Brewster Convalescent Center

Based on record review and interview, the facility failed to ensure Residents #24 and #42's medical records have the appropriate documentation of the education provided regarding the risks and benefits of the influenza and pneumococcal vaccines. This affected two (Residents #24 and #42) of five residents reviewed for immunizations.
Findings include:
1. Review of Resident #24's Consent/Declination of Pneumococcal, Influenza, and COVID-19 Vaccines form dated 11/14/23 revealed the resident did not wish to receive the pneumococcal vaccine, the influenza vaccine or the COVID-19 vaccine and/or booster.
Review of Resident #24's medical record revealed the resident refused the pneumovax and the influenza immunization. The medical record did not reveal evidence the resident was educated on the risks and benefits of the pneumovax and influenza immunizations.
Interview on 12/27/24 at 9:09 A.M. with Registered Nurse (RN) #538 confirmed Resident #42's medical record did not have evidence the education was provided regarding the risks and benefits of the influenza and pneumococcal vaccines.
2. Review of Resident #42's Consent/Declination of Pneumococcal, Influenza, and COVID-19 Vaccines form dated 10/05/21 revealed the resident did not wish to receive the pneumococcal vaccine the influenza vaccine or the COVID-19 vaccine and/or booster.
Review of Resident #42's medical record revealed the resident refused the influenza and pneumovax vaccine. The medical record did not reveal evidence the resident was educated on the risks and benefits of the influenza and pneumovax vaccines.
Interview on 12/27/24 at 9:09 A.M. with Registered Nurse (RN) #538 confirmed Resident #42's medical record did not have evidence the education was provided regarding the risks and benefits of the influenza and pneumococcal vaccines.
Review of the Resident Influenza Immunization policy dated 11/05/18 revealed before offering the influenza immunization, each resident, or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunization. The resident's medical record includes documentation that indicates, at a minimum, that the resident or resident's legal representative was provided education regarding the benefits and potential side effects of the influenza immunization.
Review of the Pneumococcal of Residents Vaccine policy reviewed 01/01/17 revealed to provide the resident or responsible party with literature on the Pneumococcal vaccine (from the Centers for Disease Control or CDC).

Based on record review, staff interview, review of facility policy, and observation, the facility failed to update the physician on a change of condition for Resident #38. This affected one (Resident #38) of one resident reviewed for changes in conditions. The facility census was 55.
Findings include:
Review of the medical record for Resident #38 revealed an admission date of 03/22/23 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease and emphysema (a condition of the lungs that causes shortness of breath).
Review of the care plan dated 04/03/23 for Resident #38 revealed she was at risk for altered respiratory status and difficulty breathing related to anxiety, chronic obstructive pulmonary disease, congestive heart failure and chronic respiratory failure. Interventions included to monitor for signs and symptoms of respiratory distress and report to the physician increased respirations, decreased pulse oximetry, restlessness, lethargy and confusion.
Review of the physician's order for Resident #38 revealed an order for oxygen at two liters via nasal cannula continuously dated 07/15/24.
Review of the treatment administration record for December 2024 for Resident #38 revealed nursing staff had been administering oxygen at two liters continuously and documenting her oxygen saturation at morning and bedtime.
Review of the nursing progress notes for Resident #38 from 12/24/24 through 12/27/24, revealed on 12/24/24 at 4:56 A.M. Resident #38 appeared slightly lethargic when the nurse woke her for her morning medications. Resident #38 stated she was tired and oxygen saturation was checked which revealed it was 90-92 percent (%) on two liters nasal cannula. The nursing progress note dated 12/24/24 at 5:21 A.M. revealed oxygen had been increased to four liters nasal cannula. There was no indication the physician was updated related to increased need for oxygen.
Observation with Registered Nurse (RN) #551 on 12/26/24 at 3:27 P.M. revealed Resident #38's oxygen concentrator was set to four liters. She verified Resident's #38's physician's orders were for two liters of oxygen continuously. RN #551 verified there was no written or verbal order for four liters of oxygen.
Interview on 12/26/24 at 3:53 P.M. with the Director of Nursing (DON) verified the physician was not updated on Resident #38's change of condition of lethargy, decreased oxygen saturation and need for increased oxygen.
Review of the facility policy titled, Use of Oxygen, dated 05/01/16, revealed oxygen therapy must be prescribed by the resident's physician. The physician was responsible for identifying the type of therapy and the rate of oxygen based on oxygen saturation and respiratory assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure interventions were implemented and monitored for Resident #33's trending weight loss. This finding affected one (Resident #33) of two residents reviewed for nutrition.
Findings include:
Review of Resident #33's medical record revealed the resident was readmitted on [DATE] with diagnoses including anxiety disorder, dementia in other diseases classified elsewhere and essential hypertension.
Review of Resident #33's initial weight dated 07/29/24 revealed the resident weighed 187.2 pounds. Resident #33's weights revealed the resident weighed 196.6 pounds on 08/20/24, 183.9 pounds on 11/07/24 and 179.2 pounds on 12/04/24.
Review of Resident #33's physician orders revealed an order dated 08/16/24 revealed a reduced carbohydrate diet, no added sodium with a regular texture, regular/thin consistency. There were no physician orders for nutritional supplements including the boost brought in by the resident's family members.
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 exhibited severe cognitive impairment.
Review of the quarterly Medical Nutrition Therapy form dated 11/05/24 revealed Resident #33 was on a reduced carbohydrate controlled diet with no added sodium, regular texture with thin liquids. The form indicated the resident received metformin as ordered and the oral intakes were greater than fifty-one percent at most per meals. The residents feeds himself after setup assistance. The weight was 183.9 pounds and has had a 3.3 pound weight loss since his initial admission weight of 187.2 pounds. No edema was noted.
Review of Resident #33's nurse aide tracking from 11/28/24 to 12/26/24 revealed documentation the resident was offered the boost for weight loss on 11/29/24, 12/07/24, 12/08/24, 12/21/24, 12/22/24, and 12/25/24. The resident refused the boost supplement on 12/16/24, 12/18/24, 12/20/24 and 12/25/24. All other dates were blank or documented as not applicable.
Review of Resident #33's medical record did not reveal evidence the resident's physician was notified of the resident's trending weight loss.
Interview on 12/27/24 at 8:39 A.M. with Registered Dietitian (RD) #600 stated Resident #33's family brought in boost nutritional supplement from home for the resident's decreasing weight loss. RD #600 stated the resident's family supplied the boost and the facility offered and monitored the resident's boost intake. RD #600 confirmed Resident #33's medical record did not have specific orders for the implementation of the boost supplement for weight loss to determine how often or how much the resident should receive the boost supplement.
Interview on 12/27/24 at 9:02 A.M. with the Director of Nursing (DON) confirmed Resident #33's medical record did not have evidence the resident's boost was offered for a specific duration and stated the facility offered the boost when the resident requested the boost supplement. The DON confirmed the medical record did not have specific orders for the resident's boost as an intervention for the resident's trending weight loss.
An additional interview on 12/27/24 at 2:58 P.M. with RD #600 revealed it was her understanding if Resident #33 consumed less than 50% of the meal offered, staff would grab a magic shake or boost and nurses would administer. She stated that was the facility policy and she confirmed the boost supplement was not a documented intervention for the resident's trending weight loss including physician notification and specific orders to implement the boost supplement.
Review of the Significant Weight Loss policy dated 01/01/17 revealed the facility has the goal of medical nutrition therapy (MNT) to stabilize the weight, identify underlying causes or factors contributing to the significant unplanned weight loss, and intervene as appropriate to resolve the problem.

Based on interview, medical record review, and facility policy review, the facility failed to ensure pre-treatment and post-treatment monitoring was completed for a dialysis resident. This affected one (Resident #24) of two residents reviewed for dialysis. The facility census was 55.
Findings include:
Review of the medical record for Resident #24 revealed an admission date of 11/13/23 and diagnoses including type two diabetes mellitus, diabetic chronic kidney disease, diabetic polyneuropathy, dependence on renal dialysis, acquired absence of left leg below knee, and stage four chronic kidney disease.
Review of physician's order dated 09/26/24 revealed Resident #24 received dialysis treatments on Tuesdays, Thursdays, and Saturdays. Resident #24 has right sided tunneled internal jugular catheter dialysis site.
The medical record revealed no evidence of monitoring of Resident #24's condition prior to or following dialysis treatments.
Interview on 12/27/24 at 11:07 A.M. with Licensed Practical Nurse (LPN) #542 revealed Resident #24's blood pressure and weight were obtained at dialysis.
Interview on 12/27/24 at 12:02 P.M. with Director of Nursing (DON) confirmed they do not assess Resident #24 prior to or returning from dialysis treatments. DON indicated pre and post weights were obtained as well as their blood pressure.
Review of the facility policy titled Managing and Monitoring Residents Receiving Outpatient Hemodialysis dated 06/01/22 revealed residents' vitals, dialysis site, and fluid retention would be assessed prior to departing for dialysis treatment. Upon return, residents' vitals, dialysis site, and symptoms of complications would be assessed. Residents would also be weighed following dialysis treatment to compare to pre-dialysis weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure appropriate hand washing or hand sanitization was completed prior to completing Residents #1 and #33's non-pressure wound care. This affected two (Residents #1 and #33) of two residents reviewed for general skin conditions.
Findings include:
1. Review of Resident #1's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease without dyskinesia, Alzheimer's disease and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 exhibited severe cognitive impairment.
Review of Resident #1's Weekly Wound Report form dated 12/17/24 revealed the resident had left buttock moisture associated skin damage (MASD)/shearing acquired 12/14/24.
Review of Resident #1's physician orders revealed an order dated 12/17/24 to cleanse the open area on the left buttock with normal saline, pat dry, apply collagen moistened with normal saline to the wound bed and apply a dry dressing in the morning for wound care and as needed.
Observation on 12/26/24 at 11:29 A.M. with Licensed Practical Nurse (LPN) #545 of Resident #1's left buttock wound care revealed the nurse sanitized her hands and put on gloves. Then the nurse removed the soiled dressing on the resident's left buttock, cleansed the wound with normal saline, applied the collagen and normal saline to the left buttock and placed a dry dressing on the left buttock wound. LPN #545 did not change her gloves during the treatment change.
Interview on 12/26/24 at 12:47 P.M. with LPN #545 verified she did not change her gloves, wash her hands and putting on new gloves prior to completing the resident's wound care after she removed the soiled dressing.
2. Review of Resident #33's medical record revealed the resident was readmitted on [DATE] with diagnoses including anxiety disorder, dementia and essential hypertension.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 exhibited severe cognitive impairment.
Review of the Weekly Wound Report dated 12/17/24 revealed Resident #33 acquired left buttock moisture associated skin damage (MASD)/shearing on the left buttock which measured 1.5 centimeters (cm) length by 1.2 cm width by 0.1 cm depth; right buttock MASD/shearing which measured 0.5 cm length by 0.5 cm width by less than 0.1 cm depth; and right buttock MASD/shearing which measured 0.5 cm length by 0.5 cm width by less than 0.1 cm depth.
Observation on 12/26/24 at 12:40 P.M. with Licensed Practical Nurse (LPN) #545 of Resident #33's left buttock dressing revealed the resident was rolled into the common bathroom on the unit. The resident was assisted in a standing position, the nurse put on gloves and cleansed the resident's left and right buttocks with normal saline, applied the collagen and normal saline on the left and right buttocks and applied a dry dressing. LPN #545 did not wash her hands prior to putting on gloves.
Interview on 12/26/24 at 12:47 P.M. with LPN #545 confirmed she did not wash or sanitize her hands prior to completing Resident #33's left buttock dressing. She stated she was nervous and that was why she forgot to disinfect her hands prior to completing the dressing.
Review of the Wound Cleansing policy dated 05/01/16 indicated the procedure indicated to adhere to Standard Universal Infection Control Guidelines/Precautions, review physician orders, explain procedure to the resident, establish a clean field with all the supplies and equipment, remove tape by pushing skin from tape, remove soiled dressing, discard dressing and change gloves, decontaminate hands and don new gloves, clean a linear wound from top to bottom working outward, dress wound with appropriate dressings following the manufacturer's guidelines for use, and discard soiled supplies in the appropriate containers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy, observation and interview, the facility did not ensure infection control practices were maintained during a wound treatment for Resident #9. This affected one resident (#9) of three residents reviewed for hospice. The facility census was 47.
Findings include:
Record review was conducted for Resident #9 who was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, type two diabetes mellitus, moderate protein calorie malnutrition, dysphagia following a stroke and peripheral vascular disease. Resident #9 was admitted to hospice on 04/01/23 for a terminal diagnosis of dysphagia.
Review of the Minimum Data Set 3.0 assessment, dated 07/10/23, revealed Resident #9 required extensive assistance by one staff for eating, dressing, toileting and hygiene and extensive assistance of two staff for transfers and bed mobility.
Review of the plan of care, revised 08/28/23, revealed Resident #9 had potential for pressure ulcer development due to incontinence, impaired mobility, and protein calorie malnutrition. Interventions included administering medications and treatments as ordered and following facility policies for the prevention and treatment of skin breakdown.
Review of a physician order dated 09/25/23 revealed Resident #9 had a wound on her coccyx and the treatment was to apply calmoseptine ointment to the wound and pad and protect the wound in the morning on Tuesday, Thursday and Saturday.
Observation made on 10/03/23 at 11:15 A.M. of wound care provided to Resident #9 by the Wound Care Nurse Registered Nurse (RN) #801 revealed infection control practices were not followed. During the observation, Hospice Aide (HA) #804 was in the room and continued to perform a complete bed bath on Resident #9 while wound care was being provided by RN #801. HA #804 took the dirty wash rag used to wash the residents back and buttocks area and set it on top the clean four-by-four gauze pads RN #801 had set out with the wound supplies. RN #801 grabbed the dirty wash rag with her gloved hands to move it and with the same gloves grabbed the gauze pads that touched the dirty wash rag and proceeded to cleanse Resident #9's wound to her coccyx with the gauze pads.
