Every finding on record at Willows at Willard the

Based on observation, medical record review, and staff interview, the facility failed to ensure residents had a functional communication system in place. This affected one (#1) of one resident reviewed for communication. The facility census was 62.Findings include:Review of the medical record for Resident #1 revealed an admission date of 03/09/24. Diagnoses included Alzheimer's disease, depression, and vascular dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/19/26, revealed Resident #1 had severe cognitive impairment. Further review of the MDS revealed Resident #1 had unclear speech, was sometimes understood, and sometimes could understand others. Resident #1 required moderate assistance with Activities of Daily Living (ADLs) and was dependent on staff for showering and bathing. Review of the care plan dated 08/06/25 revealed Resident #1 required assistance with understanding instructions, pamphlets, or other written materials from their doctor or pharmacy. Interventions included providing and explaining detailed instructions in the resident's preferred language, asking simple questions to verbalize understanding, and clarifying and defining medical terminology with the resident in a way the resident could understand. Further review of the care plan revealed no goals or interventions pertaining to Resident #1's communication barriers and needs.Interview on 04/08/26 at 9:44 A.M with Certified Nursing Assistant (CNA) #408 revealed Resident #1 spoke Italian. CNA #408 further stated that Resident #1 did not communicate with staff and staff used gestures and simple words to try to communicate with the resident.Observation on 04/08/26 at 9:44 A.M. of Resident #1's room revealed no evidence of communication devices or other forms of alternative communication to facilitate communication with the resident. Observation on 04/08/26 at 3:22 P.M. revealed Resident #1 was walking around the hallway with a walker. Registered Nurse (RN) #409 attempted to redirect Resident #1. Resident #1 spoke in a language that was not English. RN #409 spoke to Resident #1 in English and told the resident to sit down and that her daughter would be to the facility in two hours. Resident #1 continued to attempt to get up from the chair. Concurrent interview with RN #409 revealed she was familiar with Resident #1 and she just knew what the resident wanted. RN #409 stated Resident #1 spoke and understood some English. When RN #409 was asked why she asked Resident #1 to sit down instead of asking what she needed, RN #409 stated well she is looking for her daughter. RN #409 confirmed there were no communication boards in Resident #1's room and stated a sheet of paper with English to Italian words may have been behind the nurses station.Interview on 04/08/26 at 4:09 P.M. with the Director of Nursing (DON) confirmed there were no communication devices or alternative communication methods available for Resident #1. The DON stated staff have used their personal cell phones to attempt to translate to better understand Resident #1. The DON further confirmed there was no care plan pertaining to the resident's communication needs.Interview on 04/09/26 at 8:24 A.M. with Speech Language Pathologist (SLP) #454 verified no alternative communication methods had been implemented for Resident #1. SLP #454 stated she made Resident #1 a memory book in 2024 that contained pictures of the resident's family and history to help support her memory. SLP #454 stated Resident #1's family visited and primarily communicated with the resident in Italian. Interview on 04/09/26 at 2:21 P.M. with the DON revealed the facility did not have a policy on communication needs.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure nutritional assessments were completed timely. Furthermore, the facility failed to ensure a comprehensive nutritional was completed annually and after a significant change in condition. This affected one (#8) of one resident reviewed for nutrition. The facility census was 62.Findings include:Review of the medical record for Resident #8 revealed an admission date of 10/31/24. Diagnoses included dementia, dysphagia, muscle weakness, atrial fibrillation, and hypertensive chronic kidney disease.Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/25, revealed the resident had severe cognitive impairment. Resident #8 required set-up or clean-up assistance with meals. The resident had no skin breakdown. Review of the resident's weights revealed on 01/05/25 Resident #8 weighed 194 pounds and on 07/06/25 the resident weighed 168 pounds, indicating a 13 (%) percent weight loss. Interventions included the addition of fortified foods and weekly weights. On 04/06/26 the resident weighed 182 pounds.Review of the nutritional assessments dated 11/04/24, 02/11/25, 05/09/25, 08/25/25, and 11/19/25 revealed no quarterly nutritional assessment had been completed since 11/19/25. Additionally, no nutritional assessment had been completed after the resident had experienced the significant weight loss. Further review of the nutritional assessments revealed no calculations of the resident's estimated caloric, protein, and fluid needs had been completed since the initial nutritional assessment dated [DATE]. Interviews on 04/09/26 at 10:12 A.M. and 1:03 P.M. with Registered Dietician (RD) #456 verified Resident #8 previously had a significant weight loss and a nutritional assessment had not been completed. RD #456 also verified the resident had not had a quarterly nutritional assessment completed since 11/19/25. Further interview with RD #456 revealed there was no documentation the resident's estimated caloric, protein, and fluid needs had been reevaluated since 11/04/24. Review of the facility policy titled, Dining RD Management RDs, last revised 05/10/24, revealed a nutrition assessment would be completed on admission, quarterly, annually, and with significant changes and upon consultation.

