Laurels of Huber Heights The

Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure staff implemented enhanced barrier precautions when changing wounds that require dressings. This affected one (#26) of three residents reviewed for wound care. The facility census was 88.

Findings include:

Review of the medical record for Resident #26 revealed an admission on 06/18/24 with diagnoses including cerebral infarction (stroke), heart failure, end stage renal disease, type two diabetes and severe vascular dementia.

Review of the quarterly Minimum Data Set (MDS) assessment dated 12/17/24 for Resident #26 revealed a severely impaired cognition. Resident #26 requires extensive assistance for activities of daily living.

Review of the plan of care for Resident #26 dated 04/02/24 revealed resident has venous stasis skin impairment to left calk related to peripheral vascular disease (PVD). Interventions include skin injury will decrease in size, enhanced barrier precautions, observe and report signs and symptoms of infection, and evaluate wound for size, depth, and margins.

Review of the active physician orders for Resident #26 reveal an order dated 03/15/25 to cleanse area to right frontal lateral leg, pat dry and apply adaptic (petroleum gauze), cover with abdominal dressing (ABD) and wrap with kerlix daily and as needed, an or dated 03/19/25 to cleanse laceration wound to right mid anterior shin and right mid lateral skin with normal saline, pat dry, apply xeroform to eschar, cover with ABD, wrap with Kerlix and secure with ace bandage daily, an order dated 03/29/25 to cleanse skin tear to left buttock with normal saline, apply xeroform to wound bed, cover with silicone dressing every day, and cleanse wound to left medial calf (hematoma) with normal saline, pat dry and apply xeroform, cover with ABD, wrap with kerlix daily and as needed.

Observation on 04/08/25 at 8:00 A.M. of signage for Resident #26 to the right of the entrance and above her name revealed the resident was on enhanced barrier precaution. The sign stated everyone must clean their hands before entering and when leaving the room. Additionally, the sign stated that providers and staff must also wear gloves, and a gown for the following high contact resident care activities including dressing, bathing, showering, transferring, changing linen, providing briefs or assisting with toileting, device care for central line, urinary catheter, feeding tube and tracheostomy and wound care for any skin opening requiring a dressing

Observation on 04/08/25 at 8:10 A.M. revealed Licensed Practical Nurse (LPN) #5 and Certified Nurse Assistant (CNA) #84 enter Resident #26's room and donned gloves. LPN #5 advised Resident #26 that they were going to remove old dressing and measure the areas. LPN #5 removed the dressing to Resident #26's bilateral legs leaving dressing in place on the lower extremities. Wound Physician #101 donned gloves and entered room and addressed the resident, advising her he was there to measure the wounds. Wound Physician #101 measured each of the three wounds using separate disposable wound measuring devices. LPN #5 changed gloves completed hand hygiene and donned new gloves and applied dressing to left lower hematoma, leaving the right wound uncovered as the physician discontinued treatment and advised they were resolved. CNA #84 assisted Resident #26 to roll onto her right side for the physician to measure the wound to her left buttocks. Treatment to area was discontinued and physician documented area was resolved.

Interview on 04/08/25 at 8:25 A.M. with LPN #5, CNA #84, Wound Physician #101 all verified they did not don gowns prior to entering the room for Resident #26 and should have. LPN #5, CNA #84 and Wound Physician #101 confirmed Resident #26 was to be in enhanced barrier precautions.

Interview on 04/08/25 at 8:30 A.M. with the Director of Nursing (DON) verified the facility did not have a three chest drawer in the hallway to store personal protective equipment for use with Resident #26 and would get one in place outside of the door for Resident #26. The DON confirmed Resident #26 was to be in enhanced barrier precautions.

Review of the facility policy titled Infection Preventions Program Overview dated 02/28/25 stated the facility established a program (infection prevention and control program) that is based on the facility assessment and follows accepted national standards.

This deficiency represents non-compliance investigated under Complaint Number OH00162510.

Based on medical record review, staff interview, resident interview, and review of the facility policy, the facility to honor resident smoking rights. This affected one (Resident #3) of one resident reviewed for smoking. The facility identified 10 residents who smoked independently. The facility census was 85 residents.

Findings include:

Review of the medical record for Resident #3 revealed an admission date of 12/30/21 with diagnoses including cerebrovascular accident, coronary artery disease, viral hepatitis, dementia, seizure disorder, and diabetes.

Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 10/13/24 revealed the resident was severely cognitively impaired and required supervision/touching assistance for eating, and substantial/maximum assistance for toileting, bed mobility, and transfers.

Review of care plan for Resident #3 dated 10/30/24 revealed the resident wished to use smoking materials and was assessed as unsafe to smoke. The resident would go out to the smoking area and look for cigarette butts to smoke or ask other residents that smoked for cigarettes. Interventions included the following: staff members to distribute smoking materials to residents who smoke at the designated times, staff to supervise and maintain safety during smoking, staff members to maintain all smoking paraphernalia for unsafe and safe smokers such as cigarettes and lighters.

Review of smoking assessment for Resident #3 dated 11/01/24 revealed the resident was an unsafe smoker because he couldn't safely light the smoking materials, couldn't hold the materials safely, couldn't dispose of ashes in the ashtray safely, couldn't extinguish cigarette safely, and couldn't follow the policy. The summary of the assessment revealed Resident #3 was an unsafe smoker and he would be a supervised smoker.

Interview on 01/29/25 at 8:30 A.M with the Director of Nursing (DON) confirmed if a resident was admitted into the facility and could smoke independently the resident could smoke outside whenever they wished. If a resident was assessed as an unsafe smoker, the resident was not permitted to smoke on the facility grounds. The DON further confirmed the facility did not offer supervised smoking.

Interview on 01/29/25 at 10:20 A.M. with Resident #3 confirmed the resident was able to answer questions appropriately. Resident #3 confirmed he had been a smoker for quite some time and the facility would not allow him to smoke and he didn't know why.

Review of the facility policy titled Smoking Policy dated 10/17/23 revealed if the interdisciplinary team (IDT) determined that a resident was an unsafe smoker, the resident was required to wear a protective smoking vest/apron and should be supervised while smoking. The degree of supervision was determined by the team and was based on the smoking evaluation, the physical attributes of the smoking area, and other relevant factors. Staff members would maintain all smoking paraphernalia for all unsafe and safe smokers, e.g., cigarettes, cigars, pipes, lighter fluid, or any other matter or substance that contained a tobacco product. Staff members would distribute smoking materials to residents that were unsafe to smoke at the designated smoking times.

Review of the facility policy titled Resident Rights dated 05/14/24 revealed the facility must promote the exercise of rights for each resident, including any who face barriers such as communication problems, hearing problems and cognition limits in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability.

Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to follow and implement the abuse policy regarding allegations of abuse by failing to report abuse to the state agency in a timely manner, failing to provide abuse education as detailed in the SRI, failing to protect residents during an abuse investigation by suspending accused staff, and failing to complete a timely and thorough abuse investigation. This affected two (Residents #87 and #61) of three residents reviewed for abuse. The facility census was 85 residents.

Findings include:

1.Review of the medical record for Resident #87 revealed an admission date of 11/15/24 with diagnoses including quadriplegia, thrombocytopenia, obesity, and neuromuscular dysfunction of bladder and a discharge date of 01/04/25.

Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/22/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living. (ADLs.)

Review of the progress note for Resident #87 dated 01/08/25 timed at 5:08 P.M. revealed the Administrator and Director of Nursing (DON) spoke with the resident after receiving a complaint from the insurance company on 01/03/25. Resident #87 had concerns regarding staff being lax with care, the call light not being answered immediately, staff raising their voices at him, and overall poor care. The Administrator and DON interviewed Resident #87 in his room regarding the concerns. Resident #87 reported an incident with the wound nurse, Registered Nurse (RN) #131, in which the resident characterized the nurse as physically aggressive with him and physically abusive in her language. Resident #87 further stated he did not like the way RN #131 made him feel.

Review of the SRI for Resident #87 dated 01/08/25 revealed the hospital reported Resident #87's father alleged neglect against the facility. The Administrator and DON had met with Resident #87 on 01/04/25 due to a complaint filed by the resident's insurance company but the resident had not alleged neglect during that conversation. Resident #87 was at the hospital at the time when the hospital reported the alleged neglect and did not return to the facility. The facility investigated the allegation of neglect reported by the hospital but were unable to substantiate abuse. Further review of the SRI revealed as a result of the investigation the facility educated the staff on abuse and neglect prevention and reporting. Further review of the SRI revealed there was no documentation of education completed with the staff on abuse and neglect prevention.