Interview was conducted on 10/03/23 at 12:48 P.M. with RN #801 who verified she saw the dirty wash rag touch the four-by-four gauzes, and she should not of used those gauzes to cleanse the wound.
Review of the facility policy titled Nursing Skin Policies and Procedures, dated 05/01/16, revealed when changing dressings if the wound required a sterile technique, then a sterile field with all needed supplies would be established and standard universal infection control techniques/precautions would be applied.
This deficiency was an incidental finding during the investigation of Complaint Number OH00146906.

Based on observation, interview, record review, review of facility policy, and manufacturer's recommendations the facility failed to ensure open bottles of insulin for Resident's #17, #47, and #256 were dated. This had the potential to affect nine resident's (Resident's #3, #15, #17, #18, #24, #43, #48, #156, #256) requiring insulin who resided in the facility. The facility census was 51.
Findings include:
1. Review of Resident #256's medical record revealed an admission date of 04/15/19 and diagnoses included type two diabetes mellitus without complications.
Review of Resident #256's physician orders dated 08/09/23 revealed Lantus (insulin glargine) subcutaneous solution 100 units per milliliter (ml), inject 10 units subcutaneously at bedtime for type two diabetes mellitus. Further review revealed Humalog (insulin lispro) injection solution 100 units per ml, inject per sliding scale: if blood sugar was 151 to 200 administer 4 units, for blood sugar 201 to 250 administer 6 units, for blood sugar 251 to 300 administer 8 units, for blood sugar 301 to 350 administer 10 units, and for a blood sugar of 351 to 400 administer 12 units subcutaneously before meals and at bedtime for blood glucose.
2. Review of Resident #47's medical record revealed an admission date of 03/08/22 and diagnoses included type two diabetes mellitus with diabetic neuropathy.
Review of Resident #47's physician orders dated 05/30/23 revealed Humalog (insulin lispro) injection solution 100 units per ml, inject per sliding scale if blood sugar was 151 to 200 administer 4 units, for blood sugar 201 to 250 administer 6 units, for blood sugar 251 to 300 administer 8 units, for blood sugar 301 to 350 administer 10 units, for blood sugar 351 to 400 administer 12 units, call physician if blood sugar greater than 400, subcutaneously four times a day for blood sugar control.
3. Review of Resident #17's medical record revealed an admission date of 11/23/21 and diagnoses included type two diabetes mellitus with diabetic neuropathy.
Review of Resident #17's physician orders dated 08/10/23 revealed Toujeo SoloStar (insulin glargine) subcutaneous solution Pen-Injector 300 units per ml, inject 8 units subcutaneously at bedtime for type two diabetes mellitus.
Observation on 08/22/23 at 9:01 A.M. of a facility medication cart with Registered Nurse (RN) #780 revealed:
a. Resident #256 had an opened, undated bottle of insulin lispro (Humalog) in the medication cart. Further observation revealed the box the insulin lispro was stored in was labeled with Resident #256's name and dated 07/05/23. RN #780 confirmed Resident #256's bottle of insulin lispro was opened and undated. RN #780 indicated insulin was only good for a month after it was opened and first used. RN #780 stated Resident #256 was currently receiving insulin lispro. Further observation of the medication cart with RN #780 revealed Resident #256 had an opened, undated bottle of Lantus insulin (insulin glargine) stored in a box labeled with Resident #256's name and dated 06/25/23. RN #780 confirmed the box was dated 06/25/23, the bottle of Lantus insulin was opened and not dated, the box was dated almost two months ago and insulin was only good for 30 days once it was opened. RN #780 stated Resident #256 was currently receiving Lantus insulin.
b. Resident #47 had an opened, undated bottle of insulin lispro 100 units per ml in the medication cart. Resident #47's insulin was stored in a box labeled with her name and a date of 06/27/23 written on the box. RN #780 confirmed Resident #47's insulin lispro was opened, undated, and stored in a box with the date 06/27/23 written on it. RN #780 confirmed insulin was only good for a month once it was opened. RN #780 indicated Resident #47 was currently receiving insulin lispro.
c. Resident #17 had an opened Toujeo SoloStar (insulin glargine) subcutaneous solution Pen-Injector 300 units per ml, and the date on the pen was 05/06/23. RN #780 confirmed the pen was dated 05/06/23 which was three and a half months ago. RN #780 confirmed Resident #17 was currently receiving Toujeo SoloStar (insulin glargine) Pen-Injector 300 units per ml.
Interview on 08/22/23 at 9:30 A.M. of the Director of Nursing (DON) confirmed insulin bottles were opened and undated for Resident #256 and #47. The DON confirmed Resident #17's Toujeo SoloStar Pen-Injector was dated 05/06/23. The DON confirmed the insulin bottles should have been dated when they were opened, and insulin glargine and lispro were only good for a month once they were opened.
Review of the manufacturer's instructions for Insulin Lispro Injection 100 units per ml included do not use Insulin Lispro Injection past the expiration date printed on the label or 28 days after you first use it.
Review of the manufacturer's instructions for Lantus Insulin (insulin glargine injection) 100 units per ml included do not use Lantus after the expiration date stamped on the label or 28 days after you first use it.
Review of the manufacturer's instructions for Toujeo SoloStar Pen-Injector 300 units per ml included to only use your pen for up to 56 days after its's first use.
Review of the facility policy titled General Guidelines-Medication Administration dated 05/01/16 included remember to date and initial the vial (bottle) and the box of multi-dose medications the first time you use a medication. Once opened and dated, the medication can be used for 30 days.

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program in the kitchen area. This had the potential to affect all residents receiving meals from the facility kitchen. The facility identified one Resident (#38) as not receiving meals from kitchen for Nothing by Mouth (NPO) status. The facility census was 51.
Findings include:
Observations on 08/21/23 from 9:06 A.M. to 9:23 A.M. revealed significant fly and gnat activity in kitchen preparation areas. Observations revealed door through dry storage room in kitchen leading directly outside to dumpster area. There were noted kitchen cleanliness concerns in the kitchen preparation areas.
Observations on 08/23/23 from 10:51 A.M. to 11:08 A.M. revealed continued significant fly and gnat activity in kitchen preparation areas.
Interview on 08/23/23 at 11:08 A.M. with Dietary Director #900 confirmed fly and gnat activity. Dietary Director #900 indicated maintenance was responsible for pest control. Dietary Director #900 indicated staff try to mitigate activity by killing flies and gnats.
Interview on 08/23/23 at 3:08 P.M. with Maintenance Director #450 revealed the facility used a pest control service on a monthly basis. Maintenance Director #450 indicated there was a high concentration of flies in general due to weather. Maintenance Director #450 indicated it was recommended by pest control service that the dumpster outside of the dietary department be closed. Maintenance Director #450 indicated he had a meeting scheduled for next week with trash company to discuss moving the dumpster further from the building. Maintenance Director #450 stated he had planned to educate the dietary staff on using the further of the two dumpsters for food items and the closer of the two for boxes and non-perishable items. Maintenance Director #450 also stated he planned to tell dietary to keep the kitchen door closed to the outside.
Interview on 08/24/23 at 12:13 P.M. with Pest Control Representative (PCR) #702 revealed he inspects and treats the facility monthly. PCR #702 stated it was recommended the dumpster lids be closed last month. PCR #702 stated the facility had not requested additional services.
Review of Orkin Service Information reports dated 05/26/23, 06/05/23, and 07/28/23 revealed no treatments for gnats or flies. Review of Orkin Service Information report dated 06/30/23 revealed kitchen was treated for flies. There was no evidence of additional services requested to address flies or gnats.

Based on observation, interview, and record review, the facility failed to ensure clean and sanitary kitchen area and ensure appropriate glove use by kitchen staff. This had the potential to affect all residents receiving meals from the facility kitchen. The facility identified one resident (#38) as not receiving meals from kitchen for Nothing by Mouth (NPO) status. The facility census was 51.
Findings include:
Observations on 08/21/23 from 9:06 A.M. to 9:23 A.M. revealed under dry storage room storage racks was darkened, sticky flooring and there was various food debris and plasticwares. The main food preparation area contained food preparation tables, racks for storing cookware, and equipment including steamtable, deep fryer, oven with range and flat grill top. There was a microwave on a storage rack. Inside the microwave was splattered with red food substance. Under preparation tables revealed darkened flooring with grease build up with significant food debris. Observation of deep fryer revealed significant dark brown grease build up on splash guards and yellow colored build up on basket hanger. There was splatter of grease/ food debris down front of deep fryer. Observation of oven with range revealed splattering of grease/food debris down front of oven range. Observation of flat top grill revealed significant dark brown grease build up and food debris. There was splatter of grease/food debris down front and sides of flat top grill. Observation of kitchen hood revealed significant grease build up with dust sticking to grease on the fire suppression system within kitchen hood and grates. Findings were confirmed with Dietary Director #900 at time of observation.
Observation on 08/23/23 from 10:51 A.M. to 11:08 A.M. of [NAME] #520 preparing pureed lunch items revealed [NAME] #520 wearing disposable gloves. Dietary Director #900 was present during time of puree preparations. [NAME] #520 was observed to use gloved hand to scoop vegetable blend into food processor. [NAME] #520 did not dispose gloves after scooping vegetables. [NAME] #520 continued to prepare purees while wearing same disposable gloves. [NAME] #520 continued on to prepare pureed veal patties while wearing same gloves. [NAME] #520 grabbed tongs from a drawer on prep table while wearing same disposable gloves. [NAME] #520 was noted to pull down surgical mask to taste test vegetable blend puree and veal puree while wearing same disposable gloves. [NAME] #520 continued on to puree garlic bread. [NAME] #520 grabbed garlic bread out of oven with same gloved hands and did not use utensil. Observation also revealed tray of garlic bread on metal storage rack placed on top of clean cookware. The tray of garlic bread was uncovered.
Interview on 08/23/23 at 11:08 A.M. with [NAME] #520 and Dietary Director #900 confirmed findings of inappropriate glove usage and uncovered garlic bread left on the shelf.
Review of facility policy General Sanitation of Kitchen dated 2017 revealed staff would maintain the sanitation of the kitchen through a written comprehensive cleaning schedule.
Review of Weekly Cleaning Schedule undated revealed cleaning schedules for kitchen hood and filters, stove and oven, tables including bottom, floors including corner, fryer, and cook room.
Review of kitchen education on personal hygiene and hand washing dated 03/28/23 revealed glove are used to protect food and not keep hands of employee clean, gloves should be changed between each activity, and gloves were not a substitute for washing hands. The education revealed when handling food use tongs or other appropriate utensils. The education was completed by [NAME] #520 on 07/14/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, facility failed to send a referral to speech therapy after Resident #27 experienced a choking episode which required a downgrade in diet texture. This affected one resident (#27) of two residents reviewed for nutrition. The facility census was 51.
Findings included:
Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including asthma, gastro-esophageal reflux disease, hypertension, dementia, osteoporosis, and fracture of unspecified part of next of right femur.
Review of a minimum data set (MDS) completed on 06/28/23 revealed Resident #27 had a brief interview for mental status score of 3 indicating severely impaired cognition, required extensive assistance of two for bed mobility, transfer, and toilet use, and required a limited assist of one staff for eating. The MDS also revealed Resident #27 did not have any concerns with coughing or choking and was not receiving a mechanically altered diet.
Review of orders revealed Resident #27 had an order in place for a regular diet with mechanical soft texture and thin liquid consistency starting on 07/19/23.
Review of a note dated 07/19/23 revealed Resident #27 had difficultly swallowing and choked on her food leading to downgrading her diet to mechanical soft texture with no indication of the physician being notified. Review of a note from 07/20/23 revealed the dietician was aware of the choking incident.
Interview on 08/23/23 at 8:35 A.M. with Occupational Therapy Assistant (OTA) #67 revealed Resident #27 did not receive speech therapy services after having an episode of choking.
Interview on 08/23/23 at 9:36 A.M. with Therapy Manager (TM) #30 confirmed the therapy department was not made aware of Resident #27's choking episode and they did not receive a referral for speech therapy.
Interview on 08/23/23 at 1:48 P.M. with the Director of Nursing (DON) #60 confirmed the physician was not notified Resident #27 had a choking episode. The DON #60 stated a referral to speech therapy would only be sent if a diet needed upgraded, if they admitted with orders for speech therapy or if the physician requested a referral be sent.
Interview on 08/24/23 at 10:19 A.M. with Dietician #701 revealed nursing staff should send a referral to speech therapy when choking or a change in diet texture occurs.
Review of a policy titled Texture and Consistency Modified Diets, undated, revealed individuals with indicators of dysphagia, including choking and delayed swallowing, will be referred to the speech language pathologist for evaluation of dysphagia.

Based on interview, record review, and review of PBJ (Payroll Based Journal) data report the facility failed to ensure accuracy of PBJ information. This had the potential to affect all 51 residents residing in the facility.
Findings include:
Review of the facility PBJ Staffing Data Report dated 01/01/23 through 03/31/23 revealed submitted weekend staffing data was excessively low.
Review of the facility nursing schedules from 01/03/23 through 02/28/23 did not reveal documentation when nurses assigned to the Nursing Home area of the facility were also required to cover the Assisted Living area on night shift. Further review did not reveal nurses signed out from the Nursing Home when they needed to go to the Assisted Living area, and did not sign back in when they returned.
Interview on 08/21/23 at 11:30 A.M. of Registered Nurse (RN) #445 revealed she worked in the Nursing Home part of the facility, but sometimes when she worked night shift from 6:00 P.M. through 6:00 A.M. she was required to cover the Nursing Home and the Assisted Living (AL) because the AL did not have a nurse who worked night shift. RN #445 stated she could not remember the dates she covered the Assisted Living as part of her assignment. RN #445 indicated she had not been required to cover the Assisted Living for at least a couple months now. RN #445 stated she did not know what changed or why she was not required to cover the AL now. RN #445 stated she did not know if the AL staffing was better now, and if that was the reason she was not required to cover the AL now. RN #445 stated when she did cover the AL it was pretty much every other night that she worked. RN #445 indicated she could not think of any negative effect residents in the Nursing Home experienced when she covered the AL. RN #445 revealed night shift was the only time the nurses were required to take the keys for the AL and cover the AL if a nurse was needed. RN #445 stated two nurses usually worked night shift in the Nursing Home, and depending on the needs of the residents in the AL she would usually be gone about a half hour, but had been gone for two hours due to a resident fall.
