Altercare Thornville Inc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital record review, wound notes, facility and staff interviews, wound physician interview, observation, review of the facility policies, and National Pressure Injury Advisory Panel (NPIAP) information, the facility failed to develop and implement an accurate comprehensive and individualized pressure ulcer program to ensure necessary care and services to prevent the worsening of pressure ulcers for Resident #800 and #300. This affected two residents (#800 and #300) of two residents reviewed for pressure ulcers. The facility census was 47. This resulted in Immediate Jeopardy and serious life-threatening harm to Resident #800, who was assessed as requiring maximum assistance with bed mobility and transfers and was at risk for pressure ulcer development, on 05/04/25 when treatment orders for known pressure ulcers were not obtained timely, orders were entered incorrectly resulting in wrong treatments and pressure ulcer worsening and prevention care was not in place leading to an admission to the hospital for subsequent infection/sepsis. Resident #800 was ultimately placed on hospice due to multiple antibiotic use from worsening of pressure ulcers. This also resulted in Immediate Jeopardy and serious life-threatening harm to Resident #300, who was assessed as requiring maximum assistance with bed mobility and transfers and at risk for pressure ulcer development, on 06/24/25 when the resident was assessed to have a stage 4 (full thickness skin and tissue loss with exposed palpable fascia, muscle, tending, ligament, cartilage or done in the ulcer; slough and/or eschar may be visible) pressure ulcer to the right buttock that previously was a stage 3 (full thickness loss of skin, in which adipose [fat] is visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present; fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed) the week prior, due to medicated treatments not being placed in the orders for administration from 06/19/25 through 06/23/25. On 08/11/25 at 1:11 P.M., Administrator #41, Regional Nurse #68, Director of Nursing (DON) #40, and Regional Administrator #69 were notified Immediate Jeopardy began on 05/04/25 when the facility failed to provide any treatments as well as accurate treatments and necessary interventions to prevent worsening of pressure ulcers resulting in the hospitalization of Resident #800 for infection/sepsis from pressure ulcers. Resident #800 returned to the facility on [DATE] and was sent back to the hospital for continued inaccurate treatments and necessary interventions to prevent worsening of pressure ulcers on 06/27/25. Resident #800 returned to the facility on [DATE] and was ultimately placed on hospice due to multiple antibiotic use from worsening of pressure ulcers. Immediate Jeopardy also occurred on 06/24/25 when the facility failed to provide the medicated treatment of Leptospermum Honey and Alginate Calcium to be applied daily with a gauze island bordered dressing from 06/19/24 through 06/23/25 to a right buttock stage 3 pressure ulcer measuring 6.8 centimeters (cm) long, 5.4 cm wide and 0.2 cm in depth with moderate serous exudate and 50 percent necrotic tissue. On 06/24/25, the right buttock pressure ulcer was assessed to have worsened to a stage 4 and measured 7 cm long, 5.4 cm wide, and undetermined depth with 20 percent black necrotic(dead) eschar tissue, 50 percent devitalized necrotic tissue and 20 percent slough (dead tissue separating from living tissue). The immediate Jeopardy was removed on 08/11/25 when the facility implemented the following corrective actions: On 08/07/25, Resident #300 was assessed by Wound Care Physician #70 with orders received and followed by a licensed nurse, Assistant Director of Nursing (ADON)/Wound Nurse# 33. On 08/07/25, Resident #800 was assessed by Wound Physician #70 with new orders received and followed by a licensed nurse ADON/Wound Nurse# 33. On 08/07/25 at 10:00A.M., an in-service was completed for ADON/Wound Nurse #33 by DON #40 and Regional Nurse #68 on the policy of Pressure Injuries: assessment, prevention, and treatment and the policy of physician notification. On 08/07/25 at 11:30A.M., an in-service was completed for Minimum Data Set ( MDS) Nurse #42, Registered Nurse (RN) #34, RN #27, RN #56, Licensed Practical Nurse (LPN) #44, LPN #25, LPN # 65, LPN #30, and 26 Certified Nursing Assistants (CNA) by DON #40 on the policy of pressure Injuries: assessment, prevention, and treatment policy; completing head to toe assessment and documenting on skin sheet, if resident has skin alterations; documenting the initial wound observation; and contacting House Physician #66 to obtain treatment orders if not provided from the hospital. Any staff who had not received education as of 08/11/25 will not work until education is completed. All staff had received the education as of 08/11/25. On 08/07/25 at 11:30A.M., an in-service was completed for MDS Nurse #42, RN #34, RN #27, RN #56, LPN #44, LPN #25, LPN # 65, LPN #30 by the DON #40 on notifying physician of any resident change in condition. Any staff who have not received education as of 08/11/25 will not work until education is completed. All staff have received the education as of 08/11/25. By 08/11/25, a whole facility skin sweep was completed for 48 residents to identify any skin alterations by LPN #30 and ADON/Wound Nurse #33. Any residents with new skin alterations were reviewed by the DON #40 and House Physician #66 notified. No new pressure injuries were identified during whole house skin sweep. On 08/11/25 at 11:00 A.M., treatment orders for 48 residents were reviewed by the Regional Nurse #68 to ensure that treatment orders are appropriate for any skin alterations. As of 08/11/25, a list of any residents being followed by the wound care physician will be maintained by DON #40. For newly admitted residents, based on the admission skin assessment, the resident will be added to the wound consult as applicable. For current residents, any new skin alteration identified will be reviewed and added to the wound consult as applicable. On 8/11/25, at 1:30 P.M., an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with House Physician/Medical Director #66 and facility leadership DON #40, Administrator #41, MDS/RN #42, ADON/Wound Nurse #33, Regional Administrator #69, and Regional Nurse #68 on pressure ulcer care and plan of correction. An audit to ensure pressure ulcer care is being completed per policy will be conducted for five residents three times a week for four weeks and as needed (PRN) by the DON or designee. Any concerns will be forwarded to the QAPI committee for immediate follow up. An audit to ensure wound consults are accurate on the consult sheet and orders from wound consults are entered appropriately and assigned to the correct physician will be completed once a week for four weeks and PRN by the DON or designee. Any concerns will be forwarded to the QAPI committee for immediate follow-up. An audit to ensure residents being followed by the wound care physician is being maintained by the DON, newly admitted residents are added to the wound consult list as applicable, and current residents with any new skin alterations are added to the wound consult list as applicable will be conducted once per week for four weeks and PRN by the regional nurse consultant or designee. Any concerns will be forwarded to the QAPI committee for immediate follow-up. QAPI plan completed by 08/11/25. Although the Immediate Jeopardy was removed on 08/11/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #800 revealed an admission date of 04/18/25 at 4:56 P.M. Diagnoses included weakness, cerebral infarction, atrial fibrillation, type 2 diabetes, and chronic kidney disease. Review of Resident #800 ' s hospital discharge summary that was received by the facility and dated 04/18/25, revealed a wound care order for a sacrum area to cleanse the wound with mild soap and water, rinse and pat dry. Apply triad cream at dime thickness and cover with Mepitel One, a wound dressing, to be changed every three days. The summary had no wound measurements, descriptions or classification. No other treatments or open skin areas were documented in the discharge paperwork. Review of Resident #800 ' s Braden Scale for Predicting Pressure Sore Risk, dated 04/18/25, revealed a score of 14 on a scale of six (high risk) to 23 (no risk), which indicated the resident was at moderate risk for skin breakdown. Review of the admission wound goal plan of care, dated 04/18/25, revealed to be admitted with multiple pressure areas with wound prevention and treatment approaches to include encourage to turn and re-position comfortably every two hours, check skin with daily care and bathing weekly. Report any skin concerns to the nurse/Nurse Practitioner/Physician and to record wound measurements weekly. Review of the admission initial wound grid documentation, dated 04/19/25 at 1:22 A.M., revealed a left buttock stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising; may also present as an intact or open/ ruptured blister) pressure ulcer scattered areas with moisture associated skin damage (MASD) surrounding it with no measurements. Additional initial wound grid documentation, dated 04/19/25 at 1:25 A.M., revealed a right buttock unstageable (a full thickness skin and tissue loss where the depth of the tissue damage cannot be determined because it ' s obscured by slough or eschar) pressure ulcer that measured 12 cm by 5.8 cm by 0.1cm. There was no documentation of an initial wound grid for the area on Resident #800 ' s sacrum. Review of the physician order dated 04/19/25 at 2:10 A.M. revealed for the right buttock- cleanse with mild soap and water, apply Triad cream a debriding medication) at dime thickness and cover with a Mepitel One dressing and change as needed when soiled/dislodged. This order was active until discontinued on 04/23/25 at 8:33 A.M. by FWN #33. Review of the physician orders dated 04/18/25 through 04/22/25 for Resident #800 resident revealed no wound treatment order for the sacral area as noted on hospital discharge documentation; no wound treatment order for the documented area on admission for the left buttock stage 2 pressure ulcer; and no interventions for general facility pressure ulcer injury prevention and care. Review of the Treatment Administration Record (TAR) for Resident #800 dated 04/18/25 through 04/22/25 revealed no as needed dressing change was completed for the right buttock unstageable pressure injury. Review of the initial wound consult visit by Advanced Practice Registered Nurse (APRN) #71, dated 04/22/25 with no time stamp of visit, revealed Resident #800 had several pressure ulcer areas. Identified was a right buttock unstageable pressure ulcer measuring 11.2 cm by 5.9 cm with undetermined depth with moderate serous exudate and 50 percent necrotic tissue. A treatment plan of Leptospermum Honey and Alginate Calcium to be applied daily with a gauze island bordered dressing. Another identified area was the left buttock unstageable deep tissue injury (DTI) pressure ulcer measuring 8.4 cm by 4.2 cm with undetermined depth with a treatment plan of house barrier cream twice a day. Finally, identified was a coccyx unstageable pressure ulcer measuring 4.2 cm by 1.1 cm by undetermined depth with moderate serous exudate and 100 percent slough. A treatment plan of Leptospermum Honey and Alginate Calcium to be applied daily with a gauze island bordered dressing. There were recommendations for additional care plan items including a low air-loss mattress, offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800, dated 04/23/25 at 9:34 A.M. revealed a treatment for the coccyx pressure ulcer of apply Leptospermum Honey and an island adhesive dressing daily. The treatment to include Alginate Calcium was omitted from the order. The order was discontinued on 04/29/25 at 1:29 P.M. by FWN #33. Review of the physician orders dated 04/22/25 through 04/29/25 revealed on 04/24/25, an alternating low air loss mattress was ordered, but for the left buttock unstageable DTI pressure ulcer treatment plan of house barrier cream twice a day was not ordered as well as no reposition per facility protocol and offloading of the wounds. Review of the TAR for Resident #800 dated 04/23/25 through 04/28/25 revealed the incorrect treatment order was administered for the coccyx unstageable pressure ulcer. Review of the admission Minimum Data Set (MDS) assessment, dated 04/25/25, revealed Resident #800 was alert and oriented. The resident required substantial/maximal assistance with shower/bathe self, bed mobility, toilet hygiene, and transfers and was at risk for pressure ulcer injuries. Review of Wound Physician visit notes, dated 04/29/25 with no time stamp, revealed Resident #800 was seen by APRN #71. Resident #800 to still had several pressure ulcer areas. The right buttock pressure ulcer progressed to a Stage 4 and measured 7.8 cm by 5.9 cm with undetermined depth and moderate serous exudate and 50 percent necrotic tissue. A new treatment plan was for Alginate Calcium and Santyl daily with a gauze island dressing. A surgical excisional debridement was performed due to removal of necrotic tissue and to establish the margins of viable tissue. The left buttock unstageable DTI pressure ulcer measured 7.3 cm by 4.2 cm with undetermined depth. A new treatment plan was for Alginate Calcium and Santyl daily with a gauze island dressing. The coccyx pressure ulcer measured 3.9 cm by 0.9 cm with undetermined depth and moderate serous exudate and 100 percent slough. The new treatment plan was for Alginate Calcium and Santyl daily with gauze island dressing. Recommendations for additional care plan items included to offload wounds and reposition per facility protocol. Review of the physician orders dated 04/29/25 through 05/03/25 revealed the left buttock pressure ulcer treatment of Alginate Calcium and Santyl daily with a gauze island dressing from APRN #71 was not ordered as well as no reposition per facility protocol and offloading of the wounds. The interventions for the risk for skin breakdown dated 04/18/25 were not started until 05/01/25 and included to assist resident with turning and repositioning frequently while in bed and an air mattress. Review of the progress note for Resident #800, dated 05/04/25 at 10:49 A.M., documented the resident was confused and delusional, and the nurse spoke to the 24/7 on call physician line and obtained an order to send resident to the hospital. The resident left the faciity on [DATE] at 11:02 A.M. Review of the hospital documentation for Resident #800 ' s admission on [DATE] revealed cellulitis of decubitus ulcer to the sacral region confirmed by a computed tomography (CT) scan image. Treatment included surgical debridement of the site and broad-spectrum antibiotics for the area. Resident #800 was discharged back to the facility on [DATE] with intravenous antibiotics, but no wound care instructions, measurements, descriptions and classification of any skin areas. Review of the progress note dated 05/09/25 at 5:11 P.M. revealed Resident #800 returned to the facility from the hospital. Review of the admission initial wound grid documentation dated 05/09/25 at 5:39 P.M. revealed a coccyx unstageable pressure ulcer measured 14 cm by 8 cm by 0.6 cm. Review of the admission wound goal plan of care dated 05/09/25 for Resident #800 revealed resident admitted with a high wound risk, with wound prevention and treatment approaches to include encourage to turn and re-position comfortably every two hours. Review of Resident #800 ' s Braden Scale for Predicting Pressure Sore Risk dated 05/09/25 revealed a score of 14 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at moderate risk for skin breakdown. Review of the active care plan initiated on 04/18/25 from original admission for Resident #800 revealed at risk for skin break down with no new approaches added since 05/01/25 and included to assist resident with turning and repositioning frequently while in bed and an air mattress. Review of treatment orders for Resident #800 revealed for the coccyx unstageable pressure ulcer, no treatment was in place until 05/10/25 at 12:58 P.M. when the floor nurse obtained an order from Physician #66. This order was discontinued on 05/12/25 at 1:11 A.M. by FWN #33. Review of the physician orders for Resident #800 revealed a written treatment order written by FWN #33 from Wound Doctor #70 entered on 05/12/25 at 1:13 A.M. for the coccyx pressure ulcer to apply a nickel thick layer of Santyl to wound bed and cover with a comfort foam border dressing every three days. This order was discontinued on 05/13/25 at 12:51 P.M. by the FWN #33. Review of the TAR dated 05/12/25 revealed Resident #800 received a treatment completed to the coccyx unstageable pressure ulcer. Review of the medical record revealed no written order from Wound Physician #70 for the coccyx unstageable pressure ulcer to apply nickel thick layer of Santyl to wound bed and cover with a comfort foam border dressing every three days that was written by FWN #33 and entered on 05/12/25. Review of the active physicians ' orders dated 05/09/25 through 05/16/25 for this resident revealed the only intervention for pressure ulcer injury prevention and care was an alternating low air loss mattress. Review of Wound Physician Visit notes revealed Resident #800 was seen by APRN #71 on 05/13/25. Resident #800 had one pressure ulcer area to the coccyx. The area was a stage 4 and measured 11.4 cm by 8.7 cm by 2.4 cm with moderate serous exudate and 30 percent necrotic tissue. The treatment plan was sodium hypochlorite solution (Dakin ' s solution), pack wound with soaked gauze and apply daily abdominal dressing. A surgical excisional debridement procedure was also completed due to removal of the necrotic tissue to establish the margin of viable tissue. There were recommendations for additional care plan items including a low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 05/13/25 at 12:56 P.M. entered by the FWN #33 and discontinued on 05/19/25 at 11:41 A.M. by the FWN #33, revealed a treatment for the coccyx stage 4 pressure ulcer for Leptospermum Honey to fill and cover all open areas and cover all areas with Alginate Calcium, cover with an abdominal pad daily. The APRN #71 ' s treatment plan on 05/13/25 was for sodium hypochlorite solution (Dakin ' s solution) to pack wound with soaked gauze and apply daily with abdominal dressing. Review of Resident #800s TAR dated 05/13/25 through 05/18/25 revealed an incorrect treatment completed for the coccyx stage 4 pressure ulcer. Review of the physician order dated 05/16/25 revealed to turn and repositioned every two hours along with the alternating low air loss mattress, but no other pressure ulcer preventions and care. Review of the physician order for Resident #800 dated 05/19/25 at 11:41 A.M. revealed a treatment order for the coccyx stage 4 pressure ulcer to pack wound with Dakin ' s solution-soaked gauze, cover with an abdominal dressing daily. This is the order from 05/13/25 the APRN #71 originally ordered on 05/13/25. This order was discontinued on 06/13/25 at 7:38 A.M. by FWN #33. Review of Wound Physician notes dated 05/20/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 11.2 cm by 0.4 cm by 3.2 cm with moderate serous exudate and 30 percent necrotic tissue. The treatment plan was to continue sodium hypochlorite solution (Dakin ' s solution), pack wound with soaked gauze and apply daily with an abdominal dressing. A surgical excisional debridement procedure was also completed due to removal of the necrotic tissue to establish the margin of viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of Wound Physician notes dated 05/27/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.1 cm by 6.4 cm by 3 cm with moderate serous exudate and 20 percent necrotic tissue. The treatment plan was to continue sodium hypochlorite solution (Dakin ' s solution) to pack wound with soaked gauze and apply daily with an abdominal dressing. A surgical excisional debridement procedure was also completed due to removal of the necrotic tissue to establish the margin of viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of Wound Physician notes dated 06/03/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.1 cm by 6.2 cm by 2.6 cm with moderate serous exudate and 40 percent slough tissue. The treatment plan was to continue sodium hypochlorite solution (Dakin ' s solution) to pack wound with soaked gauze and apply daily with an abdominal dressing. A surgical excisional debridement procedure was also completed due to removal of thick adherent eschar and devitalized tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of Wound Physician notes dated 06/10/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 6.7 cm by 5.6 cm by 2.4 cm with moderate serous exudate and 20 percent necrotic tissue. The treatment plan was changed to alginate calcium with leptospermum honey apply daily three times a week with a foam border dressing. