Every finding on record at Willow Knoll Post-Acute and Senior Living

Based on resident interview, observation, staff interview, review of facility records, and review of the facility policy, the facility failed to ensure water temperature in resident rooms were maintained at acceptable temperatures to prevent the possibility of scalding injuries. This affected thirteen (Residents #27, #30, #31, #34, #39, #40, #43, #44, #45, #46, #52, #54, and #55) and had the potential to affect all of the residents residing in the facility. The facility census was 54 residents. Findings include:Interview on 06/16/26 at 10:30 A.M. with Resident #54 confirmed the water temperature in her bathroom sink was dangerously high. Observation on 06/16/26 at 10:30 A.M. revealed the water in Resident #54's sink was very warm to the touch almost immediately after the water was turned on. Observations made with the Maintenance Director #314 on 06/16/26 beginning at 11:12 A.M. revealed the following water temperatures:145 degrees Fahrenheit (F) in the restroom for Residents #54, #55, #53, 133 degrees F in the restroom for Resident #43, 132.5 degrees F in the restroom for Resident #46, 130 degrees F in the restroom for Residents #30, #31, #34, #39, #40, #44, #45, 125 degrees F in the restroom for Resident #27. Additionally, tankless water heaters in facility revealed a set temperature of 145 degrees F. Interview on 06/16/26 at 11:12 A.M. with MD #314 confirmed a safe water temperature range in resident rooms was 105 to 120 degrees F and resident water temperatures were too high. MD #314 stated the facility did not have a recent log of monitoring of the water heater temperature. Interview on 06/16/26 at 11:45 A.M. with Maintenance Director (MD) #314 and Maintenance Assistant (MA) #313 verified the tankless water heaters were installed following an issue with the facility failing to maintain temperatures that were between the required parameters of 105 degrees F to 120 degrees F. Interview confirmed the tankless heaters were managed by an outside service and MD #314 and MA #313 were unclear as to how the system operated. Interview on 06/16/26 at 3:20 P.M. with the Executive Director (ED) confirmed the water temperatures in resident bathrooms should be maintained between 105 to 120 degrees F and the ED acknowledged the facility had a problem with water temperatures being too hot. Review of the water temperature monitoring logs for the dates of 12/01/25 through 06/08/26 revealed the facility checked the water temperatures of the resident restrooms once every two months and all temperatures were within acceptable limits. Review of the water heater temperature monitoring revealed the last documentation of monitoring was dated 2019. Review of the facility policy Safety of Water Temperatures dated 2009 revealed the facility would keep tap water temperatures within a range of no more than 120 degrees F to prevent scalding of residents. The maintenance staff was responsible for checking thermostats and temperature controls in the facility and record these in a maintenance log.

Based on observation, interview, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents who received food from the kitchen. The facility census was 53. Findings include: A facility policy titled, Food Receiving and Storage, revised November 2022, revealed a section titled Dry Food Storage, that specified, 4. Dry foods that are stored in bins are removed from original packaging, labeled, and dated 'use by' date). Such foods are rotated using a 'first in-first out' system. The policy continued, Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated ( use by date). During an observation of the initial tour of the kitchen on 12/01/2025 at 9:25 AM, the walk-in freezer contained three trays of disposable foam cups filled with ice. Two trays of cups were uncovered. There was a bag containing brown rectangular objects that were undated. An observation of the walk-in cooler revealed a pitcher labeled pink lemonade with a date of 11/30/2025 noted. An observation of the dry goods storage room revealed the following open and undated items: a bag of cereal, in its originally packaging, a bag of powdered sugar secured in a plastic bag with a closure, two bags of pasta in their original packaging and one bag of spaghetti in its original packaging. During an observation on 12/02/2025 at 10:25 AM, the walk-in freezer contained three trays of disposable foam cups filled with ice. Two trays of cups were uncovered. A bag that contained rectangular shaped objects remained unlabeled and undated. An observation in the dry goods storage room revealed an opened bag of cereal, in its original packaging, undated. A bag of powdered sugar remained secured in a plastic storage bag with a closure that was unlabeled and undated, two bags of pasta, in the original packaging, opened and undated, and one bag of spaghetti, in its original packaging, opened and undated. During an interview on 12/03/2025 at 1:45 PM, Dietary Aide #4 revealed that all open food items in the walk-in freezer should be covered and labeled with the date they were prepared. During an interview on 12/03/2025 at 2:00 PM, Dietary Aide #5 revealed all food items should contain a date when the item was opened. She stated most food items were good for seven days and should be labeled with a use-by date. She stated various food items had different use-by dates. She stated items stored in the cooler should be wrapped tightly and labeled with the date opened prior to being placed in the cooler. Dietary Aide #5 stated items in the freezer should be labeled and dated and if possible, placed back in the original box. Dietary Aide #5 stated the facility used buckets to place dry goods in once they were opened, but these items should also be dated. During an interview on 12/03/2025 at 2:25 PM, the Dietary Manager stated she expected all dried goods to be labeled with a received date, open date, and a use-by date. The Dietary Manager stated that the discard date was changed for dry goods once they were opened, and food items should be discarded in three to five days. The Dietary Manager stated she expected the dietary employee who opened the item to secure a label with an open and discard date. She stated the cooks were responsible for auditing food in the refrigerator each shift, and the cook and prep cook should monitor food items in the freezers. She stated food items removed from the freezer should be returned to the freezer with a label that contained an open and discard date and should when possible be placed into the original container for storage. The Dietary Manager stated that the dietary aides, prep cooks, cooks, and her assistant were responsible for ensuring all open items were correctly dated and removed when out of date. The Dietary Manager indicated that the disposable foam cups were prepped over the weekend and not used by dietary staff once they located the standard dinnerware but stated the cups should be covered when in the freezer. During observation on 12/03/2025 at 2:55 PM, with the Dietary Manager, she removed an opened and undated bag of hashbrowns from the freezer. The Dietary Manager also removed a clear, undated zip bag of powdered sugar, two bags of opened and undated pasta, and an opened, undated bag of spaghetti from the dry storage area. During an interview on 12/03/2025 at 9:21 AM, the Director of Nursing (DON) revealed she was not familiar with all the kitchen policies but knew where to find them. She stated that good practice should be to cover and date all open food items, and her expectation was that staff would follow all policies.