Based on observation, review of the medical record, and interview, the facility failed to ensure assistive adaptive equipment was provided during meals. This affected one (#8) of one resident reviewed for nutrition. The facility identified 12 residents requiring adaptive equipment during meals. The facility census was 62. Findings include:Review of the medical record for Resident #8 revealed an admission date of 10/31/24. Diagnoses included dementia, dysphagia, muscle weakness, atrial fibrillation, and hypertensive chronic kidney disease.Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/25, revealed the resident had severe cognitive impairment. The resident required set-up or clean-up assistance with meals. Review of a physician order dated 08/20/25 revealed the resident had an order for a plate guard and divided dish at all meals. Review of the nutrition care plan dated 09/09/25 revealed the resident had experienced a significant weight loss. Interventions included for staff to offer encouragement and assistance with eating as needed, provide diet, supplements, medications, adaptive equipment, and snacks as ordered, and obtain weights as ordered. Observation on 04/08/26 at 12:22 P.M. revealed Resident #8 was eating lunch in the main dining room. Further observation revealed the resident's food was served on a regular dinner plate with no plate guard.Interview on 04/08/26 at 12:22 P.M. with the Director of Nursing (DON) verified Resident #8 had a regular plate with no plate guard. The DON also verified the physician ordered adaptive equipment was not listed on the resident's meal ticket. Interview on 04/08/26 at 2:31 P.M. with Regional Clinical Nurse (RCN) #452 revealed the facility had no policies regarding adaptive equipment for meals.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure personal protective equipment (PPE) was handled appropriately following use. This affected one (#10) of two residents reviewed for Enhanced Barrier Precautions (EBP). The facility identified 12 residents on EBP. The facility census was 62.Findings include:Review of the medical record for Resident #10 revealed an admission date of 10/24/23. Diagnoses included paraplegia, lumbar spina bifida without hydrocephalus, end stage renal disease, ileostomy, and neuromuscular dysfunction of bladder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/25/26, revealed Resident #10 had moderate cognitive impairment. Further review of the MDS revealed Resident #10 was dependent on staff for Activities of Daily Living (ADL). Resident #10 had a urostomy and colostomy and received surgical wound care that required treatment. Review of the care plan dated 04/19/24 revealed Resident #10 required EBP during high-contact care related to the presence of a wound with dressing.Review of the physician orders revealed an order dated 12/11/24 for staff to use EBP, wearing a gown and gloves at a minimum, during high-contact care activities. Observation on 04/08/26 at 10:24 A.M. revealed Certified Nursing Assistant (CNA) #408 and CNA #274 donned a re-usable gown and gloves to assist Resident #10 with putting on pants and transferring into the wheelchair via a mechanical lift. After Resident #10 was safely placed in the wheelchair, CNA #408 removed her gown and put it on the floor.Interview on 04/08/26 at 10:33 A.M. with CNA #408 confirmed when doffing PPE, the gown should have been placed in a container and not placed on the floor. CNA #408 stated the container for the gowns was by the door and covered by a blanket that belonged to the resident's roommate. CNA #408 further stated that the contaminated PPE bin was full and confirmed the resident's roommate's blanket should not have been touching the contaminated PPE bin.Interview on 04/08/26 at 2:30 P.M. with the Director of Nursing (DON) revealed the facility did not have a policy that specified how staff should remove and contain contaminated PPE.Review of the facility policy titled Enhanced Barrier Precautions (EBP) Standard Operating Procedure, dated 12/03/25, revealed that guidance for EBP was to decrease risk of becoming colonized and developing infections with multidrug- resistant organisms status.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure hazardous chemicals were securely stored. This had the potential to affect seventeen residents (#4, #6, #10, #11, #24, #25, #34, #37, #39, #40, #46, #47, #48, #50, #52, #55, and #169) who were identified by the facility as independently mobile and cognitively impaired. The facility census was 63. Findings include: Observation on 11/20/24 at 9:12 A.M. of a storage closet located behind a nursing desk near the beginning of the 100-hall revealed the door to the storage closet was unlocked. Located inside of the storage closet, and within reach, were a can of disinfectant spray, which was labeled for caution and as hazardous to humans and animals; a container of germicidal disposable wipes, which were labeled for caution and to keep out of reach; and a bottle of disinfectant solution, which was labeled for caution and to keep out of reach. Interview on 11/20/24 at 9:17 A.M. with Registered Nurse (RN) #446 verified the storage closet was unlocked. RN #446 reported the door to the storage closet was kept unlocked and RN #446 was unsure of whether the door was required to be locked. A follow-up interview on 11/20/24 at 10:31 A.M. with RN #446 verified the door to the storage closet was supposed to be locked.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure oxygen administration was completed per physician orders. This affected one (#5) of one resident reviewed for respiratory care. The facility census was 63. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included heart failure and shortness of breath. Review of the Minimum Data Set (MDS) assessment, dated 09/18/24, revealed Resident #5 had intact cognition. Review of the physician orders dated 03/08/24 revealed Resident #5 was ordered oxygen at two liters per minute per nasal cannula as needed for oxygen saturation levels less than 92 percent. Observation on 11/18/24 at 9:40 A.M. revealed Resident #5's oxygen administration rate was set at four liters per minute. Observation on 11/19/24 at 1:19 P.M. revealed Resident #5's oxygen administration rate was still set at four liters per minute. Interview on 11/19/24 at 1:19 P.M. with Licensed Practical Nurse (LPN) #475 verified Resident #5's oxygen rate was set at four liters per minute and should have been set at two liters per minute. Review of the facility policy titled Administration of Oxygen, revised May 2018, revealed to verify physician order for the procedure and the oxygen setting must be set and adjusted by a licensed nurse.