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue. Recommendations for additional care plan items included: low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 06/10/25 and 06/11/25 revealed the order APRN #71 gave on 6/10/25 to change the treatment to alginate calcium with leptospermum honey apply daily three times a week was not entered. Review of the TAR for Resident #800 for 06/10/25 and 06/11/25 revealed the treatment of Dakin ' s solution was done for the coccyx stage 4 pressure ulcer. Review of Wound Physician notes dated 06/12/25 revealed Resident #800 was seen by Wound Doctor #70. The coccyx stage 4 pressure ulcer measured 7.2 cm by 8.4 cm by 2.4 cm with moderate serous exudate and 20 percent slough tissue. The treatment plan was changed to alginate calcium apply daily three times a week with a foam border dressing. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 06/12/25 revealed the new order from Wound Doctor #70 was not entered. The current treatment was still the Dakin ' s solution-soaked gauze. Review of the TAR for Resident #800 dated 06/12/25 revealed the treatment of Dakin ' s solution was done. Review of the physician order dated 06/13/25 at 7:41 A.M. revealed a treatment order for the coccyx stage 4 pressure wound to be filled with generous amount of Leptospermum Honey and apply Alginate Calcium and cover with a foam border dressing daily. This was not the order from Wound Doctor #70 ' s visit on 06/12/25. This order was discontinued on 06/25/25 at 6:45 A.M. by Facility Wound Nurse (FWN) #33. Review of the TAR for Resident #800 dated 06/13/25 through 06/18/25 revealed the incorrect treatment completed for the coccyx stage 4 pressure ulcer. Review of Wound Physician notes dated 06/19/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 5.6 cm by 3.4 cm by 1.8 cm with moderate serous exudate and 20 percent slough tissue. The continued treatment plan was for Alginate Calcium, apply daily three times a week with a foam border dressing. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 06/19/25 through 06/24/25 revealed a treatment order for the coccyx stage 4 pressure ulcer wound to be filled with generous amount of leptospermum honey and apply alginate calcium and cover with a foam border dressing daily. This was not the order from Wound Doctor #70 ' s visit on 06/19/25. Review of the TAR for Resident #800 dated 06/19/25 through 06/23/25 revealed incorrect treatments completed for the coccyx stage 4 pressure ulcer. Review of Wound Physician notes dated 06/24/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 8.9 cm by 8.7 cm by 1.8 cm with moderate serous exudate and 60 percent necrotic tissue. The treatment plan was changed to Alginate Calcium and Leptospermum Honey, apply daily with a foam border dressing. A surgical excisional debridement procedure was also completed due to removal of thick adherent eschar and devitalized tissue. Recommendations for additional care plan items included a low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 06/24/25 revealed the treatment order was correct. Review of the physician order for Resident #800 dated 06/25/25 at 6:51 A.M. entered by the FWN #33 revealed a treatment for the coccyx stage 4 pressure ulcer to apply a nickel thick layer of Santyl and cover with Alginate Calcium and apply a foam border dressing daily. This order was not consistent with the order from APRN #71 ' s visit on 06/24/25. Review of the TAR for Resident #800 dated 06/25/25 through 06/27/25 revealed incorrect treatments ordered were administered for the coccyx unstageable pressure ulcer. Review of the progress note for Resident #800 dated 06/27/25 at 7:59 P.M. revealed the resident had a critically low hemoglobin with a blood pressure of 90/41 blood pressure, pulse 123, a temperature of 97.3 degrees Fahrenheit (F) and oxygen saturation of 97 percent on room air. The nurse spoke to the on-call physician and Resident #800 was sent to the emergency room. Resident #800 left the facility at 8:00 P.M. Review of the hospital documentation for Resident #800 ' s admission revealed a low hemoglobin and severe sepsis. During the hospital stay, a CT scan revealed the sacral decubitus wound extended to the underlying bone with osteomyelitis. The wound culture of the sacral decubitus wound was performed and was positive for Bacteroides fragilis, a rare gram-positive cocci and white blood cells. Intravenous antibiotics were administered throughout Resident #800 ' s stay and surgical debridement of the sacral decubitus wound was completed. The hospital discharge diagnosis was severe sepsis without septic shock from osteomyelitis (infection of the bone) from sacral decubitus wound. Resident #800 discharged back to the facility on [DATE] with oral antibiotics ordered as well as an order for a wound vaccuum system for the sacral decubitus ulcer. Further review of the hospital documentation revealed no orders for the settings of the wound vac and there were no hospital measurements or description of the decubitus ulcer. Review of the progress note dated 07/07/25 at 8:55 P.M. revealed Resident #800 arrived at the facility for readmission. Review of the admission information dated 07/07/25 for Resident #800 revealed no initial wound grid documentation for a sacrum decubitus ulcer by the admitting floor nurse. Review of wound grid documentation for Resident #800, was created on 07/09/25 at 12:42 A.M. by FWN #33 for 07/07/25 at 12:41 A.M., when the resident was not yet at the facility. The document stated Resident #800 had a stage 4 pressure ulcer to the coccyx that measured 8.9 cm by 8.7 cm by 1.8 cm. Review of Resident #800 ' s Braden Scale for Predicting Pressure Sore Risk dated 07/07/25 revealed a score of 13 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at moderate risk for skin breakdown. Review of the physician order for Resident #800 for 07/07/25 revealed no treatment for a sacral decubitus ulcer. Review of the wound grid documentation for Resident #800 dated 07/08/25 at 12:45 A.M. by the FWN #33 revealed the coccyx stage 4 pressure ulcer had a wound vacuum in place with continuous suction at 125 millimeters of mercury (mm/HG). Review of the physician order for Resident #800 dated 07/08/25 at 2:54 P.M. revealed an order entered by FWN #33 for the coccyx wound. The order was to cleanse wound bed with normal saline, window frame outside edges of wound with adhesive film, cut black foam to fit wound bed. Fill entire area including undermining. Bridge with green foam using adhesive film under foam and bring it out to the left hip, attaching to port pad. Cover the entire area with additional adhesive film. Apply NPWT @ 125 mm/hg continuous. To be changed Sunday, Tuesday, Thursday and PRN. Review of the medical record for Resident #800 revealed no written order for the wound vac system for the coccyx pressure ulcer, there was no date in the medical record when the wound vac arrived at the facility and when it was placed on the resident to start treatment. Review of the wound grid documentation for Resident #800 dated 07/10/25 at 2:54 P.M. by FWN #33 revealed a coccyx sage 4 pressure ulcer measuring 8.8 cm by 7.8 cm by 0.8 cm with a wound vacuum in place with continuous suction at 125 mm/HG. Review of the care plan revealed a plan for the pressure ulcer to the coccyx was initiated on 07/10/25. Interventions were to perform current treatments as ordered and continue with prevention care plan measures to prevent further skin breakdown. The care plan interventions were not implemented until 07/21/25. Review of the wound grid documentation for Resident #800, dated 07/15/25 at 11:24 P.M. by FWN #33, revealed a coccyx sage 4 pressure ulcer measured 7.2 cm by 6.3 cm by 0.8 cm with a wound vacuum system in place with continuous suction at 125mm/HG. Review of the wound grid documentation for Resident #800 dated 07/17/25 at 10:18 A.M. by FWN #33 revealed a coccyx sage 4 pressure ulcer measured 7.2 cm by 6.3 cm by 0.8 cm with a wound vacuum system in place with continuous suction at 125mm/HG. Review of the wound grid documentation for Resident #800 dated 07/22/25 at 1:12 P.M. by the FWN #33 revealed a coccyx sage 4 pressure ulcer measured 7 cm by 6.2 cm by .8 cm with a wound vacuum system in place with continuous suction at 125mm/HG. Review of the Wound Physician notes dated 07/24/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.4 cm by 6.6 cm by 1.4 cm with moderate serous exudate and 20 percent slough tissue. The treatment plan was a wound vacuum system with suction at 125 mm/HG, use black sponge throughout and apply three times a week. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the Wound Physician visit notes dated 07/31/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.2 cm by 5.6 cm by 1.2 cm with moderate serous exudate and 20 percent slough tissue. The treatment plan was a wound vacuum system with suction at 125mm/HG, use black sponge throughout and apply three tim

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to appropriately manage and treat a non pressure skin alteration for one (Resident #100) out of two residents with non pressure skin alterations and obtain daily weights on three (Resident #100, #400 and #500) of three residents reviewed for daily weights. The facility census was 47.Findings include:1.Review of the medical record for Resident #100, revealed an admission date of 02/26/25 and a discharge to home date of 07/03/25. Diagnoses included but were not limited to unspecified fracture of upper end of left tibia, unsteady on feet, muscle weakness, heart failure, chronic kidney disease, stage 3, and anxiety disorder with a new diagnosis of unspecified open wound to right foot 06/02/25.Review of the active care plan for Resident #100 dated 02/26/25 revealed a cardiac impairment related to congestive heart failure.Review of the active physician order for Resident #100 dated 02/26/25 revealed a daily weight once in the morning.Review of the care plan for Resident #300 dated 02/26/25 with interventions started on 03/12/25, revealed at risk for skin breakdown related to diabetes, impaired mobility, and renal disease with interventions including but not limited to observe/report any skin and symptoms of skin irritation such as lack of sensation, tingling or burning feeling, verbal/nonverbal signs of pain, discoloration, edema, excoriation, erythema, and report to physician as needed. Also revealed alteration in blood glucose metabolism related to diagnosis of insulin dependent diabetes mellitus with an intervention including but not limited to observe resident's feet for potential ulcer formation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. This resident was also assessed o be at risk for pressure injuries.Review of the wound grid documentation for Resident #100 dated 06/02/25 at 12:51 P.M. by the Facility Wound Nurse #33 revealed a right third toe abrasion, red in color measured 2.2 centimeters (cm) X 1.6 cm X no depth documented.Further review of the wound grid documentation for this resident revealed no documentation of the fourth right toe trauma for 06/02/25. The date/time of being observed for an initial assessment by the Facility Wound Nurse #33 was 06/03/25 at 6:46 A.M. measured 2.1 cm X 1.9 cm X no depth documented and no description of the trauma area. Review of the medical record for Resident #100 did not reveal how the trauma to the right third and fourth toe occurred.Review of the active physician order for Resident #100 dated 06/02/25 at 12:56 P.M. with a discontinuation date of 06/04/25 at 7:00 A.M. by the Facility Wound Nurse #33 revealed a treatment for the right foot, second and third toe- cleanse with normal saline and pat dry. Apply xeroform and an island adhesive dressing daily.Review of the Treatment Administration Record (TAR) for Resident #100 for the date of 06/02/25 and 06/03/25 the treatment order was completed as ordered for the right foot third toe, but no treatment for the right foot fourth toe. Review of the medical record for Resident #100 revealed Wound Clinic visit notes dated 06/23/25 for Resident #100 revealed a right second, third and fourth toe diabetic ulcer all measured as one area at 8 cm X 1.5 cm X 0.2 cm. an order for the right second, third and fourth toe diabetic ulcer wounds to be cleansed with normal saline and to pack wounds with betadine-soaked gauze and apply a dressing daily. Review of the active physician order for Resident #100, dated 06/24/25, entered by the Facility Wound Nurse #33, with a discontinued date of 06/26/25 by the Director of Nursing (DON), revealed the right foot-leave dressing in place until next wound clinic appointment. Do not get wet. Cover for showers.Review of the TAR for Resident #100 revealed from 06/24/25 through 06/25/25, no dressing change was completed for the right second, third and fourth toe diabetic ulcer wounds.Interview on 08/05/25 at 10:25 A.M. with the Facility Wound Nurse #33 verified there was no documentation in Resident #100's medical record for the incident on 06/02/25 regarding the trauma to the right foot third and fourth toe. She interviewed the resident, and she could not remember how it happened. They concluded it must have happened when the resident accidentally dragged her right foot over a non-skid strip. Also verified she did not document the fourth right toe on 06/02/25 and should have as that was when it was discovered and should have been documented for description and measurements.Continued interview on 08/05/25 at 10:31 A.M. with the Facility Wound Nurse #33 verified for Resident #100, the order placed on 06/02/25 through 06/04 25 was a treatment for the right foot second and third toe when the second toe was not a concern, it was the fourth toe and it did not get any treatment for those days. Review of the daily weights in vital signs results for Resident #100 revealed since admission on [DATE], no daily weights were obtained on 03/03/25, 03/10/25, 03/11/25, 03/18/25, 05/13/25 and 06/25/25.2.Review of the medical record for Resident #400, revealed an admission date of 03/27/25. Diagnoses included but were not limited to chronic combined systolic (congestive) and diastolic (congestive) heart failure, altered mental status and general weakness.Review of the active care plan for Resident #400 dated 03/27/25 revealed a cardiac impairment related to congestive heart failure.Review of the active physician order for Resident #400 dated 03/28/25 revealed a daily weight once in the morning due to congestive heart failure.Review of the daily weights in the vital signs results for Resident #400 revealed since admission on [DATE], no daily weights were obtained on 03/28/25, 04/29/25 and 06/10/25.3. Review of the medical record for Resident #500, revealed an admission date of 02/28/25. Diagnoses included but were not limited to muscle weakness, dementia and pulmonary embolism.Review of the active care plan for Resident #500 dated 02/28/25 revealed a risk of fluid imbalance/complications related to edema and diuretic use with no interventions including daily weights.Review of the active physician order for Resident #500 dated 03/04/25 revealed a daily weight once in the morning.Review of the daily weights in the vital sign results for Resident #500 since 03/04/25 revealed no daily weights were obtained on 03/04/25, 04/20/25 and 05/05/25.Interview on 08/05/25 at 3:13 P.M. with the Director of Nursing verified Residents #100, #400 and #800 had missing weights and were not due to refusals, but due to them not being obtained as no documentation could be produced for the dates for the reason they were missed.This deficiency represents non-compliance investigated under Complaint Number 1385838.