Based on observation, interview, and facility document and policy review, the facility failed to provide a homelike environment for 3 (Resident #38, #57, and #70) of 8 sampled residents reviewed for environment. The facility census was 53. Findings include: An undated facility policy titled, Homelike Environment, revealed a section titled, Policy Statement, that indicated, Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The policy revealed a section titled, Policy Interpretation and Implementation, that included, 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. clean, sanitary and orderly environment. 1. During a Resident Council meeting on 12/02/2025 at 2:44 PM, Resident #38 stated their closet door would not open. Resident #38 stated it was reported to the Maintenance Director, who said the closet door needed new rollers. During a concurrent observation and interview on 12/03/2025 at 3:18 PM, Resident #38's closet revealed two wooden doors with each door attached to a track system (metal stripping mounted to header) that allow the door to move via rollers (roller mechanism attached to the door) that glide along the track on the top portion of the door and one door on the bottom portion of the door was not attached to the bottom tracking system via rollers and the second door did not slide to open. Resident #38 stated a member of the maintenance staff had shown the resident a demonstration of how to access their belongings, which required them to move the first door by holding the door with both hands and pulling the closet door forward and lifting it towards them. Resident #38 stated that they were informed by staff that they would have to complete those steps in order to access their belongings until the closet door was repaired. Resident #38 further stated that it was difficult to get to the clothes that were behind the second door because that door did not slide open. During an observation and concurrent interview on 12/03/2025 at 3:18 PM, the Maintenance Director observed the closet doors and stated Resident #38 made a request for closet repair approximately a month to a month and a half ago. He stated that he placed new rollers on the closet doors, but the new rollers were the wrong size and did not allow both doors to slide. He stated that the closet doors were from the 1990s, and the rollers available at two local hardware stores were for more modern style doors. The Maintenance Director stated that he had not yet tried other hardware stores and acknowledged the repairs were not completed. During a follow-up interview on 12/05/2025 at 9:05 AM, the Maintenance Director stated Resident #38's closet doors would not open because the wheels were old and worn out. He stated that for the resident to be able to open and close the closet door, the first door must be off the track at the bottom. He further stated that the repair took a month and a half because he did not go to the store for supplies daily. He stated he had too many responsibilities at the facility and used the gas in his personal vehicle, so he limited trips to the store to buy supplies. The Maintenance Director further stated he was unable to provide a receipt for the purchase of the rollers for the closet door and stated the facility had not made any written documentation of Resident #38's request to repair the closet door. During an interview on 12/05/2025 at 9:11 AM, the Director of Nursing (DON) stated that she expected the maintenance department to have a team approach for repairs such that staff and residents reported any concerns found related to the environment and she expected the maintenance department to conduct routine rounds of the facility's environment to identify any concerns or repair needs. The DON stated that Resident #38's closet door should not have taken a month and a half to repair as that amount of time was not reasonable. 2. During an interview on 12/01/2025 at 11:33 AM, Resident #57 stated there was water damage to the ceiling in their room. Resident #57 stated that the water damage was like that since the resident moved into the room in 2018. Resident #57 stated the water damage was not reported because the damage was there when the resident moved in, and since staff allowed the resident to move into a room with water damage to the ceiling the resident did not think there were any plans to fix it or do anything about it. Resident #57 further stated that they would like to have the water damage to the ceiling repaired. During an interview on 12/04/2025 at 10:43 AM, the Maintenance Director stated that for the past four years he repaired leaking pipes from the sprinkler system, which had resulted in water damage to the ceiling, and once the leak was repaired, the maintenance staff replaced the ceiling tiles. During a follow-up interview on 12/05/2025 at 8:37 AM, the Maintenance Director stated his department did not have a practice of completing room rounds to identify areas in need of repair. He stated that the ceiling in that room should have been repaired and looked at, to make sure there was no mold growth. During an interview on 12/05/2025 at 9:11 AM, the Director of Nursing (DON) stated that she expected the maintenance staff to conduct routine monitoring to identify areas that needed attention and repair water damage. 3. During an observation of Resident #70's room on 12/01/2025 at 9:45 AM a large area to the ceiling did not have the ceiling texture spray applied. That area of the ceiling had a smooth finish while the remainder of the ceiling was covered with the ceiling texture spray. During a second observation of Resident #70's room on 12/04/2025 at 6:30 PM it was revealed the ceiling had not had texture spray applied to the smooth portion of the ceiling. A receipt dated 11/05/2025 provided by the Maintenance Director revealed that ceiling texture spray was purchased. During an interview on 12/05/2025 at 9:05 AM, the Maintenance Director stated that he purchased the ceiling texture spray on 11/05/2025 to spray on the ceiling after he repaired water damage to the ceiling. He stated that he repaired a leaking pipe in the ceiling from the sprinkler system before Resident #70 moved in, but Resident #70 moved into the room before he had a chance to apply the ceiling texture spray. During an interview on 12/05/2025 at 9:11 AM, the Director of Nursing (DON) stated that she expected the maintenance department to have a team approach for repairs such that nursing staff and residents reported to the maintenance department any concerns found related to the environment. The DON stated she expected the maintenance staff to conduct routine monitoring to identify areas that needed attention and make all needed repairs prior to a resident moving into a room. This deficiency represents non-compliance investigated under Complaint Number 1376435.

Based on observation, staff interview and policy review, the facility failed to ensure call lights were accessible to the residents. This affected five (#10, #15, #45, #65 and #75) randomly observed residents without their call lights within reach. The facility census was 51. Findings include: Observation on 11/08/21 from 3:56 P.M. until 4:12 P.M. during the initial tour revealed five residents were observed without call light access. Residents not having call light access included Residents #10, #15, #45, #65 and #75. Interview and observation on 11/08/21 from 4:32 P.M. until 4:42 P.M. with State tested Nursing Assistant (STNA) #24 confirmed the call lights for Residents #10, #15, #45, #65 and #75 were not accessible to the residents. The STNA #24 immediately retrieved the call lights from the floor and behind the bedside tables to provide call light access to the residents. Interview on 11/09/21 at 10:44 A.M. with the Administrator confirmed many of the resident's call lights did not have clips which help to keep the call lights falling off the bed. The Administrator confirmed the call light concerns and advised of an order to replace the call light clips. Review of the facility policy titled, Answering the Call Light, dated October 2001 revealed when the resident is confined to a chair or in bed, be sure the call light is within easy reach of the resident. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, medical record review, staff interviews, policy review and review of the Centers for Disease Control (CDC) recommendations, the facility failed to ensure staff members donned appropriate personal protective equipment (PPE) when caring/entering a resident's room on quarantine to prevent the potential spread of Coronavirus (COVID-19). This affected three (#13,#30, and #34) of three residents observed in quarantine. The facility identified 32 residents currently under quarantine. This had the potential to affect all residents. The facility census was 44. Findings include: 1. Review of the clinical record revealed Resident #30 was admitted to the facility on [DATE]. Review of the medical record revealed Resident #30 had an order dated 08/04/21 for strict single room isolation with droplet precautions related to COVID-19 exposure. Observation during tour with the Administrator, on 08/12/21 at 1:20 P.M., revealed Housekeeper #11 to be cleaning in Resident #30's room without an isolation gown donned. Housekeeper #11 did have on a N95 mask, gloves and protective eyewear. Resident #30's door contained signage indicating Stop - droplet precautions. Housekeeper #11 was observed to exit the room and then re-enter again without a gown donned. Interview on 08/12/21 at 1:25 P.M. with Housekeeper #11 confirmed he had been trained on the appropriate PPE when entering quarantined rooms. Housekeeper #11 reported he just forgot to apply the gown. 2. Review of the medical record for Resident #13, revealed an admitted [DATE]. Review of the medical record revealed Resident #13 had an order dated 08/05/21 for strict single room isolation with droplet precautions related to COVID-19 exposure. 3. Review of the medical record for Resident #34, revealed an admitted [DATE]. Review of the medical record revealed Resident #34 had an order dated 08/04/21 for strict single room isolation with droplet precautions related to COVID-19 exposure. Observation during medication administration on 08/18/21 at 9:22 A.M., revealed Licensed Practical Nurse (LPN) #33 entered Resident #13 and Resident #34's shared room without first donning an isolation gown. LPN #33 had on an N95 face mask, gloves, and protective eyewear. Observation of Resident #13 and Resident #34's door contained signage indicating Stop - droplet precautions. LPN #33 was observed to exit the room and then re-enter again without a gown donned. Interview on 08/18/2021 at 8:42 A.M., with LPN #33 stated all residents were in quarantine and the only required Personal Protective Equipment (PPE) was an N95 face mask and protective eyewear. Review of a policy titled, Infection Control dated 10/18, revealed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of the CDC Coronavirus Disease 2019 (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#print, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes ,Nursing Homes & Long-Term Care Facilities, Updated 03/29/21, Managing Residents with Close Contact-Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection states: Residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure. Residents in quarantine should be placed in a single-person room. If limited single rooms are available or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should shelter-in-place at their current location while being monitored for evidence of [CONDITION(S)]-CoV-2 infection. Residents should only be placed in a COVID-19 care unit if they have confirmed [CONDITION(S)]-CoV-2 infection. Placing a resident without confirmed [CONDITION(S)]-CoV-2 infection (i.e., with symptoms concerning for COVID-19 pending testing or with known exposure) in a dedicated COVID-19 care unit could put them at higher risk of exposure to [CONDITION(S)]-CoV-2. HCP should wear an N95 or higher-level respirator, 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. CDC PPE optimization strategies include a hierarchy of strategies to implement when PPE are in short supply or unavailable (e.g., use of a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators or a well-fitting facemask when NIOSH-approved N95 or equivalent or higher-level respirators are not available). This deficiency substantiates OH 879 and an example of the continued noncompliance from the survey dated 07/09/21.