Based on medical record review, review of nurse practitioner (NP) progress notes, staff interview and review of facility policy review, the facility failed to ensure required physician visits were completed. This affected six (#5, #11, #19, #28, #31 and #40) of six residents reviewed for physician visits. The facility census was 63. Findings include: 1. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including cellulitis and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/01/24, revealed Resident #11 was cognitively impaired. Further review of the medical record revealed Resident #11 was seen by the NP at least monthly from 01/15/24 through 11/08/24. There was no evidence of a physician visit with the resident from 01/15/24 through 11/20/24. 2. Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses including urinary retention, acute kidney failure and urinary obstruction. Review of the annual MDS assessment, dated 09/26/24, revealed Resident #19 was cognitively intact. Further review of the medical record revealed Resident #19 was seen by the NP at least monthly from 11/20/23 through 11/08/24. There was no evidence of a physician visit with the resident from 01/15/24 through 11/20/24. 44454 3. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, anemia, metabolic encephalopathy, intervertebral disc degeneration, major depressive disorder, bilateral primary osteoarthritis of hip, mild protein-calorie malnutrition, dementia,constipation, weakness, altered mental status, pain, unsteadiness on feet, age-related physical debility, anxiety disorder, and overactive bladder. Review of the quarterly MDS assessment, dated 09/10/24, revealed the resident had severely impaired cognition. Further review of the medical record revealed Resident #31 was seen by the NP at least monthly from 10/11/23 through 11/08/24. There was no evidence of a physician visit with the resident from 10/11/23 through 11/20/24. 4. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included dementia, hypothyroidism, hyperlipidemia, hypertension, muscle weakness, need for assistance with personal care and chronic kidney disease. Review of the annual MDS assessment, dated 10/18/24, revealed the resident had impaired cognition. Further review of the medical record revealed Resident #40 was seen by the NP at least monthly from 10/11/23 through 11/08/24. There was no evidence of a physician visit with the resident from 10/11/23 through 11/20/24. 35033 5. Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included heart failure and shortness of breath. Review of the MDS assessment, dated 09/18/24, revealed the resident had intact cognition. Further review of the medical record revealed Resident #5 was seen by the NP at least monthly from 10/11/23 through 11/08/24. There was no evidence of a physician visit with the resident from 10/11/23 through 11/20/24. 6. Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, vascular dementia, chronic kidney disease and polyneuropathy. Review of the quarterly MDS assessment, dated 09/09/24, revealed the resident had severely impaired cognition. Further review of the medical record revealed Resident #28 was seen at least monthly by the NP from 10/27/23 through 10/21/24. There was no evidence the resident had been seen by the physician from 10/01/23 through 11/20/24. Interview on 11/21/24 at 12:22 P.M. with the Director of Nursing (DON) revealed the DON stated the six residents were seen by the physician; however, the facility had no evidence, including progress notes or other documentation, to confirm the visits occurred. Review of the facility policy titled Guidelines for Physician Services, revised 05/11/16, revealed the resident's attending physician was responsible for conducting required routine visits and delegating and supervising follow-up visits from NPs or physician assistants to ensure the resident received quality care and medical treatments.

Based on observation, medical record review and staff interview, the facility failed to ensure beds were maintain in a safe and functional manner. This affected one (#166) of one resident reviewed for physical environment. The facility census was 63. Findings include: Review of the medical record revealed Resident #166 admitted to the facility on [DATE]. Diagnoses included hypertension, gastroesophageal reflux disease, hyperlipidemia, arthritis, anxiety and depression. Observation on 11/18/24 at 10:45 A.M. revealed Resident #166 was sitting up in a wheelchair located in their room. The headboard and footboard attached to Resident #166's bed were both slanting outward from the bed frame. Concurrent interview with Resident #166 revealed the bed had been that way since admission to the facility. Interview on 11/18/24 at 10:48 A.M. with Registered Nurse (RN) #457 verified the headboard and footboard of Resident #166's bed were slanted outward and that was not how the bed was supposed to be. RN #457 reported they would check with maintenance to see what was wrong with the bed.