Based on observation, interview and facility policy reviews, the facility failed to ensure proper hand hygiene and medical equipment was sanitized before and after resident use. This affected two residents (#701 and #802), but has the potential to affect all 47 residents residing in the facility. Findings include:Observation on 08/05/25 at 8:35 A.M. with Registered Nurse (RN) #27 revealed her to be preparing medications for Resident #701. She put on a glove to her right hand and proceeded to touch the cart, the residents' medications and the computer all with the same glove on. Once the medications were in the cup, she removed the glove, did not sanitize her hands after locking the cart and entering Resident #701's room. She took Resident #701's blood pressure and pulse ox with a machine she brought into the room. She then administered the residents' medications and proceeded to leave the room without sanitizing her hands and cleaning off the equipment. She returned to the cart at 8:48 A.M. and proceeded to prepare Resident #802's medications following the same steps. She put on a glove to her right hand, proceeded to touch the cart, medications and computer with the same glove, then removed her glove, locked the cart and did not sanitize her hands before entering Resident #802's room to administer medications. She took Resident #802's blood pressure and pulse ox with the same machine she carried into the rooms and did not sanitize them before or after use. She administered Resident #802's medications and left the room without sanitizing her hands.Interview on 08/05/25 at 9:00 A.M. with Registered Nurse #27 verified she should have changed her glove once she touched anything other than Resident #701 and #802's medications, she should have sanitized her hands before and after entering the resident's rooms and she verified she never cleaned the blood pressure and pulse ox equipment before and after each resident.Review of the facility policy titled Hand Washing-Hygiene no date, revealed it is the facility's policy for employees to conduct proper hand hygiene that will aid in the prevention and transmission of infectious diseases. Alcohol/Antimicrobial hand rub may be used in the following situations: before donning gloves, after removing gloves and before preparing or handling medications.Review of the facility policy titled Cleaning of Equipment no date revealed the facility will utilize general disinfecting procedures to prevent and control infection.This was an incidental finding discovered during the investigation for Complaint Number 1385838.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain an up to date and complete medical record for three residents (#100, #300 and #800) of three residents reviewed for receiving wound care from an outside wound consultant group. The facility census was 47. Findings include:1.Review of the medical record for Resident #100, revealed an admission date of 02/26/25 and a discharge to home date of 07/03/25. Diagnoses included but were not limited to unspecified fracture of upper end of left tibia, unsteady on feet, muscle weakness, heart failure, chronic kidney disease stage 3, and anxiety disorder with a new diagnosis of unspecified open wound to right foot 06/02/25 and sepsis 06/10/25.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed resident had intact cognition with a Brief Interview for Mental Status (BIMS) of 15 out of 15. Review of the medical record for Resident #100 revealed a skin alteration occurred on 06/02/25 at the facility per facility wound grid documentation.Further review revealed no Wound Physician visits in her closed record to review.Interview on 08/04/25 at 12:02 P.M. with the Director of Nursing (DON) revealed Resident #100 saw the Wound Physician group a few times during her stay and will get the visit notes from the Facility Wound Nurse #33 as they were not in her chart. 2. Review of the medical record for Resident #300, revealed an admission date of 05/20/25. Diagnoses included but were not limited to metabolic encephalopathy, altered mental status, muscle weakness, and cerebral infarction.Review of the most recent MDS 3.0 assessment dated [DATE] revealed resident had intact cognition with a BIMS of 14 out of 15. Review of the medical record for Resident #300 revealed a skin alteration on admission per facility wound grid documentation.Further review revealed no Wound Physician visits in the record to review.Interview on 08/06/25 at 11:09 A.M. with the Facility Wound Nurse #33 verified Resident #300 did not have any of her Wound Physician visits in her current medical record and should be uploaded after each visit.3. Review of the medical record for Resident #800, revealed an admission date of 04/18/25. Diagnoses included but were not limited to weakness, cerebral infarction, atrial fibrillation, type 2 diabetes, and chronic kidney disease.Review of the most recent MDS 3.0 assessment dated [DATE] revealed resident with intact cognition with a BIMS of 14 out of 15. Review of the medical record for Resident #800 revealed a skin alteration on admission per facility wound grid documentation.Further review revealed no Wound Physician visits in the medical record to review.Interview on 08/06/25 at 1:50 P.M. with Regional Nurse #68 verified Resident #800 did not have the Wound Physician Consultant notes uploaded into their charts and had to access them on the consultant's server, but it is the expectation that the Facility Wound Nurse #33 be uploaded after each visit to keep the residents' chart up to date and current for care.This was an incidental finding discovered during the course of this complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to ensure the facility medication administration error rate was not more than five percent. This affected one resident (#42) of eight residents observed for medication administration with four errors out of 25 opportunities resulting in an error rate of 16%. The census was 47. Findings include: Medical record review revealed Resident #42 was admitted on [DATE] with diagnoses including wedge compression thoracic vertebra fractures, depression, anxiety, atherosclerotic heart disease and constipation. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #42 was moderately impaired for daily decision-making. Review of the electronic Physician Orders dated 09/25/25 revealed medications to be administered included chewable aspirin 81 milligrams (mg) for prophylaxis, buspirone 10 (mg) for sadness/anxiety, I-vite (vitamin and mineral) for supplement and senna plus 8.6-50,mg for bowel regimen, bupropion SR 150 (mg), celexa 40 (mg), culturelle 15 billion cell, lactulose 10 grams, aspercreme lidocaine patch, lisinopril 10mg, OsCal 500 (mg) with Vit D3, Miralax 17 gm, and Vitamin C 500 (mg). On 09/25/25 between 8:00 A.M. and 8:14 A.M., observation revealed Registered Nurse (RN) #200 prepared and administered Resident #42's morning medications including enteric coated aspirin 81 (mg), buspirone 5 (mg), and senna 8.5 (mg) and I-vite was not dispensed or administered during the observation. RN #200 was observed leaving her medication administration record open upon entering the resident's room and the electronic MAR was positioned across from the nursing station and not within eye sight of the nurse. RN #200 also left the sealed Aspercreme lidocaine patch on top of the medication cart unsupervised when she went to the resident's room to administer the other medications. At the time of the observation, RN #200 verified she left the Aspercreme lidocaine patch unattended on the top of the medication cart. On 09/25/25 at 2:46 P.M., interview with RN #200 verified she documented she had administered I-Vite to the resident; however she did not administer the medication. RN #200 verified she administered enteric coated ASA and senna to Resident #42 because that was the only form of the medications available to administer in her medication cart, and the buspirone order had been changed from 5 (mg) to 10 (mg) and the old bubble pack containing the 5 (mg) dose was left in the medication cart without a label indicating directions had been changed. RN #200 verified she had not given the ordered dose. RN #200 was observed removing the buspirone 5 (mg) bubble pack from the medication cart, closed the cart drawer, did not lock the medication cart, walked to the medication/storage room beside the nursing station with the bubble pack, unlocked the door and entered the medication/storage room with the door closing behind her. No staff were noted to be within the vicinity of the medication cart and the cart remained unlocked. RN #200 verified the cart was unlocked when she came back out of the medication/storage room. Review of the policy: Specific Medication Administration Procedures dated May 2020 revealed medications were to be administered in a safe and effective manner, all medication storage areas including carts were to be locked at all times unless in use and under the direct observation of approved facility or pharmacy personnel. If medication instructions are changed during the course of therapy, it was the nurse's responsibility to add a direction change notation/sticker directly on the product to indicate as such.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to ensure residents had effective pain assessments and management. This affected three ( Resident #100, #300, and #800) of three residents reviewed for pain. The facility census was 47. Findings include:1.Review of the medical record for Resident #100, revealed an admission date of 02/26/25 and a discharge to home date of 07/03/25. Diagnoses included but were not limited to unspecified fracture of upper end of left tibia, unsteady on feet, muscle weakness, heart failure, chronic kidney disease, stage 3, and anxiety disorder with a new diagnosis of unspecified open wound to right foot 06/02/25 and sepsis 06/10/25.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. Review of the care plan dated 02/26/25 for Resident #100 revealed actual alteration in comfort/pain related to unspecified pain with interventions including but not limited to administer pain medications as ordered/observe for effectiveness and observe for episodes of breakthrough pain and medicate as ordered.Review of the physician orders dated 06/10/25 for Resident #100 revealed oxycodone-acetaminophen 5-325 milligram (mg) one tablet orally every 8 hours as needed for pain on a scale of 5-10 (0 being none and 10 being the worst.Further review of the physician orders revealed no other pain medication ordered as needed for this resident.Review of the medical record for Resident #100 revealed a skin alteration occurred on 06/02/25 at the facility per facility wound grid documentation.Further review revealed in the progress notes, starting on 06/03/25, a wound review: weekly review of this resident's pain scale related to the wound, with a treatment, documented by the Facility Wound Nurse #33. The dates with the pain scales and treatment as medication were: 06/03/25 with a pain rating of 4, 06/10/25 with a pain rating of 5, 06/17/25 with a pain rating of 3 and 06/24/25 with a pain rating of 3.Review of the medication administration record (MAR) for Resident #100 for 06/10/25 pain rating of a 5 revealed no administration of the oxycodone-acetaminophen 5-325 mg.Further review of the MAR revealed for the other dates this resident had wound pain no medications were administered.2.Review of the medical record for Resident #300, revealed an admission date of 05/20/25. Diagnoses included but were not limited to metabolic encephalopathy, altered mental status, muscle weakness, and cerebral infarction.Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 14 out of 15 which indicated intact cognition. cognitive intactness. This resident was also assessed to have unhealed pressure ulcers.Review of the care plan dated 05/20/25 for Resident #300 revealed actual alteration in comfort/pain related to abnormal posture with interventions including but not limited to administer pain medications as ordered/observe for effectiveness and observe for episodes of breakthrough pain and medicate as ordered.Review of the physician's orders for Resident #300 revealed for the dates of 05/20/25 through 07/31/25, no as needed pain medications were ordered.Review of the medical record for Resident #300 revealed a skin alteration on admission to the facility per facility wound grid documentation.Further review revealed in the progress notes, starting on 05/27/25, a wound review: weekly review of this resident's pain scale related to the wound, with a treatment, documented by the Facility Wound Nurse #33. The dates with pain scales and treatment as medications were: 06/17/25 pain rating of 4, 06/19/25 pain rating of 4, 06/24/25 pain rating of 3, 07/15/25 pain rating of 4, 07/22/25 pain rating of 4, 07/24/25 pain rating of 3 and 07/31/25 pain rating of 4.3. Review of the medical record for Resident #800, revealed an admission date of 04/18/25. Diagnoses included but were not limited to weakness, cerebral infarction, atrial fibrillation, type 2 diabetes, and chronic kidney disease.Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 14 out of 15 indicating cognitive intactness. This resident was also assessed to have a pressure ulcer injury.Review of the care plan dated 04/18/25 for Resident #800 revealed actual alteration in comfort, pain related to pressure ulcers with interventions including but not limited to administer pain medications as ordered/observe for effectiveness and observe for episodes of breakthrough pain and medicate as ordered.Review of the physician's orders dated 04/21/25 for Resident #800 revealed the pain medication of hydrocodone-acetaminophen 5-325mg tablet, one tablet every six hours as needed for severe pain of 6-10.Further review of the orders also revealed for this resident dated 04/23/25, acetaminophen 325 mg tablet, one tablet every 6 hours for mild pain rating 1-5.Further review revealed in the progress notes, starting on 04/22/25 and ending on 05/13/25, a wound review: weekly review of this resident's pain scale related to the wound, with a treatment, documented by the Facility Wound Nurse #33 were not completed weekly for pain assessment. Further review revealed The dates with pain scales and treatment as medications were: 05/13/25 pain rating of a 5, 05/20/25 pain rating of a 5, 06/03/25 pain rating of a 6, 06/10/25 pain rating of a 6, 06/12/25 pain rating of a 6, 06/17/25 pain rating of a 5, 06/19/25 pain rating of a 5, 06/24/25 pain rating of a 5, 07/15/25 pain rating of a 6, 07/17/25 pain rating of a 5, 07/22/25 pain rating of a 6, 07/24/25 pain rating of a 6, and 07/31/25 pain rating of a 6. Review of the MAR for Resident #800 for the dates of wound pain assessment, no as needed pain medication as administered. Interview on 08/07/25 at 2:30 P.M. with Assistant Director of Nursing (ADON) verified no medications were given prior to wound care treatments for pain which is the documentation in the progress notes that the ADON was documenting on for Resident #300 and #100, Resident 300 does not even have anything ordered as needed for pain. Reviewed dates of all wound review templates with medication interventions not completed and no follow up after the wound treatment was completed if still in pain, the floor nurses do a pain scale every shift, but wound nurse does not follow up after and if non pharm does not work, there were two dates for interventions that included repositioning, no follow up was documented that it helped and if other treatment such as medication was needed.Interview on 08/08/25 at 11:40 A.M. with the Facility Wound Nurse #33 verified for Resident #800, there should have been wound pain assessments completed weekly from 04/22/25 through 05/13/25 and she did not verify if the resident received pain medication. Also verified no as needed pain medication was given to this resident from 05/13/25 through 07/31/25 when the resident was assessed to have wound pain.Review of the facility policy titled Pain Assessment and Management updated 05/01/25 revealed it is the facilities policy to assess, monitor, treat and evaluate pain to ensure effective pain management is provided.This was an incidental finding discovered during the course of this complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure Resident #3 was provided with adaptive equipment for meals per physician orders. This affected one (Resident #3) of one resident reviewed for adaptive equipment. The facility census was 49.
Findings include:
Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including heart failure, dysphagia, bipolar disorder, the need for assistance with personal care, and intracranial injury without loss of consciousness.
Review of the care plan, dated 08/06/21, revealed Resident #3 should receive supervision during meals or food activities, as needed, and given verbal cues for chewing or swallowing. The care plan dated 07/28/21 revealed the resident was at risk for altered nutrition related to tremors, dysphagia, and the need for adaptive equipment to facilitate self feeding with interventions that included to apply a left handed weighted glove and a left handed curved spork supplied by the kitchen and for adaptive feeding equipment as ordered per the physician.
Review of the Minimum Data Set (MDS) assessment, dated 10/02/24, revealed Resident #3's cognition remained intact and she had no behaviors. The resident required setup or clean-up assistance for eating, was dependent on staff for dressing, and required maximum assistance for personal hygiene.
Review of physician orders revealed Resident #3 had an order in place, dated 08/28/24, for a regular plate with plate guards, built up curved utensils, and left upper extremity weighted glove for all meals. Resident #3 also had an order in place, dated 10/28/24, for a no added salt diet with a regular texture and thin liquids in handled cups with straws, a plate with guards, and small portions.
Observation on 11/12/24 at 10:37 A.M. revealed Resident #3 was sitting in her wheelchair in the hallway with food and stains on her shirt, pants, wheelchair cushion, and the floor beneath her. Resident #3 was not wearing a clothing protector. On Resident #3's tray table, there was a two-handled cup with a lid and a spout.
Interview on 11/12/24 at 10:37 A.M. with Resident #3 revealed she had to eat in the hallway so the nurse could keep an eye on her because of a recent choking related incident.
Observation on 11/12/24 at 12:05 P.M. revealed Resident #3 was in the dining room with two beverages in the two-handled cups with lids and spouts. A dark brown liquid was dribbling down Resident #3's chin. At 12:12 P.M., another resident assisted Resident #3 by using a napkin to clean her face. Resident #3 did not have a left upper extremity weighted glove on for the lunch meal.
Observation on 11/13/24 at 10:31 A.M. revealed Resident #3 was seated in the café drinking hot chocolate from a two-handled cup with a lid and a spout. The residents purple shirt was damp with spots and stains from the hot chocolate.
Observation on 11/13/24 at 4:19 P.M. revealed Resident #3 sitting in the dining room for dinner and wearing a purple shirt with dark brown stains. Resident #3 was wearing a clothing protector and had two, two-handled cups with lids and spouts. When Resident #3 would attempt to take a drink, she had tremors which caused the liquid to shake and splash out of the spout, leaving the drink dribbling down her chin. Resident #3 was served a plate of spaghetti with meat balls and marinara sauce, and the aide cut up the meatballs, but not the noodles. Resident #3 struggled to get the noodles on the weighted utensils and then get the food to her mouth. She continuously dropped noodles on her shoes, socks and on the floor. Resident #3 continued to struggle with eating for approximately five minutes before staff intervened. Resident #3 was not wearing a left upper extremity weighted glove for dinner.
Interview on 11/13/24 at 4:47 P.M. with Assistant Director of Dietary Services (ADDS) #305 confirmed Resident #3 had orders in place for a left upper extremity weighted glove and cups with handles and a straw. ADDS #305 also confirmed Resident #3 did not have either pieces of her adaptive equipment during the dinner meal and that he had not ever heard of a weight glove. ADDS #305 stated Resident #3 had been making a mess and having a hard time eating, so he requested a therapy referral to nursing. ADDS #305 further confirmed Resident #3 had dropped food onto herself, including on her shoes.
Interview and observation on 11/14/24 at 7:51 A.M. with Resident #3 revealed she was bothered by sitting in the hallway with food and stains on her clothes, wheelchair, and the floor around her, because she did not want people to see her like that. At the time of the interview, Resident #3 was wearing shoes with marinara sauce on them from the previous nights' dinner. The resident was also sitting on a dirty wheelchair cushion caked with food debris.
Review of a policy titled Adaptive Equipment, revised November 2016, revealed assistive devices shall be offered to residents requiring them to maintain or improve their ability to eat independently. Residents were to be evaluated by therapy to determine the need for assistive devices and obtain a physician's order for the equipment. The tray card and care plan shall be changed to reflect the appropriate assistive devices and nursing would ensure the resident was able to properly use the equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the facility failed to provide a homelike environment and ensure resident equipment was clean and well maintained. This affected four (#3, #13, #37, and #42) of four residents reviewed for environment. The facility census was 49.
Findings included:
1. Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including heart failure, dysphagia, bipolar disorder, need for assistance with personal care, and intracranial injury without loss of consciousness.
Observation on 11/12/24 at 8:39 A.M. revealed Resident #3 was sitting in her wheelchair in the hallway and the wheelchair cushion was caked in food debris and the extended brakes had frayed, gray duct tape on them.
Interview on 11/14/24 at 8:00 A.M. with Regional Nurse Consultant #302 confirmed Resident #3's wheelchair cushion was caked in food debris and the extended brakes had frayed, gray duct tape on them.
Interview on 11/14/24 at 8:46 A.M. with Physical Therapy Assistant #423 confirmed the tape on Resident #3's extended brakes was frayed. She stated the tape was applied to the brakes for visual cue and the brakes needed new tape.
Review of the policy titled General Environmental Policies, dated November 2020, revealed the facility should be maintained in a clean and sanitary manner.
2. Record review revealed Resident #13 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, cognitive communication deficit, and dementia.
Observation on 11/12/24 at 9:06 A.M. revealed Resident #13's room smelled strongly of urine.
Interview on 11/13/24 at 10:23 A.M. with the Minimum Data Set (MDS) Nurse #118 confirmed Resident #13's room smelled strongly of urine.
Review of the policy titled General Environmental Policies, dated November 2020, revealed the facility should be maintained in a clean and sanitary manner.
3. Record review revealed Resident #37 admitted to the facility on [DATE] with diagnoses including cerebral infarction, dementia, and atherosclerotic heart disease.
Observation on 11/12/24 at 9:13 A.M. revealed Resident #37's bathroom floor had a dark gray stain, approximately three feet long, in front of the toilet, and there was dark brown discolored caulking around the toilet and shower.
Interview on 11/14/24 at 8:19 A.M. with Lead Receptionist #146 confirmed Resident #37's floor was stained and the caulking was brown and discolored. Receptionist #146 stated she had attempted to scrub the floors but the stains would not come up.
Review of the policy titled General Environmental Policies, dated November 2020, revealed the facility should be maintained in a clean and sanitary manner.
4. Record review revealed Resident #42 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and hypertension.
Observation on 11/12/24 at 8:48 A.M. revealed Resident #42's bathroom floor was dirty, stained, and had debris on it. There was brown discolored caulking around the shower and toilet, and there were two pink plastic containers on the floor with leaves and dust in them.
Interview on 11/14/24 at 8:16 A.M. with Activity Director #164 confirmed Resident #42's floors were stained, the bathroom floor had a build-up of grime, the caulking around the shower and toilet was discolored, and there were pink containers with leaves and dust on the floor.
Review of the policy titled General Environmental Policies, dated November 2020, revealed the facility should be maintained in a clean and sanitary manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #149 admitted to the facility on [DATE] with diagnoses including altered mental status, dementia, and congestive heart failure.
Review of the electronic medical record and the paper chart revealed Resident #149's code status was not displayed prominently in the medical record.
Interview on [DATE] at 3:59 P.M. with the Director of Nursing (DON) confirmed Resident #149's medical records were missing the code status'. She revealed Resident #149 had a code status of Full Code (a medical directive that indicated cardiopulmonary resuscitation (CPR) should be used during the residents care in the event of such emergency) in place, which was now being added to the medical records.
Review of the facility's policy titled, Advanced Directives, revised [DATE], revealed prior to or upon admission of a resident to the facility, staff should offer the opportunity to form advanced directives or inquire about existing advanced directives. It also revealed if the resident were to indicate that he or she had issued advanced directives about his or her care, documentation of such directive would be recorded in the medical record, and a copy of such directive would be included in the resident's medical record.