Further review of the SRIs revealed there was no SRI initiated for the complaint received from the insurance company regarding Resident #87.

Interview on 01/29/25 at 11:04 A.M. with RN #131 confirmed she was not aware of the complaints against her from Resident #87. RN #131 reported she was never notified of the situation and was not asked to complete a statement. RN #131 also verified she was never suspended pending an investigation.

Interview on 01/29/25 at 1:51 P.M. with the Administrator confirmed the facility did not have documentation of staff education on abuse and neglect prevention which was to be completed as a result of the investigation of the SRI dated 01/08/25.

Interview on 01/29/25 at 2:23 P.M. with the Administrator confirmed the facility did not complete an SRI or an investigation of the insurance company's concerns regarding Resident #87 made on 01/03/25 because he did not feel there was enough information provided by the resident that identified as abuse. The Administrator confirmed the facility did not obtain a written statement from RN #131 nor was the nurse suspended related to the allegations from Resident #87.

2. Review of the medical record for Resident #61 revealed an admission date of 09/06/24 with diagnoses including occlusion and stenosis of right carotid artery and diabetes.

Review of the MDS assessment for Resident #61 dated 12/14/24 revealed the resident was moderately cognitively impaired and required assistance with ADLs.

Review of the facility SRI dated 01/23/25 revealed a hospital social worked called the facility Social Worker (SW) #87 on 01/15/25 and reported that former Resident #65, Resident #61's former roommate, had made allegations at the hospital that a facility nurse had threatened to withhold Resident #61's medications. The facility did not initiate an investigation of the allegation until 01/23/25 and did not interview the alleged victim, Resident #61, until 01/24/25.

Interview on 01/28/25 at 11:41 A.M with SW #87 confirmed the hospital social worker called her on the phone on 01/15/25 and reported former Resident #65 had alleged that one of the night nurses at the facility had threatened to withhold medications from Resident #61. SW #87 confirmed she did not ask the hospital social worker any further questions and she did not make a notation of the phone call in Resident #61's record. SW #87 confirmed she reported the phone call she received from the hospital social worker to the Administrator on 01/16/25.

Interview on 01/28/25 at 11:53 A.M. with the Administrator confirmed SW #87 notified him on 01/16/25 of the call she received from the hospital social worker on 01/15/25 regarding Resident #65's allegation that a facility night nurse threatened to withhold medication from Resident #61. The Administrator confirmed he did not initiate the SRI regarding the allegation until 01/23/25.

Review of the facility policy titled Abuse Prohibition Policy dated 10/14/22 revealed each resident should be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. All facility staff and volunteers should be in-serviced upon first employment and at least annually thereafter regarding guest/resident's right; including freedom from abuse, neglect, mistreatment, exploitation, and misappropriation of property. It was the responsibility of all staff to provide a safe environment for the guests/residents. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies, physician, families, and/or representative. If the accused was an employee of the facility, he/she would be suspended until the investigation had been completed.

This deficiency represents noncompliance investigated under Complaint Number OH00161688.

Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to report allegations of abuse to the state agency in a timely manner. This affected two (Residents #87 and #61) of three residents reviewed for abuse. The facility census was 85 residents.

Findings include:

1.Review of the medical record for Resident #87 revealed an admission date of 11/15/24 with diagnoses including quadriplegia, thrombocytopenia, obesity, and neuromuscular dysfunction of bladder and a discharge date of 01/04/25.

Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/22/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living. (ADLs.)

Review of the progress note for Resident #87 dated 01/08/25 timed at 5:08 P.M. revealed the Administrator and Director of Nursing (DON) spoke with the resident after receiving a complaint from the insurance company on 01/03/25. Resident #87 had concerns regarding staff being lax with care, the call light not being answered immediately, staff raising their voices at him, and overall poor care. The Administrator and DON interviewed Resident #87 in his room regarding the concerns. Resident #87 reported an incident with the wound nurse, Registered Nurse (RN) #131, in which the resident characterized the nurse as physically aggressive with him and physically abusive in her language. Resident #87 further stated he did not like the way RN #131 made him feel.