Interview on 08/21/23 at 3:59 P.M. of the Director of Nursing (DON) confirmed nurse's from the Nursing Home covered the Assisted Living during some night shifts. The DON stated nurses from the Nursing Home had not been required to cover the AL for a few months now. The DON indicated it only happened for a few months because the AL did not have enough staff, but now they had enough staff. The DON stated she could not provide information for which nights the nurses covered the Assisted Living and the time they spent in the AL meeting the residents needs. The DON stated the nursing schedule did not reflect the days the nurses were required to cover the AL. The DON stated the nurses did not sign in and out when they went to the AL and there was no way to tell how long they were in the AL. The DON stated the nurse who took the AL keys for the medication cart completed a narcotic count with the nurse who was leaving the AL, then came back to the Nursing Home.
Interview on 08/22/23 at 5:46 A.M. of RN #445 revealed she did not document how long she was gone when she left the Nursing Home and went to the AL to meet a resident's needs. RN #445 stated on the nights she was required to cover the AL, she would go to the AL when she arrived for work, complete a narcotic count with the nurse who was leaving, then return to the Nursing Home. RN #445 stated when the AL attendants called her because a resident needed her for a reason like medication administration or a fall she did not document when she left the Nursing Home or when she returned.
Interview on 08/24/23 at 1:10 P.M. of the DON revealed she was not the Director of Nursing during the months when the Nursing Home nurses covered the Assisted Living. The DON stated she could not answer any questions related to the accuracy of the PBJ data since she was not in the DON role at that time. The DON stated the facility did not have a shared staffing policy because the AL and the NH were all one entity.
This deficiency represents non-compliance investigated under Complaint Number OH00140656 and OH00137403

Based on observation, interview, record review, and review of facility policy the facility failed to identify a pattern of urinary tract infections (UTIs) did not occur for ten residents (#13, #18, #23, #34, #38, #41, #50, #156, #158 and #256) residing in the same nursing unit, the facility failed to ensure appropriate use of personal protective equipment (PPE) for resident (#308) on droplet precautions, and failed to ensure documentation of education for hand hygiene, gloves and cleansing of perineal area. This affected ten residents (#13, #18, #23, #34, #38, #41, #50, #156, #158 and #256) of 16 residents reviewed for UTIs, one (#308) out of four residents reviewed for transmission based precautions. The facility census was 51.
Findings include:
1.Review of the infection control log dated July 2023 revealed ten residents (that resided on the same nursing unit and required staff assistance with personal/incontinence care) had UTIs in July 2023; however the log did not provide the contact organism for all of them.
a. Resident #13 developed a UTI on 07/05/23. The resident was identified as incontinent by Registered Nurse (RN) #500 on 08/24/23 at 3:30 P.M.
b. Resident #18 developed a UTI on 07/20/23. The resident was identified as incontinent by RN #500 on 08/24/23 at 3:30 P. M
c. Resident #23 developed a UTI on 07/12/23. The resident was identified as incontinent by RN #500 on 08/24/23 at 3:30 P.M.
d. Resident #34 developed a UTI on 07/12/23. The resident was identified as occasionally incontinent by RN #500 on 08/24/23 at 3:30
P.M.
e. Resident #38 developed a UTI on 07/20/23. The resident was identified as incontinent by RN #500 on 08/24/23 at 3:30 P.M.
f. Resident #41 developed a UTI on 07/08/23. The resident was identified as occasionally incontinent by RN #500 on 08/24/23 at 3:30
P.M.
g. Resident #50 developed a UTI on 07/13/23. The resident was identified as occasionally incontinent by RN #500 on 08/24/23 at 3:30
P.M.
h. Resident #156 developed a UTI on 07/06/23. The resident was identified as incontinent by RN #500 on 08/24/23.
i. Resident #158 developed a UTI on 06/12/23. The resident was identified as incontinent by RN #500 on 08/24/23.
j. Resident #256 developed a UTI on 07/12/23. The resident was identified as occasionally incontinent by RN #500 on 08/24/23 at 3:30 P.M.
2. Observation and interview on 08/24/23 at 12:01 P.M. revealed a gown hanging on outside of door of Resident #308 (under isolation precautions). The gown was for staff reuse. This was verified verified by Licensed Practical Nurse (LPN) #19 at the time of the observation.
Interview on 08/24/23 at 2:23 P.M. with RN #500 revealed gowns should not be hung outside an isolation room for reuse. She stated they are disposable for a reason. RN #500 verified the trend for UTIs in July 2023 in the same nursing unit for residents (#13, #18, #23, #34, #38, #41, #50, #156, #158 and #256) who were incontinent and required staff assistance with perineal/incontinence care. RN #500 stated she completed audits for handwashing in July 2023 but only did verbal training on perineal care in July 2023. The last documented evidence of training for perineal care was in April 2023.
Review of the Hand Hygiene Contact Precautions Monitoring Tool, dated July 2023, revealed instances of hand hygiene not being completed upon entry or exit from resident room and gloves were not always worn as expected.
Review of the facility policy titled Infection Control Policies and Procedures, dated 01/01/17 revealed the facility should provide on-going employee education counseling based on results of investigation in a timely manner. Education should include proper use of personal protective equipment and sterile technique.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and interview the facility failed to ensure Resident #54's Do Not Resuscitate (DNR) advance directives/order was honored. This affected one resident (#54) of three reviewed for DNR advanced directives. The facility census was 50.
Finding include:
Review of Resident #54's closed medical records revealed an admission date of [DATE] with diagnoses including high blood pressure and chronic kidney disease. Record review revealed the resident passed away on [DATE].
Review of the resident's advance directives revealed the resident had a signed Do Not Resuscitate Comfort Care (DNR-CC) form, dated [DATE].
Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition and required extensive assistance with with bed mobility, transfers, toileting and personal hygiene.
Review of care plan dated [DATE] revealed Resident #54 had advance directives for a Do Not Resuscitate Comfort Care (DNR-CC).
Review of physician's orders dated [DATE] revealed Resident #54 was a DNR-CC.
Review of a progress note dated [DATE] authored by Licensed Practical Nurse (LPN) #200 revealed Resident #54 was observed to be unresponsive with no pulse. The progress note revealed Cardiopulmonary Resuscitation (CPR) was initiated and emergency services had been called. The progress note revealed CPR had lasted for 20 minutes until the physician had declared a time of death and Resident #54 had expired at 6:17 P.M.
Interview on [DATE] at 12:15 P.M. with the Director of Nursing (DON) confirmed the resident's physician orders, care plan and signed DNR-CC paperwork were contained in Resident #54's medical record. The DON confirmed CPR had been performed on Resident #54 and should not have been due to Resident #54's DNR-CC status.
Interview on [DATE] at 12:31 P.M. with LPN #200 revealed she was the assigned nurse for Resident #54 on [DATE]. LPN #200 stated Resident #54's roommate had put the call light on and had told her Resident #54 had not been responding to her. LPN #200 stated she had observed Resident #54 to have been unresponsive and was barely breathing. LPN #200 stated she had checked her report sheet that had indicated Resident #54 was a full code (all life saving measures to be done) as well as another nurse who had checked the computer system which also indicated Resident #54 was a full code. LPN #200 stated she had immediately began CPR until the paramedics arrived. LPN #200 stated she had been informed a few days after the incident Resident #54 was a DNR-CC and stated she was not sure why the computer and report sheet had indicated a full code status.
Review of facility undated policy titled DNR Protocol revealed no resuscitative measures should be done to save or sustain life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop care plans for a resident with pressure ulcers and included a resident's code status. This affected two residents (#17, #27) of 20 residents reviewed for care planning. The facility census was 51.
Findings include:
1. Review of the medical record for Resident #17 revealed an admission date of 04/22/23 and diagnoses included chronic kidney disease, osteoarthritis, diabetes mellitus, and diabetic neuropathy.
Review of physician's orders dated 08/15/23 revealed Resident #17 had sacral wound and left hip wound.
Review of Weekly Wound Report dated 08/15/23 revealed Resident #17 re-admitted from hospital on [DATE] with Stage 3 pressure ulcer on sacrum and a suspected deep tissue injury on left hip.
Review of the current care plan for 08/24/23 revealed no evidence of care planning for actual pressure injuries.
Interview on 08/24/23 at 9:25 A.M. with Minimum Data Set (MDS) Coordinator #73 verified there was no care plan for actual pressure injuries for Resident #17. MDS Coordinator #73 indicated she would expect to see a care plan for a specific wound and would be reviewed/revised by the wound nurse.
Interview on 08/24/23 at 10:09 A.M. with the Director of Nursing (DON) verified there was no care plan for actual pressure injuries for Resident #17.
Review of the facility policy Skin-Wound Care Treatment dated 01/30/16 revealed a plan of care was to be initiated no later than eight hours after admission regarding altered skin integrity.
2. Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including asthma, gastro-esophageal reflux disease, hypertension, dementia, osteoporosis, and fracture of unspecified part of next of right femur.
Review of a MDS completed on 06/28/23 revealed Resident #27 had a BIMS score of 3 indicating severely impaired cognition, required extensive assistance of two for bed mobility, transfer, and toilet use, and required a limited assist of one staff for eating.
Review of Resident #27's orders revealed an order in place for a do not resuscitate comfort care (DNRCC) in place.
Review of Resident #27's care plan did not indicate her code status.
Interview on 08/23/23 at 1:43 P.M. with LPN #105 confirmed Resident #27's care plan did not indicate a code status, but orders revealed a code status of DNRCC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure a resident was assisted to the bathroom timely. This affected one resident (#15) of three residents reviewed for activities of daily living (ADL) assistance. The facility census was 51.
Findings include:
Review of Resident #15's medical record revealed an admission date of 10/18/21 and diagnoses included type two diabetes mellitus with diabetic neuropathy, morbid obesity, and schizoaffective disorder, depressive type.
Review of Resident #15's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 was cognitively intact. Resident #15 required extensive assistance of two staff members for toilet use. Resident #15 was occasionally incontinent of urine and frequently incontinent of bowel.
Review of Resident #15's care plan revised 07/10/23 included Resident #15 had an ADL (Activity of Daily Living) self care deficit including incontinence. Resident #15 would maintain functional abilities through next review. Interventions included to toilet in advance of need; toileting with extensive assistance of one staff member.
Observation on 08/24/23 at 7:45 A.M. of Resident #15 revealed State Tested Nursing Assistant's (STNA)'s #46 and #703 were changing Resident #15's shirt, pants and sheets because they were saturated with urine. STNA #46 stated Resident #15 had an accident because STNA #46 could not get to her call light fast enough. STNA #46 stated she was helping another resident and by the time she got to Resident #15 she was incontinent and it saturated her clothes and bedding. STNA #46 indicated this happened sometimes because there were only three aides for 51 nursing home residents and a lot ot the residents required extensive care to meet their needs.
Interview on 08/24/23 at 8:32 A.M. of Resident #15 revealed she put her call light on because she had to go to the bathroom, but the aide did not answer her call light fast enough and she had an accident. Resident #15 stated her incontinence brief, bed and shirt needed to be changed because they were wet with urine. Resident #15 stated often she would put her call light on and the aides could not answer it fast enough and she would have an accident. Resident #15 did not remember how long her call light was on before she had an accident.
This deficiency represents non-compliance investigated under Complaint Number OH00136232.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to thoroughly assess and provide timely medical treatment to a resident with multiple fractures. This affected one resident (#31) of four residents reviewed for accidents.
Actual harm occurred on 04/16/23 when Resident #31 fell, hitting her elbow on the shower chair and landing on her buttocks. At the time of the fall, Resident #31 complained of elbow pain and tailbone pain, however only the elbow pain was assessed, and physician notified resulting in the resident receiving an Xray of the shoulder and being diagnosed with a fractured humeral head on 04/17/23. The failure of the facility to appropriately assess and document the resident's sacral pain at the time of the fall resulted in a delay in the diagnosis and treatment of the resident's fractured sacrum until 04/20/23. Harm continued 04/29/23 when facility staff failed to notify the resident's physician of swelling and pitting edema in Resident #31's left arm until 05/06/23 when the resident's physician was notified of the change in condition (swelling and pitting edema) and the resident received diagnostic testing and was diagnosed with a superficial venous thrombosis (SVT). Actual harm continued 05/06/23 when the resident's physician ordered the resident to receive a blood thinning medication in the treatment of the SVT and the treatment was not initiated until two days later on 05/08/23.
Findings included:
Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including hypertension, major depressive disorder, osteoarthritis, anxiety disorder, overactive bladder, irritable bowel syndrome, and dementia.
Review of a minimum data set (MDS) assessment completed on 04/06/23 revealed Resident #31 had a brief interview for mental status (BIMS) score of six (6) indicating moderately impaired cognition, required an extensive assist of one person for bed mobility, transfers, walking in the room and corridor, and toilet use and required the use of a walker. The MDS also indicated Resident #31 was frequently incontinent of bladder and had not been trialed on a toileting program.
Review of nursing notes dated 04/16/23 through 04/20/23 revealed the front hall nurse, Licensed Practical Nurse (LPN) #21, witnessed Resident #31 on 04/16/23 at 5:08 P.M. walking into the bathroom when she fell on her bottom and hit her left elbow on the shower chair. Resident #31 was assessed with no injuries noted, was changed due to an episode of incontinence, and given ibuprofen for elbow pain with no rating or description of pain noted. There was no documentation regarding the resident's complaints of tailbone/sacrum pain.