Based on record review, staff interview and facility policy, the facility failed to ensure that advanced directives were prominently placed in Resident #100's and Resident #149's medical records. This affected two (Resident #100 and Resident #149) of two residents reviewed for advanced directives. The facility census was 49.
Findings include:
1. Record review revealed Resident #100 was admitted on [DATE] with diagnoses that included surgical aftercare of the digestive system, intestinal obstruction, anemia, depression, gastroesophageal reflux, and malignant neoplasm of the prostate.
Review of Resident #100's electronic and physical medical records revealed that a code status was not prominently displayed in either chart.
Interview with Registered Nurse (RN) Supervisor #162 on [DATE] at 3:52 P.M. confirmed there were no advanced directives prominently displayed in Resident #100's medical chart. RN Supervisor #162 was unable to identify the code status of Resident #100. RN Supervisor #162 stated that advanced directives were normally found in the front section of the chart.
Interview with the Director of Nursing (DON) on [DATE] at 3:57 P.M. also confirmed that there were no advanced directives prominently displayed in Resident #100's medical chart.
Review of the facility's policy titled, Advanced Directives, revised [DATE], revealed prior to or upon admission of a resident to the facility, staff should offer the opportunity to form advanced directives or inquire about existing advanced directives. It also revealed if the resident were to indicate that he or she had issued advanced directives about his or her care, documentation of such directive would be recorded in the medical record, and a copy of such directive would be included in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure Resident #3 was treated with with dignity during and after dining. This affected one (Resident #3) of one resident reviewed for dignity. The facility census was 49.
Findings include:
Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including heart failure, dysphagia, bipolar disorder, need for assistance with personal care, and intracranial injury without loss of consciousness.
Review of the care plan, dated 08/06/21, revealed Resident #3 was to receive supervision during meals or food activities, as needed, and given verbal cues for chewing or swallowing.
Review of the Minimum Data Set (MDS) assessment, dated 10/02/24, revealed Resident #3's cognition remained intact and she had no behaviors. The resident required setup or clean-up assistance for eating, was dependent on staff for dressing, and required maximum assistance for personal hygiene.
Observation on 11/12/24 at 10:37 A.M. revealed Resident #3 was sitting in her wheelchair in the hallway with food and stains on her shirt, pants, wheelchair cushion, and the floor beneath her. Resident #3 was not wearing a clothing protector. On Resident #3's tray table, there was a two-handled cup with a lid and a spout.
Interview on 11/12/24 at 10:37 A.M. with Resident #3 revealed she had to eat in the hallway so the nurse could keep an eye on her because of a recent choking related incident.
Observation on 11/12/24 at 12:05 P.M. revealed Resident #3 was in the dining room with two beverages in the two-handled cups with lids and spouts. A dark brown liquid was dribbling down Resident #3's chin. At 12:12 P.M., another resident assisted Resident #3 by using a napkin to clean her face.
Observation on 11/13/24 at 10:31 A.M. revealed Resident #3 was seated in the café drinking hot chocolate from a two-handled cup with a lid and a spout. The residents purple shirt was damp with spots and stains from the hot chocolate.
Observation on 11/13/24 at 4:19 P.M. revealed Resident #3 sitting in the dining room for dinner and wearing a purple shirt with dark brown stains. Resident #3 was wearing a clothing protector and had two, two-handled cups with lids and spouts. When Resident #3 would attempt to take a drink, she had tremors which caused the liquid to shake and splash out of the spout, leaving the drink dribbling down her chin. Resident #3 was served a plate of spaghetti with meat balls and marinara sauce, and the aide cut up the meatballs, but not the noodles. Resident #3 struggled to get the noodles on the weighted utensils and then get the food to her mouth. She continuously dropped noodles on her shoes, socks and on the floor. Resident #3 continued to struggle with eating for approximately five minutes before staff intervened.
Interview on 11/13/24 at 4:47 P.M. with Assistant Director of Dietary Services (ADDS) #305 confirmed Resident #3 had dropped food onto herself, including on her shoes.
Interview and observation on 11/14/24 at 7:51 A.M. with Resident #3 revealed she was bothered by sitting in the hallway with food and stains on her clothes, wheelchair, and the floor around her, because she did not want people to see her like that. At the time of the interview, Resident #3 was wearing shoes with marinara sauce on them from the previous nights' dinner. The resident was also sitting on a dirty wheelchair cushion caked with food debris.
Interview on 11/14/24 at 8:00 A.M. with Regional Nurse Consultant (RNC) #302 confirmed Resident #3's shoes and wheelchair cushion had food debris from the previous night.
Interview on 11/14/24 at 8:38 A.M. with Registered Nurse (RN) #160 revealed Resident #3 could get messy during meals and RN #160 would attempt to help her clean up. RN #160 stated she did not feel it was very dignified for Resident #3 to sit in dirty clothes.
Review of a policy titled Resident Rights, updated October 2016, revealed the facility's policy was to treat all residents with kindness, respect, and dignity and staff were to make all attempts to ensure residents were treated with kindness, respect, and dignity.

Based on observations, interview, and facility policy, the facility failed to ensure the ice machine was maintained in a sanitary manner. This had the potential to affect all 49 of the residents residing in the facility. The facility identified all 49 residents in the facility as receiving iced beverages from the main kitchen ice machine.
Findings include:
On 11/12/24 at 8:52 A.M. an observation revealed that the inside of the ice machine in the main kitchen had a red slimy substance next to the prepared ice. On the inside of the ice machine, on the right top near the cooling mechanism, a white crusty build-up was observed.
An interview with Dietary Director #163 on 11/12/24 at 8:52 A.M. confirmed the presence of the red slimy substance next to the prepared ice and the white crusty build-up on the right side of the ice machine, near the cooling mechanism.
An interview with the Assistant Director of Dietary Services #305 on 11/12/24 at 10:27 A.M. revealed that the ice machine was deep cleaned by an outside company that serviced the machine. The Assistant Director of Dietary Services #305 stated that he had obtained bagged prepared ice for the residents to use for the day.
An observation on 11/13/24 at 10:41 A.M. revealed that the red slimy substance had been removed from the ice machine. The white crusty build-up was still observed on the inside of the ice machine on the top right side, near the cooling mechanism.
An interview on 11/13/24 at 10:41 A.M. with Assistant Director of Dietary Services #305 confirmed the presence of the white crusty build-up was still on the right side of the inside of the ice machine. On 11/13/24 at 11:50 A.M. the Assistant Director of Dietary Services #305 stated that a company had been called to de-lime the ice machine.
A facility policy titled, Ice Machine, dated October 2020, revealed that the ice machines shall be free of rust, lime and mildew at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to store respiratory equipment in a sanitary manner. This affected one (Resident #42) of one resident reviewed for respiratory equipment. The facility census was 49.
Findings included:
Record review revealed Resident #42 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and hypertension.
Review of physician orders revealed an order, dated 04/28/24, for Ipratropium-Albuterol solution for nebulization 0.5 milligrams to 3 milligrams for inhalation due to wheezing, cough and congestion every six hours as needed.
Observation on 11/12/24 at 10:57 A.M. revealed Resident #42's nebulizer was placed on her floor, plugged into the wall. The nebulizer was covered in small, brown spots.
Interview on 11/12/24 at 8:55 A.M. with Lead Receptionist #146 confirmed the nebulizer was covered in small, brown spots and placed on the floor while plugged in. Receptionist #146 stated the nebulizer should not have been on the floor, but at times, Resident #42 would move it. Receptionist #146 also stated the nebulizer needed to be cleaned.
Review of a policy titled, Respiratory Therapy- Prevention of Infection, dated November 2019, revealed it was the facility's policy to prevent infection associated with respiratory therapy tasks and equipment among residents and staff. After the completion of nebulizer therapy, the nebulizer container should be removed, rinsed with fresh tap water, and dried with a clean paper towel or gauze sponge. The nebulizer should be reconnected to the administration set-up, the mouthpiece should be wiped with a damp paper towel or gauze sponge, then stored in a plastic bag, marked with the date and the resident's name.

Based on review of medical records, observation, and staff interview the facility failed to ensure fall interventions were in place for Resident #8 per the plan of care. This affected one resident (Resident #8) of two residents reviewed for falls. The facility census was 49.
Findings include:
Review of Resident #8's medical record revealed an admission date of 05/23/23 and diagnoses including senile degeneration of the brain, dementia, depression, and a history of traumatic brain injury.
Review of the physician orders for Resident #8 revealed on 11/09/23, the resident was ordered non-skid strips to the floor in front of the resident's toilet.
Review of Resident #8's the care plan, dated 06/05/24, revealed the resident was at risk for falls/injury related to history of falls, incontinence, altered mental status, and impaired gait. Interventions included non-slip strips to the floor in front of the toilet.
Observation of Resident #8's bathroom on 11/13/24 at 2:28 P.M. revealed non-skid strips were not present in front of the residents toilet.
Interview on 11/13/24 at 2:50 P.M. with the Assistant Director of Nursing (ADON) #127 verified an order for non-skid strips in front of toilet was present in the medical record and she also verified the non-skid strips were not present in front of Resident #8's toilet. ADON #127 further verified that Resident #8 still utilized the toilet in her bathroom.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, interviews, review of facility policy, and review of equipment manuals, the facility failed to ensure alternating air mattresses were functional and set on the correct settings for pressure ulcer/injury prevention. This affected two (Resident #12 and Resident #13) of six residents reviewed for skin interventions. The facility census was 49.
Findings include:
1. Record review revealed Resident #12 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, dysphagia, dementia, and chronic obstructive pulmonary disease. Resident #12's record revealed the resident did not have any pressure ulcers. The record further revealed Resident #12 was 114.5 pounds on 06/07/23. Resident #12 was receiving hospice services and did not have additional weights in the record.
Review of the Minimum Data Set (MDS) assessment, dated 08/31/24, revealed Resident #12 had a pressure reduction device on her bed.
Review of the care plan, dated 01/19/23, revealed Resident #12 was at risk for pressure ulcers/injury related to senile degeneration of brain, heart failure, hyperlipidemia, hypertension, dementia, polyarthritis, and moderate protein-calorie malnutrition. Interventions included, but were not limited to, utilizing an air mattress that could be adjusted to resident comfort.
Review of physician orders, dated 01/19/23, revealed Resident #12 had an order for an alternating air mattress to prevent skin breakdown.
Observation on 11/12/24 at 8:43 A.M. revealed Resident #12 had an alternating air mattress in place which was unplugged, and the settings were turned to 210 pounds. Resident #12 appeared to weigh less than 210 pounds.
Interview on 11/13/24 at 10:28 A.M. with the MDS Nurse #118 confirmed the alternating air mattress was set to 210 pounds.
Interview on 11/13/24 at 10:28 A.M with Certified Nursing Assistant (CNA) #130 confirmed the bed had been unplugged, but she had just plugged the bed back in.
Review of an undated policy titled, Pressure Injuries: Assessment, Prevention & Treatment, revealed the facility identified residents at risk for developing pressure injuries, implements interventions, and providing care for existing injuries. Interventions included, but were not limited to, using pressure redistribution mattresses.
Review of the manual titled, Alternating Pressure and Low Air Loss Mattress Replacement System, revealed the Med Aire Edge Mattress Replacement System was a high quality powered air support surface that was specifically designed for the prevention and treatment of pressure injuries while optimizing patient comfort.
2. Record review revealed Resident #13 admitted to the facility on [DATE] with diagnoses including senile degeneration of brain, cognitive communication deficit, and dementia. Resident #13's record revealed the resident did not have any pressure ulcers. Resident #13 was receiving hospice services and there were no recent weights recorded in the medical record.
Review of the Minimum Data Set (MDS) assessment, dated 10/20/24, revealed Resident #13 had a pressure reducing device for her bed.
Review of the care plan, dated 05/03/19, for Resident #13 revealed the resident was at risk for skin breakdown related to impaired mobility, impaired cognition, and incontinence, with interventions that included an air mattress.
Review of physician orders, dated 11/14/24, revealed Resident #13 had an order in place for an air mattress to the bed surface.
Observation on 11/12/24 at 9:06 A.M. revealed Resident #13's alternating air mattress was set to static, normal pressure at 225 pounds.
Interview on 11/13/24 at 10:23 A.M. with MDS Nurse #118 confirmed the alternating air mattress was set to 225 pounds, and Resident #13 was likely less than 225 pounds.
Review of an undated policy titled, Pressure Injuries: Assessment, Prevention & Treatment, revealed the facility identified residents at risk for developing pressure injuries, implements interventions, and providing care for existing injuries. Interventions included, but were not limited to, using pressure redistribution mattresses.
Review of the manual titled, Alternating Pressure and Low Air Loss Mattress Replacement System, revealed the Med Aire Edge Mattress Replacement System was a high quality powered air support surface that was specifically designed for the prevention and treatment of pressure injuries while optimizing patient comfort.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the self-reported incident (SRI) and the facility's investigation, review of the facility policy, record review, and staff interviews, the facility failed to immediately report an allegation of staff-to-resident verbal abuse to the Administrator or designee. This affected one (Resident #27) of three residents reviewed for abuse. This had the potential to affect the six other residents (Resident #3, #16, #27, #35, #38, #39, and #40) who were identified by the facility to be on the Alleged Perpetrator's assignment on 10/06/23. The facility census was 40.
Findings include:
Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included senile degeneration of brain, displace fracture of right femur, acute respiratory failure with hypoxia, depression, acute kidney failure, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had severe cognitive impairment.
Review of the SRI control number 239906 dated 10/06/23 at 2:00 P.M. revealed there was an allegation of verbal abuse by a staff member to Resident #27 on 10/06/23 at approximately 8:30 A.M. State Tested Nursing Assistant (STNA) #100 and STNA #104 reported they were providing care for Resident #27 when STNA #150 (Alleged Perpetrator) entered the room. STNA #150 stated if he is going to act like a little expletive, I will not be giving him a shower today. STNA #150 then left the room. STNA #100 and STNA #104 completed care for Resident #27 and then reported the alleged incident to the nurse.
Review of the statement signed by the Administrator on 10/06/23 revealed STNA #150 was interviewed via the telephone on 10/06/23 at 2:30 P.M. STNA #150 denied making the comment in front of Resident #27. A written statement dated 10/06/23 by STNA #104 revealed STNA #100 and STNA #104 were providing care for Resident #27 when STNA #150 walked in the room. Resident #27 pulled the covers over his head. STNA #150 stated I'm not going to give him a shower if he is going to act like a expletive. Between 1:00 P.M. and 1:30 P.M., STNA #150 was yelling down the hall about STNA #100 and STNA #104 making up lies about STNA #150. A resident's family was on the hall. The incident was reported to the front office and the department heads walked STNA #150 out of the facility. A statement dated 10/06/23 revealed Licensed Practical Nurse (LPN) #200 addressed the allegation with STNA #150. STNA #150 denied making the comment. LPN #200 reported there were conflicting stories of whether the comment was made in front of Resident #27 or in the hallway. A statement dated 10/06/23 by STNA #172 revealed STNA #150 had a bad attitude that day (10/06/23).
Review of a typed statement by STNA #100 dated 10/09/23 at 10:58 A.M. revealed STNA #150 had been bragging about it being her last day and how much she hated working at the facility. STNA #150 was assigned to Resident #27. About an hour after breakfast, STNA #100 and STNA #104 went into Resident #27's room and saw Resident #27 had not touched his food and was lying in bed. STNA #100 and STNA #104 started getting things ready to provide incontinence care for Resident #27 and get Resident #27 out of bed. STNA #150 walked in to Resident #27's room. As STNA #100 started providing care, Resident #27 pulled the blanket up over his head. STNA #150 stated I am not putting him in the shower if he is going to be a expletive. STNA #100 and STNA #104 reported to the nurse what STNA #150 said. STNA #150 waited for STNA #100 at the nurse's station and STNA #150 screamed she was going to hit and beat STNA #100 and hit everyone in the building. STNA #100 walked away and STNA #150 continued to scream down the hall.
A written statement dated 10/13/23 by Licensed Social Worker (LSW) #201 revealed on 10/06/23 around 1:50 P.M., STNA #150 and STNA #103 went to the front office to speak to the receptionist. LSW #201 was not in the meeting but could hear STNA #150 loudly saying the employees were unprofessional. A few minutes after STNA #150 left the office, two STNAs came to the front and stated STNA #150 was yelling and threatening to hit people. LSW #201 contacted the Director of Nursing (DON) and Administrator by telephone. STNA #150 denied calling Resident #27 names in his presence.
Interview on 01/03/24 at 11:03 A.M. with STNA #100 revealed Resident #27 got cold when care was provided so he frequently pulled the blankets over his head during care. STNA #100 verified STNA #150 stated if Resident #27 was to going act like a little expletive, STNA #150 would not give Resident #27 a shower. STNA #100 stated after care was provided for Resident #27, STNA #100 and STNA #104 reported what STNA #150 had said in Resident #27's room.
Interview on 01/03/24 at 11:10 A.M. with STNA #104 revealed they were in the room providing care for Resident #27 when Resident #150 entered the room and called Resident #27 an expletive. STNA #104 stated the incident was reported to the nurse by STNA #100 and STNA #104.
Interview on 01/03/24 at 2:38 P.M. with the Administrator and Director of Nursing verified STNA #100 and STNA #104 reported the alleged allegation of verbal abuse to the nurse, but the nurse did not report the incident to the Administrator or designee because STNA #150 stated they did not make those comments in Resident #27's room. The nurse did not feel it was reportable since there was conflicting reports of what happened. The Administrator verified the incident of alleged verbal abuse occurred around 8:30 A.M. and the Administrator was not notified until around 2:00 P.M.
Review of the facility's undated policy titled Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation revealed staff should report all incidents/allegations immediately to the Administrator or designee.
