40, #41, #44, #45, #46, #47, #80, and #96) of 31 residents reviewed for environment. The facility census was 86. Findings include: 1. Observation on 05/10/23 at 8:21 A.M. revealed the upper light bulb in Resident #96's overbed light did not work. Interview with Resident #96 during the time of the observation on 05/10/23 at 8:21 A.M. stated the light bulb not working over her bed affected her ability to crochet. 2. Interview and observation on 05/10/23 at 9:52 A.M. with Resident #26 revealed there were broken blinds over the window which was directly above her bed. Resident #26 stated the broken blinds bothered her. Continued interview and observation revealed the soap dispenser in her bathroom was empty. Resident #26 stated it had been empty for five days and it concerned her. There was no additional soap available in the bathroom at that time. 3. Interview and observation on 05/10/23 at 10:01 A.M. with Resident #46 revealed he was concerned about the hole in the wall along side his bed, which measured approximately two inches tall and approximately three inches wide. Continued observation revealed dark brownish-red stains at the bottom edge of the privacy curtain. Resident #46 also reported a concern that the clock in his room did not have a battery. Observations and interview during a tour of the facility on 05/10/23 with Maintenance Director #134 beginning at 11:36 A.M. confirmed a toilet was filled with feces, the water to the toilet was turned off and could not be flushed, and the toilet seat and lid were broken in the bathroom shared by Resident #37 and Resident #38; a toilet was filled with feces and the water to the toilet was turned off so it could not be flushed in the bathroom shared by Resident #40, Resident #41, Resident #44, and Resident #45; a hole in the drywall, approximately two inches long by three inches wide, a soiled privacy curtain, and the mounted clock had no battery in Resident #46's room; the lower light bulb was not functioning above Resident #96's bed; the upper light bulb was not functioning above Resident #80's bed; the hand soap dispenser was empty in Resident #26's room; and the blinds were broken or missing in resident rooms where Resident #17, Resident #18, Resident #25, Resident #26, Resident #40, Resident #41, Resident #46, and Resident #47 resided. Interview on 05/10/23 at 11:36 A.M. with Maintenance Director #134 stated the facility planned to renovate the facility beginning the first week in June 2023, including patching all holes in the walls, painting all rooms, and replacing all dressers. Maintenance Director #134 stated the facility was in the process of replacing all soap dispensers in resident bathrooms. Further observation with Maintenance Director #134 verified no alcohol-based hand sanitizer dispensers were available in the hallway outside Resident #26's room. This deficiency represents non-compliance investigated under Master Complaint Number OH00142692 and Complaint Number OH00142646.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure light fixtures were maintained in a manner to allow for adequate use of lighting in the resident's room. This affected one (#80) of 31 residents reviewed for environment. The census was 86. Findings include: Review of the medical record for Resident #80 revealed an admitted [DATE] with diagnoses of cirrhosis and urinary tract infection. Review of the admission nursing observation document revealed Resident #80 was alert to person, place, time, and situation. Interview on 05/10/23 at 1:53 P.M. with Resident #80, who was sitting in a wheelchair, revealed she felt her room was too dark and she had difficulty seeing because of her cataracts. Observation at the time of the interview revealed the pull string to turn the light over Resident #80's bed was too short for Resident #80 to reach. Observation and interview on 05/10/23 at 3:03 P.M. with Maintenance Director #134 confirmed the overbed light in Resident #80's room needed a new lower bulb and confirmed the pull strings to turn on and off the light were too short for the resident to reach. Further interview revealed Maintenance Director #134 replaced the entire light fixture after Resident #80 was admitted because it had no pull cords. This deficiency represents non-compliance investigated under Complaint Number OH00142646.

Based on medical record review, review of staff witness statements, staff interview, and review of facility policy, the facility failed to notify a resident's physician and family after a fall. This affected one (#66) of three residents reviewed for falls. The facility census was 86. Findings include: Review of the medical record for Resident #66 revealed an admitted [DATE]. Diagnoses included osteomyelitis of the vertebra in the thoracic region, sepsis due to streptococcus group B, fusion of the spine in the thoracic region, pyothorax, type two diabetes mellitus, cirrhosis of the liver, schizoaffective disorder, anxiety, depressive disorder, osteoarthritis, and chronic obstructive pulmonary disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a fall witness statement date 03/30/23 from Licensed Practical Nurse (LPN) #271 revealed Resident #66 was found on the floor lying on her back in her doorway. Review of a fall witness statement dated 03/30/23 from State tested Nurse Aide (STNA) #274 revealed Resident #66 was found lying on the floor in her doorway. Review of the nursing notes dated 03/30/23 revealed no documentation of notifications made to the family or physician regarding the fall on 03/30/23. Interview on 05/10/23 at 1:45 P.M., with Assistant Director of Nursing (ADON) #128 verified there was no notification made to Resident #66's family or physician regarding the fall on 03/30/23. ADON #128 stated Resident #66 was her own responsible party. Review of the facility policy, Change in Condition and Physician Notification Policy, revised September 2019, revealed the facility would notify the residents representative and physician when an accident or incident occurs involving the resident.