Based on medical record review, observation, staff interview and review of facility policy, the facility failed to complete wound care treatments per physician orders. This affected one (#28) of one resident reviewed for pressure ulcers. The facility census was 63. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, vascular dementia, chronic kidney disease and polyneuropathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/09/24, revealed Resident #28 had no pressure ulcers. The resident had severely impaired cognition. Review of a wound progress note dated 09/19/24 revealed Resident #28 had a stage three pressure ulcer measuring 2.5 centimeters (cm) in length by four cm in width with a depth of 0.1 cm. The wound had light exudate, no odor, no undermining and no tunneling. The wound was 100 percent (%) granulation tissue with irregular wound edges. Review of a physician order dated 11/13/24 revealed an order to cleanse the right heel with Anasept Cleanser, dry, apply skin prep to peri wound, cut hydrogel impregnated gauze to size of eschar only and cover with dry bordered dressing daily. Review of the treatment administration record (TAR) revealed the right heel treatment was documented as completed on 11/19/24 by Licensed Practical Nurse (LPN) #475. Observation on 11/20/24 at 8:46 A.M. with LPN #401 of wound care for Resident #28 revealed the wound dressing in place was dated 11/18/24. LPN #401 confirmed the dressing was dated 11/18/24. LPN #401 revealed the dressing should be changed daily. Further observation revealed the resident had an unstageable pressure ulcer to the right heel with 100% eschar. The wound measured four cm in length by 2.5 cm in width with an undetermined depth with minimal serosanguinous drainage. The surrounding skin was dry and pink. Interview on 11/20/24 at 2:36 P.M. with LPN #475 verified she had not completed Resident #28's wound dressing change on 11/19/24 but documented she had completed the treatment. Review of the facility policy titled Guidelines for General Wound and Skin Care, revised 02/23/23, revealed no guidelines for completing wound care per physician orders.

Based on resident interview, family interview, staff interview and medical record review, the facility failed to ensure medications were available for administration as physician ordered. This affected one (#168) of one resident reviewed for medication administration. The facility census was 63. Findings include: Review of the medical record revealed Resident #168 was admitted to the facility on [DATE]. Diagnoses included history of severe sepsis and becoming unstable, weakness, history of urinary tract infection (UTI), history of acute kidney injury on chronic kidney disease and chronic kidney disease. Review of the admission assessment dated [DATE] revealed Resident #168 was alert and oriented with no documented memory impairment or cognitive issues. Review of the nursing progress notes dated 11/13/24 and timed 4:50 P.M. revealed Resident #168 was admitted to the facility after being admitted to the hospital for diagnoses including severe sepsis, UTI and septic shock. The resident was on antibiotic therapy for severe sepsis and UTI. Review of a physician order dated 11/13/24 revealed an order for Caspofungin (used to treat fungal infections) to be administered every day between 6:00 A.M. and 10:00 A.M. The medication was started in the hospital on 11/08/24 and had a stop date of 11/21/24. Review of the nursing progress note dated 11/14/24 and timed 3:27 P.M. revealed the Caspofungin was unavailable and Resident #168 missed the dose of medication scheduled for 11/14/24. The medication end date was changed to 11/22/24 and the medication was scheduled for delivery to the facility on [DATE]. Review of the medication administration record (MAR) for November 2024 revealed Resident #168 did not receive the Caspofungin on 11/14/24 due to the medication being unavailable. Interview on 11/18/24 at 11:20 A.M. with Resident #168 and the resident's daughter revealed the resident was discovered to have a yeast infection and sepsis while in the hospital. The resident was supposed to receive IV antibiotics for 14 days. The medication was started in the hospital and was to continue at the facility. Resident #168 missed a dose of medication on 11/14/24 due to the facility not having the medication available. Interview on 11/20/24 at approximately 4:02 P.M. with the Director of Nursing (DON) verified Resident #168 did not receive the Caspofungin per physician order on 11/14/24 due to the facility not yet having the medication from the pharmacy.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure medications were not left unattended. This affected one (#27) of one resident reviewed for medication storage. The facility census was 63. Findings include: Review of the medical record for Resident #27 revealed an admitted [DATE]. Diagnoses included dyarthria (slurred speech) following cerebral infarction (stroke), dysphagia (difficulty swallowing), atrial fibrillation and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/06/24, revealed Resident #27 had intact cognition. Review of the physician orders revealed no orders for Resident #27 to self-administer medications. Review of the plan of care initiated 09/16/20 revealed Resident #27 had impaired swallowing related to dysphagia. Interventions included to observe resident closely for signs of choking and/or aspiration. Observation on 11/18/24 at 2:01 P.M. revealed Resident #27 in her room, sitting in her wheelchair, with the bedside table in front of her. On the bedside table were seven medications on a towel. There were no staff present in Resident #27's room. Interview on 11/18/24 at 2:01 P.M. with Registered Nurse (RN) #513 verified the seven medications were left, unattended, with Resident #27. RN #513 revealed she always left the resident's medication with her. Interview on 11/20/24 at 7:16 A.M. with the Director of Nursing (DON) verified Resident #27 had no orders to self-administer medications. The DON revealed she was not aware the nurse was leaving medications in the resident's room. Review of the facility policy titled Medication Administration General Guidelines, revised November 2018, revealed medications were administered at the time they were prepared, and the resident was always observed after administration to ensure the dose was completely ingested.