The morning of 04/17/23 at 8:14 A.M. Resident #31 was complaining of left arm and shoulder pain and presented with bruising on inner left upper arm and shoulder blade. The Medical Director was contacted and gave a verbal order to send to the emergency department for evaluation. At the hospital, Resident #31 was diagnosed with a fracture of the left humeral head, widening of subacromial space, and soft tissue swelling. Resident #31 returned to the facility with new orders to follow up with an orthopedic physician.
On 04/19/23 at 9:26 P.M. a nursing note by LPN #21 stated Resident #31 was complaining of pain to her tailbone, which was tender to touch and aching. Resident's daughter had requested for day shift nursing staff to be notified of pain and to possibly get an X-ray. The order for an X-ray was not received until 04/20/23 at 2:13 P.M. and results were received at 6:40 P.M. stating Resident #31 had a fracture in her distal sacrum.
Review of a nursing note from Registered Nurse (RN) #11 on 04/29/23 at 2:52 P.M. revealed Resident #31's left hand was swollen and hanging from the arm sling. The nurse readjusted the sling but did not notify the physician of the swelling.
There were no further relevant nursing notes until a note on 05/05/23 at 2:09 P.M. from LPN #105 revealed Resident #31's daughter was made aware of a new order from the Medical Director for a doppler (ultra-sound) to the left upper extremity due to redness and edema. An additional nursing note on 05/05/23 at 3:13 P.M. revealed Resident #31 presented with +2 pitting edema with redness to her left hand.
Review of a nursing note from RN #11 on Saturday, 05/06/23 at 11:51 A.M. revealed an ultrasound had been completed and preliminary results were positive for a deep vein thrombosis. The nurse did notify the on-call physician who stated no new orders were needed until Monday (05/08/23). Resident #31's daughter was notified and requested the Medical Director be contacted to address the thrombus, but the facility staff declined stating the on-call physician had already addressed her concerns. Resident #31's daughter continued to request the Medical Director to be contacted regarding the thrombus. On 05/06/23 at 4:17 P.M. the final results for the ultrasound showed an SVT to the left basilic vein. On 05/06/23 at 6:13 P.M. the Medical Director ordered the blood thinning medication, Eliquis 2.5 milligrams (mg) twice a day for SVT.
Review of the medication administration record (MAR) from May 2023 revealed the code of 9 for the administration of Eliquis 2.5 mg on the evening on 05/06/23, both doses on 05/07/23, and the morning dose of 05/08/23. Review of the MAR code keys revealed 9 indicates to review nursing notes.
Review of MAR nursing note from LPN #105 on 05/06/23 at 6:13 P.M. revealed the order for Eliquis was received at that time and requested from the pharmacy. The MAR nursing notes on 05/07/23 from LPN #80 at 2:06 P.M. and from LPN #19 at 9:24 P.M. revealed Eliquis continued to be unavailable and was on order from the pharmacy. A MAR nursing note from RN #11 on 05/08/23 at 7:03 A.M. revealed Eliquis was not available from the pharmacy yet. The Medical Director was not notified regarding late administration of Eliquis.
Interview on 08/23/23 at 11:33 A.M. with LPN #105 revealed on 05/05/23 she was helping with meals in the dining room when she noticed Resident #31 had pitting edema to her left hand and it was red. LPN #105 stated she spoke with RN #11 who normally works that unit and RN #11 stated Resident #31's hand had been like that for a while. LPN #105 stated she then contacted the Medical Director to get a doppler ordered and she scheduled the doppler test once the order was received.
Interview on 08/23/23 at 11:49 A.M. with RN #11 revealed after Resident #31 had broken her shoulder, her hand began to swell as well, so the doctor was contacted and an order for a doppler was received. RN #11 stated she did not recall contacting the physician on 04/29/23 when she had first noticed the swelling because she thought it was related to Resident #31 leaning to her right side and the gravity was shifting the swelling to the left hand.
Interview on 08/23/23 at 12:53 P.M. with LPN #510 revealed on 04/16/23 Resident #31 got up and walked out of her room to the front hall bathroom and fell. LPN #510 stated Resident #31 had complained of pain to her tailbone, and she thought she administered Tylenol at the time of the fall. LPN #510 verified she did not assess the resident's complaints of tailbone pain, failed to document the resident's tailbone pain, and failed to notify the physician of the tailbone pain.
Interview on 08/24/23 at 9:18 A.M. with Director of Nursing (DON) revealed Eliquis was ordered on 05/06/23 which was a Saturday which would cause the medication to be delayed in arriving for administration.
Interview on 08/24/23 at 2:12 P.M. with RN #222 revealed the pharmacy is on-call during the weekends so if she doesn't hear back after the first request for medication, she follows up. RN #222 stated the pharmacy works really quick, and that if she ordered a medication, that is not a controlled substance, on the weekend at about 8:00 A.M. it would typically arrive the same day between 11:00 A.M. and 2:00 P.M.
The surveyor requested a facility policy for change in condition and notifying physician of change in condition, but none were received.
This deficiency represents non-compliance investigated under Complaint Number OH00136232.

Based on interview and record review, the facility failed to monitor a dialysis fistula site for a resident receiving dialysis. This affected one resident (#48) of one reviewed for dialysis treatments. The facility identified one resident as receiving dialysis treatments. The facility census was 51.
Findings include:
Review of the medical record for Resident #48 revealed an admission date of 06/28/22 and diagnoses included end stage renal disease, dependence on renal dialysis, diabetes mellitus, heart failure, and lymphedema.
Review of the physician order dated 01/18/23 revealed Resident #48 received dialysis treatments on Monday, Wednesday, and Friday.
Review of progress note dated 06/26/23 revealed Resident #48 had dialysis fistula (hemodialysis access connection made by joining a vein onto an artery) replaced.
Review of care plan dated 07/10/23 revealed Resident #48 had tunneled hemodialysis catheter (hemodialysis access by placement of catheter under skin and into major vein) to right internal jugular and fistula to left arm. Care plan indicated to monitor for signs and symptoms of infection to dialysis access sites.
Review of the Treatment Administration Record (TAR) for July 2023 and August 2023 revealed no evidence of monitoring dialysis access site for infection and patency.
Review of Dialysis and Nursing Home Handoff Communication Tools for July 2023 and August 2023 revealed access site monitoring on 08/21/23, 08/14/23, 08/11/23, 08/07/23, 08/04/23, 08/02/23, 07/31/23, 07/29/23, and 07/28/23. There was no additional evidence of monitoring access site.
Interview on 08/23/23 at 2:29 P.M. with Registered Nurse (RN) #222 revealed there was no order for monitoring dialysis access site. RN #222 indicated she only documents on the TAR when Resident #48 goes to dialysis and checks vitals and weight prior to treatment.
Interview on 08/24/23 at 10:07 A.M. with Director of Nursing (DON) confirmed there was no order for monitoring dialysis access site for infection or patency.
This deficiency represents non-compliance investigated under Complaint Number OH00136232.
Review of facility policy Hemodialysis Therapy dated 01/01/17 revealed dialysis shunt patency will be monitored daily by palpation of thrill and auscultation of bruit. The policy indicated staff will monitor resident for signs of infection (fever, chills, warmth around site) and report to physician and dialysis center of any findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, orthopedic consult review, therapy note review, and interview, the facility failed to manage Resident #31's pain adequately and within a timely manner. This affected one resident (#31) of one resident reviewed for pain management. The facility census was 51.
Actual harm occurred on 04/16/23 to Resident #31, who had sustained a fall with fractured left humeral head and sacrum, when staff failed to adequately address the resident's pain resulting in Resident #31 having a decline in her activities of daily living. The facility also failed to administer pain medications timely when staff were notified Resident #31 was crying out in pain during therapy sessions and was declining to participate in therapy services.
Findings included:
Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including hypertension, major depressive disorder, osteoarthritis, anxiety disorder, overactive bladder, irritable bowel syndrome, and dementia.
Review of a minimum data set (MDS) assessment completed on 04/06/23 revealed Resident #31 had a brief interview for mental status (BIMS) score of six (6) indicating moderately impaired cognition, required an extensive assist of one person for bed mobility, transfers, walking in the room and corridor, and toilet use and required the use of a walker. The MDS also indicated Resident #31 was frequently incontinent of bladder and had not been trialed on a toileting program.
Review of MDS completed on 05/18/23 revealed Resident #31 required extensive assist of two staff for bed mobility and transfers and required extensive assist of one staff for toileting.
Review of Resident #31's plan of care from 01/20/23 revealed interventions for pain included to monitor and report resident complaints of pain to the nurse and to notify physician if pain interventions are unsuccessful.
Review of physician orders revealed Resident #31 had an order that started on 12/22/22 for Tramadol 50 milligram (mg) tablet to give 0.5 tablet every 8 hours as needed for pain, and an order that started on 12/22/22 for ibuprofen tablet 200 mg to give two tablets every 8 hours as needed for pain.
The resident's current physician orders for pain management included the following:
Tylenol, 650 mg, every eight (8) hours, as needed (started 05/06/23);
Ibuprofen, 400 mg, every eight (8) hours, as needed (started 06/10/23).
Review of nursing notes dated 04/16/23 revealed the front hall nurse witnessed Resident #31 on 04/16/23 at 5:08 P.M. walking into the bathroom when she fell on her bottom and hit her left elbow on the shower chair. Resident #31 was assessed with no injuries noted, was changed due to an episode of incontinence, and given ibuprofen for elbow pain. The facility documentation did not include a description of the pain to include rate or pain level.
Review of a nursing note on 04/17/23 at 8:14 A.M. revealed Resident #31 was complaining of left arm and shoulder pain and presented with bruising on inner left upper arm and shoulder blade. Resident #31 was sent to the hospital where she was diagnosed with a fracture of the left humeral head, widening of subacromial space, and soft tissue swelling.
Review of hospital discharge orders dated 04/17/23 revealed orders for Tramadol 50 mg give 0.5 tablet every 8 hours as needed for pain and ibuprofen tablet give 200mg, two tablets every 8 hours as needed for pain, remained unchanged.
Review of a nursing note on 04/17/23 at 5:27 P.M. revealed Resident #31's family was concerned with the pain medication that was ordered, and requested staff to ask if the Medical Director could review the resident's orders for a stronger pain medication for the humeral fracture. The Medical Director declined to order more medication unless Resident #31 had additional complaints of pain. There was no documentation that Resident #31 was assessed for pain at this time.
Review of a nursing note dated 04/19/23 at 9:26 P.M. revealed Resident #31 was complaining of pain to her left arm and tailbone, which was tender to touch. Nursing note stated Resident #31 said her tailbone was aching and painful. Further assessment was not completed due to Resident #31 being in pain and not able to reposition without causing additional discomfort. Resident #31's daughter had requested for day shift nursing staff to be notified of pain and to possibly get an X-ray.
Review of a pain assessment completed on 04/19/23 revealed Resident #31 stated she had pain in the last five days frequently and it had made it hard for her to sleep at night as well as limited her day-to-day activities. Resident #31 rated her pain at an eight out of ten. Interventions listed on assessment included as needed (PRN) pain medication and ice.
Review of an orthopedic consult dated 04/19/23 revealed Resident #31's orthopedic physician increased the order for Tramadol to 50 mg every 6 hours, scheduled, and to discontinue ibuprofen.
Review of Resident #31's medication administration record (MAR) for April 2023 revealed multiple orders for Tramadol including:
•
Tramadol 50 mg, 0.5 tablet, every eight hours PRN ordered on 12/22/22 and discontinued on 04/19/23.
•
Tramadol 50 mg, four times a day ordered on 04/19/23 and discontinued on 04/20/23 which was administered four times.
•
Tramadol 50 mg, every six hours for pain, ordered on 04/20/23 and discontinued on 04/21/23 which was administered twice.
•
Tramadol 50 mg, four times a day for 14 days, ordered on 04/21/23 and discontinued on 04/21/23 which was administered twice.
•
Ibuprofen 200 mg, two tablets every eight hours PRN, ordered on 12/22/22 and discontinued on 04/19/23.
•
Tramadol 50 mg, every eight hours PRN, for 14 days ordered on 04/21/23.
•
Tramadol, 50 mg, was discontinued on 06/09/23.
There were no nursing notes regarding why the orthopedic physician orders for pain management on 04/19/23 were not followed.
Review of physician orders revealed:
An order dated 04/19/23 for a donut cushion to sit on to help alleviate tailbone pain.
An order dated 04/24/23 for physical therapy (PT) to evaluate and treat the resident.
An order dated 04/27/23 for occupational therapy (OT) to evaluate and treat the resident.
Review of a nursing note on 04/29/23 revealed Resident #31 continued with complaints of pain to lower back and left arm. Further pain descriptors were not provided.
Review of PT note from 05/04/23 at 3:21 P.M. revealed Resident #31 had complaints of left shoulder pain during treatment. Review of the May 2023 MAR revealed on 05/04/23 pain medication, Tramadol 50 mg, was given at 7:37 A.M. but was not given again after complaints of pain in therapy.
Review of OT note from 05/05/23 at 12:16 P.M. revealed Resident #31 would wince with pain during range of motion (ROM). Review of MAR for 05/05/23 revealed pain medication was administered at 7:28 A.M. but was not given after complaints of pain in therapy.
Review of PT note from 05/08/23 at 3:54 P.M. revealed Resident #31 complained of pain in her left arm. Review of MAR for 05/08/23 revealed Tylenol was administered at 5:30 P.M. and Tramadol was administered at 10:35 P.M. Both medications were administered after therapy. There was no evidence the resident was administered pain medication prior to her therapy.
Review of PT note on 05/13/23 at 11:18 A.M. revealed Resident #31 had pain in her left shoulder. Review of 05/13/23 MAR revealed pain medication was not administered until 4:41 P.M.
Review of OT on 05/16/23 at 1:00 P.M. revealed Resident #31 had complained of pain and nursing was made aware. Review of the 05/16/23 MAR revealed Resident #31 received Tramadol at 4:21 A.M. and at 3:32 P.M. Medication was ordered for administration every eight hours and could have been administered at 12:00 P.M. prior to her therapy.