Based on medical record review, review of a concern form, review of staff witness statements, staff interview, resident interview, and policy review, the facility failed to timely report, investigate, and assess a resident following a fall. Additionally, the facility failed to timely assess a resident's risk for falls. This affected one (#66) of three residents reviewed for falls. The facility census was 86. Findings include: Review of the medical record for Resident #66 revealed an admitted [DATE]. Diagnoses included osteomyelitis of the vertebra in the thoracic region, sepsis due to streptococcus group B, fusion of the spine in the thoracic region, pyothorax, type two diabetes mellitus, cirrhosis of the liver, schizoaffective disorder, anxiety, depressive disorder, osteoarthritis, and chronic obstructive pulmonary disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had intact cognition. The resident required supervision for bed mobility, transfers, and ambulation. Review of the fall risk assessment dated [DATE] revealed Resident #66 was at low risk for falls. There were no fall risk assessments completed since 07/08/22. Review of a fall witness statement dated 03/30/23 from Licensed Practical Nurse (LPN) #271 revealed Resident #66 was found on the floor lying on her back in her doorway. Review of a fall witness statement dated 03/30/23 from State tested Nursing Assistant (STNA) #274 revealed Resident #66 was found lying on the floor in her doorway. Review of the nursing notes dated 03/30/23 through 04/17/23 revealed no documentation of Resident #66's fall on 03/30/23 and no documentation of an assessment after the fall. Review of a concern form dated 04/18/23 revealed it was brought to the attention of management Resident #66 had a fall on 03/30/23 which was not properly documented. There was no documentation noting a fall, no update made to family or nurse practitioner, and no assessment completed per the fall policy. Resident #66 complained of severe pain days following the fall and was administered as needed medications on multiple days. Further review of the concern form dated 04/18/23 revealed on 04/18/23 LPN #271 and STNA #274 informed management Resident #66 had a fall a few weeks back that was not reported by LPN #150. Resident #66 was witnessed on the floor on 03/30/23 by several staff members and the fall was reported to the responsible nurse along with witness statements. LPN #150 had not completed proper documentation or reporting of the fall according to the fall policy. When questioned, LPN #150 stated she must have forgot to do the proper documentation. LPN #150 was placed on a three-day suspension then terminated. Interview on 05/10/23 at 1:45 P.M., with Assistant Director of Nursing (ADON) #128 stated the Director of Nursing (DON) and herself started asking staff questions and found out Resident #66 had a fall on 03/30/23. ADON #128 stated staff members indicated they gave Resident #66's nurse witness statements, but management never received the witness statements or a report of the fall. ADON #128 revealed the DON called LPN #150 and she admitted she forgot to report the fall. ADON #128 verified there was no documentation of the fall and no documentation of an assessment after the fall. ADON #128 stated they never found the original staff witness statements so they had to have everyone rewrite their statements for the fall on 03/30/23. ADON #128 stated Resident #66 fell on first shift, but was not aware of what time the fall occurred. ADON #128 also verified a fall risk assessment on Resident #66 should have been completed quarterly in October 2022 and January 2023. Review of facility policy titled, Falls and Fall Risk, Managing, revised 08/31/22, revealed resident's fall risk would be assess upon admission, quarterly, with a significant change in status, and status post any fall. Further review of the policy revealed no guidelines for post fall assessments and documentation. This deficiency represents non-compliance investigated under Complaint Number OH00142692.

Based on medical record review, observation, resident and staff interview, and review of the facility policy, the facility failed to maintain comfortable hot water temperatures to meet the resident's needs. This affected four (#13, #34, #37, and #60) of four residents reviewed for hot water temperatures, with the potential to affect twelve (#8, #15, #16, #18, #24, #25, #40, #41, #58, #65, #72, and #82) additional residents who resided on the South Hall. The facility census was 84. Findings include: 1. Review of Resident #13's medical record revealed a readmitted [DATE]. Diagnoses included generalized anxiety disorder, pulmonary fibrosis, and bipolar disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of Resident #37's medical record revealed a readmitted [DATE]. Diagnoses included stage III chronic kidney disease, chronic obstructive pulmonary disease (COPD), and multiple sclerosis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #37 was cognitively intact. Interview and observation on 03/11/23 at 7:43 A.M. with Residents #13 and #37 revealed they were roommates. The residents stated the bathroom water was always cold, which did not make for a comfortable bed bath. Each stated the facility had fixed something about a month ago and, while it was better, the water was still luke warm. Observation of the hot water in Resident #13 and #37's bathroom at the time of the interview revealed the hot water was cold to the touch. After running the water for approximately three minutes, the water temperature was 90 degrees Fahrenheit (F). Interview and observation on 03/11/23 at 8:51 A.M. with State tested Nurse Aide (STNA) #340 revealed there had been some issues with the hot water on the South Hall and she submitted a work request approximately one month ago. STNA #340 stated she thought something had been fixed and the water temperatures were better. Observation at the time of the interview, with STNA #340, of Resident #13 and #37's bathroom hot water temperature revealed the hot water was cold to the touch and the temperature was 88 degrees F. STNA #340 verified the finding of 88 degrees F in Resident #13 and #37's bathroom. 2. Review of Resident #34's medical record revealed an admitted [DATE]. Diagnoses included multiple sclerosis, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and schizoaffective disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #34 was cognitively intact Interview and observation on 03/11/23 at 8:35 A.M. with Resident #34 revealed she had been at the facility for several months and the hot water had never been warm. Resident #34 stated it's shocking how cold the water was. Observation of the bathroom water temperature at the time of the interview revealed it was cold to the touch. Further observation revealed the hot water temperature was 81 degrees F. Interview and observation on 03/11/23 at 8:51 A.M. with STNA #340 revealed the water temperature was 80 degrees F in Resident #34's bathroom. STNA #340 verified the finding of 80 degrees F in Resident #34's bathroom. 3. Review of Resident #60's medical record revealed an admitted [DATE]. Diagnoses included hydrocephalus, alcohol abuse, atherosclerotic heart disease, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #60 was cognitively intact. Interview and observation on 03/11/23 at 8:46 A.M. with Resident #60, revealed the water was always cold in the bathroom. Resident #60 stated sometimes it would get somewhat warmer, but it did not stay warm and would quickly get cold again. Observation of the bathroom water temperature at the time of the observation revealed the water was cold to the touch. After running the water from 8:47 A.M. until 8:51 A.M., the water temperature was 60 degrees F. Observation and interview on 03/11/23 at 8:55 A.M., with the Administrator, verified Resident #60's bathroom hot water temperature was 64 degrees F. The Administrator stated he had been running the bathroom water in Resident #13 and #37's room for approximately 10 minutes to see if the temperature increased. Continued observation with the Administrator of Resident #13 and #37's bathroom hot water temperature revealed, after running for approximately 10 minutes, the hot water was cold to the touch and the temperature was 81 degrees F. The Administrator verified the findings at the time. The Administrator stated he did not understand why the hot water was so cold because the temperature gauge on the hot water tank read 120 degrees F. Further observation with the Administrator of the hot water tank temperature gauge revealed a hot water output reading of 120 degrees F. However, when the Administrator touched the temperature gauge, the arrow indicating the temperature of the hot water moved. The Administrator verified that should not have happened and verified the gauge could not be providing an accurate reading of the hot water temperature since the device appeared to not be functioning properly. Interview on 03/11/23 at 9:40 A.M. with Maintenance Director (MD) #365 revealed he was usually made aware of needed repairs or concerns by staff just verbally telling him as he passed in the hall. MD #365 stated there was a work order form for staff to complete and place in his mailbox, but looking back to 02/02/23, he had not received any work orders related to the water temperatures. MD #365 stated there was a mixing valve concern that was repaired on 02/02/23 and he thought that had taken care of the problem related to hot water temperatures on the South Hall. In addition, MD #365 stated he had been trying to trace the pipes in the attic space to place insulation around them. MD #365 stated he was trying to force staff to utilize the paper work order system, instead of just telling him, and revealed something like water temperatures would not have been addressed if he was just verbally told about them and no work order had been completed. MD #365 denied any residents or staff had made him aware of the hot water concerns. MD #365 was surprised by the temperature readings this surveyor verified earlier this morning on the South Hall, as his water temperature logs reflected much higher water temperatures, above 107 degrees F. MD #365 requested to use his thermometer to check water temperatures. As this surveyor and MD #365 proceeded to the South Hall, the Administrator stopped and stated the hot water tank temperature had been increased and the hot water temperatures were warmer on the South Hall. Observations from 9:46 A.M. through 9:50 A.M., with MD #365 using his thermometer, revealed the hot water temperature in Resident #60's bathroom was 86.7 degrees F and the hot water temperature in Resident #13 and #37's bathroom was 81.7 degrees F. MD #365 verified the findings and stated he did not understand what the problem was. Follow up interview on 03/11/23 at 12:02 P.M. with MD #365 revealed he believed the facility had received a bad part when the mixer valve was replaced on 02/02/23. MD #365 stated he contacted the plumber and he would be out today with a new mixer valve and a new temperature gauge for the hot water tank. Review of the facility policy titled Maintenance Service, revised December 2019, revealed the functions of maintenance personnel included, but not limited to, maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. This deficiency represents non-compliance investigated under Complaint Number OH00140935.