Based on observation, staff interview, and review of a facility policy, the facility failed to ensure medications were stored in a safe and secure manner. This affected two (100 and 300) of three hallway medication carts observed. This had the potential to affect 48 (#1, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #29, #30, #31, #32, #37, #39, #40, #41, #42, #43, #44, #45, #47, #48, #49, #51, #52, #53, #54, #55, #56, #57, #61, #62, and #63) residents who resided on the 100 and 300 hallways. The facility census was 63. Findings include: 1. Observation on 08/09/23 at 8:03 A.M. revealed a medication cart on the 300 hallway was sitting in the hallway with a cup of liquid medication on top of the cart. The cart and medication were unattended by any staff members. The medication cart was observed to have Licensed Practical Nurse (LPN) #22's name badge sitting next to the cup of liquid medication on top of it. On 08/09/23 at 8:05 A.M., Registered Nurse (RN) #23 approached the medication cart and confirmed the presence of the full cup of liquid medication sitting on the medication cart. RN #23 confirmed staff should not leave any medications unattended, and removed the medication to dispose of it. 2. Observation on 08/09/23 at 8:37 A.M. revealed a medication cart on the 100 hallway sitting just outside room [ROOM NUMBER]. The medication cart was unlocked with no staff in the area. Observation on 08/09/23 at 8:45 A.M. revealed RN #21 was located on the unit. Interview with RN #21 at that time confirmed she left the medication cart unlocked and unsecured on the 100 hallway. RN #21 confirmed the medication cart should be locked at all times when not attended as to prevent unauthorized access. Review of the facility medication storage policy dated November 2018 revealed the medication supply is accessible only to licensed facility personnel and those lawfully authorized to administer medications, and medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. This deficiency represents non-compliance investigated under Complaint Number OH00144930.

Based on observation, medical record review, staff interview, and review of a policy, the facility failed to ensure fall interventions were in place as ordered and care planned. This affected one (#21) of three residents reviewed for falls. The facility census was 68. Findings include: Review of Resident #21's medical record revealed admission to the facility occurred on 12/24/18. Resident #21 had medical diagnoses including Alzheimer's disease, high blood pressure, and repeated falls. Review of Resident #21's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had severe impaired cognition, was independent with mobility in a wheelchair, and was a high risk for falling with recent falls identified. Review of Resident #21's medical record revealed a fall risk plan of care dated 01/04/19 with interventions including a sign on the bedside stand to remind to use the call light to get up, place a Dycem (non-slip pad) to the wheelchair and recliner, and a non-skid mat in front of the recliner. Review of Resident #21's physician orders also included the fall interventions that were listed in the plan of care. Observation of Resident #21's room on 08/09/23 at 9:48 A.M. with Registered Nurse (RN) #23 confirmed there was no Dycem in Resident #21's wheelchair or recliner, no non-skid mat in front of the recliner, and no sign posted on the bedside table. RN #23 confirmed Resident #21's physician orders and plan of care included the fall interventions that were not in place at the time of the observation. Observation of Resident #21's room with the Director of Nursing and RN #23 on 08/09/23 at 10:33 A.M. revealed RN #23 located the Dycem at the nursing station and placed it in Resident #21's wheelchair and recliner. The facility attempted to locate the non-skid mat that should be in front of Resident #21's recliner, and Resident #21 did not have any signs posted on the bedside stand. Review of the facility fall policy and procedure, dated 03/16/22, revealed care plan intervention should be implemented that address the resident risk factors. This deficiency represents non-compliance investigated under Complaint Number OH00144930.