Review of the SRI for Resident #87 dated 01/08/25 revealed the hospital reported Resident #87's father alleged neglect against the facility. The Administrator and DON had met with Resident #87 on 01/04/25 due to a complaint filed by the resident's insurance company but the resident had not alleged neglect during that conversation. Resident #87 was at the hospital at the time when the hospital reported the alleged neglect and did not return to the facility. The facility investigated the allegation of neglect reported by the hospital but were unable to substantiate abuse. Further review of the SRI revealed as a result of the investigation the facility educated the staff on abuse and neglect prevention and reporting.

Further review of the SRIs revealed there was no SRI initiated regarding the complaint received from the insurance company regarding Resident #87.

Interview on 01/29/25 at 11:04 A.M. with RN #131 confirmed she was not aware of the complaints against her from Resident #87. RN #131 reported she was never notified of the situation and was not asked to complete a statement. RN #131 also verified she was never suspended pending an investigation.

Interview on 01/29/25 at 2:23 P.M. with the Administrator confirmed the facility did not complete an SRI or an investigation of the insurance company's concerns regarding Resident #87 made on 01/03/25 because he did not feel there was enough information provided by the resident that identified as abuse. The Administrator confirmed the facility did not obtain a written statement from RN #131 nor was the nurse suspended related to the allegations from Resident #87.

2. Review of the medical record for Resident #61 revealed an admission date of 09/06/24 with diagnoses including occlusion and stenosis of right carotid artery and diabetes.

Review of the MDS assessment for Resident #61 dated 12/14/24 revealed the resident was moderately cognitively impaired and required assistance with ADLs.

Review of the facility SRI dated 01/23/25 revealed a hospital social worked called the facility Social Worker (SW) #87 on 01/15/25 and reported that former Resident #65, Resident #61's former roommate, had made allegations at the hospital that a facility nurse had threatened to withhold Resident #61's medications. The facility did not initiate an investigation of the allegation until 01/23/25 and did not interview the alleged victim, Resident #61, until 01/24/25.

Interview on 01/28/25 at 11:41 A.M with SW #87 confirmed the hospital social worker called her on the phone on 01/15/25 and reported former Resident #65 had alleged that one of the night nurses at the facility had threatened to withhold medications from Resident #61. SW #87 confirmed she did not ask the hospital social worker any further questions and she did not make a notation of the phone call in Resident #61's record. SW #87 confirmed she reported the phone call she received from the hospital social worker to the Administrator on 01/16/25.

Interview on 01/28/25 at 11:53 A.M. with the Administrator confirmed SW #87 notified him on 01/16/25 of the call she received from the hospital social worker on 01/15/25 regarding Resident #65's allegation that a facility night nurse threatened to withhold medication from Resident #61. The Administrator confirmed he did not initiate the SRI regarding the allegation until 01/23/25

Review of the facility policy titled Abuse Prohibition Policy dated 10/14/22 revealed each resident should be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. All facility staff and volunteers should be in-serviced upon first employment and at least annually thereafter regarding guest/resident's right; including freedom from abuse, neglect, mistreatment, exploitation, and misappropriation of property. It was the responsibility of all staff to provide a safe environment for the guests/residents. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies, physician, families, and/or representative. If the accused was an employee of the facility, he/she would be suspended until the investigation had been completed.

This deficiency represents noncompliance investigated under Complaint Number OH00161688.

Based on medical record review, review of facility Self-Reported incidents (SRIs), staff interview, and review of the facility policy, the facility failed to complete timely and thorough investigations and failed to protect residents during an abuse investigation by suspending accused staff. This affected two (Residents #87 and #61) of three residents reviewed for abuse. The facility census was 85 residents.

Findings include:

1.Review of the medical record for Resident #87 revealed an admission date of 11/15/24 with diagnoses including quadriplegia, thrombocytopenia, obesity, and neuromuscular dysfunction of bladder and a discharge date of 01/04/25.

Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/22/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living. (ADLs.)

Review of the progress note for Resident #87 dated 01/08/25 timed at 5:08 P.M. revealed the Administrator and Director of Nursing (DON) spoke with the resident after receiving a complaint from the insurance company on 01/03/25. Resident #87 had concerns regarding staff being lax with care, the call light not being answered immediately, staff raising their voices at him, and overall poor care. The Administrator and DON interviewed Resident #87 in his room regarding the concerns. Resident #87 reported an incident with the wound nurse, Registered Nurse (RN) #131, in which the resident characterized the nurse as physically aggressive with him and physically abusive in her language. Resident #87 further stated he did not like the way RN #131 made him feel.

