Every finding on record at Windsor Medical Center Inc

Based on closed record review, facility policy review, and interview the facility failed to effectively and timely communicate and provide information as requested to State and local public health authorities to mitigate the potential spread of legionella. This had the potential to affect 3 of 3 residents residing in the facility. Findings include:Review of an undated facility policy titled Water Management Policy revealed when a suspected or confirmed outbreak occurred, the Water Management Team would initiate a thorough investigation to identify the source, assess the extent of exposure, and implement control measures. Information regarding the suspected or confirmed outbreak would be communicated as soon as possible directly to the resident(s) or their responsible parties by the Infection Preventionist or their designee. Staff would be notified and updated regarding suspected or conformed outbreaks through the Kronos System. The Water Management Team would immediately notify public health authorities regarding a confirmed outbreak. The policy did not include a plan for when a public health authority notified the facility of a possible healthcare exposure of Legionella, plan for timely, collaborative and ongoing communication between the facility and public health authorities or the timely development of a Legionella sampling plan based on local public health authority recommendations. Review of the closed medical record for Resident #20 revealed the resident was at a local hospital from [DATE] through 11/13/25, was first admitted to the certified nursing facility on 11/13/25 and discharged on 11/17/25 to a local hospital for a non-respiratory related injury. The resident did not reside at the facility at the time of the survey. Review of Resident #20's hospital lab results dated 11/21/25 revealed a legionella urine antigen test was completed (during the resident's hospitalization) and the result was positive.Further review of the resident's medical record revealed no additional information related to Resident #20's Legionnaires disease diagnosis.Review of a timeline provided by Environmental Specialist #200 (a representative for the State agency) revealed on 12/15/25, the Bureau of Infectious Disease (BID) notified the Bureau of Environmental Health and Radiation Protection (BEHRP) of a possible healthcare exposure of Legionella (associated with the positive test result for Resident #20). BEHRP contacted the local county health department notifying them of the exposure and requested materials from the facility.-On 12/16/25 the local health department contacted the facility and requested materials.-On 12/17/25 the facility provided their temperature log, the past routine Legionella sampling, and a water management plan. -On 12/19/25 the State agency requested the facility to collect a representative sample set of their water system for the investigation.-On 01/05/26 the facility stated they were in the process of collecting samples to send to a lab. The State agency requested the [water] sampling plan the facility was using.-On 01/21/26, the State agency called the facility and was able to make contact. The facility verbally stated they were working with maintenance to obtain the sample plan developed and supplies ordered.-On 01/26/26, the State agency tried calling the facility again. Their contact replied via email and stated the Administrator was supposed to be sending the sample plan.-On 01/29/26, the State agency requested an update from the facility on when the sample plan was to be expected. No response was received.-On 02/03/26, the State agency requested the facility Administrator's contact information to be contacted directly.-On 02/04/26, the State agency contacted the facility's Administrator regarding the sample plan. No response was received.-On 02/10/26, the State agency leadership emailed the Administrator regarding the sample plan. No response was received.An interview on 02/24/26 at 12:15 P.M. with Environmental Specialist (ES) #200 revealed the facility had a resident admitted to the facility from 11/13/25 through 11/17/25 who later became symptomatic and tested positive for Legionnaire's disease on 11/21/25 (during hospitalization). A limited investigation was opened on 12/15/25 to develop a sampling plan and obtain sampling from the facility to ensure their water sources did not contain the Legionella bacteria. ES #200 revealed the facility had not yet sent in a plan and had stopped communication. An interview on 02/26/26 at 9:00 A.M. with a Bureau of Infectious Disease (BID) representative, (BID #109) revealed Resident #20 was at a local hospital from [DATE] through 11/13/25, she was then admitted to the facility on [DATE] and hospitalized again on 11/17/25. Resident #20 became symptomatic (of Legionnaire's disease) on 11/20/25 while at a local hospital. On 11/21/25 testing completed at the hospital was positive for Legionnaires' disease (a urine antigen test) which noted the presence of legionella bacteria. BID #109 revealed any (resident) admission in a healthcare setting 14 days prior to the onset of symptoms was considered to be a potential source of contact. She verified the facility fell within this time period and the BEHRP was notified. A follow-up interview on 02/26/26 at 10:36 A.M. with Environmental Specialist #200 revealed for a limited investigation, the priority was for the facility to develop a sampling plan. She stated while they did not have a specific timeline by which the sampling plan must be submitted, [actual] sampling should not begin until after this has occurred. She stated for this reason, they recommend the facility provide the sampling plan in a timely manner (for example, within around 10 days of initial notification). Environmental Specialist #200 stated they would be looking for a response within days to a couple weeks, not months and that it was also important to note that this investigative sampling was in response to a [positive] case which was not the same as a facility's routine sampling, as it was aimed to be more comprehensive and representative of the water system.An interview on 02/26/26 at 10:45 A.M. with the facility Administrator verified he had not submitted a sampling plan to the State agency/public health authority. He reported he was unaware there was a timeline to submit the plan and verified the State agency did contact him in December 2025 asking him for a sampling plan due to Resident #20 having a potential exposure to Legionella while residing at the facility.An interview on 03/02/26 at 9:14 A.M. with Director of Environmental Health #300 from the local health department, revealed the facility stopped communicating with them regarding developing a Legionella sampling plan on 01/06/26. This deficiency represents noncompliance investigated under Complaint Number 2748589.

Based on record review, interview, and review of facility policies, the facility failed to provide written transfer and bed hold notices to Residents #1 and #114 at the time of transfer to the hospital. This affected two residents (#1 and #114) of two reviewed for hospitalization. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 04/03/25 with diagnosis including, sepsis, diabetes type 2, hypertension, UTI, pneumonia, kidney stones, low potassium, and anemia. Resident #1 was discharged to the hospital 05/03/25. Review of progress note dated 05/03/25 at 1:15 P.M. revealed abnormal lab results were reported to the Certified Nurse Practitioner (CNP) and the response was to send Resident #1 to the hospital for further evaluation. Review of the physician's orders for Resident #1 revealed an order to send the resident to the emergency room for evaluation and treatment (ordered 05/03/25 at 2:15 P.M.). Review of Resident #1's medical record revealed no evidence Resident #1 received written notice of details of the transfer or bed hold notice. On 5/06/25 at 09:47 A.M. an interview with Social Services Designee (SSD) #586, who is also the admission Coordinator, revealed she was unaware of what the facility process was for issuing transfer and bed hold notifications or if it was being done. The nurses do a transfer summary in point click care (PCC) that is sent as part of the hospital communication. On 05/06/25 at 03:31 P.M. an interview with the SSD #586 revealed that the facility policy was for the nurses to fill out a transfer to hospital form in the electronic medical record. Notifications of transfer were made over the phone, and the family/responsible party was asked if they want to hold the bed and charges to hold beds were given at that time. She confirmed nothing was given in writing at the time of Resident #1's transfer. Review of the facility policy titled Bed Holds and Returns, dated 05/03/24, revealed that for a transfer that facility would give the resident written notice explaining duration of bed hold, payment required and details of transfer. 2. Review of the medical record for Resident #114 revealed an admission date of 05/01/25 with diagnosis including, polyneuropathy, depression, anemia, elevated WBCs, hyperlipidemia, essential hypertension, muscle weakness. Review of a progress note dated 05/04/25 at 12:39 P.M. revealed chest x-ray results showed left lower lung infiltrates and the CNP was notified and new orders were received for Doxycycline and probiotic. Upon notification of new orders, the family requested the resident be transferred to the hospital. Review of the physician's orders for Resident #114 revealed an order dated 05/03/25 at 12:45 P.M. to send the resident to the emergency room for evaluation and treatment. Review of Resident #114's medical record revealed no evidence Resident #1 received written notice of details of the transfer or bed hold notice. On 5/06/25 at 09:47 A.M. an interview with SSD #586, revealed she was unaware of what the facility process was for issuing transfer and bed hold notifications or if it was being done. The nurses do a transfer summary in point click care (PCC) that is sent as part of the hospital communication. On 05/06/25 at 03:31 P.M. an interview with the SSD #586 revealed that the facility policy was for the nurses to fill out a transfer to hospital form in the electronic medical record. Notifications of transfer were made over the phone, and the family/responsible party was asked if they want to hold the bed and charges to hold beds were given at that time. She confirmed nothing was given in writing at the time of Resident #114's transfer. Review of the facility policy titled Bed Holds and Returns, dated 05/03/24, revealed for a transfer the facility would give the resident written notice explaining duration of bed hold, payment required and details of transfer.