This deficiency represents non-compliance investigated under Complaint Number OH00149425.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the self-reported incident (SRI) and investigation, review of the facility's policy, record review, and staff interviews, the facility failed to protect the other residents from potential abuse by not immediately removing State Tested Nursing Assistant (STNA) #150 from the facility after there was an allegation of verbal abuse to Resident #27. This affected one (Resident #27) of three residents reviewed for abuse. This had the potential to affect the six other residents (Resident #3, #16, #27, #35, #38, #39, and #40) who were identified by the facility to be on the STNA #150's assignment on 10/06/23. The facility census was 40.
Findings include:
Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included senile degeneration of brain, displace fracture of right femur, acute respiratory failure with hypoxia, depression, acute kidney failure, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had severe cognitive impairment.
Review of the SRI control number 239906 dated 10/06/23 at 2:00 P.M. revealed there was an allegation of verbal abuse by a staff member to Resident #27 on 10/06/23 at approximately 8:30 A.M., STNA #100 and STNA #104 reported they were providing care for Resident #27 when STNA #150 entered the room. STNA #150 stated if he is going to act like a little expletive, I will not be giving him a shower today. STNA #150 then left the room. STNA #100 and STNA #104 completed care for Resident #27 and then reported the alleged incident to the nurse. The SRI did not list an alleged perpetrator.
Review of the written statement dated 10/06/23 by STNA #104 revealed STNA #100 and STNA #104 were providing care for Resident #27 when STNA #150 walked in the room. Resident #27 pulled the covers over his head. STNA #150 stated I'm not going to give him a shower if he is going to act like a expletive. Between 1:00 P.M. and 1:30 P.M., STNA #150 was yelling down the hall about STNA #100 and STNA #104 making up lies about STNA #150. A resident's family was on the hall.
Review of the statement dated 10/06/23 revealed Licensed Practical Nurse (LPN) #200 addressed the allegation with STNA #150. STNA #150 denied making the comment. LPN #200 reported there were conflicting stories of whether the comment was made in front of Resident #27 or in the hallway.
A statement dated 10/06/23 by STNA #172 revealed STNA #150 had a bad attitude that day (10/06/23).
Review of a typed statement by STNA #100 dated 10/09/23 at 10:58 A.M. revealed STNA #150 had been bragging about it being her last day and how much she hated working at the facility. STNA #150 was assigned to Resident #27. About an hour after breakfast, STNA #100 and STNA #104 went into Resident #27's room and saw Resident #27 had not touched his food and was lying in bed. STNA #100 and STNA #104 started getting things ready to provide incontinence care for Resident #27 and get Resident #27 out of bed. STNA #150 walked in to Resident #27's room. As STNA #100 started providing care, Resident #27 pulled the blanket up over his head. STNA #150 stated I am not putting him in the shower if he is going to be a expletive. STNA #100 and STNA #104 reported to the nurse what STNA #150 said. STNA #150 waited for STNA #100 at the nurse's station and STNA #150 screamed she was going to hit and beat STNA #100 and hit everyone in the building. STNA #100 walked away and STNA #150 continued to scream down the hall.
Review of the written statement dated 10/13/23 by Licensed Social Worker (LSW) #201 revealed on 10/06/23 around 1:50 P.M., STNA #150 and STNA #103 went to the front office to speak to the receptionist. LSW #201 was not in the meeting but could hear STNA #150 loudly saying the employees were unprofessional. A few minutes after STNA #150 left the office, two STNAs came to the front and stated STNA #150 was yelling and threatening to hit people. LSW #201 contacted the Director of Nursing (DON) and Administrator by telephone. STNA #150 denied calling Resident #27 names in his presence.
Review of the time punches for STNA #150 on 10/06/23 revealed STNA #150 clocked in at 7:00 A.M. and clocked out at 1:52 P.M.
Interview on 01/03/24 at 11:03 A.M. with STNA #100 revealed Resident #27 got cold when care was provided so he frequently pulled the blankets over his head during care. STNA #100 verified STNA #150 stated if Resident #27 was to going act like a little expletive, STNA #150 would not give Resident #27 a shower. STNA #100 stated after care was provided for Resident #27, STNA #100 and STNA #104 reported what STNA #150 had said in Resident #27's room.
Interview on 01/03/24 at 11:10 A.M. with STNA #104 revealed they were in the room providing care for Resident #27 when Resident #150 entered the room and called Resident #27 an expletive. STNA #104 stated the incident was reported to the nurse in the morning by STNA #100 and STNA #104.
Interview on 01/03/24 at 2:38 P.M. with the Administrator and Director of Nursing verified STNA #100 and STNA #104 reported the alleged allegation of verbal abuse by STNA #150 to Resident #27. The Administrator verified the incident of alleged verbal abuse occurred around 8:30 A.M. and STNA #150 did not clock out until 1:52 P.M. STNA #150 was escorted out the facility around that time. The Administrator verified STNA #150 had continued to work after an allegation of abuse was made and was not escorted out of the facility until STNA #150 was yelling and threatening coworkers in the hallway.
Review of the facility's undated policy titled Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation revealed if a staff member is accused or suspected of Abuse, Neglect, Exploitation, Mistreatment or Misappropriation of resident property, the facility should immediately remove the staff member from the facility.
This deficiency represents non-compliance investigated under Complaint Number OH00149425.

Based on observation and interview, the facility failed to ensure one resident (#9) was treated in a dignified manner. This affected one of one reviewed for dignity. The facility census was 44.
Findings Included:
Review of the medical record for Resident #9 revealed an initial admission date of 11/16/20 with the latest readmission of 08/23/21 with the diagnoses including hypertension, major depressive disorder, anxiety disorder, sleep apnea, chronic obstructive pulmonary disorder, osteoarthritis, obesity, fibromyalgia, full incontinence of feces, weakness, dysphagia, retention of urine, hyperlipidemia, atrial fibrillation, congestive heart failure, dyskinesia of esophagus, diverticulum of esophagus, diverticulosis of intestine, dysphagia, hypothyroidism, cerebral infarct, schizophrenia, dementia and gastro-esophageal reflux disease.
Review of the plan of care dated 11/16/20 revealed the resident was incontinent of bladder and was at risk for altered dignity, skin breakdown and urinary tract infection (UTI). Interventions included administer medication per physician orders, assess quarterly and as needed for any changes in elimination patterns, check and provide incontinence care as needed in elimination patterns, check and provide incontinence care as needed, apply moisture barrier cream after each incontinent episode, maintain resident dignity when checking/providing incontinence care, observe protective pads/briefs for skin tolerance, observe/report any noted redness, excoriation or open areas with incontinence care, observe protective pads/briefs for skin tolerance, observe/report any signs/symptoms of UTI, provide physical support/assist for toileting safety as indicated for resident.
Review of the plan of care dated 11/16/20 revealed the resident had bowel incontinence and was at risk for altered dignity, skin breakdown, diarrhea and constipation. Interventions included administer medication per physician orders, assess quarterly and as needed for any changes in elimination patterns, check and provide incontinence care as needed in elimination patterns, check and provide incontinence care as needed, apply moisture barrier cream after each incontinent episode, maintain resident dignity when checking/providing incontinence care, observe/record bowel movements daily for amount/consistency, observe/report any diarrhea, constipation, change in bowel movement, abdominal distention and/or discomfort, observe protective pads/briefs for skin tolerance, observe/report any noted redness, excoriation or open areas with incontinence care, observe protective pads/briefs for skin tolerance and provide physical support/assist for toileting safety.
Review of the monthly physician orders for August 2023 identified orders dated 08/23/21 for barrier cream to buttocks after each incontinent episode, record bowel movement every shift, and on 04/26/23 for toileting extensive assist of one and incontinent of bowel and bladder.
On 08/07/23 at 11:08 A.M., observation/interview with Resident #9 revealed she had not been changed since night shift and she was really wet. Resident #9 reported she had her call light on for a while and asked to verify it was working.
On 08/07/23 at 11:15 A.M., interview with State Tested Nursing Assistant (STNA) #114 answered the light call light and verified the resident was saturated with urine and had not been provided incontinence care since night shift ending at 6:00 A.M.
On 08/07/23 at 11:18 A.M., observation of STNA #114 after exiting Resident #9's room revealed she yelled down the hallway to STNA #163 using Resident #9's name and stated she was soaked from head to toe. STNA #114 verified at the time of the observation the resident was not being treated in a dignified manner and other residents and visitors were able to hear.
This deficiency represents non-compliance investigated under Complaint Number OH00144024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, staff interview, and facility policy review, the facility failed to notify one resident's (Resident #146) physicians when STAT (immediate) labs were not completed as ordered. The deficient practice affected one (Resident #146) of one reviewed for notification. The facility census was 44.
Findings Include:
Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, and Type II Diabetes Mellitus with foot ulcer.
Review of the physician orders for August 2023 revealed Resident #146 had the following orders: STAT WBC (white blood cell) dated 08/03/23 and STAT CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) dated 08/05/23.
Review of the Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #146 required extensive assistance from one staff to complete Activities of Daily Living (ADL). Resident #146 had impaired skin. Resident #146 had an infection of the foot and surgical wounds.
Review of the progress notes revealed on 08/03/23 at 2:33 P.M., the Assistant Director of Nursing (ADON)/Wound Nurse (WN) #131 documented wound rounds were completed with Wound Physician (WP) #108. There was concern over resident's left foot. STAT WBC was ordered. On 08/06/23 at 12:25 P.M., a note indicated, spoke to lab at this time regarding STAT labs that were put into the system. They stated they had no coverage for this STAT lab and labs were to be drawn on 08/07/23 in the morning.
Review of lab results for Resident #146 revealed labs were collected on 08/04/23 and 08/07/23 respectively.
There were not any additional notes indicating the physicians were notified when the STAT labs were not completed as ordered.
Review of the care plan dated 07/28/23 revealed Resident #146 had a wound infection. Interventions included obtain and report diagnostic testing and lab work per order.
Interview on 08/10/23 at 8:45 A.M. with Certified Nurse Practitioner (CNP) #145 confirmed she ordered STAT labs for Resident #146 on 08/06/23. CNP #145 confirmed she was not notified the labs had not been drawn STAT as ordered on 08/06/23.
Interview on 08/10/23 at 10:37 A.M. with WN #131 confirmed WP #108 was not notified the STAT lab was not completed on 08/03/23 as ordered.
Review of the facility policy, Change in the Residents Condition or Status, updated 11/2016, revealed the policy stated, it is the facility's policy to ensure the resident's attending physician and the residents authorized representative or interested family member are notified of changes in the resident's physical, mental, or psychosocial status.

Based on observation and interview, the facility facility to ensure medications were properly stored and labeled. This affected Resident #20 using the Lantus insulin pen and had the potential to affect 27 residents (#1, #2, #4, #5, #7, #9, #10, #11, #13, #14, #17, #19, #20, #21, #22, #25, #26, #27, #29, #30, #34, #36, #37, #38, #40, #76 and #94) who reside on the 100 unit. The facility census was 44.
Findings Include:
1. On 08/10/23 at 3:05 P.M., observation of the 100 unit medication cart revealed one Lantus insulin pen laying in the drawer with no name or date on the insulin pen. The Lantus insulin pen had been pulled from the emergency drug kit (EDK). Further observation revealed a Lispro Insulin pen laying in the drawer with no name or date on the insulin pen. The Lispro insulin pen was also pulled from the EDK. Interview with Licensed Practical Nurse (LPN) #127 at the time of the observation revealed she was unsure what resident the insulin pens were pulled from the EDK. She removed six empty clear plastic bags from the insulin drawer on the medication cart and revealed the Lantus was pulled for Resident #20 but was unsure who the Lispro belonged to but verified she used the Lantus insulin pen.
2. On 08/10/23 at 3:10 P.M., observation of the 100 unit medication storage refrigerator located in the 100 unit medication storage room revealed one vial of Tuberculin solution opened with no date when the vial had been opened. Registered Nurse (RN) #131 verified the vial of Tuberculin solution was not dated and should have been dated when opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to clarify conflicting code statuses for one resident (#20). This affected one of five residents reviewed for advance directives. The facility census was 44.
Findings Include:
Review of the medical record for Resident #20 revealed an initial admission date of 08/06/23 with the diagnoses including acute respiratory failure, abnormal posture, disorder of pituitary gland, vitamin D deficiency, major depressive disorder, anxiety disorder, chronic pain syndrome, chronic kidney disease, hypertension, dementia, cerebrovascular accident with hemiplegia, chronic obstructive pulmonary disease, diabetes mellitus, polyneuropathy, gastro-esophageal reflux disease, disorders of diaphragm, bilateral foot drop, colostomy status, osteoarthritis, bipolar disorder, contracture of left hand and contracture of left wrist.
Review of the Do Not Resuscitate (DNR) Comfort Care form dated 07/13/21 revealed the resident elected to have the code status DNR comfort care arrest do not incubate.
Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit.
Review of the Nurse Practitioner (NP) progress note dated 07/27/23 revealed the NP documented the resident was a full code since 08/30/22.
Review of the medical record revealed no physician's orders or plan of care for the resident's code status.
08/08/23 04:01 PM interview with Registered Nurse (RN) #131 verified the NP progress note documented the resident as a full code. RN #131 revealed she would treat the resident as a full code related to the conflicting documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, and facility policy review, the facility failed to ensure a resident's (Resident #18) call light was kept within reach. The deficient practice affected one resident (Resident #18) of one reviewed for call lights. The facility census was 44.
Findings Include:
Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, generalized muscle weakness, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), including bed mobility, transfers, dressing, and toileting. Resident #18 had functional limitations and range of motion impairments on both sides of both upper and lower extremities.
Review of the care plan, revised 08/07/23, revealed Resident #18 had potential for a decline of self-care and mobility, feeding, chewing and swallowing, bowel and bladder function, and communication related to Parkinson's Disease. Interventions included to keep call light in reach at all times.
Observations on 08/07/23 at 12:43 P.M., 08/08/23 at 10:01 A.M., and 08/09/23 at 8:53 A.M. of Resident #18 in her room. Resident #18's call light was observed attached to her gown near her upper chest area with her arms laying by her sides twice and was observed sitting on top of her pillow on her bed behind her when Resident #18 was sitting up in her wheelchair next to the bed. This surveyor asked Resident #18 at the time of each observation if she was able to press her touch pad call light. Resident #18 attempted to find the call light attached to her gown but was not able to do so.
Interview on 08/07/23 at 12:34 P.M. with Resident #18 and Resident #18's daughter revealed Resident #18 had range of motion impairments to both arms. Resident #18 had difficulty raising her arms up or moving her arms from side to side. Resident #18 stated she was able to press her touch pad call light as long as it was placed under or beside one of her hands.
Interview on 08/09/23 at 8:53 A.M. with Resident #18 revealed she had pressed her call light a few times in the last couple of days when she could find it. Resident #18 stated she hollered for help if she was not able to find her call light.
Observation and interview on 08/09/23 at 9:16 A.M. with State Tested Nurse Aide (STNA) #146 confirmed Resident #18's call light was placed on her pillow on her bed behind her when the resident was up in her wheelchair next to her bed and was not within reach. STNA #146 confirmed Resident #18 was able to press her touch pad call light for assistance.
Review of the facility policy, Call Light-Answering, undated, revealed the policy stated, it is the facility policy for all facility personnel to follow the guidelines below to respond to the resident's requests and needs. Ask the resident to return demonstration so that you will be sure that the resident can operate the system. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to maintain infection control practices in the manner to prevent the potential spread of infection in the area of pressure ulcer dressing change and catheter care. This affected one resident (#20) of two residents reviewed for pressure ulcers and one resident (#37) of one resident reviewed for catheter. The facility census was 44.
Findings Include:
1. Review of the medical record for Resident #20 revealed an initial admission date of 08/06/23 with the diagnoses including acute respiratory failure, abnormal posture, disorder of pituitary gland, vitamin D deficiency, major depressive disorder, anxiety disorder, chronic pain syndrome, chronic kidney disease, hypertension, dementia, cerebrovascular accident with hemiplegia, chronic obstructive pulmonary disease, diabetes mellitus, polyneuropathy, gastro-esophageal reflux disease, disorders of diaphragm, bilateral foot drop, colostomy status, osteoarthritis, bipolar disorder, contracture of left hand and contracture of left wrist.
Review of the plan of care dated 08/18/22 revealed the resident was at risk for skin breakdown related to impaired mobility, diabetes mellitus, urinary incontinence, hemiplegia, steroid therapy, renal disease, poor sensory perception, friction concerns, shearing concerns, refuses splints, heel protectors, [NAME] boots, resists showers/baths, turning/repositioning, elevating heels, ostomy care, incontinence care and getting out of bed. Interventions included apply bilateral PRAFO boots up to eight hours as tolerated four to seven days per week, check skin before application and upon removal, assist resident as needed with turning and repositioning frequently when in bed and/or shift weight to reposition when in chair as tolerated, encourage resident not to slide/scoot when in bed or chair, encourage/assist the resident to float heels as tolerated, observe resident for any incontinence episodes and provide incontinence care as needed, apply protective barrier after each incontinence episode, observe/report non-compliance with preventative skin care and notify physician as needed, observe/report any signs/symptoms of skin irritation, provide nutritional support as ordered and utilize air mattress.
Review of the plan of care dated 09/06/23 revealed the resident has a surgical wound to the coccyx related to impaired mobility, diabetes, urinary incontinence, COPD, poor nutritional intake, poor sensory perception, friction concerns, shearing concerns, history of impaired skin, resists showers/baths, turning, elevating heels and potential for wound pain. Interventions included continue with preventative care plan measures to prevent further skin breakdown, observe wound for any redness, warmth, drainage, odor and report to physician as needed, observe/report any non-compliance/rejection of care for wound management, notify physician as needed and treatment as ordered.
Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had not rejected any care. The resident required extensive assistance of two staff for bed mobility, transfers and toilet use. The resident had an ostomy and was frequently incontinent of bladder. The assessment indicated the resident was at risk for skin breakdown and had an unhealed stage III pressure ulcer to the coccyx and a surgical wound. The facility implemented the interventions pressure reducing device to bed, nutrition or hydration intervention, pressure ulcer/injury care, surgical wound care, application of nonsurgical dressing and application of nonsurgical dressings.
Review of the monthly physician orders for August 2023 identified orders dated 01/19/23 apply Triad topically to coccyx every shift, 07/27/23 cleanse wound to coccyx with normal saline (NS), pat dry, apply calcium alginate with silver to hole and undermining, cover with an island adhesive dressing daily, 08/07/23 apply bilateral PRAFO boots up to eight hours as tolerated, check skin before application and upon removal, 08/08/23 cleanse wound to coccyx with NS, pat dry, apply calcium alginate with silver to hole and undermining, cover with an island adhesive dressing as needed, complete weekly skin checks every Friday and encourage resident to float heels while in bed.
Review of the most recent weekly wound grid dated 08/03/23 revealed the wound was classified as a surgical wound measuring 2.8 centimeters (cm) by 1.5 cm by 0.5 cm with tunneling/undermining measuring 0.3 cm from 6 o'clock to 1 o' clock. The wound was described as having light serosanguinous exudate. The assessment had no description of the wound.
On 08/09/23 at 11:06 A.M., interview with Registered Nurse (RN) #131 revealed the resident was admitted to the facility with a Stage II pressure ulcer but that had healed. She revealed the resident's current wound began as a scab and the wound physician did a biopsy. She revealed the scab was pulled off with a bed pan and the wound had progressed but remained classified as a surgical wound.
On 08/09/23 at 11:20 A.M., observation of RN #131 provide the physician ordered treatment to the wound to the resident's coccyx revealed the RN placed paper towels on the bottom right side of the bed and placed the required supplies on the barrier. She removed the soiled dressing, walked around the bed and picked up the resident's trash can and placed on the floor on the right side of the bed. The RN then changed gloves without washing or sanitizing her hands. She then picked up a bullet of normal saline (NS) opened the bullet, sat the bullet on the resident's sheet. The RN then changed her gloves and cleansed the wound with NS and a split drain sponge. The RN then pat the wound dry using a drain sponge. The RN then changed her gloves without washing or sanitizing her hands, cut a square piece of calcium alginate with silver and packed the wound using a sterile Q-tip. The RN revealed the resident had undermining from 2 o'clock to 6 o'clock. The RN then changed her gloves without washing or sanitizing her hands and covered the wound with an island dressing.
On 08/09/23 at 11:38 A.M., interview with RN #131 verified the lack of the handwashing during the dressing change resulting in the potential spread of infection to the wound.
Review of the facility policy titled, Dressings, Dry/Clean, not dated reveled the purpose of the procedure was to provide guidelines for the application of dry dressings. Steps in the procedure include: adjust bedside stand to waist level, clean bedside stand, Establish a clean field. place the cleaned equipment on the bedside stand, arrange the supplies so they can be easily reached, tape a biohazard or plastic bag on the bedside stand or open on the bed, pull strips of tape adequate for securing dressing at the end of the procedure and add date, time and initials, place on edge of bedside table to enable easy access when needed, adjust the height of the bed to waist level, position resident and adjust clothing to provide access to affected area, wash and dry your hands thoroughly, put on clean gloves, loosen tape and remove soiled dressing, pull glove over dressing and discard into plastic or biohazard bag, wash and dry your hands thoroughly, open dry, clean dressings by pulling corners of the exterior wrapping outward, touching only the exterior surface, using clean technique, open other products, pour prescribed solution over the dry clean gauze into clean basin section of tray, put on clean gloves, assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage, cleanse the wound, use a syringe to irrigate the wound, if ordered, if using gauze, use a clean gausses for each cleansing stroke, clean from the least contaminated area to the most contaminated area, use dry gauze to pat the wound dry, wash and dry hands thoroughly, apply the ordered dressing and secure with tape, discard disposable items into the designated container, remove disposable gloves and discard into designated container and wash and dry your hands thoroughly.
2. Review of the medical record for Resident #37 revealed an initial admission date of 09/30/22 with diagnoses including atrial fibrillation, congestive heart failure, sepsis, urinary tract infection, retention of urine and obstructive and reflux uropathy.
Review of the plan of care dated 05/10/22 revealed the resident had an alteration in elimination related to Foley catheter. Interventions included change catheter bag per policy, change Foley catheter per physician order, irrigate catheter per physician order, Foley catheter care every shift and/or per policy, keep drainage bag below bladder and off the floor, observe for signs of UTI, use leg strap as needed to prevent tubing from pulling and position tubing so resident not sitting or lying on it.
Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of one with toileting. The assessment indicated the resident had an indwelling urinary catheter.
Review of the indwelling urinary catheter observation dated 08/07/23 revealed the resident had the catheter related to untreatable urinary blockage.
Review of the monthly physician orders for August 2023 identified orders dated 10/01/22 catheter output every shift, 10/12/22 catheter care, change catheter as needed, change urinary collection bag monthly, 10/25/22 flush catheter with 60 milliliters (ml) of normal saline (NS) every shift and as needed, 03/27/23 18 FR Coude catheter and 18 FR Coude Foley catheter to be changed monthly.
On 08/09/23 at 10:40 A.M., observation of Regional Nurse #144 and State Tested Nursing Assistant (STNA) #114 provide the physician ordered catheter care revealed they washed their hands, set-up supplies on barrier on bedside table. STNA #114 obtained a basin of water, covered the resident with a bath blanket and pulled the resident's incontinence brief down. The STNA sanitized her hands and donned clean gloves. The STNA obtained a wet washcloth and placed peri-wash on the cloth. The STNA then washed the Foley catheter back and forth using the same section of the cloth.
Review of the policy titled, Catheter Care, Urinary, last updated 11/19 revealed it was the facility's policy to prevent infection of the resident's urinary tract by implementing the following procedures. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of lab results, staff interview, and review of the facility laboratory agreement, the facility failed to obtain STAT (immediate) labs as ordered for one resident (Resident #146). The deficient practice affected one resident (Resident #146) of one reviewed for laboratory testing. The facility census was 44.
Findings Include:
Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, Type II Diabetes Mellitus with foot ulcer, and chronic kidney disease stage 3b.
Review of the Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #146 required extensive assistance from one staff to complete Activities of Daily Living. Resident #146 had impaired skin. Resident #146 had an infection of the foot and surgical wounds.
Review of the physician orders for August 2023 revealed Resident #146 had the following orders: STAT WBC (white blood cell) dated 08/03/23 and STAT CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) dated 08/05/23.
Review of the progress notes revealed on 08/03/23 at 2:33 P.M., the Assistant Director of Nursing (ADON)/Wound Nurse (WN) #131 documented wound rounds were completed with Wound Physician (WP) #108. There was concern over resident's left foot. STAT WBC was ordered. On 08/06/23 at 12:25 P.M., a note indicated, spoke to lab at this time regarding STAT labs that were put into the system. They stated they had no coverage for this STAT lab and labs were to be drawn on 08/07/23 in the morning.
Review of the care plan dated 07/28/23 revealed Resident #146 had a wound infection. Interventions included obtain and report diagnostic testing and lab work per order.
Review of lab results for Resident #146 revealed labs were collected on 08/04/23 and 08/07/23 respectively.
Interview on 08/09/23 at 6:10 P.M. with the Administrator and Regional Nurse (RGN) #144 confirmed Resident #146 had orders for STAT labs and they were not collected as ordered. RGN #144 stated the facility was currently looking into changing lab providers due to the current lab not being able to accommodate the facility's needs, especially on the weekends.
Review of the Nursing Facility Laboratory Agreement, dated 02/02/18, revealed the lab provided STAT (life threatening situation) service 24 hours per day, 365 days per year. Laboratory STAT testing would be reported within five hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #10 revealed an initial admission date of 08/31/22 with the latest readmission of 12/26/22 with the diagnoses including metabolic encephalopathy, gram-negative sepsis, urinary tract infection (UTI), acute kidney failure, hypertensive urgency, acute respiratory failure with hypoxia, personal history of COVID-19, heart failure, hypertension, diabetes mellitus, hypothyroidism, Vitamin D deficiency, hyperlipidemia, alcohol dependence in remission, major depressive disorder, subacute combined degeneration of spinal cord, benign neoplasm of major salivary gland, chronic obstructive pulmonary disease, cataract, congestive heart failure, aneurysm, contracture of muscles, panlobular emphysema, gastroesophageal reflux disease (GERD), cerebral vascular accident (CVA), urine retention, insomnia, visual hallucinations, auditory hallucinations, anxiety disorder, restlessness and agitation and Bell's palsy.
Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The resident received insulin, antipsychotic, antianxiety, antidepressant medications. The assessment indicated the resident received the antipsychotic medication on a daily basis and a gradual dose reduction (GDR) had not been attempted and the physician had not documented the GDR clinically contraindicated.
Review of the pharmacy recommendation dated 02/18/23 revealed the pharmacist recommended a review of the resident's blood pressure medication to discontinue either Doxazosin 1 mg daily or Losartan-Hydrochlorothiazide 100-12.5 mg. The physician addressed the recommendation on 03/27/23, more than 30 days after the recommendation was made.
On 08/10/23 at 9:54 A.M., interview with Regional Nurse #144 verified the 02/18/23 pharmacy recommendation was not addressed for more than 30 days following the recommendation.
3. Review of the medical record for Resident #28 revealed and admission date on 01/02/23. Medical diagnoses included acute respiratory failure with hypoxia, dementia without behavioral disturbance, anxiety disorder, and major depressive disorder-recurrent.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #28 had severely impaired cognition and scored a four out of 15 on the Brief Interview for Mental Status (BIMS) assessment. No behaviors were noted in the assessment. Resident #28 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #28 received daily antipsychotic and antidepressive medications. Antipsychotics were received on a routine basis and a GDR was documented as contraindicated on 01/16/23.
Review of the pharmacy recommendation dated 02/18/23 revealed Resident #28's psychotropic medications were reviewed to see if a trial dose reduction or discontinuation could be attempted. Resident #28 received Aripiprazole (an antipsychotic medication) 7 mg daily at night, Sertraline (an antianxiety medication) 25 mg daily, and Hydroxyzine (an antianxiety medication) 10 mg every eight hours as needed. No hallucinations, behavioral symptoms, rejection of care, or wandering was noted on the MDS assessment for Resident #28. The recommendation was to reduce Aripiprazole to 5 mg at night and continue Hydroxyzine as needed for 90 days due to only being used once in previous two weeks for anxiety.
The pharmacy recommendation was not addressed until 03/27/23 (over a month later).
Interview on 08/10/23 at 9:50 A.M. with Regional Nurse (RGN) #144 confirmed the pharmacy recommendation was not addressed for over a month. RGN #144 stated the Director of Nursing Services (DNS) was off from work during that time and no other staff caught that pharmacy recommendations had not been addressed until the DNS returned to work the end of March.
Review of a policy titled Consultation Pharmacy Reports from May 2020 revealed the facility should respond to the pharmacy recommendation in a timely manner.
Review of the facility policy, Documentation and Communication of Consultant Pharmacist Recommendations, dated 05/2020, revealed the policy stated, The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations and are responded to in an appropriate and timely fashion. Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next Medication Regimen Review (MRR).
Based on record review and interview, the facility failed to address pharmacy recommendations within thirty days and did not follow up on recommended labs. This affected three (Resident #9, #10, and #28) of three residents reviewed for medication regiment reviews. The facility census was 44.
Findings included:
1. Record review revealed Resident #9 admitted to the facility on [DATE] with diagnoses including left femur fracture, hypertension, major depressive disorder, chronic obstructive pulmonary disease, hypokalemia, anxiety disorder, sleep apnea, atrial fibrillation, diastolic congestive heart failure, schizophrenia, unspecified dementia, and hypothyroidism.
Review of minimum data set (MDS) from 05/20/23 revealed Resident #9 was cognitively intact and had no behaviors.
Review of care plan from 11/16/20 revealed Resident #9 takes psychotropic medications including an antidepressant, antianxiety, and antipsychotic.
Review of orders revealed Resident #9 was prescribed buspirone (an antianxiety medication) 10 milligrams (mg) three times a day for sadness/withdrawn, hydroxyzine (an antihistamine) 25 mg twice a day for tearful, easily irritated, Zyprexa (an antipsychotic) 5 mg at bedtime for auditory and visual hallucinations, trazodone (an antidepressant) 50 mg at bedtime to promote sleep, effexor (antidepressant) once a day 150 mg for tearful, sad, withdrawn, and effexor 75 mg at bedtime for tearful, sad, withdrawn.
Review of a pharmacy recommendation from 02/18/23 revealed a recommendation to decrease Zyprexa from 7.5 mg to 5 mg. The recommendation was not reviewed until 03/27/23.
Review of a pharmacy recommendation from 07/19/23 revealed a recommendation to decrease Zyprexa from 5 mg to 2.5 mg or to obtain genesight testing for medication optimization purposes. Provider declined the recommendation for decrease and opted for the genesight testing on 07/20/23.
Interview on 08/09/23 at 5:21 P.M. with Registered Nurse (RN) #144 confirmed the pharmacy recommendation was not reviewed within thirty days. RN #144 confirmed despite provider opting for the genesight testing, an order was never obtained for the labs and the facility had not followed up on genesight testing to be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to ensure one resident (#34) received timely meal assistance. The facility also failed to ensure one resident's (#18) fluids were accessible. Additionally the facility failed to provided one resident (#9) the physician ordered two handled cup with meals. This affected one ( Resident #34) of one resident reviewed for nutrition, one ( Resident #18) of one resident received for hydration and one ( Resident #9) of 13 sampled residents. The facility census was 44.
Findings Include:
1. Review of the medical record for Resident #34 revealed an initial admission date of 05/20/21 with the diagnoses including contracture of muscle, multiple sites, dementia, malignant neoplasm of female breast, diabetes mellitus, hyperlipidemia, vitamin D deficiency, anxiety disorder, trigeminal neuralgia, aortic valve stenosis, aortic valve insufficiency, peripheral vascular disease, depression, osteoporosis, hypertension, hematuria and abnormal posture.
Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The resident required extensive assistance of two for bed mobility, transfers, and eating.
Review of the plan of care dated 07/11/23 revealed the resident had an impaired ability to perform or participate in daily activities of daily living (ADL) care related to impaired mobility, dementia, breast cancer, diabetes mellitus, peripheral vascular disease and osteoporosis. Interventions included offer resident verbal cues if needed for chewing and swallowing or to finish eating and offer assistance with feeding if needed.
Review of the physician orders for August 2023 identified an order dated 08/11/23 eating extensive assistance of one.
Observation of the 100 hallway meal tray delivery on 08/07/23 revealed Resident #34 was delivered her tray at 12:26 P.M., the food was set on the bedside tray and the aide exited the room. State Tested Nursing Assistant (STNA) entered the room at 12:50 P.M. to feed the resident. The plate with the warmer and lid had a piece of garlic bread. The green beans and the Florentine stuffed shell with marinara was in a bowl with a plastic lid. The tray also had an ice cream which was melted. Registered Nurse (RN) #131 instructed the aide to warm the food up and the resident was supposed to be in the dining room for meals. The aide revealed the microwave on the unit no longer worked and asked if she should take the food to the kitchen to be warmed. RN #131 verified the resident should have been fed when the meal tray was delivered.
On 08/07/23 at 3:36 P.M., interview with the resident's family member revealed she had a problem with the facility assisting the resident with meals and had to tell the facility to feed her mother.
2. Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required extensive assistance from one staff to complete eating task (how resident eats and drinks). Resident #18 had functional limitations in range of motion (ROM) and impairments on both side of upper and lower extremities.
Review of physician orders dated August 2023 revealed Resident #18 had a diet order for a regular diet with thin liquids and drinks in green lidded/handled cups dated 07/21/23.
Review of care plan, revised 08/07/23, revealed Resident #18 was at risk for altered nutrition. Interventions included drinks in green lidded/handled cups with long straws.
Observations on 08/07/23 at 12:45 P.M., 08/08/23 at 10:02 A.M., 08/08/23 at 3:15 P.M., 08/08/23 at 5:41 P.M., and 08/09/23 at 8:53 A.M. revealed Resident #18 had fluids in a green lidded/handled cup with a straw as ordered but the fluids were not within reach of the resident to be able to get a drink.
Interview on 08/08/23 at 10:24 A.M. with Resident #18 confirmed fluids were on her bedside table but she was not able to reach it to get a drink. Resident #18 stated, it is hard for me to talk because I'm dry.
Interview on 08/09/23 at 8:53 A.M. with Resident #18 confirmed fluids with straw were not within her reach to be able to take a drink. Resident #18 stated she went for long periods of time with drinking anything. Resident #18 stated she was thirsty at the time of the interview. Observed Resident #18 attempt to reach lidded/handled cup with straw to take a drink and was not able to reach the cup. Resident #18 reported staff had checked on her approximately 30 minutes ago but did not offer to assist resident with getting a drink at that time.
Interview on 08/09/23 at 9:16 A.M. with State Tested Nurse Aide (STNA) #146 confirmed fluids were not within reach of Resident #18.
Review of the facility policy, Hydration, undated, revealed the policy stated, resident's shall be offered sufficient fluids to maintain proper hydration and health.
3. Record review revealed Resident #9 admitted to the facility on [DATE] with diagnoses including left femur fracture, hypertension, major depressive disorder, chronic obstructive pulmonary disease, hypokalemia, anxiety disorder, sleep apnea, atrial fibrillation, diastolic congestive heart failure, schizophrenia, unspecified dementia, and hypothyroidism.
Review of minimum data set (MDS) from 05/20/23 revealed Resident #9 requires set-up help with supervision for meals.
Review of care plan revealed Resident #9 should use adaptive equipment as ordered for her nutritional status.