Review of PT note from 05/17/23 at 3:48 P.M. revealed Resident #31 had pain and excessive swelling in LUE. There was no documented evidence the resident's complaints of pain and swelling were reported to the nursing staff. Review of 05/17/23 MAR revealed Resident #31 received Tramadol 25 mg at 7:40 P.M. There was no evidence the resident was medicated for pain prior to her therapy appointment and was not provided pain medication until four hours after her she complained of pain during therapy.
Review of PT note from 05/19/23 revealed at 11:07 A.M. Resident #31 had pain in her LUE. Review of OT note for 05/19/23 revealed Resident #31 yelled out and screamed with any movement to shoulder, 40-45 degrees of flexion was completed, and resident was visibly in pain even with pain medication prior to treatment. Occupational Therapy continued even with Resident #31 screaming out in pain. Review of the 05/19/23 MAR revealed Resident #31 had received 50 mg of Tramadol at 8:05 A.M. and Tylenol at 2:01 P.M.
Review of OT note from 05/25/23 at 1:29 P.M. revealed Resident #31 had complained of pain to LUE with behaviors of screaming at therapist. Review of 05/25/23 MAR revealed Resident #31 received Tramadol 50 mg at 8 A.M., 2 P.M., and 8 P.M.
Review of OT note from 05/30/23 at 7:47 A.M. revealed Resident #31 screamed out and moaned that ROM was painful with eight out of ten pain scale after medication was administered. Review of 05/30/23 MAR revealed Resident #31 received Tramadol 50 mg at 8 A.M., 2 P.M., and 8 P.M. The resident did not receive pain medication prior to ROM being performed.
Interview on 08/23/23 at 8:37 A.M. with Physical Therapy Assistant (PTA) #501 revealed when Resident #31 received therapy, she had a seven out of ten pain at rest, and eight out of ten pain with movement. PTA #501 stated Resident #31 would yell out in pain during therapy at the slightest touch, but PTA #501 felt it was behavioral more than actual pain.
Interview and observation on 08/24/23 at 9:00 A.M. with Resident #31 revealed she was unable to recall the incident (the fall on 04/16/23). Resident #31 was holding her upper left arm and complaining of pain stating, it hurts, hurts, hurts, at the time of the interview.
Interview and observation on 08/24/23 at 9:03 A.M. with State Tested Nursing Assistant (STNA) #37 revealed Resident #31 does still complain of pain often in her LUE. STNA #37 explained Resident #31's ROM in left arm has decreased and Resident #31 no longer walks around the facility like she did before but uses the wheelchair to get around. Wheelchair was in room at this time and observed to be without the donut cushion. When asked about the donut cushion missing from Resident #31's wheelchair, STNA #37 stated resident did not like the donut cushion because it hurt her. There was no documentation of Resident #31 refusing the donut cushion. During interview STNA #37 was helping Resident #31 go to the bathroom and resident complained of pain.
Interview on 08/24/23 at 10:44 A.M. with RN #780 revealed Resident #31 does still complain of pain and guards her left arm. When asked if pain medication had been administered on this date (08/24/23), RN #780 stated no one had reported the resident complained of pain.
Review of a policy titled General Pain Management revealed the nurse should assess a resident's pain and evaluate the effectiveness of the interventions, reassess pain, and document findings in the medical record. It stated dosage conversations should be held with the interdisciplinary team.
This deficiency represents non-compliance investigated under Complaint Number OH00136232.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #33 had planned interventions in place and was properly assessed to ensure new interventions were implemented after falls and failed to ensure staff utilized a gait belt for ambulation with Resident #195 as planned. This affected one of two residents reviewed for falls and one additional resident observed during ambulation.
Findings include:
1. Resident #33 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease and a history of falls.
Review of the quarterly Minimum Data Set (MDS) 3.0, dated 06/18/21, revealed Resident #33 was alert and oriented and able to make her needs known. The resident needed extensive assistance for activities of daily living including one person assist with a walker for ambulation and needed glasses for corrective vision.
Review of the current fall plan of care revealed Resident #33 had a history of falls due to gait/balance problems. Interventions included to ensure appropriate footwear, follow the fall protocol, provide a safe environment and ambulate with a walker.
Review of the 02/11/21 nurses notes revealed when the State Tested Nurse Aide (STNA) was assisting with toileting Resident #33 fell onto the floor. The STNA was not using a gait belt. The intervention was to in-service staff on proper use of a gait belt. Further review revealed there was no evidence of the gait belt in-service.
Review of the 06/06/21 nurses notes revealed an STNA was transferring Resident #33 out of the recliner when the back of the recliner fell off causing the resident to fall and hit her head resulting in a hematoma to the right side of her head. Further review of the investigation revealed there was no evidence the resident was wearing glasses nor if the walker was in use. The investigation stated the STNA was transferring the resident into the recliner when the back fell off which contradicted the nurses notes. The resident was sent to the emergency room for evaluation. There were no new interventions or education completed to prevent further falls.
Review of the 06/27/21 nurses notes revealed the STNA was walking with Resident #33 when she started walking too fast with the walker and fell. There was no evidence a gait belt was in use nor if the resident had on her glasses or if proper footwear was in place. Further review of the investigation revealed the same and again no evidence of proper footwear or glasses in place or use of a gait belt.
Review of the 07/17/21 nurses notes revealed after showering Resident #33, the STNA assisted the resident out of the tub and was pulling up her pants when the resident fell backwards. There was no evidence of glasses in place or a gait belt being used at the time of the fall. Further review of the investigation revealed the resident did not have on proper footwear and there was no evidence of glasses nor a gait belt being used. The new intervention was to wear proper footwear which was already an intervention. There was no evidence of education of staff.
On 07/21/21 at 11:17 A.M., STNA #66 was observed walking Resident #33 back to her room and into her bathroom. The resident was using her walker, had on glasses and proper shoes. STNA #66 had her hand touching the resident's back but was not using a gait belt. At 11:21 A.M., Resident #33 activated her bathroom call light and an unidentified STNA entered the room and assisted the resident back to her recliner without the use of a gait belt.
On 07/21/21 at 11:22 A.M., interview with STNA #66 verified she did not use a gait belt when ambulating with Resident #33.
On 07/21/21 at 9:30 A.M., interview with Director of Nursing (DON) verified she was not able to provide any documentation of gait belt education to staff including for the 02/11/21 fall for Resident #33. When informed of the above observations of staff assisting residents without the use of a gait belt, the DON verified gait belts are part of the uniform (meaning all STNAs were to wear a gait belt around their waist at all times) and a gait belt should always be used when transferring and ambulating residents who needed assistance.
On 07/22/21 at 9:45 A.M., interview was completed with the DON for review of the above falls.
•
For the fall on 02/11/21 the DON verified there was no education provided as planning for any of the staff for not using the gait belt.
•
For the fall on 06/06/21 (in the exercise/activity room) the DON verified the nurses notes and the witness statements (as part of the investigation) contradicted each other and no one attempted to determine the actual event other than the back of the recliner broke. Further review of the narrative in the investigation revealed the resident did not sustain any injuries but the DON verified the resident was sent to the emergency room with a hematoma caused by hitting her head during the fall. The DON also verified there was no documentation of use of a gait belt when transferring the resident.
•
For the fall on 06/27/21 there was no documentation a gait belt in use when the STNA was ambulating with the resident, nor was there evidence the resident was wearing glasses or proper footwear.
•
For the 07/17/21 fall the DON verified the STNA did not have proper footwear on the resident after bathing. There was no evidence a gait belt was in use and no education was provided. The DON verified a gait belt should have been used in all the above falls.
On 07/22/21 at 10:50 A.M., interview with Resident #33 verified some staff utilized the gait belt while other staff did not when transferring and/or ambulating her.
Review of the gait belt policy, dated 05/01/16, revealed a gait belt would be used at all times when transferring, moving, and/or ambulating a resident unless clinically contraindicated. A gait belt was an assistive device used to lift a resident from a sitting position, to transfer a resident from one seat to another and to provide support when helping a resident to walk. Instructions included to immobilize the bed, chair and/or wheelchair then assist the resident to a sitting position with the feet resting on the floor. Ensure appropriate, non skid footwear were in place and the resident was balanced before changing positions. Grip the gait belt with one hand placed at the resident's back and the other hand placed on the belt portion (weaker side if indicated).
Review of the fall policy, dated 12/01/17, revealed the facility would identify residents at risk for falls and initiate measures that would help reduce falls. Education was to be provided yearly to staff and all new admissions would be considered a fall risk for the first five days. Residents were to wear proper footwear, glasses and hearing aids as deemed appropriate. Assessments were to be completed on admission, after each fall, quarterly and with annual review. The fall risk log, which was to be completed by the DON, would be discussed at morning stand up meetings. Staff would offer toileting to residents every two hours or as required depending on the functional ability of the resident. A plan of care would be initiated on admission and adjusted as necessary. A fall investigation would be completed and logged on a tracking log. For every fall at least one intervention was required immediately and other long term interventions as needed. The medical director would review the monthly quality assurance report for input.
2. On 07/22/21 at 10:20 A.M., observation of Physical Therapy Assistant (PTA) #40 and Activities Director (AD) #17 assisting Resident #195 who was utilizing a walker revealed there was no use of a gait belt.
On 07/22/21 at 10:23 A.M., interview with PTA #40 verified a gait belt should have been used for any residents requiring contact guard or assistance of staff with ambulation including Resident #195 but no gait belt was used.
On 07/22/21 at 10:25 A.M., interview with AD #17 verified Resident #195 needed assistance with ambulation and no gait belt was used for the ambulation from the resident's room into the exercise room.
On 07/22/21 at 2:40 P.M., interview with the DON verified the above concern.

Based on record review and interview the facility failed to ensure State Tested Nurse Aides (STNA) received at least 12 hours of training annually including dementia care training. This had the potential to affect all 42 residents currently residing in the facility.
Findings include:
Review of the most recent dementia care training for staff revealed it was completed December of 2019.
Review of STNA #49's personnel file revealed she was hired on 06/11/20 and had only received nine hours of training which included her orientation training and no evidence of annual dementia care training.
Review of STNA #76's personal file revealed she was hired on 01/12/21 and had not received the dementia care training.
Review of STNA #83's personnel file revealed she was hired on 07/12/21 and had not received the dementia care training.
On 07/22/21 at 10:00 A.M., interview with the Director of Nursing (DON) verified there was no evidence of staff dementia care training since December 2019. The DON verified STNA #49 did not receive the required 12 hours annually of training.
On 07/23/21 at 4:12 P.M., interview with Nursing Secretary (NS) #46 verified the human resource director had been out and there was no tracking system in place to ensure the STNAs received their required 12 hours of annual training. NS #46 was able to find STNA #49 had nine hours of training since being hired on 06/11/20 and did not meet the required 12 hours of training annually including dementia care training.
Review of the Facility Assessment, not dated, revealed the facility provided Alzheimer's and/or dementia care for all levels of cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #25's medical record revealed diagnoses including chronic obstructive pulmonary disease, gastro-esophageal reflux disease, anemia, and chronic congestive heart failure. Review of the July 2021 Medication Administration Record (MAR) revealed medication scheduled for administration at 9:00 A.M. included abilify (antipsychotic), calcium carbonate with vitamin D, vitamin D, ferrous sulfate (iron), levothyroxine (thyroid medication), omeprazole (medication used to treat gastro-esophageal reflux disease), potassium, symbicort inhaler (used to treat chronic obstructive pulmonary disease), venlafaxine (used to treat depression), cholestyramine (used to treat high cholesterol), furosemide (diuretic), acetaminophen, midodrine (vasopressor used to treat low blood pressure), and lorazepam (used to treat anxiety).
Review of Medscape information regarding administration of levothyroxine indicated it should be administered with a full glass of water preferably 30 minutes to one hour before breakfast on an empty stomach. Medscape indicated levothyroxine should be administered greater than four hours apart from drugs known to interfere with absorption. Medication which was identified as affecting absorption of levothyroxine included ferrous sulfate and omeprazole. It indicated furosemide increased risk of toxicity of levothyroxine.
Review of meal times revealed breakfast was scheduled at 7:00 A.M.
Review of the June 2021 pharmacy recommendation revealed no recommendations for change in the administration time of levothyroxine.
On 07/21/21 at 1:53 P.M., Pharmacist #80 verified levothyroxine should not be given with other medications and was usually given around 6:00 A.M. to avoid other medications and foods.
On 07/22/21 at 10:32 A.M., RN #53 indicated there was no medical reason or other rationale for Resident #25 receiving levothyroxine at the same time as other medications.
On 07/22/21 at 11:04 A.M., Pharmacist #80 indicated due to COVID 19 his medication regimen reviews were completed off-site. Pharmacist #80 stated he did not have access to medication administration times so he did not address co-administration of levothyroxine with other medications or in relation to meal times.
Based on observation, review of the medical record, interview with staff, and review of Medscape website the facility failed to ensure Synthroid was given at least four hours before any other medications per manufacturer's recommendations. This affected three (Resident #9, #25, and #28) of six residents reviewed for unnecessary medications.
Findings include:
1. Resident #28 was admitted to the facility on [DATE] with diagnoses of infection in left knee, arthritis, severe protein calorie malnutrition, epilepsy, altered mental status, gastro-esophageal reflux disease, osteoarthritis, COVID-19, major depression, hypertension, hemiplegia, and hemiparesis to left side following a cerebrovascular disease, and psychosis.
Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition, required extensive assistance for all activities of daily living, and had one stage two and one stage three pressure ulcer.
Review of the July 2021 physician's orders revealed Resident #28 had an order for Synthroid (for hypothyroidism) 50 micrograms (mcg) in the morning.
Review of the July 2021 Medication Administration Record (MAR) revealed Resident #28 was scheduled to receive Synthroid 50 mcg in the morning, Lasix (a diuretic) 20 milligrams (mg) at 9:00 A.M. and omeprazole (for gastric reflux) 20 mg in the morning.