Based on review of the Centers for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) report, staff interview, review of posted daily staff levels, and review of staff timecards, the facility failed to ensure eight hours of daily registered nurse (RN) coverage. This affected all 80 residents of the facility. Findings include: Review of the CMS PBJ report, dated July 2022, revealed the facility had a high number of days without RN coverage. Interview on 10/26/22 at 2:25 P.M. of Scheduler #304 revealed the facility utilized agency staff to cover open shifts to ensure the daily requirement of RN coverage. Review of the daily posted staffing from 09/01/22 through 10/25/22 revealed the facility did not have RN coverage on the following dates: 09/05/22, 09/14/22, 09/18/22, 09/22/22, 09/23/22, 09/24/22, 10/16/22 and 10/22/22. Additionally, on 09/17/22 the facility only had RN coverage for four hours. Review of timecards confirmed the facility did not have RN coverage for eight hours on each of the above dates. Interview on 10/27/22 at 6:59 A.M. of the Administrator confirmed facility census had not been below 60 during the time period from 09/01/22 through 10/25/22. The Administrator stated the DON had provided RN floor coverage outside of her DON hours but confirmed the DON was not working on the above dates. Additionally, the Administrator confirmed the DON was off work 09/12/22 through 09/26/22. Corporate Nurse (CN) #320 was in the building in the DON's absence to cover the DON duties. The Administrator verified without the use of the DON the facility did not meet the eight hour daily requirement for RN coverage. This deficiency represents non-compliance investigated under Complaint Number OH 778.

Based on observation, staff interview, review of the Pot Sink Sanitation Record, review of manufacturer's recommendations, review of work orders, and review of facility policy, the facility failed to ensure foods were properly stored and labeled after opening. Additionally, the facility failed to ensure adequate sanitization of dishes. This affected all 79 residents who received food from the kitchen. The facility identified one resident (#69) who did not receive food from the kitchen. The facility census was 80. Findings include: 1. Observation on 10/24/22 at 8:36 A.M. of kitchen revealed the reach in refrigerator in the food preparation area had an opened and undated package of turkey luncheon meat wrapped in plastic wrap; an opened and undated package of roast beef luncheon meat wrapped in plastic wrap; three packages of opened, unlabeled and undated cheese wrapped in plastic wrap; a plastic container of unlabeled and undated pears; a plastic container of unlabeled and undated gravy; a metal container of unlabeled and undated spaghetti sauce; and a plastic container of undated and unlabeled shredded lettuce. Interview at the time of the observation with Dietary Supervisor (DS) #354 verified the above findings. Observation on 10/24/22 at 8:52 A.M. of the reach in refrigerator located in the dry storage room revealed an opened and undated package of cheese blend and two packages of opened and undated parmesan cheese. Interview with DS #354 at the time of the observation verified the findings. Observation on 10/24/22 at 10:34 A.M. of the reach in freezer located in the dry storage room revealed an uncovered, undated and unlabeled metal pan, approximately one-quarter full, of ice cream cake. Dietary Assistant (DA) #310 verified the finding and stated he believed the cake had been served the previous evening. Review of facility procedure titled Leftovers, undated, revealed proper storage techniques included food should be wrapped, labeled with name of item, and dated; food should be discarded if not used within three days; and if food is part of an opened can, the remaining product should be moved into an appropriate storage container and labeled with item name and date. Additionally, all food storage areas should be monitored daily to identify any food items that must be discarded or used. 2. Observation on 10/24/22 at 8:44 A.M. of the three-compartment sink revealed the facility utilized the sink to wash dishes, with the dishes being sanitized with quaternary ammonia. Observation of the sanitization compartment of the sink revealed the sanitization level was less than 10 parts per million (ppm). Interview with DS #354 at the time of the observation verified the sanitization level was not sufficient. DS #354 stated the equipment was recently serviced and he was unsure why the sanitizer was not dispensing into the sanitization compartment. DS #354 confirmed the three compartment sink was utilized by kitchen staff to wash pots, pans, and utensils and those dishes were not run through the dishwasher for sanitization. Observation on 10/24/22 at 10:36 A.M. of the kitchen revealed DA #306 walk to the three compartment sink and pick up serving utensils that were drying. DA #306 verified the serving utensils had been washed in the three compartment sink and the sanitizer had not been repaired yet, resulting in the no sanitizer being used when washing the dishes. DA #306 returned to the steam table and placed the serving utensils into the prepared foods and began plating lunch for residents. DA #306 stated the sanitizer had not worked all day today and she was unsure why. Review of the Pot Sink Sanitation Record on 10/24/22 at 10:36 A.M. revealed no sanitizer testing entries for 10/24/22. Review of the sanitizer's manufacturer's directions revealed the quaternary ammonia was an effective sanitizer when prepared at 200 ppm. Observation on 10/25/22 at 9:30 A.M. of the three-compartment sink in the kitchen revealed a bottle of sanitizer/disinfectant sitting on the sink. Interview of DS #354 at the time of the observation revealed the servicing company had been out on 10/24/22 to check the function of the sanitizer dispenser and discovered the dispenser had a leak, resulting in no sanitizer being dispensed into the sanitization compartment of the sink. DS #354 stated parts had to be ordered to repair the dispenser and staff had to manually add one ounce of sanitizer for every three gallons of water until the dispenser could be repaired. Review of the Pot Sanitation Record on 10/25/22 at 9:30 A.M. revealed sanitization testing results had been entered on 10/24/22 at 5:00 A.M. and 11:00 A.M., with each test resulting in a sanitization level of 200 ppm. Interview of DS #354 at the time of the observation verified the entries on 10/24/22 at 5:00 A.M. and 11:00 A.M. were inaccurate because it had already been determined there was no sanitizer detected during observations made by this surveyor on 10/24/22. During a follow-up interview on 10/25/22 at 11:45 A.M., DS #354 stated the company who serviced the sanitizer dispenser for the three-compartment sink was at the facility at approximately 9:30 A.M. on 10/24/22 and remained at the facility for a couple of hours. DS #354 stated the sanitizer test result on the Pot Sink Sanitization Record on 10/24/22 at 5:00 A.M. was