Review of orders revealed an order for Resident #9 to use a two-handled cup with meals dated 05/05/23.
Observation on 08/09/23 at 5:07 P.M. revealed STNA #112 provided Resident #9 with tea glasses of sweet tea in regular cups.
Interview on 08/09/23 at 5:07 P.M. with STNA #112 confirmed Resident #9 was given regular cups instead of a two-handled cup.
A policy for adaptive equipment states residents shall be offered assistive devices that enable them to be more independent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #9 revealed an initial admission date of 11/16/20 with the latest readmission of 08/23/21 with the diagnoses including hypertension, major depressive disorder, anxiety disorder, sleep apnea, chronic obstructive pulmonary disorder, osteoarthritis, obesity, fibromyalgia, full incontinence of feces, weakness, dysphagia, retention of urine, hyperlipidemia, atrial fibrillation, congestive heart failure, dyskinesia of esophagus, diverticulum of esophagus, diverticulosis of intestine, dysphagia, hypothyroidism, cerebral infarct, schizophrenia, dementia and gastro-esophageal reflux disease.
Review of the plan of care dated 11/16/20 revealed the resident was incontinent of bladder and was at risk for altered dignity, skin breakdown and urinary tract infection (UTI). Interventions included administer medication per physician orders, assess quarterly and as needed for any changes in elimination patterns, check and provide incontinence care as needed in elimination patterns, check and provide incontinence care as needed, apply moisture barrier cream after each incontinent episode, maintain resident dignity when checking/providing incontinence care, observe protective pads/briefs for skin tolerance, observe/report any noted redness, excoriation or open areas with incontinence care, observe protective pads/briefs for skin tolerance, observe/report any signs/symptoms of UTI, provide physical support/assist for toileting safety as indicated for resident.
Review of the plan of care dated 11/16/20 revealed the resident had bowel incontinence and was at risk for altered dignity, skin breakdown, diarrhea and constipation. Interventions included administer medication per physician orders, assess quarterly and as needed for any changes in elimination patterns, check and provide incontinence care as needed in elimination patterns, check and provide incontinence care as needed, apply moisture barrier cream after each incontinent episode, maintain resident dignity when checking/providing incontinence care, observe/record bowel movements daily for amount/consistency, observe/report any diarrhea, constipation, change in bowel movement, abdominal distention and/or discomfort, observe protective pads/briefs for skin tolerance, observe/report any noted redness, excoriation or open areas with incontinence care, observe protective pads/briefs for skin tolerance and provide physical support/assist for toileting safety.
Review of the monthly physician orders for August 2023 identified orders dated 08/23/21 for barrier cream to buttocks after each incontinent episode, record bowel movement every shift, and on 04/26/23 toileting extensive assist of one and incontinent of bowel and bladder.
On 08/07/23 at 11:08 A.M., observation/interview with Resident #9 revealed she had not been changed since night shift and she was really wet. Resident #9 reported she had her call light on for a while and asked to verify it was working.
On 08/07/23 at 11:15 A.M., interview with State Tested Nursing Assistant (STNA) #114 answered the light call light and verified the resident was saturated with urine and had not been provided incontinence care since night shift ending at 6:00 A.M.
Review of the facility policy, Perineal Care, dated 06/07/22, revealed the policy stated, it is the facility's policy to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.
No additional policies related to toileting or incontinence care were provided by the facility.
Based on record review, observations, resident and staff interviews, and facility policy review, the facility failed to complete timely incontinence care and toileting assistance for two residents (Residents #9 and #18). The deficient practice affected two residents (Residents #9 and #18) of two reviewed for bowel and bladder. The facility census was 44.
Findings Include:
1. Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required extensive assistance from two staff to complete Activities of Daily Living (ADLs), including toileting. Resident #18 had functional limitations in range of motion (ROM) and impairments on both side of upper and lower extremities. Resident #18 was frequently incontinent of bowel and bladder.
Review of the care plan, revised 08/07/23, revealed Resident #18 was incontinent of bladder and was at risk for altered dignity, skin breakdown, and urinary tract infection (UTI). Interventions included check and provide incontinence care as needed, apply moisture barrier cream after each incontinent episode, provide physical support/assistance for toileting safety as indicated for resident.
Observation and interview on 08/09/23 at 8:53 A.M. with Resident #18 in her room. The resident was out of bed and sitting in her wheelchair next to her bed. Resident #18 stated she had been waiting approximately an hour for staff to assist her onto bed pan. Resident #18 stated she had not had an accident but had been holding it for a long time. Resident #18 stated it took two staff to assist her out of her wheelchair, transfer her back into bed, and place her on the bedpan.
Interview on 08/09/23 at 9:30 A.M. with State Tested Nurse Aide (STNA) #150 confirmed Resident #18 requested to go to the bathroom this morning, approximately 45 minutes ago. STNA #150 stated she had been feeding another resident breakfast and forgot to inform the other aide that Resident #18 needed to use the bedpan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to timely complete initial comprehensive assessments of identified pressure injury areas for one resident (Resident #146). The deficient practice affected one resident (Resident #146) of three residents reviewed for pressure ulcers. The facility census was 44.
Findings Include:
Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, and Type II Diabetes Mellitus with foot ulcer.
Review of the Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #146 required extensive assistance from one staff to complete Activities of Daily Living. Resident #146 had impaired skin. Resident #146 had an infection of the foot and surgical wounds. The assessment did not indicate Resident #146 had any pressure ulcers.
Review of the Wound Grid Documentation for the skin area on the right side of Resident #146's scrotum revealed the observation was opened on 07/28/23 at 6:01 P.M. by LPN #127, charting started on 07/29/23 at 11:20 A.M. by LPN #127, and completed on 08/08/23 at 9:13 A.M. by WN #131. The skin area was identified by LPN #127, however, a comprehensive assessment of the area was not completed until 08/03/23 (six days after admission) by WN #131. The area was described as a Stage I pressure injury by WN #131.
Review of the Wound Grid Documentation for the skin area on Resident #146's right buttock revealed the observation was opened on 07/28/23 at 6:03 P.M. by LPN #127, charting started on 07/29/23 at 11:22 A.M. by LPN #127, and completed on 08/09/23 at 6:42 A.M. by WN #131. The skin area was identified by LPN #127, however, a comprehensive assessment of the area was not completed until 08/03/23 (six days after admission) by WN #131. The area was described as an unstageable pressure injury by WN #131.
Review of the Wound Grid Documentation for the skin area on Resident #146's left buttock revealed the observation was opened on 07/28/23 at 6:04 P.M. by Licensed Practical Nurse (LPN) #127, charting started on 07/29/23 at 11:24 A.M. by LPN #127, and completed on 08/09/23 at 7:12 A.M. by Wound Nurse (WN) #131. The skin area was identified by LPN #127, however, a comprehensive assessment of the area was not completed until 08/03/23 (six days after admission) by WN #131. The area was described as an unstageable pressure injury by WN #131.
Interview on 08/10/23 at 10:37 A.M. with Wound Nurse (WN) #131 revealed if a resident was a new admission and had identified wounds upon admission, the wounds should be assessed one to two days after admission. WN #131 confirmed a comprehensive assessment of the above skin areas was not completed until 08/03/23 (six days after admission).
Interview on 08/10/23 at 2:45 P.M. with Regional Nurse (RGN) #144 confirmed the expectation would be for an initial comprehensive assessment of any wounds to be completed the same day as admission if possible. However, if a resident was admitted on the weekend with a treatment in place, the admitting nurse should note the areas and a full comprehensive assessment should be completed within 72 hours (three days) of admission.
Review of the facility policy, Pressure Injuries: Assessment, Prevention & Treatment, undated, revealed the policy stated, it is the facility's policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure one resident (Resident #18) had a soft cervical collar placed when out of bed as ordered. Additionally, the facility failed to timely complete initial comprehensive wound assessments for one resident's (Resident #146) surgical wounds. The deficient practices affected two residents (Residents #18 and #146) of two residents reviewed for quality of care. The facility census was 44.
Findings Include:
1. Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required extensive assistance from two staff to complete Activities of Daily Living (ADLs), including personal hygiene. Resident #18 was totally dependent on one staff for bathing. Resident #18 had functional limitations in range of motion (ROM) and impairments on both side of upper and lower extremities.
Review of the physician orders dated August 2023 revealed Resident #18 had an order to wear soft collar when out of bed every shift dated 08/07/23.
Review of the care plan, revised 08/07/23, revealed Resident #18 had impaired ability to perform ADL care. Interventions included resident to wear cervical collar when out of bed.
Observation on 08/09/23 at 8:53 A.M. revealed Resident #18 was out of bed, sitting in her wheelchair without soft neck collar on.
Interview on 08/09/23 at 9:16 A.M. with State Tested Nurse Aide (STNA) #146 confirmed Resident #18 was out of bed and did not have a soft neck collar on as ordered. STNA #146 stated she was not sure if Resident #18 was supposed to have the collar on or not because she had been told different things.
Review of the facility policy, Matrix: General Order Policy and Procedure, undated, revealed the policy stated, it is the facility's policy to follow the general order physician guidelines.
2. Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, and Type II Diabetes Mellitus with foot ulcer.
Review of the Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #146 required extensive assistance from one staff to complete Activities of Daily Living. Resident #146 had impaired skin. Resident #146 had an infection of the foot and surgical wounds.
Review of the Illustration of Documentation and Measurements of Skin Areas dated 07/28/23 revealed Resident #146 had foot wounds identified.
Review of the Wound Grid Documentation for the wound on the lateral top of Resident #146's left foot revealed the initial observation was dated 08/01/23 at 11:09 A.M. (four days after admission) and was completed on 08/07/23 at 1:20 P.M. Resident #146 was admitted with the surgical wound.
Review of the Wound Grid Documentation for the wound on the top of Resident #146's left foot revealed the initial observation was dated 08/01/23 at 11:12 A.M. (four days after admission) and completed on 08/07/23 at 1:10 P.M. Resident #146 was admitted with the surgical wound.
Interview on 08/10/23 at 10:37 A.M. with Wound Nurse (WN) #131 revealed if a resident was a new admission and had identified wounds upon admission, the wounds should be assessed one to two days after admission.
Interview on 08/10/23 at 1:58 P.M. with WN #131 revealed the admitting nurse, Licensed Practical Nurse (LPN) #127, identified the surgical wounds on Resident #146's foot on the skin grid upon admission on [DATE] but did not complete a comprehensive assessment including measurements or a description of the wounds. WN #131 stated she added measurements to the skin grid later. WN #131 confirmed she did not complete a comprehensive assessment of the surgical wounds until 08/01/23 (four days after admission) because Resident #146 was admitted on the weekend which she does not work over the weekend and she was scheduled to work on the floor on Mondays so she was not available to complete a comprehensive assessment until Tuesday, 08/01/23.
Interview on 08/10/23 at 2:45 P.M. with Regional Nurse (RGN) #144 confirmed the expectation would be for an initial comprehensive assessment of any wounds to be completed the same day as admission if possible. However, if a resident was admitted on the weekend with a treatment in place, the admitting nurse should note the areas and a full comprehensive assessment should be completed within 72 hours (three days) of admission.
Review of the facility policy, Pressure Injuries: Assessment, Prevention & Treatment, undated, revealed the policy did not address non-pressure skin areas. No additional skin policies were provided by the facility that addressed non-pressure skin areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required extensive assistance from two staff to complete Activities of Daily Living (ADLs), including personal hygiene. Resident #18 was totally dependent on one staff for bathing. Resident #18 had functional limitations in range of motion (ROM) and impairments on both side of upper and lower extremities.
Review of the care plan, revised 08/07/23, revealed Resident #18 had impaired ability to perform ADL care. Interventions included provide nail care and shampoo hair with showers per weekly schedule.
Observation on 08/07/23 at 12:34 P.M. of Resident #18's feet revealed the resident's toenails were long, thick, jagged, and discolored.
Interview on 08/07/23 at 12:34 P.M. with Resident #18 revealed her toenails sometimes bother her because they snagged her bed sheets. Resident #18 stated she would like to have her toenails trimmed and staff had not offered to complete toenail care for her since she was admitted to the facility.
Interview on 08/09/23 at 8:53 A.M. with Resident #18 revealed she received a shower on 08/08/23 and no foot or toenail care was offered or provided.
Interview on 08/09/23 at 9:16 A.M. with State Tested Nurse Aide (STNA) #146 confirmed Resident #18's toenails were long, thick, jagged, and discolored with a yellow tint. STNA #146 confirmed Resident #18's toenails needed trimmed. STNA #146 stated she thought aides were allowed to trim fingernails but not toenails.
Review of the facility policy, Fingernails/Toenails-Care of, dated 06/08/22, revealed the policy stated, it is the facility's policy to clean the nail bed, to keep nails trimmed, and to prevent infections.
Based on record review, observation, interview, and policy review, the facility failed to ensure showers were completed for Resident #37 and failed to ensure toenail care was completed for Resident #18. This affected two (Resident #18 and #37) of two residents reviewed for activities of daily living (ADL). The facility census was 44.
Findings included:
1. Record review revealed Resident #37 admitted to the facility on [DATE] with diagnoses including acute respiratory failure, sepsis, hypertension, sleep apnea, atrial fibrillation, heart failure, aortic aneurysm of unspecified site, kidney failure, and gastroesophageal reflux disease.
Review of a minimum data set (MDS) completed on 05/06/23 revealed Resident #37 has a brief interview for mental status (BIMS) of 15 indicating he is cognitively intact, he requires an extensive assist of two people for bed mobility, extensive assist of one person for toileting, and total dependence of one person for bathing.
Review of a shower schedule revealed Resident #37 was scheduled to receive showers three times a week; one on Tuesday, one on Thursday, and one on Saturday during first shift.
Review of ADL documentation and shower sheets for January 2023 through August 10, 2023 revealed Resident #37 did not receive scheduled showers on January 14th or January 19th; February 4th, 18th, or 25th; March 9th or 18th; April 1st, 4th, 6th, 8th, 13th, 22, 27, or 29th; May 6th, 13th, 20th, or 27th; June 1st, 15th, 17th, 20th, or 27th; July 15th or 27th; and August 1st or 3rd.
Interview on 08/07/23 at 10:30 A.M. with Resident #37 revealed he is supposed to receive showers every Tuesday, Thursday, and Saturday. Resident #37 did state the he refuses at times, but often is not offered his scheduled showers.
Interview on 08/10/23 at 1:32 P.M. with Registered Nurse (RN) #144 confirmed Resident #37 did not receive several showers as scheduled. RN #144 stated each resident should receive a minimum of two showers a week, then additional showers per resident preference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility failed to submit a new Pre-admission Screening/Resident Review (PASRR) once a resident received a new diagnosis of major depressive disorder. This affected one (Resident #37) of two residents reviewed for PASRR. The census was 44.
Findings included:
1. Record review revealed Resident #37 admitted to the facility on [DATE] with diagnoses including acute respiratory failure, sepsis, hypertension, sleep apnea, atrial fibrillation, heart failure, aortic aneurysm of unspecified site, kidney failure, and gastroesophageal reflux disease.
Review of chart revealed Resident #37 was given a new diagnosis of major depressive disorder on 03/02/23.
Review of Pre-admission Screening/Resident Review (PASRR) dated 03/07/22 revealed no evidence of Resident #37 having a mood disorder.
Interview on 08/09/23 at 12:01 P.M. with Social Services Director #171 confirmed a new PASRR had not been completed to indicate Resident #37 had a new diagnosis of major depressive disorder.
A policy for PASRR was requested on 09/09/23 at 4:16 P.M. but was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a Facility Reported Incident (FRI) investigation, staff interview, and facility policy review, the facility failed to report an allegation of physical abuse to the Ohio Department of Health (ODH) within two hours for one resident (Resident #35). The deficient practice affected one resident (Resident #35) of one reviewed for abuse. The facility census was 44.
Findings Include:
Review of the medical record for Resident #35 revealed an admission date on 12/09/21. Medical diagnoses included encephalopathy, cognitive communication deficit, Alzheimer's Disease, anxiety disorder, and major depressive disorder.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had severely impaired cognition. Resident #35 required extensive assistance from two staff to complete Activities of Daily Living (ADLs).
Review of the progress note dated 01/16/23 at 8:37 P.M. revealed Registered Nurse (RN) #130 entered Resident #35's room to administer medications. Resident #35's daughter was present at bedside. Resident #35 was compliant with taking medications initially however, when the resident's daughter approached the bed, and insisted the resident take his medications, Resident #35 attempted to expel the medication from his mouth. Resident #35's daughter placed her hand over the resident's mouth to prevent the resident from spitting the medications out. RN #130 offered to return at a later time and Resident #35 agreed however, the resident's daughter insisted Resident #35 take his medication. RN #130 attempted to administer two more medications. Resident #35 successfully took one pill but spit the other one out despite the resident's daughter holding her hand over Resident #35's mouth. Resident #35 accepted a drink of water despite a high state of distress.
Review of the facility report incident (FRI) basic case information revealed the investigation was created on 01/17/23 at 4:27 P.M., 20 hours after the incident occurred.
Interview on 08/09/23 at 6:15 P.M. with the Administrator and Regional Nurse (RGN) #144 confirmed RN #130 reported the incident to the Administrator immediately. The Administrator confirmed the allegation of physical abuse for Resident #35 was not reported to the Ohio Department of Health (ODH) until 01/17/23 and was not reported within two hours. The Administrator stated she was not aware that any abuse allegations needed to be reported within two hours and thought the allegation only needed to be reported within two hours if there was bodily injury.
Review of the facility policy, Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property, undated, revealed the policy stated, all allegations of abuse, neglect, misappropriation, injuries of unknown origin must be reported immediately to both the Administrator and to the Ohio Department of Health (ODH).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and policy review, the facility failed to ensure a resident and/or their resident representative was invited to attend care planning conferences quarterly as required. This affected one (Resident #4) of one reviewed for care planning conferences.