Based on record review and interview, the facility failed to ensure resident assessments were completed accurately. This affected two (Residents #116 and #117) of 11 residents reviewed for accuracy of assessments. Findings include: 1. Review of the medical record for Resident #116 revealed an admission date of 03/10/25 with diagnoses including adult failure to thrive, congestive heart failure and hypertension. Resident #116 remained in the facility as of the survey on 05/08/25. Review of Resident #116's Minimum Data Set (MDS) 3.0 assessments the facility had completed revealed the facility had submitted a discharge return not anticipated assessment on 04/17/25. Interview on 05/08/25 at 2:18 P.M. with Registered Nurse (RN) #554 verified she had completed Resident #116's MDS assessment on 04/17/25 as discharge return not anticipated. She stated Resident #116's insurance had changed and she was paying privately for her room. She verified Resident #116 did not discharge from the facility or change beds to a licensed only bed. 2. Review of the medical record for Resident #117 revealed an admission date of 03/24/25 with diagnoses including hypertension and diabetes mellitus. Resident #117 remained in the facility as of the survey on 05/08/25. Review of Resident #117's MDS 3.0 assessments the facility had completed revealed the facility had submitted a discharge return not anticipated assessment on 04/12/25. Interview on 05/08/25 at 2:18 P.M. with RN #554 verified she had completed Resident #117's MDS assessment on 04/12/25 as discharge return not anticipated. She stated Resident #117's insurance had changed and she was paying privately for her room. She verified Resident #117 did not discharge from the facility or change beds to a licensed only bed.

Based on record review and interview, the facility failed to ensure medications were obtained timely from the pharmacy and were administered as ordered. This affected one (Resident #65) of eight residents reviewed for medications being administered as ordered. Findings include: Review of the medical record for Resident #65 revealed an admission date of 01/02/25 with diagnoses including congestive heart failure, chronic respiratory failure and glaucoma (eye condition with high pressure in the eye causing damage to the optic nerve). Review of the physician's orders for Resident #65 revealed she had an order for Latanoprost Ophthalmic Solution 0.005%, one drop in both eyes at bedtime for glaucoma, dated 01/04/25. Review of the Medication Administration Record (MAR) for Resident #65 revealed she did not receive her Latanoprost Ophthalmic Solution on 02/17/25, 03/18/25 and 04/25/25 as ordered. Review of the nursing progress notes for Resident #65 revealed on 02/17/25 at 7:41 P.M. Latanoprost Ophthalmic Solution was not available to administer. On 03/18/25 at 8:11 P.M. the nursing progress note stated the Latanoprost Ophthalmic Solution was not available and on order. On 04/25/25 at 7:56 P.M. it was noted the Latanoprost Ophthalmic Solution was unavailable and would be in the night's drop box from the pharmacy. Interview on 05/06/25 at 9:45 A.M. with Registered Nurse (RN) #506 verified Resident #65 did not receive her Latanoprost Ophthalmic Solution as ordered on the dates listed above due to the facility not having the medication. RN #506 stated most of the medications would come on a monthly cycle rotation, however, this medication did not arrive timely from the pharmacy. Review of the facility policy titled, Administering Medications, dated 04/17/24, revealed medications must be administered in accordance with the orders including any required time frame.