Based on observations, medical record review, staff interview, and review of medication policy, the facility failed to administer medications in a timely manner and prevent significant medication errors. This affected four residents (#2, #3, #19, and #23) of eight residents reviewed for medications. The facility census was 44. Findings include: 1. Review of the medical record for Resident #2 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's medical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M.: [MEDICATION(S)] 10 mg, [MEDICATION(S)] powder, [MEDICATION(S)] 1000 mg, senna tablet 8.6 mg, and [MEDICATION(S)] 5 mg tablet. Resident #2 was scheduled to take the following medications at 9:00 A.M.: [MEDICATION(S)] [MEDICATION(S)] 5 mg, [MEDICATION(S)] 40 mg delayed release tablet, and [MEDICATION(S)] 17 gram packet. 2. Review of the medical record for Resident #3 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's medical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. 3. Review of the medical record for Resident #19 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's medical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Aspirin tablet 81 mg chewable by mouth one time a day, [MEDICATION(S)] HCL capsule delayed release 20 mg by mouth one time a day, [MEDICATION(S)] tablet 1 mg by mouth at bedtime, [MEDICATION(S)] tablet 20 mg give 40 mg by mouth at bedtime, [MEDICATION(S)] Extended Release (ER) 50 mg tablet by mouth one tome a day, [MEDICATION(S)] 7.5 mg tablet by mouth at bedtime, multi vitamin with iron and minerals tablet by mouth at bedtime, [MEDICATION(S)] tablet 25 mcg by mouth in the morning, vitamin B 1 100 mg tablet by mouth at bedtime, Vitamin D 3 tablet 50 mcg by mouth at bedtime, [MEDICATION(S)] solution 10 Gram/15 ml 15 ml by mouth two times a day for increased [MEDICATION(S)] levels, and [MEDICATION(S)] 5 mg tablet by mouth three times daily (muscle spasms). Review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. included [MEDICATION(S)] [MEDICATION(S)] 10 mg, aspirin 81 mg chewable tablet, [MEDICATION(S)] ER 50 mg tablet, [MEDICATION(S)] 10 gram/15/ml solution 15 ml by mouth, and [MEDICATION(S)] 5 mg tablet. 4. Review of medical record for Resident #23 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medical record for Resident #23 revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M.: Aspirin 81 mg, [MEDICATION(S)] 10 mg, [MEDICATION(S)] 20 mg, [MEDICATION(S)] 6.25 mg, [MEDICATION(S)] 600 mg, [MEDICATION(S)] ER 400 mg tablet, [MEDICATION(S)] Solution 2% drop, and [MEDICATION(S)] HCL 10 mg tablet. Observation of medication administration on 08/18/2021 at 9:50 A.M. revealed the computer on the medication cart displayed four resident names (Resident #2, #3, #19, and #34) in red boxes which indicated medications scheduled at 8:00 A.M. had not been administered including medications to prevent [CONDITION(S)], hypertension, elevated blood [MEDICATION(S)] levels, and seizures. Interview on 08/18/2021 at 9:50 A.M., with Licensed Practical Nurse (LPN) #33 verified medications were not given within the ordered times for four residents (#2, #3, #19, and #23). LPN #33 stated when asked about procedure that she needed to give the medications as soon as possible and did not need to notify anyone about medications being late. Review of policy titled, Administering Medications dated April 2019, revealed medications were administered in accordance with prescriber's orders and within one hour of the prescribed time unless otherwise specified. This deficiency substantiates Complaint Number OH 885 and an example of the continued non compliance from the survey dated 07/09/21.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure medications were administrated per physician orders. This affected two (#34 and #46 ) of eight residents reviewed for medications. The facility census was 44. Findings include: 1. Review of the closed medical record for Resident #46 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included hypertension, type two diabetes mellitus, [CONDITION(S)] with acute exacerbation, [CONDITION(S)], gastroesophageal reflux disease, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], nontoxic goiter, diabetic neurological complications, diabetic polyneuropathy, vitamin D deficiency, oligomenorrhea, asthma, severe [CONDITION(S)] with alveolar hypoventilation, obstructive sleep apnea, unilateral primary [CONDITION(S)], elevated urine levels of drugs - medicaments and biological substances, [CONDITION(S)], shortness of breath, [CONDITION(S)], obesity, localized swelling/mass and lump in neck, asymptomatic varicose veins of lower extremity, [CONDITION(S)], chronic pain, chronic kidney disease - stage two, [CONDITION(S)], mixed incontinence, myalgia, spondylosis with radiculopathy of lumbosacral region, [CONDITION(S)] osteoarthropathy, left shoulder [CONDITION(S)], post-traumatic stress disorder, pulmonary hypertension, acute maxillary sinusitis, unspecified bacterial pneumonia, acute respiratory failure with [CONDITION(S)], acute kidney failure with tubular necrosis, metabolic [CONDITION(S)] and enterocolitis due to [CONDITION(S)]. Review of Resident #46's medical record revealed physician orders for the following medications: Aspirin 81 milligrams (mg) orally at every morning, [MEDICATION(S)] (cholesterol lowering) 40 mg orally at every morning, Cetrizine (allergy medication) 10 mg orally every morning, [MEDICATION(S)] Sulfate Syrup (iron supplement) five milliliters (ml) every morning, [MEDICATION(S)] antidepressant) 40 mg orally every morning, Flucticasone (breathing medication) 50 micrograms (mcg) one spray each nostril every morning, [MEDICATION(S)] Insulin 12 units subcutaneously every morning, [MEDICATION(S)] ER 30 mg orally every morning, [MEDICATION(S)] (nonsteroidal anti-inflammatory) 100 mg orally twice daily, [MEDICATION(S)] ([CONDITION(S)]) 200 mg orally twice daily, Lactobacillus two capsules orally twice daily, [MEDICATION(S)] Patch (pain relief) topically twice daily - on 12 hours and off 12 hours, [MEDICATION(S)] (anxiety medication) 15 mg orally three times daily, [MEDICATION(S)] Powder (antifungal) topically four times daily, and [MEDICATION(S)] (to treat infection) 50 mg per ml - five ml orally four times daily. Review of the Medication Administration Record (MAR) from 08/06/21 through the time of the resident leaving Against Medical Advice (AMA) on 08/10/21, the following medications were documented with a 5 on the MARs which corresponded with coding indicating hold/see nurses notes: on 08/06/21 Aspirin 81 mg orally at 7:00 A.M., [MEDICATION(S)] 40 mg orally at 7:00 A.M., [MEDICATION(S)] 10 mg orally at 7:00 A.M., [MEDICATION(S)] Sulfate Syrup five ml at 7:00 A.M, [MEDICATION(S)] 40 mg orally at 7:00 A.M., Flucticasone 50 mcg one spray each nostril at 7:00 A.M., [MEDICATION(S)] Insulin 12 units subcutaneously at 7:00 A.M., [MEDICATION(S)] ER 30 mg orally at 7:00 A.M., [MEDICATION(S)] 100 mg orally at 7:00 A.M., [MEDICATION(S)] 200 mg orally at 7:00 A.M., Lactobacillus two capsules orally at 7:00 A.M., [MEDICATION(S)] ch topically at 7:00 A.M., [MEDICATION(S)] 15 mg orally at 12:00 P.M., [MEDICATION(S)] Powder topically at 10:00 A.M an 4:00 P.M., and [MEDICATION(S)] 50 mg per ml - five ml orally at 10:00 A.M and 4:00 P.M. Continued review of the MAR revealed the following medications to be documented with a 9 indicating other/see nurses notes: Cetrizine 10 mg orally on 08/09/21 at 7:00 A.M., [MEDICATION(S)] 200 mg orally on 08/07/21 and 08/08/212 at 7:00 P.M. and on 08/09/21 at 7:00 A.M., and [MEDICATION(S)] Patch topically on 08/06/21 at 7:00 P.M. Review of the nursing progress notes for the above dates and times revealed them to be silent surrounding any reasoning for the above mentioned medications being withheld. Interview on 08/19/21 at 11:00 A.M. with the Director of Nursing (DON) confirmed the medications were not documented as administered and that the progress notes were silent for corresponding reasons as to the medication not being administered. 2. Review of the medical record for the Resident #34 revealed an admitted [DATE]. Diagnoses included cerebral infarction, type II diabetes, and hypertension. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Resident #34 was a two-person physical assist and required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene and supervision for eating and locomotion. Review of Resident #34's medical record revealed physician order for [MEDICATION(S)] [MEDICATION(S)] Solution pen injector 300 units/ml (long acting insulin) inject 18 units subcutaneously two times daily for [CONDITION(S)]. Review of Medication Administration Record (MAR) dated August 2021 revealed Resident #34 was scheduled to receive [MEDICATION(S)] [MEDICATION(S)] Solution pen injector 300 unit/ml, 18 units subcutaneously two times a day for [CONDITION(S)] at 8:00 A.M. and 8:00 P.M. Observation on 08/18/2021 at 9:22 A.M., revealed Licensed Practical Nurse (LPN) #34 searched the medication cart and refrigerator in the medication room and did not locate Resident #34's [MEDICATION(S)] insulin pen. Interview on 08/18/2021 at 9:34 A.M., LPN #34 verified Resident #34's [MEDICATION(S)] insulin was not administered because the medication was unavailable. Review of a policy titled, Administering Medications dated 04/2019, revealed medications are administered in a safe and timely manner, and as prescribed. This deficiency substantiates Complaint Number OH 885.