Review of the SRI for Resident #87 dated 01/08/25 revealed the hospital reported Resident #87's father alleged neglect against the facility. The Administrator and DON had met with Resident #87 on 01/04/25 due to a complaint filed by the resident's insurance company but the resident had not alleged neglect during that conversation. Resident #87 was at the hospital at the time when the hospital reported the alleged neglect and did not return to the facility. The facility investigated the allegation of neglect reported by the hospital but were unable to substantiate abuse. Further review of the SRI revealed as a result of the investigation the facility educated the staff on abuse and neglect prevention and reporting. Further review of the SRI revealed there was no documentation of education completed with staff on abuse and neglect prevention.

Further review of the SRIs revealed there was no SRI initiated regarding the complaint received from the insurance company regarding Resident #87.

Interview on 01/29/25 at 11:04 A.M. with RN #131 confirmed she was not aware of the complaints against her from Resident #87. RN #131 reported she was never notified of the situation and was not asked to complete a statement. RN #131 also verified she was never suspended pending an investigation.

Interview on 01/29/25 at 1:51 P.M. with the Administrator confirmed the facility did not have documentation of staff education on abuse and neglect prevention which was to be completed as a result of the investigation of the SRI dated 01/08/25.

Interview on 01/29/25 at 2:23 P.M. with the Administrator confirmed the facility did not complete an SRI or an investigation of the insurance company's concerns regarding Resident #87 made on 01/03/25 because he did not feel there was enough information provided by the resident that identified as abuse. The Administrator confirmed the facility did not obtain a written statement from RN #131 nor was the nurse suspended related to the allegations from Resident #87.

2. Review of the medical record for Resident #61 revealed an admission date of 09/06/24 with diagnoses including occlusion and stenosis of right carotid artery and diabetes.

Review of the MDS assessment for Resident #61 dated 12/14/24 revealed the resident was moderately cognitively impaired and required assistance with ADLs.

Review of the facility SRI dated 01/23/25 revealed a hospital social worked called the facility Social Worker (SW) #87 on 01/15/25 and reported that former Resident #65, Resident #61's former roommate, had made allegations at the hospital that a facility nurse had threatened to withhold Resident #61's medications. The facility did not initiate an investigation of the allegation until 01/23/25 and did not interview the alleged victim, Resident #61, until 01/24/25.

Interview on 01/28/25 at 11:41 A.M with SW #87 confirmed the hospital social worker called her on the phone on 01/15/25 and reported former Resident #65 had alleged that one of the night nurses at the facility had threatened to withhold medications from Resident #61. SW #87 confirmed she did not ask the hospital social worker any further questions and she did not make a notation of the phone call in Resident #61's record. SW #87 confirmed she reported the phone call she received from the hospital social worker to the Administrator on 01/16/25.

Interview on 01/28/25 at 11:53 A.M. with the Administrator confirmed SW #87 notified him on 01/16/25 of the call she received from the hospital social worker on 01/15/25 regarding Resident #65's allegation that a facility night nurse threatened to withhold medication from Resident #61. The Administrator confirmed he did not initiate the SRI regarding the allegation until 01/23/25

Review of the facility policy titled Abuse Prohibition Policy dated 10/14/22 revealed each resident should be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. All facility staff and volunteers should be in-serviced upon first employment and at least annually thereafter regarding guest/resident's right; including freedom from abuse, neglect, mistreatment, exploitation, and misappropriation of property. It was the responsibility of all staff to provide a safe environment for the guests/residents. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies, physician, families, and/or representative. If the accused was an employee of the facility, he/she would be suspended until the investigation had been completed.

This deficiency represents noncompliance investigated under Complaint Number OH00161688.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to provide the appropriate level of supervision to prevent accidents involving residents while smoking cigarettes. This affected one (Resident #3) of one resident reviewed for smoking practices. The facility identified 10 residents in the facility who smoked independently. The facility census was 85 residents.