Observation on 07/21/21 at 7:54 A.M. revealed Licensed Practical Nurse (LPN) #73 administered; Synthroid 50 mcg, Lasix 20 mg, divalproex sodium (for seizure disorders) 500 mg, Risperdal (an antipsychotic) 0.5 mg, Paxil (an antidepressant) 20 mg, omeprazole 20 mg, and MS Contin (a narcotic) 15 mg to Resident #28.
Interview on 07/21/21 at 1:53 P.M. revealed Pharmacist #80 indicated Synthroid should not be given with other medications and was usually given around 5:00 or 6:00 A.M. to avoid administration with other medications and foods.
Interview on 07/22/21 at 8:50 A.M. with the Director of Nursing (DON) verified they gave the Synthroid with other medication if the resident did not want to be wakened early. She indicated it was the resident's choice what time they took their medications. She verified there was no documentation in the medical record or plan of care indicating Resident #28 did not want to be wakened early to take the Synthroid at 5:00 A.M.
Interview on 07/22/21 at 10:35 A.M. with Registered Nurse (RN) #53 indicated they did not give Resident #9 Synthroid at 5:00 A.M. because she did not like to be wakened. She verified there was no reason why Resident #28 could not receive his Synthroid at a different time.
Interview on 7/22/21 at 11:04 A.M. with Pharmacist #80 indicated when doing the medication regimen reviews off-site he did not have access to medication administration times so he did not address co-administration of Synthroid with other medications.
Review of the Consultant Pharmacist's Medication Regimen Review for February, March, April, May and June 2021 revealed no recommendations for addressing co-administration of Synthroid with other medications for Residents #9 and #28.
Review of the Medscape administration guidelines revealed Synthroid was to be taken with a full glass of water preferably 30 minutes to one hours before breakfast on an empty stomach and to administer oral Synthroid at least four hours apart from drugs known to interfere with absorption.
Review of the Medscape drug interactions checker revealed omeprazole decreased levels of levothyroxine by increasing gastric potential hydrogen (pH) in the oral form of the medication.
Review of the Medscape Drug Interactions checker revealed a minor interaction between Lasix and Synthroid. The Lasix increased toxicity of Synthroid and higher doses of Lasix may inhibit binding of thyroid hormones to carrier protein and result in transient increase in free thyroid hormones, followed by overall decrease in total thyroid hormone levels.
2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of hypertension, anxiety disorder, hypothyroidism, osteoporosis, COVID-19, insomnia, and dementia with behaviors.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 had severely impaired cognition.
Review of the July 2021 physician's orders revealed Resident #9 had an order for Synthroid 112 mcg every morning.
Review of the July 2021 MAR revealed Resident #9 received her Synthroid in the morning with her other medications.
Observation on 07/21/21 at 8:15 A.M. revealed RN #53 administered; Bursar (antidepressant) 15 mg, diltiazem (for high blood pressure) 30 mg, divalproex sodium 125 mg, Namenda (for dementia) 14 mg, Synthroid 112 mcg, Protonix (for gastric reflux) 40 mg, and aldactone (diuretic) 25 mg to Resident #9.
Interview on 07/21/21 at 1:53 P.M. with Pharmacist #80 indicated Synthroid should not be given with other medications and was usually given around 5:00 or 6:00 A.M. to avoid administration with other medications and foods.
Interview on 07/22/21 at 8:50 A.M. with the DON verified they gave the Synthroid with other medications if the resident did not want to be wakened. She indicated it was their choice what time they took their medications. She verified there was no documentation in the medical record or plan of care indicating Resident #9 did not want to be wakened to take the Synthroid at 5:00 A.M.
Interview on 07/22/21 at 10:35 A.M. with RN #53 indicated they did not give Resident #9 Synthroid at 5:00 A.M. because she did not like to be wakened.
Interview on 7/22/21 at 11:04 A.M. with Pharmacist #80 indicated when doing the medication regimen reviews off-site he did not have access to medication administration times so he did not address co-administration of Synthroid with other medications.
Review of the Consultant Pharmacist's Medication Regimen Review for February, March, April, May and June 2021 revealed no recommendations for addressing co-administration of Synthroid with other medications for Resident #9.
Review of the Medscape Drug Interactions checker revealed a minor interaction between Protonix and Synthroid. The Protonix decreases the levels of Synthroid by increasing gastric potential hydrogen. This applies only to oral form of both agents.
Review of the Medscape administration guidelines revealed Synthroid was to be taken with a full glass of water preferably 30 minutes to one hours before breakfast on an empty stomach and administer oral Synthroid at least four hours apart from drugs known to interfere with absorption.
Review of the Medscape Drug Interactions checker revealed a minor interaction between Lasix and Synthroid. The Lasix increased toxicity of Synthroid and higher doses of Lasix may inhibit binding of thyroid hormones to carrier protein and result in transient increase in free thyroid hormones, followed by overall decrease in total thyroid hormone levels.

Based on medical record review, policy review, and interview the facility failed to ensure a resident receiving psychotropic medications had time limits for the use of anti-anxiety medication ordered on an as necessary basis and failed to ensure a physician provided rationale for refusal of gradual dose reductions of psychotropic medication. This affected one (Resident #10) of five residents reviewed for medication use.
Findings include:
Review of Resident #10's medical record revealed diagnoses including depression, dementia, Alzheimer's disease, and psychotic disorder with delusions. An April 2021 pharmacy recommendation indicated Resident #10 had been receiving risperidone (an antipsychotic) 0.25 milligrams (mg) in the morning and 0.5 mg in the evening starting 09/30/20. The pharmacist inquired if a gradual dose reduction would be appropriate. A response dated 05/11/21 indicated no with documentation hospice patient. A May 2021 pharmacy recommendation indicated Resident #10 was receiving duloxetine (medication used to treat depression and anxiety) 60 mg twice a day. The pharmacist asked if a gradual dose reduction would be advisable. The word no was written on the form but with no rationale. A June 2021 pharmacy recommendation indicated Resident #10 was receiving duloxetine 60 mg twice a day and again inquired if a gradual dose reduction was advisable. The response indicated the duloxetine was discontinued on 12/24/19. However, the duloxetine order remained on the July 2021 orders. Resident #10 also had a physician's order for ativan (anti-anxiety) 0.5 mg every six hours as needed which was dated 07/22/20 with no end date or time frame for re-evaluation. No pharmacy reviews addressed the order for ativan on an as necessary basis or a need for time limits of a psychotropic medication ordered as necessary.
On 07/21/21 at 12:00 P.M., the Director of Nursing (DON) verified although Resident #10 was a recipient of hospice services, the ativan ordered on an as necessary basis should be time limited with a time frame for re-evaluation of its needed use. The DON verified the order for ativan on an as necessary basis had not been addressed by the pharmacist during monthly medication regimen reviews. The DON indicated the physician would usually not order gradual dose reductions of medication ordered by hospice or the psychiatrist.
On 07/21/21 at 2:30 P.M., the DON indicated no on the May recommendation for a gradual dose reduction of duloxetine was written because the duloxetine had been discontinued. The DON indicated she had written the note on the June pharmacy recommendation indicating duloxetine had been discontinued after reviewing Resident #10's medication list. Neither of the recommendations contained documentation by the physician. Orders for duloxetine remained current on July medication orders. The DON reported the facility had no policy regarding pharmacy recommendations.
On 07/06/21 at 2:40 P.M., Pharmacist #80 verified he had not addressed a needed time limit for the order of ativan on an as necessary basis because the medical director had indicated the hospice orders for ativan generally were not used until end stage.
Review of the facility's Psychotropic Medications policy (effective 05/01/16) indicated frequent reassessment for reduction or elimination of psychotropic medication would be completed by the interdisciplinary team. The DON or designee would monitor reduction and need of psychotropic medications and encourage the attending physician to titrate medications to find the lowest dose necessary and/or actual need for medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interviews the facility failed to ensure a medication error rate below five percent. Observation of 37 medications administered with two medication errors resulted in a medication error rate of 5.4 percent. This affected two (Residents #9 and #28) of six residents observed for medication administration.
Findings include:
1. Resident #28 was admitted to the facility on [DATE] with the diagnoses of infection in left knee, arthritis, severe protein calorie malnutrition, epilepsy, altered mental status, gastro-esophageal reflux disease, osteoarthritis, COVID-19, major depression, hypertension, hemiplegia, and hemiparesis to left side following a cerebrovascular disease, and psychosis.
Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition.
Review of the July 2021 physician's orders revealed Resident #28 had an order for Synthroid 50 micrograms (mcg) in the morning.
Review of the July 2021 Medication Administration Record (MAR) revealed Resident #28 was scheduled to receive Synthroid 50 mcg in the morning, Lasix 20 (diuretic) milligrams (mg) at 9:00 A.M. and omeprazole (for gastric reflux) 20 mg in the morning.
Observation on 07/21/21 at 7:54 A.M. revealed Licensed Practical Nurse (LPN) #73 administered; Synthroid 50 mcg, Lasix 20 mg, divalproex (anti seizure) sodium 500 mg, Risperdal (antipsychotic) 0.5 mg, Paxil (anti depressant) 20 mg, omeprazole 20 mg, and MS Contin (narcotic) 15 mg to Resident #28.
Interview on 07/21/21 at 1:53 P.M. revealed Pharmacist #80 indicated Synthroid should not be given with other medications and was usually given around 5:00 or 6:00 A.M. to avoid other medications and foods.
On 07/22/21 at 8:50 A.M. the Director of Nursing (DON) verified they gave the Synthroid with other medication if the resident did not want to be woken up. She indicated it was the resident's choice what time they took their medications. She verified there was no documentation in the medical record or plan of care indicating Resident #28 did not want to be woken up to take the Synthroid at 5:00 A.M.
Interview on 07/22/21 at 10:35 A.M. Registered Nurse (RN) #53 indicated they did not give Resident #9 Synthroid at 5:00 A.M. because she did not like to be woke up. She verified there was no reason why Resident #28 could not receive his Synthroid at a different time.
Interview on 7/22/21 at 11:04 A.M. revealed Pharmacist #80 indicated when doing the medication regimen reviews off-site he did not have access to medication administration times so he did not address co-administration of Synthroid with other medications.
Review of the Consultant Pharmacist's Medication Regimen Review for February, March, April, May and June 2021 revealed no recommendations for addressing co-administration of Synthroid with other medications for Resident #28.
Review of the Medscape administration guidelines revealed Synthroid was to be taken with a full glass of water preferably 30 minutes to one hours before breakfast on an empty stomach and administer oral Synthroid at least four hours apart from drugs known to interfere with absorption.
Review of the Medscape drug interactions checker revealed omeprazole decreases levels of levothyroxine by increasing gastric potential hydrogen (pH) in the oral form of the medication.
Review of the Medscape Drug Interactions checker revealed a minor interaction between Lasix and Synthroid. The Lasix increased toxicity of Synthroid and higher doses of Lasix may inhibit binding of thyroid hormones to carrier protein and result in transient increase in free thyroid hormones, followed by overall decrease in total thyroid hormone levels.
2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of hypertension, anxiety disorder, hypothyroidism, osteoporosis, COVID-19, insomnia, and dementia with behaviors.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 had severely impaired cognation.
Review of the July 2021 physician's orders revealed Resident #9 had an order for Synthroid 112 mcg every morning.
Review of the July 2021 MAR revealed Resident #9 received her Synthroid in the morning with her other medications.
Observation on 07/21/21 at 8:15 A.M. revealed RN #53 administered; Bursar (anti depressant) 15 mg, diltiazem (for high blood pressure) 30 mg, divalproex sodium 125 mg, Namenda (for dementia) 14 mg, Synthroid 112 mcg, Protonix (gastric reflux) 40 mg, and aldactone (diuretic) 25 mg to Resident #9.
Interview on 07/21/21 at 1:53 P.M. with Pharmacist #80 indicated Synthroid should not be given with other medications and was usually given around 5:00 or 6:00 A.M. to avoid other medications and foods.
Interview on 07/22/21 at 8:50 A.M. revealed the DON verified they gave Synthroid with other medication if the resident did not want to be woken up. She indicated it was their choice what time they took their medications. She verified there was no documentation in the medical record or plan of care indicating Resident #9 did not want to be woken up to take the Synthroid at 5:00 A.M.
Interview on 07/22/21 at 10:35 A.M. RN #53 indicated they did not give Resident #9's Synthroid at 5:00 A.M. because she did not like to be woke up.
Interview on 07/22/21 at 11:04 A.M. revealed Pharmacist #80 indicated when doing the medication regimen reviews off-site he did not have access to medication administration times so he did not address co-administration of Synthroid with other medications.
Review of the Consultant Pharmacist's Medication Regimen Review for February, March, April, May and June 2021 revealed no recommendations for addressing co-administration of Synthroid with other medications for Resident #9.
Review of the Medscape Drug Interactions checker revealed a minor interaction between Protonix and Synthroid. The Protonix decreases the levels of Synthroid by increasing gastric potential hydrogen. This applies only to oral form of both agents.
Review of the Medscape administration guidelines revealed Synthroid was to be taken with a full glass of water preferably 30 minutes to one hours before breakfast on an empty stomach and administer oral Synthroid at least four hours apart from drugs known to interfere with absorption.
Review of the Medscape Drug Interactions checker revealed a minor interaction between Lasix and Synthroid. The Lasix increased toxicity of Synthroid and higher doses of Lasix may inhibit binding of thyroid hormones to carrier protein and result in transient increase in free thyroid hormones, followed by overall decrease in total thyroid hormone levels.
Observation from 07/20/21 at 10:30 A.M. to 07/22/21 at 8:15 A.M. of the medication administration revealed 37 medications were observed, for six of residents, administered by four nurses, with two medications errors made for a medication error rate of 5.4 percent.

Based on record review and interview the facility failed to ensure the Facility Assessment (FA) was comprehensive and reviewed annually as required. This had the potential to affect all 42 residents currently residing in the facility.