entered in error but the 11:00 A.M. entry was correct because the servicing company had confirmed by that time the sanitizer dispenser was not working and staff began manually adding sanitizer to the water. DS #354 stated he added the sanitizer to the sanitization compartment at approximately 10:00 A.M., which was why a test result was entered on 10/24/22 at 11:00 A.M. DS #354 provided this surveyor with the work order from the dispenser servicing company. DS #354 verified he signed the work order on 10/24/22 at 12:31 P.M. and confirmed he signed the work order when the technician completed work on the sanitizer dispenser. Additionally, DS #354 confirmed the work order indicated the technician spent approximately 0.5 hours at the facility, placing the technician at the facility at approximately 12:00 P.M. on 10/24/22. DS #354 verified staff manually added sanitizer to the sanitization compartment after the service technician left, indicating there was no sanitizer in the sanitization compartment until after 12:30 P.M. and the 11:00 A.M. test result entered on the Pot Sink Sanitization Record was inaccurate. Observation on 10/26/22 at 9:00 A.M. of DS #354 test the sanitizer level in the sanitization compartment of the three-compartment sink revealed a sanitization level of 150 ppm. DS #354 added additional sanitizer to the water in the sanitization compartment. Review of facility policy titled Pot Sink, undated, revealed all pots and large wares would be cleaned and sanitized using the pot sink. Further review revealed the third compartment was used to sanitize with a sanitizing solution mixed at a concentration specified on the manufacturers label and to test chemical sanitizer concentration using an appropriate test strip.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, review of CMS website for county COVID-19 positivity rates, review of guidance from the Centers for Disease Control (CDC) and Prevention website related to; preparing for Coronavirus Disease 2019 (COVID-19), Infection Prevention and Control (IPC) recommendations, responding to COVID-19 for nursing homes and health care facilities, return to work criteria, strategies for optimizing the supply of N95 respirators, and strategies for optimizing the supply of isolation gowns, surveyor observations, medical record reviews, staff interviews, review of the facility Bed Board-COVID List, review of the staff schedule, review of Timesheet Approval form, review of facility policy regarding isolation precautions, review of facility policy for returning to work and testing during COVID-19 pandemic, and review of facility policy regarding COVID-19 prevention and management, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 which included; allowing COVID-19 positive staff to provide care for residents who had not tested positive, not ensuring staff were wearing proper Personal Protective Equipment (PPE) while working on or entering the COVID-19 isolation unit and in rooms of residents on quarantine, failed to change PPE between providing care for residents on a COVID-19 unit and between residents on quarantine, failed to wear PPE properly, failed to reuse PPE properly, failed to have PPE immediately available for use, failed to use eye protection in a county of high transmission, not posting proper signage at the entrance to resident rooms identifying the necessary PPE to be worn, and failed to ensure social distancing between residents during outside smoking. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or negative health outcomes for three residents (#112, #118, and #124) who tested positive for COVID-19 after a COVID-19 positive staff member was allowed to work on the COVID-19 isolation unit, providing care to Resident #112, Resident #118, and Resident #124, and staff working the COVID-19 isolation unit stated they did not change PPE between providing care to COVID-19 positive residents and these three residents. Furthermore, 19 additional residents (#137, #144, #148, #168, #161, #162, #163, #164, #165, #166, #167, #168, #169, #170, #171, #172, #173, #174, and #175) were placed in Immediate Jeopardy with the potential for serious life-threatening harm and/or negative health outcomes when staff were not wearing proper PPE to provide care for residents in quarantine, wore PPE incorrectly, did not change PPE between care of residents, and did not have signage in place identifying the need for PPE to be worn upon entrance to the resident room resulting in all 19 residents testing positive for COVID-19. Additionally, six residents (#148, #158, #162, #168, #169, and #173) who smoked and had not yet tested positive for COVID-19, were observed not socially distancing while smoking. On 01/06/21, all 74 residents at the facility had tested positive for COVID-19. The facility census was 74. On 01/07/21 at 12:29 P.M., the Corporate Registered Nurse was notified that Immediate Jeopardy began on 01/01/21 when Licensed Practical Nurse (LPN) #300 tested positive for COVID-19 and was allowed to work on the COVID-19 isolation unit with three residents (#112, #118, and #124) who had not tested positive for [MEDICAL CONDITION]. On 01/06/21, Resident #112, #118, and #124 tested positive for COVID-19. Facility staff, LPN #300, were unaware these three residents had tested negative for COVID-19. Interviews on 01/05/21 revealed Personal Protective Equipment (PPE) was not changed between COVID-19 positive residents and the residents who had tested negative for COVID-19. Additionally, on 01/04/21, the general care unit had 19 residents (#137, #144, #148, #168, #161, #162, #163, #164, #165, #166, #167, #168, #169, #170, #171, #172, #173, #174, and #175) who had not tested positive for COVID-19. Observations on 01/04/21 and 01/05/21 revealed staff were not wearing required PPE to care for residents who should have been under quarantine, staff was wearing PPE incorrectly, and staff did not change PPE between residents when providing care. Signage identifying the required PPE for entrance to the room was not present on the door of Resident #166 and #167. On 01/06/21, these 19 residents had tested positive for COVID-19. Observations on 01/04/21 at 10:57 A.M. revealed six residents (#148, #158, #162, #168, #169, and #173) who smoked and had not yet tested positive for COVID-19, were observed not socially distancing while smoking. On 01/06/21, all 74 residents at the facility have tested positive for COVID-19. The Immediate Jeopardy was removed on 01/08/21 at 2:00 P.M. when all staff were educated on the facility COVID-19 infection control policies and the facility implemented the following corrective actions: · On 01/07/21, finishing at 3:00 P.M., the facility Quality Assurance committee met to develop the facility Immediate Jeopardy removal plan. The committee consisted of the Administrator, the Director of Nursing (DON), the Regional Director of Clinical Services, Social Services, Admissions, and the Director of Environmental Services. The Medical Director attended the meeting by telephone. · On 