Based on record review, review of facility self-reported incidents, review of the facility policy and procedure related to Abuse and staff interview the facility failed to ensure allegations of staff to resident physical and verbal abuse that occurred on 02/22/23 were reported timely to ensure all facility residents were protected. This resulted in Immediate Jeopardy on 02/22/23 at approximately 1:30 A.M. when State tested Nursing Assistant (STNA) #374 witnessed STNA #370 potentially physically and verbally abuse Resident #26, a resident who resided in a facility licensed only bed but failed to immediately report the incident. On 02/22/23 at approximately 4:45 A.M. STNA #374 witnessed STNA #370 potentially verbally abuse a second resident, Resident #36, who also resided in a facility licensed only bed but failed to immediately report the incident. The lack of timely reporting placed all facility residents at risk for physical, verbal, emotional, psychosocial harm as STNA #370 continued to work additional shifts before the incidents were ultimately reported and the STNA was suspended on 02/24/23. This had the potential to affect all 18 residents (#2, #4, #5, #6, #9, #10, #11, #12, #15, #16, #17, ##19, #20, #30, #31, #33, #34 and #40) who resided in facility certified beds and for whom STNA #370 could have potential contact with as the building the facility was located in had certified and licensed only beds assigned to the same staff. The facility certified bed census was 18. On 03/01/23 at 5:25 P.M. the Administrator and Human Resources #429 were notified Immediate Jeopardy began on 02/22/23 at approximately 1:30 A.M. when STNA #374 witnessed an incident of potential staff to resident physical and verbal abuse and failed to immediately report the abuse to a supervisor. The Immediate Jeopardy continued 02/22/23 at approximately 4:45 A.M. when STNA #374 witnessed another potential incident of staff to resident verbal abuse and failed to immediately report the abuse to a supervisor resulting in the perpetrator, STNA #370 remaining on the schedule and working for additional shifts placing all residents at risk for situations of abuse by the STNA. The Immediate Jeopardy was removed on 03/03/23 when the facility implemented the following corrective action: On 02/24/23 and 10:41 P.M., the facility suspended STNA #370 upon report of the allegations of staff to resident verbal and physical abuse involving Resident #26 and Resident #36, residents who resided in licensed only beds in the same facility. Beginning on 02/24/23 and 10:41 P.M. and ending on 02/25/23 at 11:45 A.M. the Administrator began an investigation of the allegations of verbal and physical abuse when STNA #374 reported the abuse to Registered Nurse (RN) #395. RN #395, LPN #349, and the Director of Nursing (DON) took STNA #370 off the schedule and did skin sweeps to see to see if non-interviewable residents (#20 and #33) had any signs of abuse and interviewed (#2, #5, #6, #9, #11, #12, #15, #17, #30, #34, #40, and #42) who had a Brief Interview for Mental Status (BIMS) of eight or higher for any concerns related to abuse. No new evidence of abuse was identified. On 02/26/23 between 8:00 A.M. and 8:30 A.M. the DON notified facility Medical Director #430 of the staff to resident physical and verbal abuse On 03/01/23 and 5:39 P.M., the facility terminated STNA #370 upon determining there was potential that the allegations of verbal and physical abuse occurred to safeguard the residents affected as well as the other residents in the facility. On 03/01/23 and 5:45 P.M., the facility terminated STNA #374 and LPN #319 for failing to timely report the alleged staff to resident verbal and physical abuse to protect all residents in the facility. On 03/03/23 the Administrator began staff training for all staff related to Abuse, Neglect, and Misappropriation with additional information to highlight for all staff the reporting requirements which also addressed the failures to report that occurred and the repercussions thereof. A plan for any staff unable to attend the in-service revealed they would have to complete an online in-service prior to working their next shift. As of 03/06/23 four administrative staff, the DON, the Assistant Director of Nursing (ADON), five activities staff, four maintenance staff, four medical secretary/reception staff, Human Resources, 61 nursing staff, seven housekeeping staff, 30 dietary staff, and the beautician had completed the in-service. Beginning on 03/03/23 a plan for all new hires to receive education during orientation by Medical Secretary #301 and Human Resources Director #429, on Abuse, Neglect, and Misappropriation and annually thereafter during the facility wide Abuse, Neglect, and Misappropriation in-service. On 03/03/23 a plan for the Administrator, DON, and Director of Human Resources #429, or their designees to audit staff knowledge utilizing quizzes administered quarterly for one year then resume annual in-service training with quizzes and also quizzes during the annual competency training held in November was implemented. On 03/03/23 a plan for Human Resources #429 or designee to audit four staff members weekly times four weeks via a quiz regarding when to report allegations of abuse and who to report the allegations of abuse to. Human Resources continue random quizzes quarterly this year, and then the quizzes will be completed after annual abuse and competency training. The facility identified all grievances and concerns would be forwarded to the Quality Assurance and Performance Improvement (QAPI) committee for further review and recommendations. There was no change to the grievance systems or the QAPI review process during the review of these incidents of abuse. All staff were responsible to identify and report abuse in a timely manner. A concern would be put on a concern form. The residents get information on filing grievances upon admission and are invited to resident council. Family members are educated on how to file a grievance upon admission, and they are also invited to come to the resident council. These systems are being maintained and are in place. Interviews completed on 03/06/23 from 8:10 A.M. to 8:27 A.M. with Receptionist #31, RNs #373 and #394, STNAs #336, #345, and #378, Hospitality Aides #357 and #417, Housekeeping #313, and Environmental Services #418 revealed staff had been recently educated in person on 03/03/23 or had taken an online course prior to starting shift on abuse. All staff interviewed knew what abuse was, what to do when abuse occurs, and to report abuse immediately. Although the Immediate Jeopardy was removed on 03/03/23, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Review of the facility SRI, tracking number 232428 dated Saturday 02/25/23 and timed 9:03 A.M. revealed it was discovered on 02/24/23 STNA #374 had witnessed STNA #370 slap Resident #26 on Wednesday morning (02/22/23). The facility initiated an investigation of the incident at that time. Resident #26 was noted to reside in a facility bed that was licensed only. Review of the facility SRI, tracking number 232429 dated Saturday 02/25/23 and timed 9:15 A.M. revealed it was discovered on 02/24/23 STNA #374 had witnessed STNA #370 make disparaging comments about Resident #36 on Wednesday morning (02/22/23). The facility initiated an investigation of the incident at that time. Resident #36 was noted to reside in a facility bed that was licensed only. Review of schedule dated 02/21/23 to 02/23/23 revealed STNAs #370 and #374 were the two direct care staff scheduled from 10:00 P.M. to 6:00 A.M. to provide care to all 41 residents in the nursing facility, which included 18 residents who resided in certified nursing home beds. Interview with the Administrator on 03/01/23 at 11:11 A.M. confirmed STNA #374 did not report the observations of abuse timely, and STNA #370 remained on the schedule and provided care to nursing facility residents until she punched out in the morning on Friday 02/24/23. When the Administrator was notified of the alleged abuse on 02/24/23 at 10:41 P.M., STNA #370 was taken off the schedule until an investigation could be completed. The Administrator revealed facility staff were last in serviced on the facility abuse policy in June of 2022 and STNA #374 attended that in service. During the abuse in service, staff were educated that any observation of abuse should be reported immediately. The Administrator confirmed the notification from STNA #374 was not timely, and if the abuse had been reported timely by STNA #374, STNA #370 would have been taken off the schedule and not have worked two full shifts after the observation. Observation on 03/01/23 at 12:15 P.M. revealed the facility certified beds and licensure beds were intermingled throughout the facility and not divided into distinct parts. Interviews on 03/01/23 at 11:42 A.M. and 1:34 P.M. with STNA #374 revealed when there were two STNAs scheduled from 10:00 P.M. to 6:00 A.M. and they found it easier to tag team (care of residents), so both STNAs provided care to all facility residents, those 18 residents who resided in beds that were certified and the additional residents who resided in licensed only beds. The STNA revealed on 02/22/22 at approximately 1:30 A.M. STNA #374 witnessed STNA #370 say disparaging words and hit Resident #26. On 02/22/23 at approximately 4:45 A.M. STNA #374 witnessed STNA #370 say disparaging words to Resident #36 during care. STNA #374 stated she didn ' t say anything to anyone regarding what she witnessed that day because she had to take STNA #370 home from work, and she was afraid of what would happen to her. On the night of 02/22/23, STNA #374 stated she tried to tell LPN #319, who stated, Oh you know how [STNA #370] is. STNA #374 felt LPN #319 was not taking it seriously. On Thursday 02/23/23 STNA #374 stated she did not work. On Friday 02/24/23 STNA #374 reported the incident to RN #395 at the beginning of her shift when she got to work. STNA #374 confirmed the notification of the observed abuse was not immediate and any observation of abuse should be reported immediately. Review of the punch detail report for STNA #370 revealed STNA #370 punched in at 9:54 P.M. on Tuesday 02/21/23 and punched out at 6:04 A.M. on Wednesday 02/22/23, punched in at 9:54 P.M. on Wednesday 02/22/23 and punched out on Thursday 02/23/23 at 6:09 A.M., punched in at 9:53 P.M. on Thursday 02/23/23 at 9:53 P.M. and punched out on Friday 02/24/23 at 6:03 A.M. STNA #370 did not work since after she punched out on Friday 02/24/23 at 6:03 A.M. Review of facility policy titled Abuse/Neglect/Mistreatment/Misappropriation, revised 02/22/23, revealed all alleged incidents or suspicions involving abuse, neglect, mistreatment, or misappropriation of property would be immediately reported to the employee ' s immediate supervisor, Director of Nursing (DON) and/or the Administrator. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00140682 and Control Number OH00140677.