Findings included:

Review of the medical record for Resident #3 revealed an admission date of 12/30/21 with diagnoses including cerebrovascular accident, coronary artery disease, viral hepatitis, dementia, seizure disorder, and diabetes.

Review of the annual Minimum Data Set (MDS) assessment for Resident #3 dated 10/13/24 revealed the resident was severely cognitively impaired and required supervision/touching assistance for eating and substantial/maximal assistance for toileting, bed mobility, and transfers.

Review of care plan for Resident #3 dated 10/30/24 revealed the resident wished to use smoking materials and was assessed as unsafe to smoke. The resident would go out to the smoking area and look for cigarette butts to smoke or ask other residents that smoke for cigarettes. Interventions included the following: staff members to distribute smoking materials to residents who smoke at the designated times, staff to supervise and maintain safety of residents during smoking, staff members to maintain all smoking paraphernalia for unsafe and safe smokers such as cigarettes and lighters.

Review of the smoking assessment for Resident #3 dated 11/01/24 revealed the resident was an unsafe smoker because he couldn't safely light the smoking materials, couldn't hold the materials safely, couldn't dispose of ashes in the ashtray safely, couldn't extinguish cigarettes safely, and couldn't follow the policy. The summary of the assessment revealed Resident #3 was an unsafe smoker and he should be supervised while smoking.

Review of the progress note for Resident #3 dated 12/21/24 revealed the resident was sitting outside of the nursing station and Registered Nurse (RN) #113 noticed a smoke smell and saw Resident #3 with smoke coming from his left pant leg with an ember lit area. Staff put out the embers with water and assisted Resident #3 with changing his clothes. The nurse completed a skin check following the incident of unsupervised smoking and noted a small, reddened area to the top of resident's left thigh.

Interview on 01/28/25 at 3:30 P.M. with the Administrator confirmed Resident #3 was an unsafe smoker and had poor safety awareness. The Administrator confirmed the resident should be monitored for safety while smoking to ensure the safety of the resident and the other residents in the facility.

Interview on 01/28/25 at 3:43 P.M. with RN #113 confirmed on 12/21/24 Resident #3 was sitting by the nursing station and the nurse smelled smoke and saw Resident #3 had smoke coming from his paint leg with a lit ember. Staff threw water on the resident and the ember was extinguished. RN #113 did a skin assessment on the Resident #3 and discovered a small, reddened area to the top of the resident's left upper thigh. RN #113 confirmed Resident #3 wasn't supposed to go out to smoke, but he had a behavior of going outside and getting cigarette butts left by other resident smokers. RN #113 believed Resident #3 had gotten a lit cigarette butt which caused the injury to his upper thigh.

Review of the facility policy titled Smoking Policy dated 10/17/23 revealed if the interdisciplinary team (IDT) determined that the resident was an unsafe smoker, the resident was required to wear a protective smoking vest/apron and was to be supervised while smoking. The degree of supervision was determined by the team and was based on the smoking evaluation, the physical attributes of the smoking area, and other relevant factors. Staff members would maintain all smoking paraphernalia for all unsafe and safe smokers, e.g., cigarettes, cigars, pipes, lighter fluid, or any other matter or substance that contains a tobacco product. Staff members would distribute smoking materials to residents that were unsafe to smoke at the designated smoking times.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), and staff interview, the facility failed to ensure the medical record was complete and included pertinent resident information. This affected one (Resident #61) of three reviewed for medical records. The facility census was 85 residents.

Findings include:

Review of the medical record for Resident #61 revealed an admission date of 09/06/24 with diagnoses including occlusion and stenosis of right carotid artery and diabetes.

Review of the Minimum Data Set (MDS) assessment for Resident #61 dated 12/14/24 revealed the resident was moderately cognitively impaired and required assistance with activities of daily living (ADLs.)

Review of the progress notes for Resident #61 dated 01/15/25 revealed there was no documentation of a phone call from the hospital social worker to the facility social worker regarding concerns of possible resident mistreatment.

Review of the facility SRI dated 01/23/25 revealed a hospital social worker called the facility Social Worker (SW) #87 on 01/15/25 and reported that former Resident #65, Resident #61's former roommate, had made allegations at the hospital that a facility nurse had threatened to withhold Resident #61's medications.