Based on record review, staff interview and policy review, the facility failed to attempt non-pharmacological interventions prior to administering anti-anxiety medications. This affected one (Resident #70). The facility identified no residents taking as needed anti-anxiety medications at the time of the survey. The facility census was 55. Findings include: Review of Resident #70's medical record revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE] to another facility. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed the resident had a low cognitive function. The resident had behaviors of rejecting care and yelling, cussing and hitting staff. Review of the care plan revealed the resident had exit seeking behaviors. Interventions included re-directing away from exits as needed and to offer diversional activities. An attempt to complete non-pharmacological interventions should be done prior to administering as needed anxiolytics. Review of Resident #70's nursing notes revealed between her admission and 11/04/20 the resident exhibited many negative behaviors related to refusal for care, refusal to eat and paranoid features such as other residents were studying her. Review of the nursing note dated 10/09/20 revealed the nurse received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing notes revealed no documentation that non-pharmacological interventions were attempted prior to administering the medication. Interview with Corporate Registered Nurse #800 on 10/12/21 at 3:15 P.M. verified no non-pharmacological interventions were documented prior to staff administering the Lorazepam. Review of the facility policy titled Administration of PRN Medications Guidelines dated 05/22/18 revealed non-pharmacological interventions (i.e. activity, food, re-direction, emotional support, position and comfort or other interventions are defined on the individualized plan of care) shall be attempted and documented prior to administration of PRN medications. This deficiency substantiates Complaint Number OH 176.

Based on observations, resident and staff interviews and review of the facility policy, the facility failed to ensure residents were provided a homelike environment when the facility used overhead paging for non-related emergencies. This affected one (#23) resident interviewed for noise concerns. The total facility census was 52. Findings include: Observations of the 200 unit on 10/15/20 at 9:05 A.M., revealed a non-emergency overhead page was heard being made by Certified Resident Care Assistant (CRCA #15) at the nurse's station of the 200 unit. The page was transmitted loudly throughout the facility and entailed asking another staff person to come to the 200 unit. This page was repeated twice. Observations of the main office corridor on 10/15/20 at 11:51 P.M., revealed a non-emergency overhead page transmitted loudly throughout the facility. This page provided a brief interruption in the music that had been playing continually. The page entailed a female staff asking another staff to pick up a call on an extension number and was repeated twice. Interview with Social Worker (SW) #56 on 10/15/20 at 10:56 A.M., verified the facility had an overhead paging system. SW #56 stated it was not used often and indicated it was usually used in the event of a fire or emergency. Interview with Resident #23 on 10/15/20 at 11:50 A.M., revealed there was a lot of noise during the night regarding the overhead paging and at times would woke her up. Telephone interview with the Administrator on 10/15/20 at 4:47 P.M., revealed the overhead paging system was transmitted throughout the entire facility and audible from all hallways. She stated she was not aware of any residents who were woke from the noise level of the overhead paging. The Administrator revealed the overhead paging was not homelike for residents in the facility and was to be used for emergency's only. Telephone interview with Licensed Practical Nurse (LPN) on 10/19/20 at 6:25 A.M., stated she did not utilize the paging system for the 300 unit because it was for emergency use only. LPN #60 stated an example of emergency use of the overhead paging at the facility would be to call a code, or if there was a threat. LPN #60 said the overhead page should not be used by staff to contact one another. Review of facility undated policy titled, Guidelines for Overhead Paging, revealed staff will only use overhead paging in case of emergency, other staff to staff communication shall occur via dialing the phone extension or desk paging through the phone system, and staff will be advised of the guidelines for overhead paging and randomly throughout their employment, as the purpose stated in the policy was to provide residents with an environment that was not disruptive or distracting by overhead paging. This deficiency substantiated Master Complaint Number OH 055.

Based on record review, staff interview, and review of the Wanderguard manufacturers instructions and facility policy, the facility failed to ensure Wanderguard bracelets were applied properly and according to the manufacturer's instruction. This affected one (#14) of two residents reviewed for the placement of Wanderguards. The total facility census was 52. Findings Include: Review of Resident #14's record revealed the nurses progress notes dated 04/22/20 and 04/23/20, indicated the resident was not wearing the Wanderguard correctly and was able to remove it. The notes further documented on 05/28/20, the device was on a table in the resident's room and was not worn by the resident on multiple occasions. Review of Resident #14's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed the Wanderguard/Elopement alarm was marked as being used daily. Interview with Licensed Practical Nurse (LPN) #55 on 10/20/20 at 2:50 P.M., revealed she was unaware of any residents in the facility who could easily remove their Wanderguard bracelets by slipping them off. When asked if the bracelets on the device could be tightened, she revealed the facility had new bands that can be applied. Review of the Wanderguard Manufacturer's instructions revealed the bracelet needs to be worn securely in order to be effective and safe for the user. The instructions further revealed serious harm or death could occur if the device was not applied correctly and that no device was a substitution for proper nursing care. Review of the undated facility policy titled, Elopement Risk Assessment and Prevention, revealed the Wanderguard should be placed on the resident and individual resident alarms checked to ensure proper functioning. This deficiency substantiated Complaint Number OH 826.