Based on observation, visitation signage, interview, and review of the Centers for Medicare and Medicaid Services (CMS) guidance, the facility failed to ensure residents were allowed visitation. This affected all of the residents who resided in the facility. The census was 45. Findings include: Review of the coronavirus website for the county positivity rate for Covid-19 revealed as of 06/22/21, the positivity rate in [NAME] county was 1.9%. Review of the list of vaccinated residents in the facility, dated 06/28/21, revealed 22 of 45 residents, or 48 percent, had been vaccinated. Observation of signs on the front door to the entrance of the facility on 06/28/21 at 9:00 A.M. revealed visitation was not allowed unless it was scheduled through the facility. Observation of the Resident Council Meeting conducted on 06/28/21 at 10:57 A.M. by Activities Director (AD) #68 revealed there were questions about visitation and the response was when the residents received more vaccinations the facility would be opening up for more visitation. Interview with Resident #22 on 06/28/21 at 3:30 P.M. revealed the facility was not conducting visitation right now. The families could stand outside the window if they wanted to visit with the residents. There was renovations in the facility and visitors are not allowed in to visit. She revealed she hadn't seen her family in over a year. Interview with AD #68 on 06/29/21 at 7:36 A.M. revealed there were supervised visits in the lobby with the receptionist and it was conducted on Tuesdays and Thursdays due to the low vaccination rate in the facility. The appointments could be made at 1:30, 2:30, or 3:30 P.M. and they lasted 30 minutes. Since the renovations have started in the facility, the visitation is limited to one day a week right now. Interview with the Receptionist #29 on 06/29/21 at 1:11 P.M. revealed the families schedule appointments and make sure one day of the week, when the construction wasn't going on, visitation was set up in the main lobby on Thursdays. She stated visitors could not go to the resident rooms due to the low vaccination rate of the residents. The families and residents are encouraged to receive their vaccinations so the facility could be opened up for visitation. She revealed during the visitation it was kind of supervised to make sure the families don't touch anybody. The visit has to be six feet apart, there could be no hugging or touching, or exchange any items during the visit. Observation of visitation on 07/01/21 at 1:31 P.M. revealed there were four tables with chairs around them placed six feet apart. Scheduler #8 was monitoring the visitation. She was in and out of the room. At 1:57 P.M. the Scheduler told the visitors they had two minutes left for the visit and they had to leave to ensure the next visitation was set up for 2:30 P.M. At 2:00 P.M. the Scheduler told the residents they couldn't touch anything in the room and to go back to their rooms. Interview with Resident #20's family member on 07/01/21 at 1:58 P.M. revealed the families were told they could only visit once a week due to renovations. They were told they couldn't hug or touch the residents or hand them anything on the visit. If the policy had changed the families hadn't been informed of the change. Interview with the Administrator on 07/01/21 at 3:15 P.M. revealed the facility only allowed visits on Tuesdays and Thursdays due to the renovations and the low vaccination rates of the residents. She revealed she was following the guidance from the Department of Aging that was out of date. She stated no one in the building had Covid-19 and no residents were on quarantine. Review of CMS QSO memo 20-39, revised on 04/27/21, stated under Indoor Visitation: Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission (note: compassionate care visits should be permitted at all times). These scenarios include limiting indoor visitation for: · Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated; · Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met two criteria to discontinue Transmission-Based Precautions; or · Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine.

Based on record review and interview, the facility failed to ensure care conferences were held for residents. This affected three (Residents #18, #24 and #43) of three residents reviewed for care planning. The facility census was 45. Findings include: 1. A review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. She had a quarterly Minimum Data Set (MDS) assessment completed on 04/17/21. There was no evidence a care conference had been held since admission. During interview on 07/01/21 at 3:30 P.M., the Administrator and the Director of Nursing (DON) stated there was no evidence that a care conference had been held for Resident #18. 2. Record review for Resident #24 revealed an admitted [DATE]. The last quarterly MDS assessment was dated 05/03/21. Review of care conferences for Resident #24 revealed the last one was held on 11/11/20. Interview with a family member on 06/28/21 at 3:02 P.M. revealed there hasn't been a care conference in several months. The family member stated they do have care conference, but due to their work schedule, they cannot attend. There have been no other arrangements made to attend a care conference. During interview on 07/01/21 at 1:38 P.M., Social Worker Designee (SWD) #26 confirmed the last care conference was on 11/20/20. 3. Record review for Resident #43 revealed an admitted [DATE]. The last quarterly MDS assessment was dated 06/13/21. Review of care conferences for Resident #43 revealed a care conference had never been held. During interview on 06/28/21 at 11:42 A.M., Resident #43 stated no care conference had been held since he admitted to the facility. During interview on 07/01/21 at 1:38 P.M., SWD #26 confirmed no care conference had ever been held for Resident #43. Review of the facility policy titled Resident Participation-Assessment/Care Plans, dated 12/01/16, revealed the resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan.

Based on record review, interview and policy review, the facility failed to initiate care plans for medication use for two (Residents #18 and #22) of five residents reviewed for unnecessary medication. The facility census was 45. Findings include: 1. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment, completed on 04/17/21, assessed the resident as alert and oriented. Resident #18 was receiving [MEDICATION(S)] Capsule Delayed Release Particles 20 milligrams (mg) to give two capsules by mouth one time a day for depression, Lorazepam Tablet 0.5 mg to give one half tablet by mouth every eight hours as needed for anxiety, and [MEDICATION(S)], 100 mg to give 100 mg by mouth at bedtime for [CONDITION(S)] depression. Review of Resident #18's care plans revealed she did not have a care plan addressing psychoactive medications. During interview on 07/01/21 at 3:30 P.M., the Administrator and Director of Nursing (DON) verified the resident did not have a care plan addressing the psychoactive medications. 2. Record review revealed Resident #22 was admitted on [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of quarterly MDS dated [DATE] revealed Resident #22 was cognitively intact. Review of physician orders for Resident #22 revealed she was prescribed Losartan 100 milligram (mg), [MEDICATION(S)] 25 mg ER and [MEDICATION(S)] Extended Release (ER) 180 mg and for high blood pressure, [MEDICATION(S)] 10 mg for high cholesterol, [MEDICATION(S)] 40 mg for depression, and [MEDICATION(S)] 125 micrograms (mcg) for low [CONDITION(S)]. Review of the revised care plans, dated 04/28/21, revealed no plan of care for high cholesterol, [CONDITION(S)], depression and hypertension. During interview on 07/06/21 at 2:11 P.M. , MDS Licensed Practical Nurse (LPN) #54 verified there were no care plans for the use of the above medications. Review of the facility policy titled Care Plans, dated 04/01/09, revealed care plans shall incorporate goals and objectives that lead to the residents highest obtainable level of independence. 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 2. When goals and objectives are not achieved, the residents clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. 3. Care plan goals and objectives are derived from information contained in the residents comprehensive assessment and: a. Are resident oriented; b. Are behaviorally stated; c. Are measurable; and d. Contain timetables to meet the residents needs in accordance with the comprehensive assessment. 4. Goals and objectives are entered on the residents care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. 5. Goals and objectives are reviewed and/or revised: a. When there has been a significant change in the resident's condition; b. When the desired outcome has not been achieved; c. When the resident has been readmitted to the facility from a hospital/ rehabilitation stay; and d. At least quarterly. 6. The resident has the right to refuse to participate in establishing care plan goals and objectives. When such refusals are made, appropriate documentation will be entered into the residents clinical records in accordance with established policies.