Based on observation and staff interview the facility failed to ensure an ice scoop was properly stored in a clean and sanitary manner to prevent contamination. This had the potential to affect 16 of 16 residents residing in the facility. Findings include: On 06/22/2 at 7:19 A.M. Stated tested Nursing Assistant (STNA) #800 was observed to retrieve an ice scoop from inside the ice machine. The ice scoop was observed directly on top of the ice. The STNA proceeded to fill a glass up with ice for a resident and then placed the ice scoop back into the ice machine directly on top of the ice without any type of protective barrier. On 06/22/22 at 7:19 A.M. interview with STNA #800 verified she had retrieved the ice scoop directly from inside the ice machine and after using it, she placed the scoop back in the machine. The STNA revealed she did not know what to do with the ice scoop because there was no where else to put it. Following the interview, the STNA obtained a paper towel, put the paper towel on the counter and placed the ice scoop on the paper towel. Review of the undated facility policy titled Cleaning Instructions: Ice Machine and Equipment, revealed the ice scoop was to be stored beside or on top of the machine in a clean non porous container that allowed the water to drain off and not pool around the scoop.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #5 and Resident #8, who required staff assistance with activity of daily living (ADL) care were provided timely and adequate nail care to maintain proper hygiene. This affected two residents (#5 and #8) of three residents reviewed for activities of daily living. Findings include: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/13/22 revealed Resident #5 had moderately impaired cognition. The assessment revealed the resident required limited assistance from one staff for personal hygiene. On 06/21/22 at 10:32 A.M., 06/22/22 at 7:44 A.M. and 06/23/22 at 8:50 A.M. Resident #5 was observed to have long dirty fingernails. On 06/22/22 at 1:20 P.M. interview with the Director of Nursing (DON) revealed nail care was to be completed by the staff with showers. On 06/23/22 at 8:50 A.M. interview with Licensed Practical Nurse (LPN) #803 verified the fingernails of Resident #5 were long and dirty Review of the facility policy titled Policy on Care of Resident fingernails/Toenails, dated 02/10/21 revealed State tested Nursing Assistants, Certified Nursing Assistants, and appropriately credentialed activity staff should provide care to the fingernails of residents to ensure they were maintained to clinical standards. Residents who were unable to care for their own fingernails would require assistance in keeping nails clean and trimmed. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment, dated 04/29/22 revealed Resident #8 had moderately impaired cognition. The assessment revealed the resident required extensive assistance from one staff for personal hygiene. On 06/21/22 at 10:21 A.M. and 06/23/22 at 8:40 A.M. Resident #8 was observed to have long dirty fingernails. On 06/22/22 at 1:20 P.M. interview with the DON revealed nail care was to be completed by staff with showers. On 06/23/22 at 8:40 A.M. interview with Resident #8 revealed his nails were long and needed trimmed but nobody had cut them for him. Review of the facility policy titled Policy on Care of Resident fingernails/Toenails, dated 02/10/21 revealed State tested Nursing Assistants, Certified Nursing Assistants, and appropriately credentialed activity staff should provide care to the fingernails of residents to ensure they were maintained to clinical standards. Residents who were unable to care for their own fingernails would require assistance in keeping nails clean and trimmed.

Based on record review, facility policy and procedure review and interview the facility failed to ensure a pressure ulcer for Resident #5 was properly assessed on admission, failed to ensure treatments were completed as ordered (between 04/07/22 to 05/09/22) and failed to ensure the ulcer was properly staged following debridement. This affected one resident (#5) of three residents reviewed for pressure ulcers. Finding include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued on 04/08/22. Review of the admission Braden (skin risk) scale, dated 04/07/22 revealed Resident #5 was at moderate risk for developing pressure injuries. Review of the admission assessment, dated 04/07/22 revealed Resident #5 had an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough (nonliving tissue) and or eschar (necrotic tissue) in the wound bed) pressure injury to her mid spine. However, there were no measurements of the area. Review of the skin assessment, dated 04/11/22 revealed Resident #5 had an unstageable pressure ulcer she had been admitted with which measured 4.5 centimeters (cm) in length by 2.5 cm in width by 0.0 in depth. The wound had 100 percent slough with a scant amount of serous drainage. The treatment was to cleanse the wound with wound cleanser and apply a bordered foam dressing daily. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/13/22 revealed Resident #5 had moderately impaired cognition. The assessment revealed the resident required limited assistance from one staff for personal hygiene and had an unstageable pressure injury she was admitted with. Review of the skin assessment dated [DATE] revealed Resident #5 had an unstageable pressure ulcer which measured 4.5 cm in length by 2.5 cm in width by 0.0 in depth. The wound had 100 percent slough The treatment was to cleanse the wound with wound cleanser and apply a bordered foam dressing daily. Review of the skin assessment dated [DATE] revealed Resident #5 had an unstageable pressure which measured 4.5 cm in length by 2.5 cm in width by 0.1 in depth. The wound had 100 slough with a scant amount of serosanguinous drainage. The treatment was to cleanse the wound with wound cleanser and apply a bordered foam dressing daily. Review of the April 2022 Treatment Administration Record (TAR) revealed there was no documentation a treatment had been completed to the mid-spine of Resident #5 from 04/07/22 to 04/30/22. Review of the skin assessment dated [DATE] revealed Resident #5 had an unstageable pressure which measured 2.0 cm in length by 1.0 cm in width by 0.2 in depth. The wound had 100 slough with a scant amount of serosanguinous drainage. The treatment was changed to cleanse with wound cleaner and apply Dermafilm daily and as needed. Review of the physician's orders revealed an order, dated 05/03/22 to cleanse the mid-spine wound with wound cleanser, apply Dermafilm everyday and as needed. Review of the May 2022 TAR revealed no documentation a treatment had been completed to the mid-spine of Resident #5 from 05/01/22 to 05/09/22. Review of the skin assessment dated [DATE] revealed Resident #5 had an unstageable pressure which measured 2.0 cm in length by 1.0 cm in width by 0.2 in depth. The wound had 100 slough with a scant amount of consanguineous drainage. The assessment revealed the treatment was changed to cleanse with wound cleaner and apply Dermafilm daily and as needed. There was no evidence of any skin assessment for Resident #5 from 05/10/22 through 05/24/22. Review of the skin assessment dated [DATE] revealed Resident #5 had an unstageable pressure which measured 2.7 cm in length by 2.0 cm in width by 0.2 in depth. The wound had 100 slough with a scant amount of serosanguinous drainage. The note indicated the treatment was changed to cleanse with wound cleaner and apply Dermafilm daily and as needed. An appointment was made with the wound clinic. The note also indicated the wound had gotten worse. Review of the wound clinic notes dated 05/26/22 revealed Resident #5 had a wound to her back. The wound was covered with soft yellow eschar (necrotic tissue) with no odor and the peri-wound was clean. The wound measured 1.5 cm in length by 1.6 cm in width by 0.8 cm depth. There was a large amount of serosanguinous drainage noted. There was no granulation in the wound bed. There was a large amount of necrotic tissue within the wound bed including slough. The wound was debrided and post wound measurements were 1.6 cm in length by 1.0 cm in width by 0.6 cm depth. The wound was now assessed to be a Stage III (full thickness skin loss which may extend into the subcutaneous tissue). Review of the physician's orders revealed Resident #5 had an order (dated 05/26/22) for a waffle mattress to the and bed and a waffle cushion to the wheelchair every shift for offloading. Review of the physician's orders revealed Resident #5 had an order, dated 05/27/22 to cleanse the thoracic spine with wound cleanser, apply Mesalt to the wound bed, cover with an abdominal pad and secure with medifix tape. Review of the skin assessment, dated 05/31/22 revealed Resident #5 had an unstageable pressure which measured 1.8 cm in length by 1.5 cm in width by 0.5 in depth. The wound was derided on 05/26/22 and the slough was no longer present. On 06/22/22 at 2:19 P.M. interview with the Director of Nursing (DON) revealed no assessments/measurements were completed on admission due to the facility wound nurse not assessing the area until the following week. The DON revealed she did not feel the nurses on the floor were qualified to stage/measure wounds. On 06/23/22 at 1:51 P.M. during a follow up interview, the DON revealed the facility policy indicated it was in the nurses scope of practice to measure a wound. She verified there were no measurements from admission to determine how large the spine wound for Resident #5 was on admission, there was no documentation of a treatment being done from 04/07/22 to 05/09/22, and no documentation of a skin assessment from 05/10/22 to 05/24/22. The DON also revealed there were no measurements of the area from the hospital when the resident had been admitted . On 06/23/22 at 2:39 P.M. interview with the DON verified the wound clinic documentation, dated 05/26/22 identified the area as a Stage III following the debridement of the wound on this date. However, the facility failed to include that information in their assessments or any subsequent assessments completed between 05/26/22 to present date. The DON revealed she had just been reviewing the measurements on the assessments and not the staging component. Review of the facility policy titled Wound Documentation, dated 03/31/22 revealed accurate documentation was an essential part of determining appropriate treatment and management of skin. It was within the scope of practice for registered nurses and licensed practical nurse to document wound measurements as applicable. The area wound be identified as pressure, surgical or other skin condition at the time of the initial findings with staging to be done as appropriate.