Based on observation, staff interview, record review, review of the facility policy and the Centers for Disease Control (CDC) guidelines, the facility failed to ensure appropriate PPE was distributed to staff caring for residents on the quarantine unit. This deficient practice had the potential to affect 16 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16) of 16 residents residing on the 100 and 300 units. The facility census was 63. Findings include: Record review of Residents #10, #11, and #12, revealed droplet precaution orders were in place for all three residents. Observation on 09/14/20 at 6:40 A.M., identified three residents (#10, #11, #12) with droplet isolation in place. These resident rooms had signage posted at the room entry doors indicating droplet isolation and isolation PPE carts were in place outside each of the resident rooms. Housekeeper #100 was noted to be exiting Resident #12's room wearing a KN95 mask with ear loops, gown, goggles and gloves. Observation on 09/14/20 at 8:35 A.M., revealed Registered Nurse (RN) #201 had a KN95 mask with ear loops applied with a surgical mask covering, donned goggles, gown, and gloves and proceeded into Resident #10's room. Observation and interview on 09/14/20 at 7:30 A.M., with the Administrator and Acting Director of Nursing (ADON), revealed the facility was utilizing KN95 masks for all staff. New admissions were placed in droplet isolation for 14 days and staff were required to wear a KN95 mask with a surgical mask covering the KN95 mask, gown, goggles and gloves when entering the isolated resident rooms. The ADON confirmed Residents #10, #11, #12 were the only new admissions in droplet isolation. Observation inside the facility PPE storage room, revealed KN95 masks inside boxes with the writing non-medical KN95. Further interview at the time of observation, revealed the Administrator and ADON were unaware the KN95 mask were for non-medical use. The ADON stated the KN95 masks were distributed to all staff for use in the facility. On 09/14/20 at 7:50 A.M., interview with facility designated Infection Control Preventionist (ICP) #1, revealed she was unaware the KN95 masks were not approved for medical use and indicated they were being used by staff while providing care to residents in droplet isolation. ICP #1 stated the facility utilizes what the corporate office supplies them with for PPE. On 09/14/20 at 8:30 A.M., interview with Registered Nurse (RN) #201, revealed her assignment included the residents on the 100 unit (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12) with four additional residents residing on the 300 unit (#13, #14, #15, #16). RN #201 stated she provides care to the three current newly admitted residents in droplet isolation and the additional 13 residents on the two units. RN #201 was unaware if the KN95 masks being utilized were approved for medical use and indicated she wore what the facility provided. Review of the facility policies titled, Enhanced Infection Prevention and Control Program for COVID-19 and COVID-19 Supply Inventory Supply and Protocol, revealed the senior campus leadership will monitor/inventory all Personal Protective Equipment, including N95 masks. Review of the Centers for Disease Control and Prevention website (https://www.cdc.gov/niosh/npptl/usernotices/counterfeitResp.html) updated 08/25/20, revealed per CDC information and guidelines: Counterfeit respirators are products that are falsely marketed and sold as being NIOSH-approved and may not be capable of providing appropriate respiratory protection to workers. Signs that a respirator may be counterfeit: No markings at all on the filtering facepiece respirator No approval (TC) number on filtering facepiece respirator or headband No NIOSH markings NIOSH spelled incorrectly Presence of decorative fabric or other decorative add-ons (e.g., sequins) Claims for the of approval for children (NIOSH does not approve any type of respiratory protection for children) Filtering facepiece respirator has ear loops instead of headbands

Based on observation, medical record reviews and staff interviews, the facility failed to ensure a physician was notified when a residents pressure ulcer increased in size. This affected one one (#43) out of five residents reviewed for pressure ulcers. The facility identified a total of five residents with pressure ulcers. Facility census was 66. Findings include: Review of Resident #43's medical record identified admission to the facility occurred on 04/30/13 with medical [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #43 is alert, oriented and cognitively intact and high risk for pressure ulcer development. The record included a written plan of care, dated 05/21/19, for pressure ulcer interventions. The plan including the development of a pressure ulcer to the right hip and to notify the physician if treatments were not effective. Observation of Resident #43's right hip pressure ulcer was completed on 06/12/19 at 10:45 A.M. with Registered Nurse (RN) #103. The wound is observed as a stage II pressure ulcer and was measured by the wound nurse 1.8 centimeters (cm) by 1.8 cm by 0.1 cm. RN #103 confirmed she did notify the physician today and the treatment was changed. Review of Resident #43's progress notes dated 05/20/19 at 11:04 A.M. identified a pressure ulcer to the right hip was noted. The wound was measured to be a Stage II Pressure Ulcer: Partial-thickness skin loss with exposed dermis presenting as a shallow open ulcer. The measurements on 05/20/19 identified 0.3 cm by 0.5 cm by 0.1 cm at that time, with a new order for cleaning with house wound cleanser and apply house wound gel every other day. Review of the treatment administration record (TAR) confirmed the wound was treated as ordered. Wound notes dated 05/22/19, identified the right hip wound measured 1.0 cm by 0.8 cm by 0.1 cm and continued to be a stage II. The TAR confirmed no changes in treatments were completed. Wounds notes dated 05/29/19 identified the right hip measured 1.2 cm by 1.0 cm 0.1 cm and continued to be a stage II. The records identified no notification to the physician and or change in the treatment of [REDACTED]. Wound notes dated 06/05/19 identified the right hip wound measured 1.3 cm by 1.2 cm 0.1 cm and continued to be a stage II. The notes identified no notification to the physician and change in the treatment of [REDACTED]. Review of the TAR from 05/20/19 through 06/07/19 identified the facility was uses dermal cleanser and Gel solosite (house supplies) every other day during this time; however, there was no evidence of physician notification of decline in wound measurements and or changes made to the wound treatments. Interview with RN #103 on 06/11/19 at 1:21 P.M. The interview confirmed there was not evidence of physician notification and/or change in treatments to Resident #43' right hip from 05/20/19 through 06/08/19 even though the wound was deteriorating/increasing in size during that time.