Based on record review and interview, the facility failed to ensure the physician documented review of pharmacy recommendations. This affected three (Residents #18, #22 and #35) of five residents reviewed for unnecessary medications. The facility census was 45. Findings include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE]. Pharmacy recommendations dated 04/06/21, 05/05/21, and 06/02/21 were not reviewed, signed or dated by the physician. 2. Record review revealed Resident #35 was admitted to the facility on [DATE]. A review of the pharmacy recommendations dated 04/07/21, 04/19/21, and 05/17/21 were not reviewed, signed or dated by the physician. 3. Medical record review for Resident #22 revealed she was admitted on [DATE]. Review of consultation report from the pharmacy issued on 03/02/21 and 05/05/21 revealed a request for [MEDICATION(S)] 10 units in the morning and 25 units in the evening to be combined and given in the evening. The recommendation was not reviewed, signed or dated by the physician. During interview on 07/01/21 at 3:30 P.M., the Administrator and Director of Nursing (DON) stated the Assistant Director of Nursing (ADON) had the pharmacy recommendation records offsite and they would try to get the information from the pharmacy. At the time of exit, no policy on pharmacy recommendations and none of the information from the offsite location or the pharmacy had been provided.

Based on observation, staff interview and policy review the facility failed to prime insulin needles before administration for one (#26) of one reviewed for insulin injections during the medication administration. The facility identified six residents who received insulin pens. The census was 45. Findings include: Medical record review for Resident #26 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician orders dated 06/22/21 revealed [MEDICATION(S)] KwikPen Solution Pen Injector to inject as per sliding scale, to be given subcutaneously before meals and at bedtime for [CONDITION(S)]. During observation on 07/01/21 at 8:16 A.M., Registered Nurse (RN) #70 drew up four units on the [MEDICATION(S)] insulin pen. She did not dial up two units and did not expel the insulin to ensure the pen was working properly. She stated she had primed the needle on the insulin pen when it was first opened and not the beginning of each administration of the pen. She wasn't aware she was supposed to expel two units of the insulin upon every use of the pen. Review of the facility policy titled Medication Safety Alert/Insulin Pen Use, dated 01/01/14, revealed to turn the dose selector to two units and hold the insulin pen with the needle pointing up and tap the cartridge gently a few times to move air bubbles to the top. Press the push button all the way until the dose selector is back to zero. A drop of insulin should appear at the tip of the needle. This must be done before each injection.

Based on observation, record review, interview and policy review, the facility failed to ensure a staff member donned appropriate personal protective equipment when caring for a resident on quarantine. This affected one (Resident #9) of three residents identified by the facility as being under quarantine. The facility census was 45. Findings include: Review of the clinical record revealed Resident #9 was admitted to the facility on [DATE]. She was discharged to the hospital on 06/23/21 and was readmitted on [DATE]. She had an order on 06/25/21 for strict single room isolation with droplet precautions related to readmission from hospital regarding COVID precautions every shift for 14 days. During observation on 06/28/21 at 12:17 P.M., State tested Nursing Assistant (STNA) #22 set up the resident's lunch tray and sat on the side of the bed to assist the resident with eating. STNA #22 was wearing a surgical mask, but no other personal protective equipment (PPE). During interview on 06/28/21 at 12:20 P.M., Licensed Practical Nurse (LPN) #62 also observed STNA #22 sitting on the side of the resident's bed. She stated the only PPE STNA #22 was wearing was a surgical mask. LPN #62 stated Resident #9 was on quarantine because of her recent hospital admission. LPN #62 stated anyone going into the room would have to wear full PPE, as if the resident had COVID. A review of the facility's policy titled Infection Prevention and Control Program stated to implement appropriate isolation precautions when necessary and follow established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). Review of the CDC Coronavirus Disease 2019 (COVID-19) fact sheet stated the preferred PPE included a face shield or goggles, an N95 or higher respirator, an isolation gown and a pair of clean non-sterile gloves. These are to be used when caring for a patient with confirmed or suspected COVID-19.

Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to provide bathing on a regular basis to residents who required assistance from staff to complete the task. This affected three Residents (11, #14, and #21) of five reviewed for bathing. The facility identified all 47 residents residing in the facility required assistance from staff or were dependent on staff for bathing. Findings include: 1. Review of the medical record revealed Resident #11 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required staff assistance for most activities of daily living, bathing the resident required total dependence, had and indwelling catheter and was always incontinent of bowel. The resident used a wheelchair to aid in mobility. Interview with State tested Nurse Aide (STNA) #51 on 03/18/21 at 6:45 A.M., revealed the facility was short of staff and she mostly gets the job done. STNA #51 verified she was unable to get showers done for her residents and there was about four to five total but she did not have time to look to see exactly how many. Interview with Resident #11 on 03/18/21 at 8:20 A.M. revealed he had not been getting his showers twice a week on Wednesday and Saturday. The Resident stated he was supposed to get them on night shift but if there was only one aide on his hallway the showers would not get done. Review of the shower documentation revealed Resident #11 had not received showers on 02/25/21, 02/28/21, 03/04/21, 03/07/21 and 03/17/21. Interview with the Director of Nursing (DON) on 03/26/21 at 10:20 A.M., verified Resident #11 had not received showers on 02/25/21, 02/28/21, 03/04/21, 03/07/21 and 03/17/21. The DON stated documentation for showers should be in the electronic record. 2. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance for personal hygiene. The assessment revealed bathing had not occurred in the previous seven days. Interview with Resident #14 on 03/18/21 at 7:40 A.M., revealed she was not getting showers. The Resident stated she was suppose to get showers on Wednesday and Saturday. She verified when there was only one aide on the hallway she can not get a shower. Review of the Electronic charting on 03/18/21 revealed Resident #14 had not received showers on 02/28/21 and 03/17/21. Interview with the Director of Nursing (DON) on 03/26/21 at 10:20 A.M. verified Resident #11 had not received showers on 02/28/21, and 03/17/21. 3. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance for most activities of daily living. The resident required physical help in part of her bathing. Interview with Resident #21 on 03/18/21 at 8:50 A.M., revealed she received a shower on 03/11/21 and that was the first time she received a shower in three weeks. Review of the shower documentation revealed there was no documented showers for Resident #21 from 02/20/21 to 03/18/21. Interview with the Director of Nursing (DON) on 03/26/21 at 10:20 A.M. verified Resident #21 had no electronic documentation for showers from 02/20/21 to 03/18/21. Review of the facility's policy titled Bath, Shower/Tub, dated 02/01/18, revealed the purpose of this procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. It is the facility's practice to offer and/or schedule each resident a shower at least once a week. The resident could request more frequent showers if he/she so chooses. This deficiency substantiates Complaint Master Number OH 227, Complaint Number OH 006, and Complaint Number OH 470. This deficiency is continued noncompliance from the survey dated 02/18/21.

Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to have sufficient nursing staff to provide bathing on a regular basis to residents who required assistance from staff. This affected three Residents (#11, #14, and #21) of five reviewed for bathing. The facility identified all 47 residents residing in the facility requiring assistance from staff or were dependent on staff for bathing. Findings include: 1. Review of the medical record revealed Resident #11 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required staff assistance for most activities of daily living, bathing the resident required total dependence, had and indwelling catheter and was always incontinent of bowel. The resident used a wheelchair to aid in mobility. Interview with State tested Nurse Aide (STNA) #51 on 03/18/21 at 6:45 A.M., revealed the facility was short of staff and she mostly gets the job done. STNA #51 verified she was unable to get showers done for her residents and there was about four to five total but she did not have time to look to see exactly how many. Interview with Resident #11 on 03/18/21 at 8:20 A.M. revealed he had not been getting his showers twice a week on Wednesday and Saturday. The Resident stated he was supposed to get them on night shift but if there was only one aide on his hallway the showers would not get done. Review of the shower documentation revealed Resident #11 had not received showers on 02/25/21, 02/28/21, 03/04/21, 03/07/21 and 03/17/21. Interview with the Director of Nursing (DON) on 03/26/21 at 10:20 A.M., verified Resident #11 had not received showers on 02/25/21, 02/28/21, 03/04/21, 03/07/21 and 03/17/21. The DON stated documentation for showers should be in the electronic record. 2. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance for personal hygiene. The assessment revealed bathing had not occurred in the previous seven days. Interview with Resident #14 on 03/18/21 at 7:40 A.M., revealed she was not getting showers. The Resident stated she was suppose to get showers on Wednesday and Saturday. She verified when there was only one aide on the hallway she can not get a shower. Review of the Electronic charting on 03/18/21 revealed Resident #14 had not received showers on 02/28/21 and 03/17/21. Interview with the Director of Nursing (DON) on 03/26/21 at 10:20 A.M. verified Resident #11 had not received showers on 02/28/21, and 03/17/21. 3. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance for most activities of daily living. The resident required physical help in part of her bathing. Interview with Resident #21 on 03/18/21 at 8:50 A.M., revealed she received a shower on 03/11/21 and that was the first time she received a shower in three weeks. Review of the shower documentation revealed there was no documented showers for Resident #21 from 02/20/21 to 03/18/21. Interview with the Director of Nursing (DON) on 03/26/21 at 10:20 A.M. verified Resident #21 had no electronic documentation for showers from 02/20/21 to 03/18/21. Review of the facility's policy titled Bath, Shower/Tub, dated 02/01/18, revealed the purpose of this procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. It is the facility's practice to offer and/or schedule each resident a shower at least once a week. The resident could request more frequent showers if he/she so chooses. This deficiency substantiates Complaint Master Number OH 227, Complaint Number OH 006, and Complaint Number OH 470. This deficiency is continued noncompliance from the survey dated 02/18/21.