Findings include:
A review of Resident #4's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included joint replacement surgery, a wedge compression fracture of T-9 and T-10 vertebrae, major depressive disorder, generalized anxiety disorder, juvenile onset diabetes mellitus, panic disorder, hypertension, hearing loss, osteoarthritis, and repeated falls.
A review of Resident #4's demographics revealed she was widowed. Her son was listed as her emergency contact.
A review of Resident #4's Minimum Data Set (MDS) assessments revealed she had an admission assessment completed on 02/08/21. Her most recent MDS assessment completed was a quarterly MDS completed on 05/14/21.
A review of Resident #4's electronic health record (EHR) revealed no documented evidence of the resident having had any care planning conferences held since her admission. The facility provided a copy of a written care conference meeting note that was completed on 02/18/21. The resident was indicated to have been in attendance as the meeting was held in her room. The family was indicated to have declined to attend. There was no documented evidence of any care planning conferences being held for the resident after 02/18/21. She did not have evidence of a quarterly care planning conference being held in May 2021 when her most recent quarterly MDS assessment was completed.
On 08/16/21 at 3:44 P.M., an interview with Resident #4 revealed she did not recall the facility inviting her to attend any care plan conferences held on her behalf. She did not recall a care planning conference being held in her room on 02/18/21.
On 08/17/21 at 2:07 P.M., an interview with the Director of Nursing (DON) revealed the facility's social worker was responsible for coordinating care planning conference meetings when they were due. She stated they scheduled them around the time of the MDS assessments or when a resident had a change that warranted a care planning conference to be completed. She confirmed care planning conferences should be documented in the EHR under observations or the progress notes. She then reported the social worker may have a written copy of a care planning conference if held and not documented in the EHR.
On 08/17/21 at 2:55 P.M., an interview with Licensed Social Worker #26 revealed she did not have documentation of the facility holding any additional care planning conferences for Resident #4 other than the one documented on 02/18/21. She denied a care planning conference for the resident had been completed around the time her quarterly MDS assessment was done in May 2021.
A review of the facility's policy on Care Plans/ Assessment- Resident/ Family Participation updated 10/16 revealed it was the facility's policy that each resident and his/ her family members were encouraged to participate in the development of the resident's comprehensive assessment and care plan. The procedure indicated the resident and his/ her family were invited to attend and participate in the resident's assessment and care planning conference. The resident assessments were begun on the first day of admission and completed no later than the 14th day after admission. Advance notice of the care planning conference was provided to the resident and authorized representative. Such notice would be provided in writing. The social service director or designee was responsible for contacting the resident's family and for maintaining records or such notices. Documentation was to include the date and time the resident and authorized representative were provided notification of the conference, the method of contacting the resident and the authorized representative, reason the resident and/ or authorized representative were unable to attend, and the date and signature of the individual providing notification of the conference to the resident and the authorized representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to ensure a resident with known significant weight loss had their meal intakes consistently recorded to aid in monitoring her nutritional status. This affected one (Resident #25) of one residents reviewed for nutrition.
Findings include:
A review of Resident #25's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia, dysphagia, feeding difficulties, mood disorder, anxiety disorder, and cognitive communication deficit.
A review of Resident #25's physician's orders revealed she was on a no added salt diet, pureed texture with thin liquids. Her meals were to be served in bowls and she was to receive her beverages in a two handed spouted cup for self feeding. She received a four ounce frozen nutritional treat with her lunch. They were to record her total intake for all three meals.
A review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. Mood indicators present included a poor appetite. She required an extensive assist of one for eating. Her height was 63 inches and her weight was 117 pounds. The resident was identified as having had a significant weight loss and not on a physician prescribed weight loss program.
A review of Resident #25's care plans revealed she was at risk for an altered nutrition. Her goals were to receive adequate nutrition to meet her estimated nutrition needs, not have a significant weight loss and her labs to be maintained within normal limits. Her interventions included offering/ providing a substitute of an equal nutritive value if less than 50% was consumed at her meals and monitor weekly weights x 4, then monthly if stable.
A review of Resident #25's weights recorded under the vital sign tab of the electronic health record revealed she had a significant weight loss noted on 08/02/21. Her weight had reduced from 128 pounds on 05/17/21 to 116 pounds on 08/02/21 representing a 12 pound or 9% weight loss in three months.
A review of Resident #25's progress notes confirmed she was known to have had a significant weight loss as a dietician note dated 07/07/21 identified a significant weight loss x one and three months related to diminished intakes. She was receiving nutritional supplements and had been started on Remeron (an antidepressant) as an appetite stimulant.
A dietician's note dated 07/28/21 revealed Resident #25 continued with weight loss over the past week as her weight was down to 115.6 pounds. The dietician indicated the resident's intakes remained varied and she was known to refuse breakfast meals at times. The resident's house supplement order was increased from 4 ounces twice a day to 4 ounces three times a day.
A review of Resident #25's meal intakes recorded in the electronic health record under the vital sign tab for the last 32 days (07/17/21- 08/16/21) revealed the staff were not consistently recording the resident's meal intakes after each meal. Out of the the 96 meals that should have been recorded, only 54 had been recorded. There were 42 meals in which the percentage of the resident's meal intake were not recorded. There were seven days (07/21/21, 07/26/21, 07/27/21, 07/28/21, 08/09/21, 08/10/21, and 08/12/21) in which none of the three meals provided that day were recorded to show how much the resident ate or if she ate at all. Findings were verified by the Director of Nursing (DON).
On 08/17/21 at 2:07 P.M., an interview with the DON revealed STNA's were responsible for documenting a resident's meal percentage consumed in the kiosk after each meal was served. She was asked what the purpose was of recording a resident's meal intake and she confirmed it was to help in monitoring their nutritional status. She acknowledged Resident #25 had multiple missing meal intakes for July and August 2021 and was known to have had a significant weight loss. She also confirmed the dietician would use that information to determine the need for any additional interventions to supplement the resident's nutritional intake if she was not consuming much of her meals.
The facility's administrative staff denied having any nutritional policies that addressed the need to record a resident's meal intake with each meal.

Based on observation, interview, record review, and policy review, the facility failed to ensure the medication error rate was less than five percent. Three errors out of 25 opportunities were observed, resulting in a 12 percent medication error rate. This affected two residents (Resident #22 and Resident #193) out of three residents observed for medication administration.
Findings include:
1. Review of Resident #22's medical record revealed an admission date of 08/20/18, with diagnoses including hypertension, peripheral vascular disease, and diabetes mellitus.
Review of Resident #22's August 2021 physician orders revealed an order for Flonase Allergy Relief spray with directions for two sprays in each nostril daily, and Lidocaine adhesive four percent patch with directions to apply the patch to the resident's lower back at night and remove in the morning.
Observation of Resident #22 on 08/18/21 at 7:48 AM revealed Registered Nurse (RN) #48 apply only one spray of Flonase Allergy Relief to each nostril. Continued observation revealed RN #48 take off the resident's Lidocaine patch and apply a new one to her lower back.
Interview on 08/18/21 at 8:43 AM RN #48 verified that she should have administered two sprays of Flonase into each of Resident #22's nostrils and should not have applied a new Lidocaine patch.
Review of the facility's policy titled, Medication Administration-General Guidelines, dated 05/2020, revealed before administering each medication the five rights should be assessed. These included the right resident, right drug, right dose, right route, and right time.
2. Review of Resident #193 medical record revealed an admission date of 08/08/21, with diagnoses including hypertension, diabetes mellitus, and muscle weakness.
Review of Resident #193 August 2021 physician orders revealed an order for Humalog Insulin 100 units/milliliter to be given per sliding scale. The scale revealed that insulin should not be administered until the resident reached a blood sugar level of 150. At that time two units should be given.
Observation on 08/18/21 at 11:04 A.M. Licensed Practical Nurse (LPN) #42 obtained Resident #193's blood sugar which showed a result of 137. Continued observation at 11:20 A.M. revealed LPN #42 administer two units of Humalog insulin to Resident #193.
Interview on 08/18/21 at 11:22 A.M. LPN #42 verified with a blood sugar of 137 Resident #193 should not have received any insulin.
Review of the facility's policy titled, Medication Administration-General Guidelines, dated 05/2020, revealed before administering each medication the five rights should be assessed. These included the right resident, right drug, right dose, right route, and right time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two vials of tuberculin solution were labeled correctly after they were opened. This had the potential to affect all 44 residents residing in the facility.
Findings include:
Observation [DATE] at 9:39 A.M. of the facility medication storage room revealed two vials of Aplisol Tuberculin solution that were open, used, but were not dated.
Interview on [DATE] at 9:45 A.M. Registered Nurse (RN) #10 verified that the facility failed to date the bottles of Tuberculin after opening, and therefore she was unable to verify when the vials would expire or if they were expired.
Review of the Aplisol tuberculin insert for the tuberculin revealed that vials in use more than 30 days should be discarded.
Review of the facility's policy, Medication Storage dated 05/2020, revealed medications dispensed in the manufacturers original container will be labeled with the manufactures expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to implement appropriate infection control practices in response to known and/ or suspected COVID-19 infections within the facility. This had the potential to affect all 44 residents that resided in the facility.
Findings include:
1. On 08/16/21 at 12:10 P.M., an observation of the dining process for the lunch meal served on the 100 hall revealed there were eight residents (Resident #6, #7, #8, #14, #15, #25, #35 and #42) sitting in the hallway awaiting their meal. The staff had them sitting in the hall near the television that was on the wall outside room [ROOM NUMBER]. The residents had bedside tables set up in front of them to be served their lunch meal on them. Six of the residents were noted to be sitting at a distance of less than six feet from one another. All of the residents had surgical masks on but five of the eight had their mask pulled down underneath their nose. All of the residents observed in that area were supposed to be under droplet precautions following a possible exposure to a COVID-19 positive employee.
On 08/16/21 at 12:15 P.M., nursing staff were observed to be delivering trays into the resident rooms for those on the 100 hall that were not out in the hallway for their meal. The nursing staff were observed to leave the resident's room after donning and doffing their personal protective equipment (PPE), which included a gown, gloves, surgical mask over an N95 mask and eye goggles. The staff continued to wear their eye goggles when leaving the room but were not observed to properly disinfect the eye goggles with an appropriate disinfectant cleaner when leaving the room. The staff were then noted to enter the next resident's room to deliver trays. State tested Nursing Assistant (STNA) #21 was noted to leave room [ROOM NUMBER] and enter room [ROOM NUMBER] without disinfecting her eye goggles. STNA #100 was noted to enter room [ROOM NUMBER] and then room [ROOM NUMBER] without disinfecting her eye goggles when leaving both rooms. STNA #21 was then noted to enter room [ROOM NUMBER] and room [ROOM NUMBER] with PPE on. Both rooms were of residents who were on droplet isolation precautions and neither had barrels in them for the disposal of her PPE. STNA #21 left the room and entered the hallway with her PPE on before doffing (removing) her PPE on while standing in the middle of the hall. When she left room [ROOM NUMBER], she was noted to tuck her potentially contaminated gown between her left upper arm and her torso so she could retrieve a plastic bag out of her pocket to put the PPE in. She then took the plastic bag down the hall to dispose of it in a utility room.
On 08/16/21 at 12:43 P.M., an interview with STNA #21 revealed they did not have PPE barrels in rooms 129 or 136 and verified she did not doff her PPE until she entered the hallway after leaving the residents' room. She was not sure why those rooms did not have barrels in them for the disposal of PPE as all residents on the hall were in droplet isolation precautions. She confirmed she did not disinfect her eye goggles when leaving room [ROOM NUMBER] and before she entered room [ROOM NUMBER]. She also denied disinfecting her goggles when she left room [ROOM NUMBER]. She stated the nurses' medication administration cart had alcohol wipes in it for them to use to disinfect their goggles. She denied they had them in the PPE carts that were located in the hallway. She was then asked about the dining room being closed and why they were placing the residents in the hallway in close proximity to one another. She acknowledged they were not socially distanced as they should be. She stated they quit using the dining room when they had a positive COVID-19 resident and acknowledged by placing them all in the same area in the hall defeated the purpose of closing the dining room down. She reported those eight residents who were served their meals in the hallway were those that needed supervision or feeding assistance with their meals. She stated they probably should have them outside their doorway so they were not congregated in one small area where social distancing could not be met.
On 08/16/21 at 12:55 P.M., an interview with the Administrator revealed the facility shut down it's dining room when a resident tested positive on a rapid test for COVID-19. She acknowledged by sitting the residents in close proximity to one another in the hallway for their meal defeated the purpose of closing the dining room as they were still not being socially distanced as they should be. She reported they were still looking into the process to ensure residents were being socially distanced as they should be. She acknowledged rooms [ROOM NUMBERS] did not have barrels in them for the disposal of soiled linen and trash despite the residents in those rooms being on droplet isolation precautions. She confirmed the rooms should have barrels in them and denied any shortages to explain why they were not. She reported they must not have been put in there yet. She also acknowledged staff were observed to leave those rooms with their PPE on not doffing them until they came out into the hallway. She was informed STNA's were observed to leave resident rooms who were on droplet isolation precautions without cleaning their goggles. She stated they could disinfect them with an alcohol wipe or use soap and water in the resident's bathroom but should be done when leaving the room and before entering another resident's room.
2. On 08/18/21 at 8:23 A.M., an observation noted three residents (Resident #22, #25, and #35) to be sitting in the hallway by the 100 hall nurses station. None of the three residents were noted to have masks on. The residents were not eating at the time the observation and did not have their trays in front of them to show they recently finished eating.
On 08/18/21 at 8:34 A.M., Resident #7 was observed to be wheeled out of her room by a staff member. The resident did not have a mask on when assisted out of her room and down the hall. She was placed in the hall in front of the TV and was not encouraged by staff to put her mask on. Findings were verified by RN #48.
On 08/18/21 at 8:38 A.M. an interview with RN #48 revealed all residents on that unit were considered to be in droplet isolation precautions following a possible exposure to a COVID-19 positive resident. She reported they were to encourage the residents to remain in their room but, if they came out, they were supposed to have a mask on. She reported the three that were observed in the hall by the nurses station required supervision, which is why they put them in the hall.
3. On 08/18/21 at 8:35 A.M., an observation noted staff to be collecting breakfast trays from resident rooms and placing them in a closed food cart. STNA #100 was noted to be out in the hallway receiving the trays from another staff member who was in the residents' rooms with PPE on passing the trays through the doorway. STNA #100 handled the trays with ungloved hands placing them inside the food cart. She was then observed to record the residents' meal intake on a clipboard she had on top of the food cart with a pen. She was observed to handle the drawers of a PPE cart outside a resident's room to don PPE before entering the room to retrieve a breakfast tray. She did not perform hand hygiene or use hand sanitizer after handling the trays before touching and potentially contaminating other surfaces. Findings were verified by STNA #100.
On 08/18/21 at 8:40 A.M., an interview with STNA #100 confirmed she did not have gloves on when she handled the breakfast trays passed out of the residents' rooms for her to load into the food cart. She also confirmed she did not wash her hands or use hand sanitizer, after handling the trays removed from the residents' rooms who were on droplet precautions, before touching other surfaces with her potentially contaminated hands.
A review of the facility's policy on Transmission Based Precautions: Droplet Precautions undated revealed the facility would utilize droplet precautions (in addition to standard precautions), for specified residents known or suspected to be infected with microorganisms transmitted by droplet that can generate by the resident during coughing, sneezing, talking, or the performance of procedures. The procedure included wearing a mask when working within six feet of the resident. For resident transportation, they were to limit the movement and transport of the resident from the room to essential purposes only. If transport or movement was necessary, minimize resident dispersal of droplets by masking the resident.
A review of the facility's COVID-19 policy revealed the facility was to limit communal dining and group activities. They were to remind residents and staff to practice social distancing when not delivering/ receiving direct care. They were to remind staff about the importance of good hand hygiene. They were to perform proper hand hygiene with soap and water or alcohol based hand rub before and after all resident contact, contact with potentially infectious material and before putting on and upon removal of PPE, including gloves.
A review of the facility's policy on Face Shields and Goggles updated 04/26/21 revealed it was the facility's policy to wear face shields or goggles to reduce the risk of transmission of infectious agents when engaging in resident care encounters. Employees providing care and services to residents would be provided a face shield or goggles to utilize throughout their shift. Eye protection was required when caring for residents in quarantine or isolation rooms. Eye protection was to be disinfected when exiting a COVID-19 quarantine room, when visibly soiled or when donning/ doffing.
4. Observation on 08/16/21 from 12:40 P.M. to 12:51 P.M. revealed Therapist #50 walking into Resident #33 and Resident #194 room with full personal protective equipment (PPE) on (gown, gloves, mask, and eye protection/face shield). They walked out of that room, doffed (took off) all of their PPE appropriately and used appropriate hand washing techniques. They did not clean the face shield. After that room, they put full PPE back on and walked into Resident #13 and Resident #197 room. After finishing in that room, they completed the same doffing and hand washing tasks; but did not clean the face shield again. At the time of the observation all residents in the facility were on droplet isolation precautions.
Interview with Therapist #50 on 08/16/21 at 12:51 P.M. confirmed that the facility keeps cleaning wipes in the PPE carts near each room so they can clear their eye protection after entering each resident's room. Therapist #50 confirmed that they are to clean their face shield after entering/leaving each room that is on isolation precautions; and confirmed that this process was not completed.
Review of facility Face Shield and Goggles policy (dated 04/26/21) revealed the purpose of the policy was to reduce the risk of transmission of infectious agents, face shields/eye protection will be utilized when engaging in patient care encounters. Eye protection is required when caring for residents in a quarantine or isolation room. Eye protection is to be disinfected when exiting a COVID-19 quarantine room, when visibly soiled, and when donning/doffing. Disinfect the inside and outside of the faceshield or goggles using an EPA approved disinfectant or bleach solution.