Based on observation, record review and interview the facility failed to ensure oxygen equipment for Resident #8 and #15 was dated as to when changed last and failed to properly store an oxygen nasal cannula when not in use in a clean and sanitary manner for Resident #15. This affected two residents (#8 and #15) of five residents observed with oxygen. Findings include: 1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the June 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/29/22 revealed Resident #8 had moderately impaired cognition, required extensive assistance from one staff for personal hygiene and had oxygen. On 06/21/22 at 10:21 A.M. observation of Resident #8's oxygen tubing and nasal cannula revealed they were undated as to when they had last been changed. On 06/21/22 at 10:22 A.M. interview with Licensed Practical Nurse (LPN) #804 revealed oxygen tubing and nasal cannulas were to be dated when they were changed. 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment, dated 06/06/22 revealed Resident #15 had moderately impaired cognation and was not on oxygen therapy. On 06/21/22 at 10:25 A.M. observation revealed Resident #15 had oxygen tubing laying directly on the top of an oxygen concentrator in the resident's room. The tubing was not in any type of protective barrier/bag (storage). In addition, there was also no date as to when it had been changed last. On 06/21/22 at 10:25 A.M. interview with LPN #804 revealed the oxygen tubing for Resident #15 should have been stored in a protective barrier and dated as to when it was last changed.

Based on record review and interview the facility failed to ensure staff screening for COVID-19 was completed and failed to design a monitoring system to audit the staff COVID self- assessment screenings to identify possible communicable diseases or infections including COVID-19 before they could spread to other persons in the facility. This had the potential to affect all 18 residents residing in the facility. Findings include: On 11/25/20 at 9:27 A.M. interview with the Director of Nursing (DON) and Infection Preventionist (IP) nurse revealed the facility had their first positive Covid-19 cases on 11/09/20, two staff members, Dietary Staff #1 and Activity Assistant #10. Review of the facility self-screening (for COVID-19) questionnaires from 11/05/20 to 11/08/20 revealed Dietary Staff #1 and Activity Assistant #10 did not self-screen prior to their shift on 11/08/20. On 11/25/20 at 10:30 A.M. interview with the Human Resource Director (HR) revealed Dietary Staff #1 and Activity Assistant #10 worked the day prior to testing positive for COVID-19. HR Director further revealed both employees tested positive on 11/09/20. Furthermore, Activity Assistant #10 was hired to screen all visitors coming to the facility. On 11/25/20 at 11:30 A.M. interview with the IP nurse revealed she could not locate any self-screening assessments for either Dietary Staff #1 or Activity Assistant #10. The IP nurse further revealed there was no auditing of the process to verify each staff member self-screened for COVID-19 upon entry to the facility. Furthermore, the IP nurse was not able to conclude whether the 18 new cases of resident positive cases for Covid-19 on 11/16/20 could be traced back to staff, due to the lack of staff self-screening. Review of Dietary Staff #1 and Activity Assistant #10's personnel files revealed both staff were PCR (protein chain reactive) tested on [DATE] and the results were positive. Review of the facility policy and procedure titled Covid-19 Staff Screening (created on 12/01/20 at the time of the survey) revealed all staff must self-screen by taking their own temperature and filling out their own questionnaire prior to their shift. The policy did not include a plan for how these self screening questionnaires would be monitored by the facility to timely identify staff symptomatic of COVID-19 to prevent the potential spread. This deficiency substantiates Complaint Number OH 496.