Based on observation and staff interview the facility failed to have a functioning system for residents to call for assistance from staff. This affected three Residents (#05, #11, and #48) of 47 who were residing in the building. Findings include: 1. Observation on 03/24/21 at 11:30 A.M. revealed Resident #11 had his call light on inside the room. A red light was lit up inside the Resident room where the call light is plugged into the wall. Outside of the door in the hallway there is a lamp that has a light bulb in it that was not lighting up. Observation of the nurse station revealed an audible tone for a call light going off but no lights were lit up on the call light board showing what room was in need of assistance. Interview with State tested Nurse Aide (STNA) #02 on 03/24/21 at 11:35 A.M., verified there was an audible tone going off at the nurse station however she was not sure what room the call light button was going off from. STNA #02 went to Resident #11 room after the surveyor informed her that was where the call was being made from. STNA #02 verified the call light was showing it was going off in his room, but there was not a light functioning outside his room or a light showing at the nurse station. 2. Observation on 03/24/21 at 11:40 A.M. revealed Resident #05 had her call light on in her room. The light outside of the door in the hallway was not lighting up that showed she needed assistance. Interview with Licensed Practical Nurse (LPN) #40 verified Resident #05 call light outside of her room was not functioning when the call light was put on in the room. 3. Observation on 03/24/21 at 11:55 A.M. revealed Resident #48 call light was on in her room. The light was on outside her room but the display showing her room number was not lighting up at the nurse station. Interview with STNA #02 on 03/24/21 at 11:57 A.M., verified the light from Resident #48 call light was not going off at the nurse station when she had her call light on. This deficiency substantiates Complaint Master Number OH 227.

Based on medical record review and staff interview the facility failed to ensure physician ordered weekly weights were obtained to ensure newly admitted residents maintained an acceptable parameter of nutritional status and were monitored for weight loss. This affected one Resident (#31) of three reviewed for nutrition. The facility census was 47. Findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #31 discharged to another nursing facility on 04/05/21. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required total dependence for bed mobility, dressing, eating, toilet use, personal hygiene and bathing. The resident had an indwelling urinary catheter and was always incontinent of bowel. Review of the Physician order [REDACTED].>Review of the electronic medical record on 04/07/21 revealed the only weight in the record was an admission weight on 03/16/21 of 160.4 pounds. The Resident discharged to another facility on 04/05/21. Interview with the Administrator on 04/08/21 at 4:31 P.M., revealed there was no other weights for Resident #31. The Administrator stated the facility had no policy for weight loss. This deficiency substantiates Complaint Master Number OH 227.

Based on medical record review, staff and resident interview, observation, and facility policy review, the facility failed to ensure there was enough staff to provide activities of daily living including bathing and brushing teeth to the residents. This affected three residents (#7, #19 and #30) reviewed for staffing. This had the potential to affect all 45 residents residing in the facility. Findings included: 1. Medical record review for Resident #19 revealed an admitted d of 04/15/19. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/04/20 revealed Resident #19 was cognitively intact. Function status for bathing was one-person physical help. The resident had no rejection of care during the seven day assessment reference date. Review of the facility's bathing documentation for Resident #19 from 01/09/21 through 02/09/21 revealed the resident received two showers or two bed baths in 32 days. She had a shower on 01/21/21 and 01/28/21. She received a bed bath on 01/23/21 and 02/04/21. There were no refusals marked during the 32 days. Interview with Resident #19 on 02/04/21 at 7:40 A.M. revealed the staff weren't providing bathing for him because they tell him they don't have enough staff to do it. She prefers her bathing to take place in the evening. 2. Medical record review for Resident #30 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 11/10/20, revealed she was cognitively intact. Functional status for bathing was physical help with one-person assistance. Review of the facility's bathing documentation for Resident #30 from 01/09/21 through 02/09/21 revealed there was no documentation she received a bath or shower during the 32 days. Interview with Resident #30 on 02/08/21 at 10:46 A.M. revealed she hasn't received a shower in a week. She stated staff use one excuse after the other. She said if there was one aide on the hall at night or day, she won't receive her bathing. 3. Medical record review for Resident #7 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED].#7 was cognitively intact. He was a total dependence for bathing with one-person physical assistance. Review of the bathing documentation for Resident #7 from 01/15/21 through 02/15/21 revealed he received a bed bath six times in 32 days. The bed baths were given on 01/21/21, 01/25/21, 01/28/21, 02/01/21, 02/04/21, and 02/15/21. Interview and observation of Resident #7 on 02/11/21 at 8:20 A.M. revealed he was lying in bed and his hair was greasy and he had flakes of skin on his face and dried food, and had a yellow substance on his teeth. He stated there wasn't enough staff to provide the care for him. He couldn' remember the last time he has had a bath or shower. He stated his teeth haven't been brushed in a very long time. The aide was in the room at the time and stated he got a bed bath during the night but denied she brushed his teeth and after the aide left the room the resident said he didn't receive the bath. 4. Observation of staffing on 02/04/21 at 6:05 A.M. revealed there were two aides and two nurses for the census of 45. Interview with State tested Nursing Aide (STNA) #28 on 02/04/21 at 6:21 A.M. revealed she was taking care of 25 residents and couldn't get any showers done. she said most of the time she takes care of 20-25 residents at night time. She said when she was by herself, she couldn't get them done. She said it was hard to get her work done. Interview with STNA #68 on 02/04/21 at 6:37 A.M. revealed she was taking care of 20 residents and didn't get any showers done. She said when it was just her for 20 residents, she couldn't complete any showers. She said she normally takes care of 20 residents but sometimes it was more. Interview with STNA #58 on 02/12/21 at 8:37 A.M. revealed she worked by herself on 01/29/21 for a census of about 42. She stated she was the only aide on the night shift on 01/15/21 as well for a census of 42. She stated on 01/15/21, the Administrator and the Director of Nursing (DON) worked that evening but stayed in the office and only passed snacks out to the residents. She said the residents were left sopping wet and no bathing was provided. She has been told to not give showers if there was not enough help. Interview with the Administrator on 02/17/21 at 9:22 A.M. revealed the facility was staffing challenged, but they didn't have a staffing shortage. She stated she was meeting the state licensure regulation of 2.50 staffing to resident ratio. She stated her management team have been going out onto the floor to help and she helped a couple of nights ago since she has her STNA license because the facility was short on staff. She said there has been a huge turnover and she knows the staff at night were taking 20 and 25 residents to take care of at night and the daytime. She said they were in the hiring process, use agency and the management team to fill in, but the staff called off and that puts more work on everyone else. She says it has been difficult, but she was doing the best she could. The Administrator verified there were no active cases of COVID-19 in the facility at the time of the survey. Review of the facility's policy titled Staffing, dated 10/01/17, revealed the facility provided sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. This deficiency substantiates Complaint Number OH 889, OH 702, OH 550, OH 327 and OH 180.