01/07/21 at 3:00 P.M., the DON/Designee ensured no COVID-19 positive staff on duty were caring for any resident who had not tested positive for COVID-19. · On 01/07/21 at 3:00 P.M., the DON/Designee began daily audits to observe PPE was changed between COVID-19 positive and COVID-19 negative residents, to observe proper Transmission Based Precautions (TBP) were implemented, to ensure signage of TBP were in use, to ensure staff changed PPE between residents, and to ensure residents maintained a six foot physical distance when they were not wearing masks. After 30 days the QA committee will review all audits to determine any need to continue daily completion. · On 01/07/21 at 3:00 P.M., the Regional Director of Clinical Services/Designee began educating staff members on the facility's COVID-19 prevention and management policy, on proper wearing, changing, donning, and doffing of PPE between COVID-19 positive residents and residents who had not tested positive for COVID-19, proper implementation of TBP for residents with a known direct exposure to COVID-19, care of residents who have not tested positive for COVID-19, proper posting of signage for residents on TBP, and ensuring physical distancing of six feet for residents during times they are not wearing a facemask, such as smoking. On 01/08/21 at 2:00 P.M. all staff members had been provided training. · On 01/07/21 at 11:00 P.M., the Director of Nursing (DON)/Designee had assessed the vital signs and respiratory status of all residents in the facility. No residents exhibited any signs and symptoms of distress. · Interviews on 01/11/21 from 2:18 P.M. to 3:28 P.M. with State tested Nursing Assistant (STNA) #323, Licensed Practical Nurse (LPN) #324, and STNA #325 verified they had received education on 01/07/21 and 01/08/21 via telephone regarding the facility's COVID-19 infection control practices. · The medical records for five current residents (#112, #118, #124, #141, and #155) and the closed record for Resident #176, were reviewed for COVID-19 monitoring, testing, and follow-up care after testing. Although the Immediate Jeopardy was removed on 01/08/21, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO 20-20-ALL dated 03/23/20 revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. 1) Review of the medical record for Resident #112 revealed an initial admission date of [DATE] and re-entry on 02/14/20. [DIAGNOSES REDACTED]. Review of the medical record for Resident #118 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the medical record for Resident #124 revealed an initial admission date of [DATE] and re-entry on 07/26/18. [DIAGNOSES REDACTED]. Review of the Bed Board-COVID List form, dated 01/04/21, which identified the COVID-19 status of each facility resident, revealed Resident #112, Resident #118, and Resident #124 had not tested positive for COVID-19 and resided on the East/100 Hall, which was for residents with behaviors who required a secured environment. The Bed Board revealed all other residents on the East/100 Hall had tested positive for COVID-19. Interview on 01/04/21 at 3:31 P.M., LPN #300 stated she received positive COVID-19 results on 12/30/20. On 01/01/21, she returned to work on the East/100 Hall. LPN #300 reported the Assistant Director of Nursing (ADON) had informed her all residents on the East/100 Hall had tested positive for COVID-19. LPN #300 verified she had not talked to the local health department regarding a return to work date. LPN #300 revealed she was currently wearing a disposable gown that she had also worn on a previous shift. At the end of the previous shift, a few days prior, she put the gown into a bag with her face shield. LPN #300 stated she donned the gown for her current shift because she didn't have time to locate a new gown. During an additional interview on 01/05/21 at 4:35 P.M., LPN #300 stated she reported to the ADON she had tested positive for COVID-19. When she became asymptomatic, the ADON told her she could work. Review of the Timesheet Approval verified LPN #300 had punched in for work on 01/01/21 from 2:34 P.M. to 01/02/21 at 7:03 A.M., on 01/02/21 from 4:00 P.M. to 01/03/21 at 7:00 A.M., and on 01/04/21 from 2:29 P.M. to 01/05/21 at 6:47 A.M. Review of the staffing schedules for 01/01/21, 01/02/21, and 01/04/21 revealed from 2:30 P.M. to 10:30 P.M., LPN #300 was scheduled as the nurse on the back section of the East Hall and from 10:30 P.M. until 7:00 A.M. she worked the entire East Hall. Review of an E-mail received on 01/05/21 at 4:31 P.M. from the DON verified LPN #300 was tested for COVID-19 outside of work and received a positive result on 12/30/20. Interview on 01/06/21 at 11:15 A.M., LPN #300 verified the staff did not know Resident #112, Resident #118, and Resident #124 were negative for COVID-19. LPN #300 believed all residents on the East/100 Hall were COVID-19 positive. LPN #300 stated she did not change PPE between residents when providing care. 2) Observation and interview on 01/04/21 at 3:42 P.M. revealed LPN #308 on the East/100 Hall wearing a cloth gown. LPN #308 stated she takes the gown home nightly, wears the same cloth gown for two days, and washes it after two days of use. Observation and interview on 01/04/21 at 3:59 P.M. on the East/100 Hall revealed STNA #306 wearing a cloth gown. STNA #306 stated she wears the cloth gown all day and takes the gown home to wash it. STNA #306 revealed it varies how often she obtains a new N95 mask. STNA #306 stated when she comes to work if she notices an unused N95 mask with the available PPE, she will use it. She may not get a new N95 mask daily and sometimes wears the same mask for two days. Observation and interview on 01/05/21 at 11:48 A.M., revealed STNA #312 was working on the East/100 Hall. STNA #312 was wearing a cloth gown. STNA #312 stated she believed all residents on the East/100 Hall were COVID-19 positive. STNA #312 stated Resident #112 was on transmission-based precautions due to going to the hospital. Prior to providing care for Resident #112 she was supposed to place a disposable gown over the washable gown she was wearing. STNA #312 stated there was not always time to change PPE between providing care for Resident #112 and other residents. STNA #312 stated the PPE cart across the hall from Resident #112's room was empty except for a box of gloves in the top drawer. Observation on 01/05/21 at 11:48 A.M. revealed a PPE cart across the hall from Resident #112's room. This cart contained only a box of gloves. There was no other PPE present. Observation on 01/05/21 at 11:55 A.M. revealed a second PPE cart on the East/100 Hall had half of a bag of disposable gowns in the top drawer, the middle drawer was taped shut, and the third drawer had red garbage bags. There were no gloves present in this PPE cart. Interview on 01/05/21 at 12:03 P.M., LPN #313 and LPN #314 reported all residents on the East/ 100 Hall COVID-19 unit had tested positive for COVID-19 so they did not change gowns between residents. LPN #313 and LPN #314 were not aware Resident #112, Resident #118, and Resident #124 had tested negative for COVID-19. 