Based on observation, interview, record review, and policy review, the facility failed to ensure staff were adequately trained to identify type of precautions and appropriate use of personal protective equipment, to ensure a lunch meal was served with in an appropriate manner to a resident on contact precautions, and to update and implement COVID-19 policies. This had the potential to affect two residents (Residents #9 and #18) who were on contact precautions, one resident (Resident #18) who was provided the lunch meal on 10/05/20 in incorrect manner, and all residents residing in the facility. The facility census was 20. Findings include: Review of the record revealed Resident #18 was admitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the record for Resident #9 indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. 1. On 10/05/20 at 9:55 A.M., an interview with Environmental Services Staff (ESS) #100 revealed for cleaning resident rooms who were new admissions, she would wear a gown, gloves, mask, and goggles if needed. She indicated she was not sure but had a paper with personal protective equipment (PPE) needed for cleaning rooms of newly admitted residents. After finding the sheet on her cleaning cart, ESS #100 reported PPE to be used included gown, mask, goggles or face shield, and gloves. If goggles were not available in the isolation cart outside the resident's room she would ask the nurse for them. On 10/05/20 at 10:06 A.M., an interview with State tested Nursing Assistant (STNA) #105 indicated she had cared for newly admitted residents. PPE included gloves, mask, and a yellow disposable gown. Staff were allowed to wear cloth or surgical masks. In isolation rooms, surgical masks were worn. Staff did not have to wear any eye covering (gogglrs) or a face shield. She thought staff wore eye covering or a face shield in the isolation rooms. STNA #105 checked the isolation cart in front of Resident #18's room. She indicated there was no face shield or goggles available. On 10/05/20 from 12:04 P.M. to 12:18 P.M., an observation outside Resident #18's room was completed. The resident had an isolation cart in the hallway just outside his door and a yellow colored sign attached to the exterior surface of his door instructing to report to nurse before entering the resident's room. Licensed Practical Nurse (LPN) #109 prepared medications then took them into Resident #18's room. She donned a surgical face mask, disposable gown, and gloves prior to entering the resident's room. After she administered medications and provided the resident his meal, an interview was completed at 12:18 P.M. During the interview, LPN #109 was unable state what type of precautions Resident #18 was on. The nurse apologized several times, looked through her report sheets, then checked the electronic medical record. LPN #109 was still unable to state the type of precautions Resident #18 was on. She knew the resident was a new admission. During an interview on 10/05/20 at 5:02 P.M., Acting Director of Nursing (ADON) #112 confirmed both Residents #9 and #18 were on contact precautions due to being new admissions. Residents were maintained on isolation for 14 days following admission or return from a hospital stay. Review of the facility's Transmission Based Precautions (dated 07/01/17) indicated isolation signs with yellow colored backgrounds indicates contact precautions. 2. On 10/05/20 from 12:04 P.M. to 12:18 P.M., an observation outside Resident #18's room was completed. The resident had an isolation cart in the hallway just outside his door and a yellow colored sign attached to the exterior surface of his door instructing to report to nurse before entering the resident's room. LPN #109 was inside Resident #18's room when STNA #105 delivered the resident's meal tray. The STNA placed the meal tray on top of the isolation cart and informed the nurse that the tray was just outside the door. On the plastic meal tray was a palate to keep food warm and a palate cover. Everything else including utensils, cups, and dessert cup were disposable. At 12:12 P.M., LPN #109 took the entire tray into Resident #18's room including the plastic tray, the palate, and palate cover. During an interview on 10/05/20 at 12:38 P.M., the surveyor asked LPN #109 why she took the whole lunch tray into Resident #18's room. The nurse indicated she made a mistake. She agreed there was a disposable Styrofoam plate inside the palate/palate cover. Review of dietary department's COVID-19 Isolation Policy (dated 09/28/20) indicated all residents returning from a hospital stay or a new admission to the facility will be placed in 14 day isolation. All meals will be put on disposable products. 3. Observations on 10/05/20 between 8:24 A.M. and 8:54 A.M. and 9:35 A.M. to 9:55 A.M. revealed no staff were wearing face shields or goggles to provide eye protection. During an interview on 10/05/20 at 9:55 A.M., ESS #100 indicated if she needed a face shield or goggles she would asked the nurse. She approached ADON #112. The ADON indicted face shields and goggles were stored in a room down the hall. The lead charge nurse had a key to the storage room containing PPE. Additional observations on 10/05/20 between 11:38 A.M. and 12:38 P.M., revealed staff were not wearing eye protection. After repeated attempts to obtain additional COVID policies, the facility did not provide a policy regarding eye protection for the staff working directly with residents. During an interview on 10/05/20 at 5:26 P.M., ADON #112 confirmed(NAME)County was color coded orange in the Ohio Public Health Advisor System. Orange indicated an increased exposure and spread of COVID-19. During the exit conference on 10/05/20 at 6:20 P.M., the Administrator indicated staff caring for residents were not wearing eye protection due to the lack of availability of PPE. 4. On 10/05/20 at 6:00 P.M. after sharing with the Administrator that the facility's COVID testing policy was incomplete, he added information to the policy including monitoring of positivity rates and COVID testing for staff based on the county's positivity rates. Review of the COVID-19 Testing Policy (undated) indicated upon suspicion of a COVID-19 infection, the Director of Nursing shall obtain an order to test the individual in question. Residents shall be placed on transmission-based protocols while the test results are pending. The test shall be conducted as soon as is practicable. The test shall be conducted according to the instructions provided by the lab completing the test. Take appropriate action based on results. Included was a chart including testing triggers including symptomatic individual identified, outbreak, and routine testing for staff and residents. The policy included an asterisk on frequency and duration of outbreak testing. Nothing else was provided. The COVID-19 Testing Policy and other COVID-19 policies lacked facility protocols including if a resident refused COVID-19 testing and if a staff refused COVID-19 testing. The policy also lacked the facility's protocol on what to do if they were having difficulties meeting the 48-hour turn-around time for testing.

Based on medical record review, staff interview, review of the facility Managing Outbreaks/Clusters of Illness Among Residents for COVID-19 policy and review of Centers for Disease Control and Prevention (CDC) Preparing for COVID-19 in Nursing Homes and Long-Term Care Facilities Guidance, the facility failed to establish and implement a COVID-19 surveillance plan to include monitoring all residents for fevers. This affected two sampled residents (#3 and #4) and had the potential to affect 15 of 18 residents residing in the facility, with the exception of Resident #7, #9 and #12 who had evidence of daily temperature monitoring. The facility census was 18. Findings include: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further medical record review revealed Resident #3's temperature was obtained six times during the month of May 2020, on 05/01/20, 05/11/20, twice on 05/13/20, 05/19/20 and 05/21/20. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further medical record review revealed Resident #4's temperature was obtained only once during the month of May 2020, on 05/04/20. Interview on 05/28/20 at 10:27 A.M. with the Director of Nursing (DON) revealed the facility was licensed for 50 beds but only 20 of those beds were certified. The total certified census at the facility was 18 and the total licensed census at the facility was 40. The certified beds were all intermingled throughout the facility and care was provided by the same staff to all residents. During the interview the DON revealed only residents who received skilled services had their temperatures monitored daily. The DON reported only three residents, Resident #7, #9, and #12 received skilled services and had their temperatures monitored daily. The remaining residents were long term care and were assessed by the nurses three times daily. If there was a change in their condition or if they had any symptoms such as a cough, then their vital signs would be obtained. Otherwise, the facility did not routinely monitor the body temperature of asymptomatic residents. Review of facility Managing Outbreaks/Clusters of Illness Among Residents for COVID-19 policy, dated 05/11/20 revealed procedures for residents who developed respiratory symptoms and/or tested positive for COVID-19. However, the policy did not include monitoring guidelines for asymptomatic residents (including obtaining and assessing body temperature). Review of CDC Preparing for COVID-19 in Nursing Homes and Long-Term Care Facilities Guidance updated 05/19/20 revealed to actively monitor all residents upon admission and at least daily for fever. The CDC provided guidance that a temperature would be above 100 degrees Fahrenheit.

Based on interview, record review and policy review, the facility failed to ensure they did not employ staff who were convicted of disqualifying criminal offenses/Medicaid Fraud. This had the potential to affect all 41 residents currently residing in the facility. Findings include: Review of the Certified Nurse Aide (CNA) #500 (in house trained nurse aide, not a State tested Nurse Aide/STNA) employment application dated 01/03/18 revealed, on page one, a question, have you ever been convicted of any crime, CNA #500 answered Yes and noted, will explain during interview. On 01/12/18, CNA #500 was hired at the facility and submitted for fingerprinting and background checks. On 01/24/18 CNA #500's background check record returned positive with a 2014 criminal conviction to include felony Ohio Revised Code (ORC) 2913.40(1)(B)(1) listed on the Ohio Administrative Code (OAC) 3701-13-05 disqualifying offenses list as well as three other felony convictions not listed. Performance evaluations dated 04/30/18 and 01/16/19 demonstrated CNA #500 continued to work as a nurse aide, direct care staff at their sister Assisted Living Facility (ALF) which was attached to the Skilled Nursing Facility (SNF). There were no documented sanctions or conditions related to employment in light of the background check information in CNA #500's personnel file. Review of time clock/punch details from 10/01/19 to 01/07/20 revealed CNA #500 worked full time as a CNA/direct care staff at the ALF. Assignment sheets from the SNF revealed on 10/14/19, 10/15/19, 10/22/19, 10/27/19, 10/28/19, 10/29/19, 11/05/19, 11/19/19 and 12/13/19, CNA #500 worked as a habitation aide at the SNF. Interview on 01/22/20 at 11:11 [NAME]M. with Director of Human Resources (DHR) #200 verified, on 01/12/18, CNA #500 was hired to work at the attached ALF. DHR #200 stated CNA #500 submitted to fingerprinting and background checks and on 01/24/18, CNA #500's background check returned positive for 2014 criminal convictions with one charge being a disqualifying offense in the State Regulations (as noted in the first paragraph above). DHR #200 stated she reported the disqualifying offense to their Administrator who decided to continue CNA #500's employment until 01/06/20 when they placed CNA #500 on a do not use status due to ongoing health conditions. DHR #200 stated, from (MONTH) 2019 to (MONTH) 2020, CNA #500 worked as a habitation aide in the SNF passing water and and performing other duties that did not require an STN[NAME] DHR #200 stated they had abuse policies that prohibited hiring individuals with disqualifying offenses. Interview on 01/22/20 at 12:22 P.M. with the Administrator verified the above concern. Review of the facility undated, New Hire Screening and Training Policy, undated, revealed the applicant will submit to fingerprinting and criminal background check per facility policy and in compliance with Federal/ State regulations; the offer for employment remains contingent upon results received from the background checks. Review of the facility's abuse policy and procedure, dated 06/06/19, stated no individual who has been found guilty of abuse, neglect, mistreatment or misappropriation of property by court of law shall be employed by the facility. This deficiency substantiated Complaint Number OH 374.