Based on review of timecard punch detail and staff interview the facility failed to ensure the Director of Nursing (DON) worked full time hours of at least 35 hours per week. They also failed to ensure a Registered Nurse (RN) worked eights hours a day, seven days a week. This had the potential to affect all the residents. The census was 45. Findings include: Review of timecard punch detail for Interim Director of Nursing (IDON) #112 from 08/07/21 through 11/10/21 revealed the week of 08/30/20 through 09/05/20 she worked 30 hours and 39 minutes. The week of 09/13/20 through 09/19/20 she worked 38 hours and 8 minutes. The week of 10/11/20 through 10/17/20 she worked 33 hours and 10 minutes. The week of 10/25/20 through 10/31/20 she worked 29 hours and 51 minutes. Interview with IDON #112 on 02/18/21 at 8:20 A.M. revealed during the timeframe from 08/07/21 to 11/10/21 she worked on night shift, 12-hour shifts, three days a week. She wasn't sure if she worked full time hours each week or not. She said she covered the responsibilities of the DON at that time. During an interview with the Administrator on 02/18/21 at 9:11 A.M., she revealed the IDON did work three days a week and she thought she had worked full time hours each week. Schedules were requested for the timeframe of 08/07/21 to 11/10/21 to review RN coverage. The Administrator stated according to her Payroll Based Journal (PBJ) (A system used by Centers for Medicaid and Medicare Services (CMS) to analyze staffing patterns and populate the staffing component of the Nursing Home Compare website) during that time frame the facility only received a one star rating indicating an RN did not work eight hours a day, seven days a week. She stated the facility did the best they could with what they had at the time. This citation substantiated Complaint Number OH 889, OH 702, OH 550, and OH 180.

Based on review of staff professional licenses and staff interview the facility failed to ensure an Registered Nurse (RN) held an active license in the state where the facility was located. This had the potential to affect all the residents who reside in the facility. The census was 45. Findings include: Review of the professional license for RN #122 revealed the license had expired in the state of Ohio on [DATE]. There was an action taken against the license on [DATE], but there wasn't any information on what the action was. Review of the professional license for RN #122 revealed she had an active license in the state of Kentucky with an issue date of [DATE] and expiration date of [DATE]. Interview with RN #122 on [DATE] at 2:06 P.M., revealed was working under the emergency pandemic and was a consultant for the facility. She denied she used pen and paper to approve anything in the facility or pass medications for the facilities in Ohio that she managed. She stated her license for the state of Ohio was in good standing. She stated she had been with the company who consulted for the facility for about seven years. S he said she had been asked about this before, but she was covered under the emergency pandemic rule and sent emails regarding the emergency staffing during the pandemic. Interview with the Administrator on [DATE] at 4:15 P.M. revealed RN #122 was only a consultant for the facility and she didn't administer any medications. She revealed the RN had been consulting with the facility for at least two years, which was as long as she had been employed at the facility. This deficiency substantiated Complaint Number OH 327.

Based on medical record review, observation, staff interview, review of the U.S. Food and Drug Administration Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Healthcare, and review of the facility's policy on use of side rails, the facility failed to assess the residents for the risk of entrapment from half bed rails prior to installation to ensure they were safely applied and obtain physician orders for use in accordance with facility policy. This resulted in Immediate Jeopardy and serious life-threatening harm for one resident (#20) when her head and neck became wedged between the half bed rail and mattress with her legs at a kneeling position on the floor, subsequently causing her respiratory distress. Additionally, two residents (#17 and #23) were placed at potential risk for harm that was not Immediate Jeopardy because the gap between Resident #17's mattress and the bed rail exceeded five inches allowing for possible entrapment between the rail and the mattress and the spaces within Resident #23's bed rail allowed for potential head entrapment within the perimeter of the rail. This affected three (#17, #20, #23) of six residents reviewed for use of bed rails. On 01/17/18 at 1:53 P.M., the Licensed Nursing Home Administrator (LHNA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) #28 were notified Immediate Jeopardy began on 12/05/17 at 10:30 P.M. when Resident #20 was discovered by State tested Nurse Aide (STNA) #41 and Licensed Practical Nurse (LPN) #74 hanging from the bed rail by her neck. The resident's head and neck were wedged between the bed rail and mattress and her legs were noted in a kneeling position touching the floor. Resident #20 was cyanotic (blue in color) and STNA #41 stated Resident #20 was gasping for air. The resident was removed from the bed rail, repositioned in bed and assessed by the nurse who noted the skin around her neck was red and had indentations. Nine-one-one was called and the resident was transported to the hospital for evaluation and treatment. The Immediate Jeopardy was removed on 12/06/17 at 10:30 P.M. when the facility implemented the following corrective actions: · On 12/05/17, Resident #20 was transported to the hospital for evaluation and treatment. · On 12/05/17 at 10:45 P.M., the DON directed licensed nursing staff on-duty to unlock and release all bed rails to the down position, place resident beds in the lowest positions, and apply fall mats to the floor where appropriate. · On 12/05/17 at 10:45 P.M., the DON began educating all staff on-duty on the use of bed rails, and the increased risk of injury or death. The DON utilized the resource titled Recommendations for Consumers and Caregivers About Bedrails. All staff in-service was completed by 12/06/17 by 10:30 P.M. · On 12/05/17 at 11:00 P.M., the DON notified the Administrator of the incident and made the decision to remove all bed rails from resident beds. · On 12/06/17 at 4:30 A.M., Resident #20 returned to the facility and neuro checks were initiated upon return for eight hours, ending at 12:30 P.M. New interventions implemented prior to the resident returning to the facility included the following: the half bed rails were removed, the bed was placed in the lowest position, fall mats were applied on bilateral sides of the bed and an air mattress with bolsters was ordered. On 12/06/17 from 4:30 A.M. until 4:00 P.M., Resident #20 was placed on 15 minutes checks. · On 12/06/17 at 7:30 A.M., Maintenance Supervisor (MS) #74 began removal of all bed rails. · On 12/06/17 at 7:30 A.M. and ending at 4:00 P.M., the Interdisciplinary Disciplinary Team (IDT), including the DON, ADON #28, Social Services Designee (SSD) #42, Activity Director #32, and Minimum Data Set (MDS) assessment nurse (#62) reviewed and assessed residents with bed rails regarding mental status and physical state to determine safety regarding the use of bed rails. The IDT provided education to residents and/or their legal representatives related to bed rails. · On 01/17/18, all current residents (#1, #2, #3, #17, #25, #43) with bed rails were reassessed for risk of entrapment and bed rail appropriateness. Physician orders for use of bed rails were obtained. · On 01/17/18 at 6:00 P.M., the DON and the IDT began an all staff in-service using the Centers for Medicare and Medicaid Services (CMS) guidelines for use of bed rails. · On 01/19/18 at 10:00 A.M., observations of bed rails for Resident's #1, #2, #3, #17, #25, and #43 revealed no concerns. · Beginning on 01/20/18, the Administrator and/or designee will monitor utilization of bed rails. The administrator and DON will be performing rounds separately five times per week for 30 days. The Quality Assurance (QA) committee will be updated at the monthly meeting beginning on 01/24/18. Concerns identified will be reported and discussed with the IDT Monday through Friday during morning meetings. · Bed rail assessments are to be completed on all residents with bed rails by charge nurses and reviewed by the IDT monthly for three months. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm but potential for more than minimal harm that is not Immediate Jeopardy), as the facility is still in the process of implementing their corrective action plans and monitoring for on-going compliance. Findings include: Medical record review for Resident #20 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was moderately cognitively impaired. She required extensive assistance from staff for bed mobility and personal hygiene and was totally dependent on staff for transfers, locomotion on and off the unit and toilet use. There was no documented evidence of an assessment for risk of entrapment and no physician order for [REDACTED]. Review of the nursing progress notes dated 12/05/17 revealed Resident #20 was found with her neck caught between the bed rail and the mattress with her legs on the floor. Her face was cyanotic, staff dropped the bed rails and the resident was removed to the floor for an assessment. The resident's skin around her neck was red and had indentations. She was responsive with increased confusion from her baseline. Documentation revealed the resident had bile emesis. Emergency Medical Services (9-1-1) was called and transported the resident to the hospital. Review of the facility's fall investigation dated 12/05/17 at 10:30 P.M. revealed Resident #20 was in bed with feet on the floor and neck was under the bed rail. The document noted the skin color was ashen and staff assisted in removing the resident from under the bed rail. It was not documented whether the bed rails should have or shouldn't have been on her bed. New interventions were to remove half rails, place bed in the lowest position, place fall mats to both sides of the bed, apply an air mattress with bolsters to bed and 15 minute checks till the morning. Review of the resident's hospital discharge summary dated 12/06/17 revealed the squad reported they were called due to the resident getting her neck lodged between the bed railing and the bed. Observation of Resident #20 on 01/16/18 at 10:30 A.M. revealed she was lying in her bed with her husband sitting at the bedside. Her bed was low to the floor and pushed up against the wall with a fall mat on the left side of the bed. She did not have bed rails on the bed and she was on an air loss mattress with bolsters. Interview with STNA #19 on 01/16/18 at 3:51 P.M. revealed she was called to Resident #20's room and when she arrived she saw LPN #74 and STNA #41 standing at the resident's bedside and the resident had her neck and oxygen tubing under the bed rail and they could not get the bed rail off her neck. She stated the resident was leaning, so she stuck a pillow under her. She stated the resident was on her knees with her head under the bed rail. She stated she couldn't reach the resident's neck so she jumped up on a recliner, so she could get over the top of everyone, and was then able to reach the bed rail release handle which released Resident #20's neck from under the bed rail. She stated Resident #20 had a bluish tinge to her face. STNA #19 stated after the resident's neck was disengaged, the resident vomited and then was lowered to the floor, assessed and put back into bed with a Hoyer lift. Interview with STNA #41 on 01/16/18 at 4:06 P.M. revealed LPN #74 and herself were coming through the doors from the Assisted Living unit and looked in Resident #20's room and discovered Resident #20 was hanging from the bed rail by her neck. Her face was purple and she was gasping for air. She stated they called for help and LPN #10 and STNA #19 came into the room. She stated LPN #74 and herself held the resident's head until STNA #19 could reach the bed release handle which released the resident's neck from under the bed rail. An attempt to interview LPN #10 and LPN #74 during the survey was unsuccessful. 2. Medical record review for Resident #17 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's comprehensive MDS 3.0 assessment dated [DATE] revealed she was cognitively intact. There was no documented evidence of an assessment for risk of entrapment and no physician order for [REDACTED]. Observation of Resident #17's half bed rail with the LNHA on 01/16/18 at 5:10 P.M. revealed the gap measurement from Resident #17's mattress to her bed rail measured 5.5 inches. The LNHA stated Resident #17's bed would be replaced with properly fitting bed rails. Observation of the replacement bed for Resident #17 on 01/16/18 at 6:15 P.M. revealed the bed had properly fitting bed rails. 3. Medical record review for Resident #23 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's comprehensive MDS 3.0 assessment dated [DATE] revealed she was cognitively intact. There was no documented evidence of an assessment for risk of entrapment and no physician order for [REDACTED]. Observation of Resident #23's half bed rail with the LNHA on 01/16/18 at 5:20 P.M. revealed the measurement of Resident #23's bed rail measured 12 inches by 5.5 inches on the two outer sides of the bed rail and the middle of the bed rail measured at 5.5 inches. The LNHA stated he would place pads against the bed rails for Resident #23's bed. Observation of Resident #23's bed rails on 01/16/18 at approximately 6:16 P.M. revealed the pads were placed up against her bed rails. During an interview with the DON on 01/16/18 at 6:18 P.M. she verified there was no assessments for risk of entrapment and no physician orders for the use of bed rails documented in the medical records for Resident #17, #20, and #23. She stated a new company acquired the facility on 12/01/17 and the old company did not require assessments and physician orders for the use of bed rails. She further stated the new company's requirements were to use nursing judgement when utilizing a bed rail for a resident. Interview with the LNHA on 01/22/18 at 2:25 P.M. revealed the policy for the new company carried over from the old company policy. Review of the U.S. Food and Drug Administration (FDA) Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes, and Home Health Care dated 09/2013 indicated potential risks of bed rails may include: strangling, suffocating, bodily injury or death when patients or part of their body are caught between bed rails, or between the bed rails and mattress. The bed rail entrapment prevention between the bed rail and the mattress (the space between the inside surface of the bed rail and the mattress compressed by the weight of a patient's head) the space should be small enough to prevent head entrapment when considering the mattress compressibility, any lateral shift of the mattress or bed rail, and degree of play from loosened bed rails. A dimension of less than 4 ¾ inches was recommended because the head was presumed to enter the space before the neck. The FDA recommended a dimensional limit of less than 120 millimeters (4 ¾ inches) for the area between the inside surface of the bed rail and the compressed mattress. Review of the facility's policy for side (bed) rails dated 04/2013 revealed prior to implementation, side (bed) rail utilization would be evaluated by the IDT to determine the reason for side (bed) rail use and any alternative devices that may be used to achieve the same goal. The policy further revealed to obtain a physician's order for side (bed) rail use and the order was to include reason for use, type of side (bed) rail, length of time to be used and the plan for side (bed) rail reduction and/or elimination.