Interview on 01/28/25 at 11:41 A.M with SW #87 confirmed the hospital social worker called her on the phone on 01/15/25 and reported former Resident #65 had alleged that one of the night nurses at the facility had threatened to withhold medications from Resident #61. SW #87 confirmed she did not ask the hospital social worker any further questions and she did not make a notation of the phone call in Resident #61's record.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff maintained appropriate enhanced barrier precautions (EBP) during wound care and incontinence care and failed to ensure staff practiced appropriate hand hygiene during incontinence care. This affected one (Resident #23) of three residents reviewed for incontinence care and wound care. The facility census was 85 residents.

Findings include:

Review of the medical record for Resident #23 revealed an admission date of 01/04/25 with diagnoses including fracture of superior rim of left pubis, heart failure, and atrial fibrillation.

Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 01/11/25 revealed the resident had intact cognition and required partial assistance with eating and transfers, substantial assistance with toileting and bathing, and was dependent with dressing.

Review of the progress note for Resident #23 dated 01/06/25 timed at 4:10 P.M. revealed the resident had an unstageable pressure ulcer to the buttock which measured 10.5 centimeters (cm) in length by 12.2 centimeters in width.

Review of the physician's orders for Resident #23 dated January 2025 revealed the resident did not have orders for enhanced barrier precautions (EBP).

Observation on 01/29/25 at 8:56 A.M. of wound care for Resident #23 per Registered Nurse (RN) #131 with the assistance of Certified Nursing Assistant (CNA) #96 revealed the nurse and aide did not don gowns prior to providing wound care.

Observation on 01/29/25 at 9:09 A.M. of incontinence care for Resident #23 per CNA #96 revealed the aide did not don a gown during care. Prior to care, CNA #96 completed hand hygiene and applied gloves. CNA #96 did not change gloves during care or after completing incontinence care. CNA #96 used soiled gloves to touch bed controls, the call light, and the bedside table after care was completed.

Interview on 01/29/25 at 9:21 A.M. with CNA #96 confirmed she did not wear a gown when performing incontinence care or when assisting the nurse with wound care for Resident #23. CNA #96 confirmed she did not remove soiled gloves before touching the resident's bed controls, the call light, and the bedside table.

Interview on 01/29/25 at 9:24 A.M. with RN #131 confirmed she did not wear a gown when completing wound care for Resident #23. RN #131 further confirmed she thought Resident #23 should be in EBP due to the unstageable wound and wearing a gown was required for provision of direct care for residents in EBP.

Review of the facility policy titled Enhanced Barrier Precautions (EBP) dated 04/01/24 revealed EBP were indicated for residents with any of the following: infection of colonization with a Centers for Disease Control (CDC)-targeted multidrug resistant organism (MDRO), when contact precautions did not otherwise apply, resident had a wound or indwelling medical device, even if the resident was not known to be infected or colonized with a MDRO. The EBP for a resident with a wound or indwelling medical device should remain in place for the duration of a resident's stay or until resolution of the wound or discontinuation of the indwelling medical device. Chronic wounds generally included for EBP chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Staff should post signage for EBP precautions on the door or wall outside of the resident's room indicating type of precautions and the required personal protective equipment (PPE.). Health care personnel caring for residents on EBP should wear gloves and gowns during high-contact resident care including dressing, bathing, transferring, hygiene, changing linens, changing briefs, or wound care.

Review of the facility policy titled Hand Hygiene dated 10/11/23 revealed hand washing was generally considered the most important single procedure for preventing healthcare-associated infections. Hand hygiene should be performed before and after contact with the resident, after contact with blood, body fluids, visibly contaminated surfaces or other objects in the resident's room, after removing personal protective equipment, and direct resident contact.

Based on record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure staff timely answered a resident's call light. This affected one (#9) of six residents reviewed for call lights. The census was 83.

Findings include:

Review Resident #9's medical record revealed an admission date of 08/14/24. Diagnoses listed included type two diabetes mellitus, hypertension, major depressive disorder, and acute kidney failure.

Review of a quarterly Minimum Data Set (MDS) assessment dated 11/11/24 revealed Resident #9 had moderate cognitive impairment, was frequently incontinent of bowel, and had a indwelling urinary catheter.