Findings include:
Review of the FA revealed it was not dated, updated nor did it contain any signatures, and was not comprehensive. The FA did not mention a Legionella bacteria plan, the capacity of the facility, the care required by the resident population and overall acuity level nor a comprehensive review of staff competencies necessary to provide the level and types of care needed for the resident population.
On 07/22/21 at 10:00 A.M., interview with the Director of Nursing (DON) verified the FA was not dated and there were no signatures available to show the assessment was reviewed annually as required.
On 07/22/21 at 4:40 P.M., interview with Administrator #82 verified the FA was not dated and did not have any signatures to show it was reviewed annually. The Administrator also verified the Legionella policy indicated the FA would identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system but there was no evidence or mentioning of a Legionella plan in the FA. Additionally, the FA did not contain the census, or adequate amount needed based on the acuity level (no acuity level) and no comprehensive review of staff competencies necessary to provide the level and types of care needed for the resident population was found.
Review of the water management program to reduce/eliminate Legionella bacteria policy, dated 09/21/17, revealed the facility would actively identify and manage hazardous conditions that support the growth and spread of Legionella, the facility would implement a water management program to reduce Legionella growth and spread by following the Center for Disease Control (CDC) guidelines. This included conducting a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. The program would include control measures including physical controls, temperature management, disinfectant level control, visual inspections and environmental testing of pathogens. The facility would identify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken as needed. In addition to testing areas of the building where pipes are continually wet, equipment such as breathing machines and hydrotherapy equipment may be tested.

Based on record review and interview the facility failed to ensure a comprehensive program to reduce and/or eliminate Legionella bacteria. This had the potential to affect all 42 residents currently residing in the facility.
Findings include:
Review of the most recent potable water samples report, completed by an outside company, was dated 01/11/2018. There was no further evidence of monitoring, testing, tracking, measuring or preventing Legionella bacteria.
On 07/22/21 at 4:40 P.M., interview with Administrator #82 verified the facility put the program in place in 2017 and the most recent monitoring, testing, tracking and/or prevention was 01/11/18. Administrator #82 verified the facility had a policy (which was not provided) that stated further monitoring, testing, tracking, and/or prevention measured would be implemented with an outbreak of Legionella bacteria.
Review of the water management program to reduce/eliminate Legionella bacteria policy, dated 09/21/17, revealed the facility would actively identify and manage hazardous conditions that support the growth and spread of Legionella, the facility would implement a water management program to reduce Legionella growth and spread by following the Center for Disease Control (CDC) guidelines. This included conducting a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. The program would include control measures including physical controls, temperature management, disinfectant level control, visual inspections and environmental testing of pathogens. The facility would identify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken as needed. In addition to testing areas of the building where pipes are continually wet, equipment such as breathing machines and hydrotherapy equipment may be tested.
Review of the undated Facility Assessment revealed it did not address Legionella bacteria.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #31 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, urinary retention and chronic obstructive pulmonary disease.
Review of the current plan of care related to bladder incontinence and urinary tract infections (UTI) revealed to monitor Resident #31 for signs and symptoms (s/s) including pain, burning, blood tinged urine, cloudiness, no urine output, deepening of urine color, increased temperature, urinary frequency, foul smelling urine, chills, altered mental status, change in behaviors and/or eating patterns. Check and change every two hours and as needed for incontinence. Wash, rinse and dry perineum after each incontinence episode, encourage adequate fluids and give antibiotic therapy as ordered. Notify the physician with any signs or symptoms (s/s) of a UTI.
Review of the physician progress note dated 05/18/21 revealed there were no concerns with Resident #31 continue to encourage fluids.
Review of the nurse notes dated 05/17/21, 05/18/21 and 05/19/21 revealed there was no evidence Resident #31 had any s/s of a UTI.
Review of the 05/19/21 urinalysis/culture and sensitivity (UA/C&S) test was submitted to the laboratory for testing. Further review of the physician order revealed an antibiotic (ATB) was started for 10 days.
Review of the nurses notes dated 05/19/21 revealed the physician was notified Resident #31 did not meet the criteria for the ATB stewardship program.
Review of the suspected UTI SBAR revealed Resident #31 did not meet the criteria to initiate ATB. The assessment was not signed or dated by any staff including the physician but did indicate an ATB was initiated.
Review of the UA/C&S results dated 05/21/21 revealed the results were received from the facility to show Resident #31 had escherichia coli in her urine.
Review of the medication administration record (MAR) revealed Resident #31 received the ATB as ordered from 05/19/21 through 05/29/21.
Review of the nurses notes dated 06/01/21 revealed Resident #31 had foul smelling urine but no other s/s and a UA/C&S was collected on 06/02/21.
Review of the nurses notes was dated 06/04/21 revealed to start Resident #31 on an intramuscular ATB due to the UA/C&S reported 06/04/21 stated Resident #31 had proteus mirabilis and providencia stuartii in her urine.
Review of the suspected UTI SBAR, dated 06/04/21, revealed Resident #31 did not meet the criteria to start an ATB therapy. There were no signatures on the assessment.
Review of the physician progress note dated 06/08/21 revealed there was no evidence Resident #31 had any recent UTIs.
Further review of the MAR revealed Resident #31 continued the course of ATB until it was finished on 06/14/21.
Review of the bladder assessment, dated 06/16/21, revealed Resident #31 was incontinent of urine.
Review of the nurses notes 06/14/21 through 06/25/21 revealed Resident #31 had no s/s of a UTI but on 06/20/21 a follow up UA/C&S was collected.
Review of the results of the UA/C&S reported 06/23/21 revealed Resident #31 had enercoccoccus faecalis in her urine and was started on an ATB.
Review of the suspected UTI SBAR, dated 06/24/21, revealed Resident #31 did not meet the criteria for starting ATB therapy. The assessment was not signed.
Further review of the nurses notes dated 06/26/21 revealed Resident #31 had a change in mental status and no other s/s.
Review of the MAR revealed Resident #31 started a course of ATB in the evening of 06/24/21 and continued to course until 07/01/21. The nurses notes dated 06/27/21, 06/28/21 and 07/01/21 indicated Resident #31 had foul smelling urine but no other s/s.
Review of the annual minimum data set (MDS) 3.0 dated 07/01/12 revealed Resident #31 was cognitively intact but needed assistance of staff for toileting.
Review of the physician progress note dated 07/06/21 revealed there was no evidence Resident #31 had recent UTIs.
Review of the nurses notes dated 07/07/21 revealed a follow up UA/C&S was obtained. Further review of the results reported on 07/09/21 revealed Resident #31 had pseudomonas airuginosa in her urine and the physician ordered an ATB despite not having any s/s.
Review of the suspected UTI SBAR, dated 07/09/21, revealed Resident #31 did not meet the criteria for initiating ATB therapy. The assessment was not signed.
Further review of the MAR revealed the ATB therapy was given as ordered from 07/09/21 through 07/19/21.
On 07/19/21 at 12:20 P.M., interview with Resident #31 denied any concerns with incontinence or UTIs.
On 07/20/21 at 8:17 A.M., 10:32 A.M., 11:23 A.M. and 12:35 P.M., Resident #31 was observed in bed. At 1:17 P.M., the resident was receiving incontinence care by State Tested Nurse Aide (STNA) #56 and #66.
On 07/20/21 at 1:36 P.M., interview with STNA #56 verified Resident #31 frequently refused to be taken to the toilet and frequently refused incontinence care. This was the first time all day she would allow them to do incontinence care. When the resident was taken to the toilet she performed her own pericare but when incontinent the staff provided pericare.
On 07/20/21 at 1:45 P.M., interview with STNA #66 verified Resident #31 had been refusing to be toileted and changed all day because she liked to stay in bed and not be bothered. When the resident was taken to the toilet she performed her own pericare but when incontinent the staff provided pericare.
On 07/21/21 at 9:40 A.M., Resident #31 was observed sleeping in bed.
On 07/21/21 at 10:58 A.M., interview with the Director of Nursing (DON) and LPN #62, who was assisting in the infection prevention role, verified the medical director (MD) #80 was the physician at the facility and he saw all the residents. The DON stated MD #80 thought Resident #31 may have a dropped bladder but the resident refused to go see a urologist. LPN #62 verified she initiated all above suspected UTI SBAR assessments and they may not have been completed timely and verified there were no signatures by any staff nor the physician. LPN #62 also verified the SBARs showed Resident #31 did not meet the criteria for initiated ATB therapy and when she informed the physician he would still continue the ATB therapy. The DON stated the nurse who received the results of the UA/C&S should inform the physician of the results with the results of the suspected UTI SBAR but there was no evidence this was being done. The DON stated it was the physician's decision when to use the ATB and had not done any education and/or training with the physician related to the ATB stewardship program. The DON verified the ATB stewardship policy and procedures were not being followed in an attempt to reduce the use of ATBs.
On 07/21/21 at 11:27 A.M. and 2:00 P.M., Resident #31 was observed sleeping in bed.
On 07/21/21 at 3:08 P.M., interview with Pharmacist (RPH) #80 revealed he was not included in the ATB stewardship program nor did he receive any of the UA/C&S results. RPH #80 stated the facility had a high rate of ATB usage and was informed of this but there had not been any discussions in an attempt to try and reduce the amount of ATB use.
On 07/21/21 at 4:10 P.M., Resident #31 was receiving incontinence care.
On 07/22/21 at 3:12 P.M., phone interview with MD #80 verified he attended the quality assurance meetings as well as addressed any concerns the day they arise and does not wait until a meeting. When asked about ATB stewardship program he stated there was still some debate on that but verified he was not involved in the program. The physician stated he tried not to use an ATB unless they were needed. He verified Resident #31 was on four different ATBs that did not meet the criteria for use since May 2021 but his progress notes did not reflect the resident had any UTIs.
Review of the ATB stewardship program policy, dated 11/11/17, revealed the program would improve resident safety and potentially impact rates of antimicrobial resistance. The act of using ATBs appropriately by using ATBs only when truly needed and by using the correct ATB for each infection. Stewardship or protecting the effectiveness of ATB, which is the most important tool available to treat life threatening bacterial infections. ATB resistance occurs when the bacteria adapt so drugs used to treat infections are less effective or do not work at all. The facility would work closely with the Center for Disease Control (CDC) recommendations and implement their core elements consisting of the infection preventionist (IP) having resources, the Medical Director being responsible for the program outcomes and the pharmacist working with staff to improve (reduce) ATB use. The facility would work together to identify recommended actions as an ATB time out 48-72 hours after the initial ATB had been started. This would include working closely with the physician and the pharmacist after the culture results become available to see if the ATB is the right choice, dose and route. And if an ATB should be given and if so for how long the ATB should be given. The facility would monitor at a minimum: if started in the facility, was the suspected UTI SBAR form used, which ATB was prescribed, cultures that were performed including results, was ATB appropriate or were there resistance patterns. The IP would report at a minimum quarterly, at the quality assurance meeting, to the physician, nurses and relevant staff the findings on ATB use and resistance and the on-going process. Education would be completed and performed to staff on an on-going and case-by-case bases on audits of the suspected UTI SBAR use, ATB initiation and result findings. The facility would educate staff on the Stop-and-Watch program to help identify changes in the resident conditions. Staff would fill out the Stop-and-Watch form, located at both nurses stations, when a change in condition or something out of the normal was recognized. The facility would follow the policy titled minimum criteria for common infections.
Review of the minimum criteria for common infections, dated 11/22/17, revealed it was aimed at reducing the unnecessary prescribing for the three infections where ATB were most frequently prescribed including UTIs. The resident suspected of having an infection would be assessed and a suspected UTI SBAR form would be completed. For UTIs without an indwelling catheter, the resident should meet criteria of one of the three situations: acute dysuria alone OR fever of 100 degrees Fahrenheit AND at least one of the following new or worsening conditions: urgency, frequency, suprapubic pain, gross hematuria, costovertebral angle tenderness, urinary incontinence OR no fever, then two or more of the following: urgency, frequency, suprapubic pain, gross hematuria or urinary incontinence. Also, urine cultures should not be used to identify UTIs in the absence of symptoms. Smelly or cloudy urine is not a symptom of a UTI. Urine cultures should be used to identify the most appropriate ATB use if needed.
Based on medical record review, policy review, review of infection control tracking logs, and interview, the facility failed to ensure residents who received antibiotic orders were reviewed for appropriateness of use in a timely manner to permit communication with the physician regarding those residents who did not meet criteria of infections. The facility also failed to involve the pharmacist in the antibiotic stewardship program after multiple residents were treated with antibiotics without criteria for infections being met. This affected one (Resident #31) of two residents reviewed for urinary tract infections and had the potential to affect all 41 other residents currently residing in the facility. The facility census was 42.
Findings include:
1. Review of the facility's Antibiotic Stewardship Program policy (effective 11/11/17) revealed the pharmacist was to work with staff to improve antibiotic use. The facility would monitor antibiotics started in the facility if the SBAR (SBAR is an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication.) was form was used and if the antibiotic use was appropriate. The policy indicated the facility was to follow a policy titled Minimum Criteria for Common Infections.
Review of the facility's policy, Minimum Criteria for Common Infections (effective 11/22/17), indicated the purpose of the policy was to reduce unnecessary use of antibiotics. If a resident did not meet criteria the nurse could ask the physician for supporting treatment. The SBAR form was to be used on an as needed basis any time an infection was suspected regardless of the type of infection. The policy indicated minimum criteria were necessary for initiating an antibiotic.
Review of the May 2021 Infection control tracking log revealed the following residents were treated for infections but evaluation on the SBAR revealed the residents did not meet the criteria for infections:
Resident #200 for a urinary tract infection (UTI)
Resident #205 for pneumonia
Resident #210 for UTI
Resident #215 for pneumonia
Resident #31 for UTI
Resident #43 for UTI
Review of the June 2021 Infection control tracking log revealed the following residents were treated for infections but evaluation on the SBAR revealed the residents did not meet the criteria for infections:
Resident #31 for UTI with onset dates of 06/05/21 and 06/24/21
Review of the July 2021 Infection control tracking log revealed the following residents were treated for infections but only one resident (Resident #31) had an evaluation on the SBAR and criteria for infection was not met:
Resident #43 for UTI
Resident #36 for wound infection
Resident #31 for UTI
Resident #44 for skin infection
Resident #6 for UTI
Resident #1 for pneumonia
Resident #12 for pneumonia
On 07/21/21 at 3:13 P.M., Pharmacist #80 stated he had not been involved in the antibiotic stewardship program, indicating he had not been asked to discuss the use of antibiotics for residents who did not meet criteria for infections with the physician.