Based on medical record review, observation, resident interview, staff interviews, and review of the facility's policy on nutrition, the facility failed to timely assess Resident #28's nutritional status with significant weight loss, failed to ensure nutrition recommendations were implemented, and failed to attempt new nutrition interventions. Actual harm occurred to Resident #28 when nutrition recommendations were not implemented and no new interventions were attempted resulting in the resident losing 35.2 pounds with an avoidable 20.1 percent significant weight loss during this time period. This affected one (#28) of four residents reviewed for weight loss. The facility identified seven residents with significant weight loss. The facility census was 45. Findings include: Medical record review for Resident #28 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and was able to feed herself with tray setup assistance from staff. It also revealed the resident had significant weight loss that was not prescribed by the physician and there were no nutrition approaches in place. Review of Resident #28's current nutritional care plan revealed a problem of significant weight loss in 30, 90, and 180 days and the goal was for no significant weight changes through the next review. The interventions included to monitor the resident's food and fluid preferences, and food intake, laboratory values and medications. There was no documented evidence of nutrition recommendations that the resident refused and/or the facility recommended in the resident's plan of care. Review of the resident's weight summary form revealed the resident weighed the following: 06/02/17 175 pounds (lbs.); 07/05/17 174.0 lbs.; 08/08/17 176 lbs.; 09/07/17 156 lbs.; 09/21/17 157 lbs.; 10/10/17 157 lbs.; 11/06/17 141.0 lbs.; 12/22/17 139.8 lbs. This revealed the resident lost 17.2 lbs. in three months indicating an 11.0 percent (%) significant weight loss, and 35.2 lbs. in six in months indicating a 20.1% significant weight loss. Review of the resident's dietary note dated 08/10/17 revealed the resident had a significant weight loss for 180 days. However, the resident's weight was stable in the 170's since 02/2017 and there were no recommendations made. The dietary note dated 09/12/17 revealed the resident's current body weight was 156 lbs. and had a significant weight loss for 30 and 90 days. The note stated the root cause of the weight loss was due to poor appetite, antibiotic for urinary tract infection, and the use of a diuretic. The note revealed the resident's dietary preferences would be updated and weekly weights would begin. The physician and family were updated. Review of the dietary note dated 11/09/17 revealed Resident #28 was not on a weight loss program and the root cause of the resident's weight loss might be related to pain from her left hip surgery, limited food preferences, and a history of refusing an appetite stimulant and high calorie nutritional supplements. The note stated to continue weekly weights. There was no documented evidence that weekly weights were obtained from the initial nutrition recommendation made on 09/12/17 to 01/19/18, excluding one exception on 09/21/17, in the medical record. There was also no documented evidence of the resident's food preferences being obtained from the nutrition recommendation made on 09/12/17 and there was no evidence the facility tried any nutritional supplements in the medical record. There was no documented evidence of a nutritional assessment being completed after 11/09/17 when the resident continued to lose weight on 12/22/17 in the medical record. Observation and interview with Resident #28 on 01/16/18 at 10:49 A.M. revealed the resident ate 75% or greater of her breakfast meal. She stated she liked the food at the facility. She stated she was happy with some of her weight loss but was not sure why she continued to lose weight. Interview with Dietary Supervisor (DS) #6 on 01/18/18 at 10:17 A.M. revealed she denied knowledge of Resident #28's weight loss and confirmed obtaining resident weights had been an issue. She confirmed Resident #28's current body weight was 139.8 lbs. on 12/22/17 which indicated a weight loss greater than 19% in six months. The DS stated the facility did not have any registered dietitian or dietetic technician for the month of 12/2017. The former registered dietitian left when the new company took over on 12/01/17 and the new company did not replace the registered dietitian until this month of 01/2018. Interview with the Director of Nursing (DON) on 01/19/18 at 10:10 A.M. confirmed there were no weekly weights for Resident #28, no documentation of nutritional supplements being refused, or any additional interventions related to Resident #28's significant weight loss. Review of the facility's policy titled, Nutritional Practice, dated 06/2015 revealed interventions to be considered were meal substitutions, assistance or assistive devices, enhanced foods, house supplements, location of meal, and family involvement. The interventions would be revised in the resident's care plan.