Based on interview, record review and policy review, the facility failed to implement their policy and procedure prohibiting the employment of persons with disqualifying offenses listed in the State Regulations. This had the potential to affect all 41 residents currently residing in the facility. Findings include: Review of Certified Nurse Aide (CNA) #500's (in house trained nurse aide, not a State tested Nurse Aide/STNA) employment application dated 01/03/18 revealed, on page one, a question, have you ever been convicted of any crime, CNA #500 answered Yes and noted, will explain during interview. On 01/12/18, CNA #500 was hired at the facility and submitted for fingerprinting and background checks. On 01/24/18 CNA #500's background check record returned positive with a 2014 criminal conviction to include felony Ohio Revised Code (ORC) 2913.40(1)(B)(1) listed on the Ohio Administrative Code (OAC) 3701-13-05 disqualifying offenses list as well as three other felony convictions not listed. Performance evaluations dated 04/30/18 and 01/16/19 demonstrated CNA #500 continued to work as a nurse aide, direct care staff at their sister Assisted Living Facility (ALF) which was attached to the Skilled Nursing Facility (SNF). There were no documented sanctions or conditions related to employment in light of the background check information in CNA #500's personnel file. Review of time clock/ punch details from 10/01/19 to 01/07/20 revealed CNA #500 worked full time as a CNA/direct care staff at the ALF. Assignment sheets from the SNF revealed on 10/14/19, 10/15/19, 10/22/19, 10/27/19, 10/28/19, 10/29/19, 11/05/19, 11/19/19 and 12/13/19, CNA #500 worked as a habitation aide at the SNF. Interview on 01/22/20 at 11:11 [NAME]M. with Director of Human Resources (DHR) #200 verified, on 01/12/18, CNA #500 was hired to work at the attached ALF. DHR #200 stated CNA #500 submitted to fingerprinting and background checks and on 01/24/18, CNA #500's background check returned positive for 2014 criminal convictions with one charge being a disqualifying offense in the State Regulations (as noted in the first paragraph above). DHR #200 stated she reported the disqualifying offense to their Administrator who decided to continue CNA #500's employment until 01/06/20 when they placed CNA #500 on a do not use status due to ongoing health conditions. DHR #200 stated, from (MONTH) 2019 to (MONTH) 2020, CNA #500 worked as a habitation aide in the SNF passing water and and performing other duties that did not require an STN[NAME] DHR #200 stated they had abuse policies that prohibited hiring individuals with disqualifying offenses. Interview on 01/22/20 at 12:22 P.M. with the Administrator revealed on 01/24/18 when he received notification of the disqualifying offense he contacted their corporate office. It was decided since CNA #500 had no other disqualifying offenses and no exclusionary data was found for other web based reports that were checked, they could hire CNA #500 to work as an aide at the facility Review of facility New Hire Screening and Training Policy, undated, revealed a statement the applicant will submit to fingerprinting and criminal background check per facility policy and in compliance with Federal/ State regulations; the offer for employment remains contingent upon results received from the background checks. Review of the facility's abuse policy and procedure, dated 06/06/19, stated no individual who has been found guilty of abuse, neglect, mistreatment or misappropriation of property by court of law shall be employed by the facility. This deficiency substantiated Complaint Number OH 374.

Based on interview and record review, the facility failed to ensure a resident was not physically restrained in order to provide incontinence care. Actual Harm occurred when a State tested Nurse Aide (STNA) held Resident #13's arms down and against his chest in an attempt to change his incontinence brief. The resident sustained [REDACTED]. This affected one (Resident #13) of three residents reviewed for abuse. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was mobile in a wheelchair. Review of the nursing note dated 01/20/18 at 2:04 A.M. revealed the resident was combative and accused STNA #58 of stealing from him. Registered Nurse (RN) #66 removed the STNA from the resident's care. RN #66 went into the resident's room in an attempt to calm him down but was unsuccessful. She then asked STNAs #71 and #72 to put the resident in bed. Review of the incident note dated 01/21/18 revealed the STNA brought the resident out to the dining room and showed LPN #54 a dark purple bruise on his right wrist and two small areas to the chin. His skin was intact but the resident did have some pain when the wrist was touched. On 03/01/18 at 8:40 A.M., interview with the Director of Nursing (DON), and Assistant DONs #60 and #61 revealed Resident #13 was physically aggressive with staff and instead of leaving the resident alone, STNAs #71 and #72 held the resident down to provide incontinence care because they did not think he was able to refuse. On 03/01/18 from 11:25 A.M. unit 11:55 A.M., interview with Resident #13 revealed he was pleasant and calm. When the surveyor asked if anyone had hurt him, he said yes they grabbed his wrist, shoved his hands crossed by his chest, and held him down. He stated, He hurt me because he did not get his way trying to get me up. Then the resident raised both of his arms up as high above his head, started to get loud and said he was trying to show his power saying, I am the boss. He said he told many people but no one listened to him. On 03/01/18 at 3:24 P.M., phone interview with STNA #71 revealed RN #66 asked her to take over care for Resident #13 because he was very agitated and combative with STNA #58. STNA #71 stated she attempted to provide incontinence care but the resident was combative and she tried to hold his arms down so she could complete care but she was not able to. STNA #71 stated she asked STNA #72 to assist her in providing care. She stated she did not know the resident could refuse care but thought the resident needed to be changed every two hours no matter what. She verified the resident had not been physically aggressive before. On 03/01/18 at 3:39 P.M., phone interview with STNA #72 verified STNA #71 asked him to help provide incontinence care to Resident #13. He stated STNA #72 told the resident they were going to change his brief. STNA #72 held down the resident's arms crossed over his chest while STNA #71 changed his brief. STNA #72 stated, He was trying to hit us and we were just trying to do our job. He verified the resident had not been physically aggressive before. On 03/02/18 at 5:12 A.M., interview with STNA #57 verified she observed a large bruise on top of Resident #13's hand from his knuckles up a few inches past his wrist. She verified she had never seen the resident be physically aggressive. On 03/02/18 at 11:15 A.M., interview with STNA #53 revealed in the morning of 01/20/18 Resident #13 told her his wrist hurt because someone grabbed it and hurt it. She verified she had never seen the resident be physically aggressive. This deficiency substantiated Complaint Number OH 324.