3) Review of the Bed Board-COVID List form, dated 01/04/21, revealed the 200 Hall had a COVID-19 unit and a non-COVID-19 unit. Residents #137, #144, #148, #168, #161, #162, #163, #164, #165, #166, #167, #168, #169, #170, #171, #172, #173, #174, and #175 resided on the non-COVID-19 unit. Interview on 01/04/21 at 9:15 A.M., the DON revealed the 200 Hall housed all residents who were negative for COVID-19, including three residents (#165, #166, and #167) on transmission based precautions due to being a new admission or on [MEDICAL TREATMENT] and eight residents (#144, #148, #161, #162, #172, #173, #174, and #175) who had been exposed to COVID-19 by their former roommates. Observation on 01/04/21 at 9:53 A.M. on the 200 Hall revealed Housekeeper #317 revealed the staff wearing a disposable gown over a cloth gown and a surgical mask under an N95 mask. Interview on 01/04/21 at 10:24 A.M., Housekeeper #317 verified wearing a washable gown when entering the non-COVID 200 Hall and she placed a disposable gown over the washable gown upon entering the hall and does not change these until exiting the hall. Housekeeper #317 verified wearing a surgical mask under the N95 mask to protect her face from breaking out. Observation on 01/04/21 at 9:55 A.M. of the 200 Hall revealed a PPE bin outside Resident #166 and #167's resident room door. There was no signage identifying what PPE was required to be used to enter the room. Interview on 01/04/21 at 9:55 A.M., LPN #318 confirmed Resident #166 and #167 were on transmission-based precautions due to a new admission and there was no signage outside the door to alert staff to what PPE should be used to enter the room. Observation on 01/04/21 at 9:56 A.M. revealed STNA #301 entered the room of Resident #166 and Resident #167 without a gown and wearing an N95 mask with the bottom strap under her chin. When STNA #301 exited the room, LPN #318 asked STNA #301 to wear a gown. STNA #301 reported to the nurse there were no gowns available on the unit. Interview on 01/04/21 at 10:02 A.M., STNA #301 verified not wearing the N95 correctly and stated the bottom strap was under her chin due to it giving her a headache. STNA #301 did not know if Resident #166 or Resident #167 were on transmission-based precautions. Observation and interview on 01/04/21 at 11:11 A.M., revealed Laundry Personnel #320 was pushing a laundry basket to the 200 Hall wearing a surgical mask under an N95 face mask. Laundry Personnel #320 verified she was wearing a surgical mask under the N95 mask. Observation and interview on 01/04/21 at 1:44 P.M., revealed STNA #302 was on the COVID-19 isolation area of the 200 Hall wearing a cloth gown. Interview with STNA #302 revealed she had one washable gown she uses and she takes it home daily to wash. STNA #302 revealed the facility has been short on disposable gowns. Interview on 01/04/21 at 2:50 P.M., STNA #304 revealed she wears her N95 mask for five days and then changes them. STNA #304 stated the facility needed to provide more gowns and masks. Observation on 01/05/21 at 10:01 A.M. revealed LPN #318 enter the room of Resident #168 and #169 without eye protection. LPN #318 was wearing a cloth gown and did not change the gown before or after entering the resident's room. Observation on 01/05/21 at 10:12 A.M. revealed STNA #322 was wearing a cloth gown and no eye protection in the hallway of the non-COVID-19 area of the 200 Hall. She then entered the room of Resident #166 and Resident #167 with no eye protection. Upon exiting the room STNA #322 doffed the cloth gown and laid it on the PPE bin outside the resident room. Observation on 01/05/21 at 10:13 A.M. revealed Therapy Staff #321 entered Resident #174's room with two unidentified therapy staff, all wearing a gown. Therapy Staff #321 and one of the other therapy staff repositioned Resident #174 in the bed. Therapy Staff #321 and the two other therapy staff did not change their gowns prior to entering the room or exiting the room. Interview on 01/05/21 at 10:21 A.M. with Therapy Staff #321 confirmed not changing the gown upon entering or exiting Resident #174's room. Interview on 01/06/21 at 11:03 A.M., the DON verified Resident #144, Resident #161, Resident #162, Resident #172, Resident #173, Resident #174, and Resident #175 were exposed to COVID-19 by a former roommate and were not placed on quarantine. The DON stated it was not the facility's policy to place COVID-19 exposed residents on transmission-based precautions. 4) Interview on 01/04/21 at 10:17 A.M., Resident #148 verified she smokes outside with other residents every two hours from the hours of 7:00 A.M. to 11:00 P.M. Observation on 01/04/21 at 10:57 A.M. revealed Resident #169 smoking outside the exit door with three other residents. Interview on 01/04/21 at 10:57 A.M., Resident #169 verified the residents are supposed to be six feet apart when smoking and stated they try to social distance, but it is not possible due to the sidewalk space and slope of the sidewalk. Review of an E-mail dated 01/07/21 at 9:13 A.M. from the DON revealed the 22 negative residents (#112, #118, #124, #137, #144, #148, #168, #161, #162, #163, #164, #165, #166, #167, #168, #169, #170, #171, #172, #173, #174, and #175) in the facility had received positive test results on 01/06/21. Review of the undated facility policy titled Isolation Precautions identified when transmission-based isolation precautions are implemented, an isolation cart will be used for supplies, the cart should be kept stocked, and a sign is placed on the resident room door or doorframe. Review of the facility policy titled Return to Work and Testing Policy During COVID-19 Pandemic,: dated 11/30/20, indicated a staff with confirmed [DIAGNOSES REDACTED]. Review of facility policy titled COVID-19 Prevention and Management, dated 12/30/20, revealed the facility will identify residents who are confirmed or suspected to have signs or symptoms of COVID-19, to ensure proper treatment of [REDACTED]. The core principles of COVID-19 Infection Prevention interventions included social distancing at least six feet between persons and appropriate staff use of PPE. The facility will identify direct care staff members to care for COVID-19 positive resident and consistent assignments should be exercised as best possible to decrease the number of interactions between residents and staff members. The facility will ensure adequate supply of PPE based on availability. Facility staff will ensure PPE is always readily available to all staff and applicable to their duties and responsibilities. Under the section titled Employee Precautions, the policy reveals surgical masks will be worn over N95 respirators and disposed of upon exiting a quarantined or isolation room on COVID-19 negative units, N95 respirators will be disposed of with each doff, employees will wear eye protection while providing direct care where county COVID-19 positivity rates are above 5% on the CMS website. Eyewear will be sanitized upon