Observation on 12/23/24 at 10:04 A.M. revealed the call light was on for Resident #9's room. The light above the door was illuminated and an audible beeping could be heard. At 10:12 A.M. Licensed Practical Nurse (LPN) #160 could be seen sitting at the nurse's station at the end of the hall. Resident #9's room call light remained on. At 10:25 A.M. LPN #160 walked by Resident #9's room and LPN #160 did not address the call light. At 10:26 A.M. the Administrator and entered Resident #9's room to answer the call light.

During an interview on 12/23/24 at 10:29 A.M. interview with the Administrator revealed Resident #9 had his call light on to ask to had incontinence brief changed. The Administrator confirmed a call light should be answered timely. The Administrator confirmed confirmed 22 minutes was not considered timely. The Administrator confirmed any staff member can address a resident call light. The Administrator confirmed LPN #160 should have addressed Resident #9's call light.

Interview with Resident #9 on 12/23/24 at 12/23/24 at 10:33 A.M. revealed he had his call light on due to concerns with his urinary catheter leaking. Resident #9 stated it takes awhile to have call lights answered.

Review of the facility policy titled Call Lights dated effective 04/01/22 revealed call lights should be answered in a timely manner.

This deficiency represents non-compliance investigated under Complaint Number OH00160868.

Based on record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure a resident's call light was kept within reach. The affected one (#7) of six residents reviewed for call lights. The census was 83.

Findings include:

Review of Resident #7's medical record revealed an admission date of 08/04/23. Diagnoses listed included type two diabetes mellitus, vascular dementia, and glaucoma.

Review of a significant change Minimum Data Set (MDS) assessment dated 10/18/24 revealed Resident #7 was cognitively intake.

Observation on 12/23/24 at 8:40 A.M. revealed Licensed Practical Nurse (LPN) #170 asked Resident #7 to put on her call light so an aide could assist her with getting out of bed. Resident #7 could not find her call light. Resident #7 stated she could not find her call light all night. LPN #170 looked for Resident #7's call light and found it behind a dresser drawer cabinet located to the left and behind Resident #7's bed. LPN #170 had to move the dresser drawer cabinet to get Resident #7's call light.

During an interview during the observation on 12/23/24 at 8:40 A.M. LPN #170 stated that stuff like this happens a lot. LPN #170 confirmed she was referring to call lights being found not within a residents' reach. LPN #170 confirmed Resident #7's call light was not within her reach.

Review of the facility policy titled Call Lights dated effective 04/01/22 revealed call lights should be within a resident's reach.

This deficiency represents non-compliance investigated under Complaint Number OH00160868.

Based on observation, staff interview, and review of facility resident census, the facility failed to ensure water temperatures were comfortable for residents. This had the potential to affect 42 (#5, #6, #7, #9, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, and #97) residents residing on the 300 and 400 halls. The census was 83.

Findings include:

Observation of the shower room located in the 400 hall with Maintenance Director (MD) #100 on 12/23/24 at 2:48 P.M. revealed hot water temperatures in shower stalls did not reach 105 degrees Fahrenheit (F). Water temperatures in each of two shower stalls reached a maximum temperature of 90 degrees F. MD #100 confirmed hot water temperatures only reached 90 degrees F. MD #100 denied any recent hot water concerns.

Review of water temperature logs revealed hot water temperatures below 105 degrees F had been documented consistently since 10/25/24 on the 400 hall. Issues with 400 hall hot water and working with a local plumbing company to solve the issue was noted. Water temperatures of 89 degrees F were documented on 12/17/24, 90 degrees F on 12/16/24, and 88 degrees F on 12/10/24 on the 400 hall.

During an interview on 12/30/24 at 10:00 A.M. the Administrator and MD #100 confirmed the 400 hall had been having hot water concerns. A local plumbing company had been contracted to fix the problem. The Administrator and MD #100 confirmed that temperatures below 105 degrees F had been documented for the 400 since October 2024. MD #100 shower room 400 hall did not reach 105 degrees F on 12/23/24. MD #100 reported he had recently adjusted a water temperature mixing valve to help correct the problem. The Administrator confirmed residents that resided in the 300 and 400 halls would take showers in the 400 hall shower room.

Review of facility census revealed 42 (#5, #6, #7, #9, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, and #97) residents resided on the 300 and 400 halls.

This deficiency represents non-compliance investigated under Complaint Number OH00160422 and Complaint Number OH00160868.