On 07/22/21 at 1:45 P.M., Licensed Practical Nurse (LPN) #62 stated she was responsible for notifying the physician if residents with antibiotic orders did not meet criteria for infections. The physician did not provide rationale for continuing antibiotics without the criteria being met.
On 07/22/21 at 2:30 P.M., Administrator #43 stated he was aware of the physician prescribing antibiotics without criteria being met. Administrator #43 stated the facility discussed antibiotic use and infections every month during Quality Assurance meetings but refused to provide a topic list of areas discussed.
On 07/22/21 at 4:40 P.M., LPN #62 stated the facility had not evaluated antibiotics ordered in July 2021 to determine if criteria for infections was met. LPN #62 agreed the facility would not be able to address if an ordered antibiotic did not meet criteria for an infection if staff did not evaluate if criteria was met in timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure the physician was notified of a change in status of a pressure ulcer for Resident #28. This affected one (Resident #28) of three residents reviewed for pressure ulcers.
Findings include:
Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with the diagnoses of infection in left knee, arthritis, severe protein calorie malnutrition, epilepsy, altered mental status, gastro-esophageal reflux disease, osteoarthritis, COVID-19, major depression, hypertension, hemiplegia, and hemiparesis to left side following a cerebrovascular disease, and psychosis.
Review of the plan of care dated 01/21/21 revealed Resident #28 was at risk or had altered skin integrity due to being admitted with wounds and being at risk for skin breakdown due to immobility, disease process and weakness. Interventions included to follow the facility skin protocol, immediately report any skin redness or breakdown to the nurse, inspect the skin with showers and baths and provide information to the nurse to review, notify the physician of any changes in the skin as needed, and perform treatments as ordered.
Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition, required extensive assistance with all activities of daily living and had a stage three (Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) in house pressure ulcer.
Review of the Weekly Wound Report dated 02/16/21 revealed Resident #28 was found to have a stage three pressure ulcer to his left outer ankle which measured 4.0 centimeters (cm) in length by 1.0 cm in width by less than 1.0 cm in depth.
Review of the Weekly Wound Report dated 03/30/21 revealed Resident #28 had a stage three pressure ulcer to his left outer ankle which measured 2.5 cm in length by 1.3 cm in width by less than 1.0 cm in depth
Review of the Weekly Wound Report dated 04/20/21 revealed the left ankle wound of Resident #28 measured 1.5 cm in length by 1.0 cm in width by 1.0 cm in depth, was a stage three, and had 25 percent slough in the wound bed.
Review of the Weekly Wound Report dated 04/27/21 revealed the left ankle wound of Resident #28 measured 2.5 cm in length by 2.0 cm in width by 1.0 cm in depth, was a stage three, and had 25 percent slough in the wound bed. There was no documentation the physician was notified of the decline.
Review of the nursing notes/wound notes dated 04/27/21 at 7:37 A.M. revealed Resident #28 had a stage three pressure ulcer on the left ankle due to rubbing the foot repeatedly on the bed and from the plastic AFO (ankle foot orthosis) brace. There was no documentation of the decline or the physician was notified of the decline.
Interview on 07/22/21 at 2:50 P.M. with the Director of Nursing confirmed there was no documentation the physician was notified on 04/27/21 of the change in status of the left ankle pressure ulcer of Resident #28.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #33 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease and urinary tract infections.
Review of the quarterly MDS 3.0, dated 06/18/21, revealed Resident #33 was alert and oriented and able to make her needs known. The resident needed extensive assistance of one person for toileting.
Review of the current constipation plan of care revealed Resident #33 was at risk for constipation due to decreased mobility. Interventions included to follow the bowel protocol, monitor, document and report any signs or symptoms related to constipation and record bowel movements (BM) each day.
Review of the BM record for June 2021 revealed Resident #33 did not have a BM after 06/15/21 at 1:58 P.M. until 06/20/21 at 1:13 A.M. There was no evidence the as needed medication for constipation was given. Further review of the June 2021 BM into July 2021 revealed after 06/28/21 at 11:14 P.M. Resident #33 did not have a BM until the afternoon of 07/03/21 at 5:37 P.M. There was no evidence the as needed mediation for constipation was given.
On 07/22/21 at 11:39 A.M., interview with the DON verified the as needed medication for constipation was not given as planned. If no BM after three days a resident should be given milk of magnesia which was the standard of practice and was not done. Further review of the current constipation protocol verified it was not consistent with the standard of practice and needed updated.
Based on medical record review, policy review, and interview the facility failed to implement a bowel protocol for two (Residents #10 and #33) of five residents reviewed for medication use.
Findings include:
1. Review of Resident #10's medical record revealed diagnoses including dementia, type 2 diabetes mellitus, and pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was moderately cognitively impaired. Resident #10 required extensive assistance for toilet use and was always incontinent of bowel. Resident #10 had physician orders for two tablets of senna 8.6 milligrams (mg) in the morning for constipation, a dulcolax suppository every 72 hours as needed for constipation, and 30 milliliters (ml) of milk of magnesia every 72 hours as needed for constipation per bowel protocol. Resident #10's plan of care was silent regarding constipation and/or bowel protocol to be implemented. Review of bowel movement (BM) records since 06/22/21 revealed no recorded bowel movement from 06/23/21 to 06/26/21, 07/08/21 to 07/11/21, or 07/15/21 to 07/18/21. There was no evidence of milk of magnesia or dulcolax suppositories being administered according to physician orders.
Review of the facility's Constipation policy (dated 01/30/16) revealed the night shift charge nurse would monitor bowel movement records daily and a bowel movement list would be created every night on a communication board. If a resident had no bowel movement for two days the resident would receive a laxative from the day shift charge nurse. If the resident did not have an order for a laxative to be administered on an as necessary basis, standing orders could be utilized. If the resident had no bowel movement for three days the night shift charge nurse would administer a suppository. If the resident did not have an order for a suppository, standing orders could be utilized. If the resident had no bowel movement for four days the charge nurse would administer a fleets enema during day shift or the first two hours of afternoon shift. The enema could be administered in accordance with standing orders. When a resident refused the laxative or suppository and there was no bowel movement within 24 hours a primary care provide had to be notified. When a resident refused an enema the primary care provider needed notified the same day.
On 07/22/21 at 11:47 A.M. Registered Nurse (RN) #53 verified Resident #10's care plan did not address constipation.
On 07/22/21 at 9:30 A.M. the lack of documentation of bowel movements and lack of documentation of bowel medications being administered was addressed with the Director of Nursing (DON). No additional information was provided.
Review of the facility's Bowel Training policy (effective 05/01/16) indicated daily bowel movement was not necessary but time between bowel movements should not exceed three days. Staff were to ascertain when the last bowel movement occurred. If there was no bowel movement within three days, a digital rectal exam was to be completed. If firm stool was felt on digital exam, give gentle soapsuds enema or enema of choice ordered by the physician. Staff were instructed to document the following in the resident's record: bowel program established and results, pertinent information, and instructions given to resident/caregiver.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, interviews with staff, and review of the facility policy the facility failed to prevent the development of a pressure ulcer for Resident #28. Actual harm occurred when Resident #28 developed an avoidable, in house acquired, stage three (full thickness wound with fat and tissue exposed) pressure ulcer to the left outer ankle. This affected one (Resident #28) of three residents reviewed for pressure ulcers. The facility census was 42.
Findings include:
Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including infection in left knee, arthritis, severe protein calorie malnutrition, epilepsy, altered mental status, gastro-esophageal reflux disease, osteoarthritis, COVID-19, major depression, hypertension, hemiplegia, and hemiparesis to left side following a cerebrovascular disease, and psychosis.
Further review of the medical record revealed Resident #28 was discharged to the hospital on [DATE] and the order for the Left Ankle Foot Orthosis (AFO) brace was discontinued on 11/24/20. Resident #28 was readmitted to the facility on [DATE] without an order for the left AFO, however, the staff continued to place the AFO on the resident.
Review of the Braden scale dated 12/02/20 revealed Resident #28 was high risk for developing pressure ulcers.
Review of the significant change in status Minimum Data set 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition, required extensive assistance for all activities of daily living (ADLS), and was at risk for pressure ulcers. The resident did not have any unhealed pressure ulcers and had a surgical wound.
Review of the plan of care dated 01/21/21 revealed Resident #28 was at risk or had altered skin integrity due to being admitted with surgical wounds and being at risk for skin breakdown due to immobility, disease process and weakness. Interventions included to follow the facility skin protocol, immediately report any skin redness or breakdown to the nurse, inspect the skin with showers and baths and provide information to the nurse to review, notify the physician of any changes in the skin as needed, and perform treatments as ordered.
Review of the January 2021 and February 2021 Medication Administration Record and Treatment Administration Record revealed no documentation of skin checks of the left ankle and/or under the AFO brace of Resident #28.
During review of the medical record there was no evidence found of skin checks or shower sheets with skin checks for Resident #28.
Review of physician orders for January and February 2021 revealed Resident #28 did not have an order for an AFO brace to the left foot.
Review of the wound/skin progress note dated 02/16/21 revealed Resident #28 had a stage three pressure ulcer on the left outer ankle due to him rubbing his foot repeatedly on the bed and from the plastic AFO brace.
Review of the Weekly Wound Report dated 02/16/21 revealed Resident #28 was found to have a stage three pressure ulcer to his left outer ankle which measured 4.0 centimeters (cm) in length by 1.0 cm in width by less than 1.0 cm in depth.
Review of the physician's orders dated 02/16/21 revealed Resident #28 had an order to hold the use of the AFO brace due to a pressure area on the left ankle.
Interview on 07/21/21 1:20 P.M. the Director of Nursing (DON) indicated the State Tested Nursing Assistants (STNA) did not document under tasks for skin observations.
During a telephone interview on 07/21/21 at 1:40 P.M. Registered Nurse (RN) #51, who was the facility's wound nurse, indicated she was told by the wound company to stage Resident #28's wound at a stage three for proper treatment. She indicated his AFO brace was rubbing his ankle and caused a pressure ulcer.
During interview on 07/21/21 at 2:00 P.M. the DON verified there was no documentation of skin observation prior to the facility finding the stage three pressure ulcer to the left outer ankle of Resident #28 and there were no shower sheets to indicate the staff had been performing skin assessments on Resident #28 per his plan of care.
During interview on 07/21/21 at 4:10 P.M. STNA #74 indicated they were to check a resident's skin during their bath or shower. They would then fill out a shower sheet and give it to the nurse, the nurse would sign it and they would put it in the shower book. She stated Resident #28 did get up and get a shower every week before he went on hospice but now hospice does his shower. She indicated they put the resident's AFO brace on when he got up out of bed and took it off while he was in bed.
Review of the medical record revealed Resident #28 did not go under hospice care until 02/28/21.
During interview on 07/21/21 at 4:15 P.M. Licensed Practical Nurse ((LPN) #73 indicated the STNA would fill out the shower sheet, give the sheets to the nurses, the nurses would sign the shower sheet and the STNA would put the sheet into the shower book on the unit. She indicated she had been checking the skin under Resident #28's AFO brace, however, she had not documented anywhere in his chart she had done it.
During interview on 07/22/21 at 8:37 A.M. LPN #62 indicated Resident #28 had been in and out of the hospital so many times the order for his AFO brace must have dropped off and was never picked back up. She verified Resident #28 did not have an order for the AFO brace at the time he acquired the stage three pressure ulcer to his left outer ankle.
During interview on 07/22/21 at 8:45 A.M. Resident #28 indicated he was unable to move his left leg and didn't feel much, however, he had told the staff his ankle was bothering him and that was when they found the sore. He indicated the staff did take the brace off at night, but they did not take his socks off.
Observation on 07/22/21 at 11:09 A.M. revealed LPN #63 provided wound care to the left outer ankle pressure wound of Resident #28 with no concerns. The wound was approximately 1.0 cm in width by 1.0 cm in length with an undetermined depth due to the nurse did not measure the wound. The wound bed and peri wound was pink with granulation. There was a small amount of yellow drainage on the old dressing.
Review of the facility policy, Nursing-Skin, dated 05/01/16 revealed the policy was to identify resident at risk for the development of pressure ulcers and define early interventions. Early interventions refer to treatment prescribed for those residents determined to be a risk for developing pressure ulcers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record and interviews with staff the facility failed to ensure Resident #12 had her oxygen on as ordered. This affected one (Resident #12) of two residents reviewed for respiratory therapy.
Findings include:
Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of pulmonary embolism, hypertension, spondylosis, chronic kidney disease, hernia, myocardial infarction, and chronic sinusitis.
Review of the admission Minimum Data Set 3.0 assessment revealed Resident #12 had moderately impaired cognition and did not require oxygen.
Review of the July 2021 physician's orders revealed Resident #12 had an order dated 05/12/21 for oxygen at two liters via nasal cannula, continuously, for shortness of breath.
Observation on 07/21/21 at 3:45 P.M. revealed Resident #12 was in bed without her oxygen on. The nasal cannula was hanging on the oxygen concentrator across the room.
Interview on 07/21/21 at 3:45 P.M. with Resident #12 indicated she had not had it on for awhile because they never put it on her when she came back from her appointment.
Observation on 07/21/21 at 3:47 P.M. revealed Licensed Practical Nurse (LPN) #73 checked Resident #12's oxygen saturation and she was at 83 percent. LPN #73 had put the resident's oxygen back on her and her oxygen saturation immediately came up to 88 percent. An interview at this time with LPN #12 verified Resident #12's oxygen should have been on her continuously per physician's orders.