exiting quarantine or isolation rooms on COVID-19 negative units. Review of the CMS COVID-19 Nursing Home data website (https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg) of the county positivity rates revealed the facility's county percent positivity in the prior fourteen days was 17.6% and coded the color red, indicating substantial community transmission. Review of the CDC website COVID-19 guideline titled Responding to COVID-19 in Nursing Homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html), dated 04/30/20, revealed Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. For new admissions PPE should be worn during care of residents, 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 disposable face shield that covers the front and sides of the face), gloves, and gown. Review of the CDC website COVID-19 guidelines titled Preparing for COVID-19 in Nursing Homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html), dated 11/20/20, revealed the recommendations in this guideline supplement the guideline titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic. These guidelines indicate under the heading Core Practices revealed 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. Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices. Make necessary PPE available in areas where resident care is provided. If extended use of gowns is implemented the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohorted in the same area of the facility. Roommates of residents with COVID-19 should be considered exposed and potentially infected. Under the heading Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown the guideline indicates Healthcare Personnel (HCP) should wear 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 when caring for these residents. Under the heading Reopening Status it indicates to implement social distancing Measures of remaining at least six feet apart from others. Review of the CDC website COVID-19 guidelines titled Return-to-Work Criteria (https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html), dated 08/10/20, revealed HCP with mild to moderate illness who are not severely immunocompromised can return to work after at least ten days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms have improved. Review of the CDC website COVID-19 guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html), dated 12/14/20, revealed under Section 2.: Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection, revealed HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions, put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, put on clean, non-sterile gloves upon entry into the patient room or care area, and put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. The guideline also indicates if worn properly, a facemask helps block respiratory secretions produced by the wearer from contaminating other persons and surfaces (often called source control). The guidance also revealed HCP (Healthcare Personnel) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with COVID-19 infection. The guidance further noted HCP should also wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Review of the CDC guideline Strategies for Optimizing the Supply of Isolation Gowns (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html), updated 10/09/20, revealed In general, CDC does not recommend the use of more than one isolation gown at a time by HCP when providing care to patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Reusable (i.e., washable) gowns are typically made of polyester or polyester-cotton fabrics. Gowns made of these fabrics can be safely laundered after each use. Review of the CDC guideline Strategies for Optimizing the Supply of N95 Respirators (https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html), dated 11/23/20, revealed during crisis capacity during periods of limited re-use of N95 respirators, if no manufacturer guidance is available, a reasonable limitation should continue to be five total donnings regardless of the number of hours the respirator is worn. If re-use is occurring the amount of time between use should be 72 hours. This deficiency substantiates Complaint Number OH 725 and Compliant Number OH 722.

Based on medical record review, staff interview, and review of a local police report, the facility failed to provide adequate supervision as care planned to monitor the safety of one resident (#1). This resulted in Immediate Jeopardy and serious life-threatening injuries when Resident #1 was not monitored for safety every hour and was ultimately found lying face down on the floor of his room unresponsive, with blood pooled at his head after falling out of bed. The resident subsequently stopped breathing and expired. This affected one (#1) of five (#1, #2, #3, #9, #10) residents reviewed for being at risk for falls. The facility census was 68. On [DATE] at 4:00 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 12:30 A.M. when Resident #1 was last observed by facility staff and was subsequently discovered three hours and fifty minutes later unresponsive on the floor of his room. The resident had sustained an injury to his head and there was blood pooled on the floor. Consequently, the resident stopped breathing and cardiopulmonary resuscitation (CPR) was initiated. Emergency Medical Services (EMS) attempted to revive the resident and after 35 minutes the resident was pronounced dead. The facility was unaware Resident #1's care plan identified the need for one hour monitoring throughout the night due to a history of falling from the bed. The Immediate Jeopardy was removed on [DATE] when all staff were educated regarding monitoring residents per their assessed frequencies, and the facility implemented the following corrective actions: · On [DATE], the medical records for all current residents were reviewed by the DON to determine the frequency each resident required monitoring for safety, fall risk assessments were reviewed and updated for each resident, and care plans were updated based on the results of the assessments. · On [DATE], the facility implemented a new procedure to document the required monitoring frequency on the Treatment Administration Record (TAR) for each resident assessed to require safety monitoring every two hours. · On [DATE], the DON began in-service training for all nursing staff on the topic of Fall Protocol, Care Planning, and Rounding. This education included guidelines for the new procedure of documenting completion of visual monitoring on each resident's TAR. On [DATE] at 8:00 A.M., all nursing staff had been educated. · On [DATE] and [DATE], review of four additional residents (#2, #3, #9, and #10), identified at risk for falls, noted appropriate monitoring and interventions had been implemented. The medical record for two residents (#9 and #10) identified by the facility to require monitoring every two hours for safety, revealed no concerns. · On [DATE] from 7:05 A.M. through 11:38 A.M., interviews with Registered Nurse (RN) #204, Licensed Practical Nurse (LPN) #206, RN #207, and LPN #208 verified attendance and knowledge of monitoring and documenting observation of residents requiring one to two-hour checks. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident was a Full Code status. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #1 was alert, oriented, and able to make his needs known. The resident was independent with supervision for the completion of activities of daily living which included transfers. The resident required set-up help with locomotion. Review of the most recent fall assessment dated [DATE] noted the resident was at risk for falls and required interventions for safety. Review of the plan of care dated [DATE] and revised on [DATE], revealed the resident was at risk for falls related to gait/balance problems, balance deficits related to left [MEDICAL CONDITION], prosthetic use, and a history of falling asleep on the bedside. Interventions included to anticipate and meet the resident's needs, monitor resident if sleeping on bedside and redirect as needed, and place the right side of the bed against the wall. Review of the care plan dated [DATE] and revised on [DATE], revealed Resident #1 chose to sleep on the edge of the bed which placed the resident at risk for falling out of bed. Interventions included to monitor the resident every hour throughout the night and observe for falls, and staff will educate resident on safety concerns of sleeping by the edge of the bed. Review of the medical record lacked documentation indicating the resident was checked every hour throughout the night and observed for falls. Review of nursing notes on [DATE] at 12:30 A.M. documented Resident #1 was observed to be sleeping in bed with oxygen in place. There were no signs of discomfort or distress. The record contained no evidence of any further observations of the resident until 4:20 A.M. when RN #203 found Resident #1 lying face down on the floor with blood pooled on the floor beside his head. The resident was still wearing oxygen via nasal cannula. The nurse alerted State tested Nurse Aides (STNA) #102 and #101 for help. The resident was assessed as non-responsive, snoring, and vital signs included a blood pressure (B/P) of ,[DATE] millimeters of mercury (mm/HG), pulse of 80 beats per minute, and respirations of 16 breaths per minute. The resident's hands were cold and the nurse was unable to obtain an oxygen saturation level. At 4:25 A.M., the nurse phoned emergency services (911) and Police Officer #1 arrived shortly after. While waiting for EMS, the resident's breathing slowed, and staff were unable to find a pulse. The nurse, the police officer, and STNA #102 rolled the resident onto his back, increased the oxygen to five liters per minute, and began chest compressions. Chest compressions were performed for approximately 50 seconds before EMS arrived and took over resuscitation. At 5:05 A.M., EMS pronounced Resident #1's time of death. Interview via telephone on [DATE] at 11:53 A.M., STNA #101 verified she worked the night of [DATE]. STNA #101 stated Resident #1 was not on bed checks and was only checked on when he called out for assistance. STNA #101 verified she did not check Resident #1 during her entire shift which began at 10:00 P.M. on [DATE] and ending on [DATE] at 6:30 A.M. STNA #101 stated on [DATE] at approximately 4:20 A.M., RN #203 summoned STNA #101 and STNA #102 to Resident #1's room. The resident was lying face down on the floor with blood at his head. STNA #101 stated RN #203 then proceeded to contact 911. Interview on [DATE] at 2:20 P.M., RN #203 stated on [DATE] at 12:30 A.M. she assisted Resident #1 with filling his beverages. She did not see the resident again until approximately 4:20 A.M. when she discovered him face down on the floor next to his bed. The resident had a pool of blood at his head and was unresponsive. RN #203 stated she summoned STNA #101 and STNA #102 to the resident's room and assessed his vital signs. RN #203 contacted 911 and returned to the room. Police Officer #1 arrived at the resident's room and upon completing further assessment, the resident no longer had a pulse. RN #203, STNA #102 and Police Officer #1 proceeded to place the resident to his back and began CPR. After approximately 50 seconds the EMS arrived and took over the resident's care. The EMS continued resuscitation efforts for approximately 30 minutes before pronouncing the resident deceased . Police Officer #1 then contacted the Coroner and reported Resident #1's death. The Coroner released the body pending the physician's approval. The physician was contacted and released the body to the funeral home. RN #203 was unaware of how long Resident #1 may have been lying on the floor unresponsive and bleeding. RN #203 stated she was unaware Resident #1 required hourly checks during the night. RN #203 stated she would have monitored Resident #1 every hour during the night had she known. Interview via telephone on [DATE] at 8:00 A.M., STNA #102 stated she was unaware Resident #1 required one-hour checks during the night. The resident would ask for assistance and transfer himself as needed. STNA #102 stated at 4:00 A.M., RN #203 summoned her and STNA #101 to Resident #1's room. Upon entrance, the resident was observed face down on the floor with blood in his hair and on his face. STNA #102 counted respirations while RN #203 obtained vital signs and contacted 911. During that time Police Officer #1 arrived and upon entry to the room, the resident stopped breathing. STNA #102 stated she assisted RN #203 and Police Officer #1 to begin CPR after repositioning the resident onto his back. Shortly after starting CPR, the EMS arrived and took over the resident's care. Review of the local police report dated [DATE] documented Police Officer #1 was dispatched to the facility at 4:24 A.M. due to an unconscious person. Upon arrival, the resident was observed on the floor in his room next to the bed, lying face down with blood pooled around his head. Several staff were in the room and stated they found the resident in this condition at approximately 4:20 A.M. The last time the resident was observed prior to that time was 12:30 A.M. The resident was breathing when Police Officer #1 arrived, but stopped breathing a short time later. RN #203 and Police Officer #1 initiated chest compressions and EMS took over upon their arrival. EMS attempted to revive Resident #1 for approximately 35 minutes and were determined to be unsuccessful at 5:06 A.M. Interview on [DATE] at 2:45 P.M., the DON revealed she was unaware Resident #1 had a plan of care related to the resident choosing to sleep on the edge of the bed which placed him at risk of falling out of bed. The DON was unaware of the interventions on the plan of care which indicated to monitor the resident every one hour throughout the night and observe for falls. The DON confirmed there was no evidence indicating the resident was monitored by staff every one hour. This deficiency substantiates Complaint Number OH 828.