Based on interview, review of the facility get up sheets and record review, the facility failed to ensure residents were afforded the opportunity to choose when they were gotten out of bed and dressed for breakfast. This affected four (Residents #20, #21, #31, and #13) of four residents reviewed for get up preferences. Findings include: Review of the night shift get up sheet listed room numbers on each of the three sections. Currently residing in three of those beds were Residents #20, #21 and #31. Review of the day shift get up sheet indicated Resident #13 was on the list. There were no time preferences when the residents wanted to get up. On 03/02/18 at 10:15 A.M., interview with Assistant Director of Nursing (ADON) #60 verified the facility did not have a system in place to ensure the residents were afforded the opportunity to choose the times they were able to get up for the morning. She verified the night shift was assigned certain room numbers and the residents who residing in those rooms were the ones they got up unless the resident and/or family requested different. She verified the residents were no periodically asked what there preferences were for get up times. She said the feed dining room started at 7:15 A.M. and those residents had to be up, dressed and in the dining room prior to the start of breakfast. The surveyor informed her of the observation of the residents up and sleeping in their wheelchair at 5:10 A.M. this morning including Residents #20 and #21. And further interviews with Resident's #20, #21, #13 and #31 who requested to sleep in later. 1. Review of Resident #13's admission assessment dated [DATE] revealed he wanted to get up at 7:30 A.M. Review of the plan of care revealed there was no evidence the facility asked the resident his get up preferences. On 03/01/18 at 11:25 A.M., interview with Resident #13 revealed he had asked many times to be able to sleep in but he was told he had to get up early to eat breakfast and could not sleep in. On 03/02/18 at 6:59 A.M., the resident was observed in bed with the lights out and his eyes closed. On 03/02/18 at 7:00 A.M., State tested Nurse Aide (STNA) #64 woke up the resident and said he had to get up for breakfast. On 03/02/18 at 7:50 A.M., interview with STNA #64 verified she had a list of rooms she had to get up, dressed and to the dining room for breakfast including Resident #13. She verified the resident was sleeping when she woke him up to get him out of bed. On 03/02/18 during breakfast observation the resident was brought to the dining room at 8:10 A.M. and kept closing his eyes. He was the last one to finish his breakfast about 30 minutes after the other residents because he keep falling asleep and was looking around like he was dazed or confused. After he finished he was asked if he wanted to go back to bed which he did and he was assisted back to bed. He did not eat very much of his breakfast. 2. Review of Resident #20's admission assessment dated [DATE] revealed the resident preferred to get up at 6:00 A.M. Review of the resident's medical record including the plan of care revealed there was no evidence the facility asked the resident her get up preferences. On 03/02/18 at 5:10 A.M. Resident #20 was observed in the common area in her wheelchair sleeping. On 03/02/18 at 5:20 A.M., interview with STNA #62 verified the resident had been up since about 4:30 A.M. She verified she had so many residents to get up by 6:00 A.M. she had to start early to get them all up and ready for breakfast. The resident was not interviewable. 3. Review of Resident #21's admission assessment dated [DATE] revealed the resident preferred to get up at 6:00 A.M. Review of the resident's medical record including the plan of care revealed there was no evidence the facility asked the resident her get up preferences. On 03/02/18 at 5:10 A.M. Resident #21 was observed in the common area in her wheelchair sleeping. On 03/02/18 at 5:20 A.M., interview with STNA #62 verified the resident had been up before 5:00 A.M. She verified they had a list of who they had to get up on night shift and it has to be done by 6:00 A.M. and it takes over an hour to get them all up so they had to start early. On 03/02/18 at 7:45 A.M., the resident was observed sitting at the dining room table and said to the nurse, Why do I have to get up so early and then sit here forever waiting on my breakfast? On 03/02/18 at 7:50 A.M., the surveyor approached the resident (who said she was blind) and asked if she requested to sleep if she was allowed and she said no they make her get up because she had to be out here for breakfast. Then she had to sit here and wait on her breakfast. Sometimes she would just like to sleep in. 4. Review of Resident #31's admission assessment dated [DATE] revealed the resident get up time preference was blank. Review of the resident's medical record including the plan of care revealed there was no evidence the facility asked the resident his get up preferences. On 03/02/18 at 7:45 A.M., during the breakfast meal, the surveyor heard Resident #31 telling another resident how he wished he could sleep in and not have to get up so early and sit at the table waiting on breakfast. On 03/02/18 at 8:00 A.M., interview with the resident verified they made him get up for breakfast even if he was sleeping and he would like to sleep in. This was an incidental finding discovered during the course of the complaint investigation.

Based on interview, review of a self reported incident (SRI) report and record review, the facility failed to ensure a resident's allegation of abuse was reported immediately. This affected one (Resident #13) of three residents reviewed for abuse. Findings include: Review of the self reported incident (SRI) report submitted to the state agency on 01/21/18 indicated on 01/21/18, Resident #13 alleged to Licensed Practical Nurse (LPN) #54 that physical abuse by a staff member had occurred on 01/20/18. Review of the statement from State tested Nurse Aide (STNA) #71 verified she held down the resident's hands in order to provide incontinence care. Review of the nursing note dated 01/20/18 at 2:04 A.M. revealed Resident #13 was combative and accused STNA #58 of stealing from him. Registered Nurse (RN) #66 removed the STNA from the resident's care. RN #66 went into the resident's room in an attempt to calm him down but was unsuccessful. She asked STNAs #71 and #72 to put the resident in bed. On 03/02/18 at 11:15 A.M., interview with STNA #53 revealed on the morning of 01/20/18 Resident #13 told her his wrist hurt because someone grabbed it and hurt it. She verified she did not tell anyone. STNA #53 verified that on 01/21/18 when she was putting on the resident's jacket, she noticed a large bruise on the top of his hand and up past the wrist and she then told LPN #54. This deficiency substantiated Complaint Number OH 324.

Based on observations, interviews and record review the facility failed to ensure Resident #29's Foley catheter (urine drainage system) bag was placed in a protective bag and off the floor to prevent possible contamination. This involved one of four residents reviewed with Foley catheters. Findings include: Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#29 had a Foley catheter with a drainage collection bag. Staff were to provide catheter care every shift, keep the urine drainage bag below bladder level and staff were to assess for signs and symptoms of urinary tract infections. Observations of the Foley bag on 05/22/17 at 7:31 A.M. with Licensed Practical Nurse (LPN) #10 revealed Resident #29 was lying in his bed. His Foley drainage bag was partially filled with urine. The Foley bag was lying directly on the floor under the bed. LPN #6 verified the Foley catheter bag was lying directly on the floor and the protective bag was attached to the wheelchair. Contact with the floor surface could be a source of bacteria and could contribute to the development of infections. Review of the Resident Care Policy and Procedure for Foley catheter drainage (no date) revealed staff were to place the drainage bag in the protective pouch bag. Staff were to attach the Foley catheter bag to the bed frame using the Velcro closures, secure the drainage tubing to the residents thigh using a leg strap and were to keep the Foley catheter drainage bag off of the floor. Interview with the Director of Nursing and the Assistant Director of Nursing on 05/22/17 at 5:17 P.M. revealed staff were to keep the Foley catheter bag in the protective bag on the wheelchair for dignity. When the resident is in his/her room, the Foley catheter bag is to be placed on the bed frame and should not be placed directly on the floor.