Based on medical record reviews and staff interviews, the facility failed to ensure the ombudsman was notified when residents were discharged to the hospital. This affected three (#43, #46 and #68) out of three residents reviewed for hospitalization . Facility census was 66. Findings include: 1. Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The record identified Resident #43 required hospitalization s on 02/17/19 through 02/22/19; 02/27/19 through 03/03/19; 04/02/19 through 04/07/19. The record identified evidence the resident was provided with written evidence of notification of the reason for each of the transfers; however, there was no evidence of notification to the ombudsman. 2. Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The record identified Resident #46 went to the hospital on [DATE] through 03/25/19. The discharge summary dated 03/23/19 confirmed the family was notified; however, no information was provided to the ombudsman. 3. Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The record identified Resident #68 was transferred to the hospital on [DATE] and remained in the hospital until 03/24/19 when the resident passed away. The record review revealed the family received notification of the hospital; however, there was no notification to the ombudsman completed. Interview with the Director of Nursing (DON) occurred on 06/11/19 09:21 A.M. The interview confirmed the ombudsman notification was not completed for Resident #43, Resident #46 and Resident #68 all of whom went to the hospital.

Based on observation, medical record reviews and staff interviews, the facility failed to ensure a resident received a change in treatment and/or the physician was notified when a residents pressure ulcer increased in size. This affected one one (#43) out of five residents reviewed for pressure ulcers. The facility identified a total of five residents with pressure ulcers. Facility census was 66. Findings include: Review of Resident #43's medical record identified admission to the facility occurred on 04/30/13 with medical [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #43 is alert, oriented and cognitively intact and high risk for pressure ulcer development. The record included a written plan of care, dated 05/21/19, for pressure ulcer interventions. The plan including the development of a pressure ulcer to the right hip and to notify the physician if treatments were not effective. Observation of Resident #43's right hip pressure ulcer was completed on 06/12/19 at 10:45 A.M. with Registered Nurse (RN) #103. The wound is observed as a stage II pressure ulcer and was measured by the wound nurse 1.8 centimeters (cm) by 1.8 cm by 0.1 cm. RN #103 confirmed she did notify the physician today and the treatment was changed. Further review of Resident #43's progress notes dated 05/20/19 at 11:04 A.M. identified a pressure ulcer to the right hip was noted. The wound was measured to be a Stage II Pressure Ulcer: Partial-thickness skin loss with exposed dermis presenting as a shallow open ulcer. The measurements on 05/20/19 identified 0.3 cm by 0.5 cm by 0.1 cm at that time, with a new order for cleaning with house wound cleanser and apply house wound gel every other day. Review of the treatment administration record (TAR) confirmed the wound was treated as ordered. Wound notes dated 05/22/19, identified the right hip wound measured 1.0 cm by 0.8 cm by 0.1 cm and continued to be a stage II. The TAR confirmed no changes in treatments were completed. Wounds notes dated 05/29/19 identified the right hip measured 1.2 cm by 1.0 cm 0.1 cm and continued to be a stage II. The records identified no notification to the physician and or change in the treatment of [REDACTED]. Wound notes dated 06/05/19 identified the right hip wound measured 1.3 cm by 1.2 cm 0.1 cm and continued to be a stage II. The notes identified no notification to the physician and change in the treatment of [REDACTED]. Review of the TAR from 05/20/19 through 06/07/19 identified the facility was uses dermal cleanser and Gel solosite (house supplies) every other day during this time; however, there was no evidence of physician notification of decline in wound measurements and or changes made to the wound treatments. Interview with RN #103 on 06/11/19 at 1:21 P.M. The interview confirmed there was not evidence of physician notification and/or change in treatments to Resident #43' right hip from 05/20/19 through 06/08/19 even though the wound was deteriorating/increasing in size during that time.