Every finding on record at Alpine Nursing and Rehabilitation Center

.THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to prevent the misappropriation of resident medications. This affected one (Resident #35) of three residents reviewed for misappropriation. The facility census was 72 residents.Findings include: Review of the medical record for Resident #35 revealed an admission date of 10/31/22 with diagnoses including congestive heart failure, schizoaffective disorder bipolar type, generalized anxiety disorder, and chronic pain syndrome.Review of the Minimum Data Set (MDS) assessment for Resident #35 dated 07/18/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the controlled substance administration record for Resident #35 revealed 30 hydrocodone-acetaminophen 5-325 milligrams (mg) tablets were dispensed on 05/16/25. The administration record indicated there should be 19 doses remaining.Review of the record of disposal for controlled substances revealed the hydrocodone-acetaminophen tablets dispensed for Resident #35 on 05/16/25 with an original quantity of 30 tablets indicated 15 tablets had been destroyed on 06/13/25.Review of the facility SRI regarding Resident #35 dated 06/13/25 revealed a blister pack of the resident's hydrocodone-acetaminophen which was scheduled to be destroyed had gone missing. The facility began an investigation, and the blister pack was found in Resident #18's room with 15 pills remaining. Resident #18 reported he was unaware how the medication ended up in his room. The SRI indicated the Director of Nursing (DON) had removed multiple controlled substances from a locked drawer and had them on her desk to destroy when Housekeeping Supervisor (HS) #300 came to the office to vacuum. The DON walked to the front side of the desk while HS #300 vacuumed. The DON and additional nursing staff then began wasting the controlled substances and discovered the blister pack was missing.Interview on 08/05/25 at 10:33 A.M. via telephone with HS #300 confirmed she had been terminated because of a failed drug test. HS #300 stated she found a plastic bag in the conference room with the blister packs of medication and removed one from the plastic bag. HS #300 reported she opened four pills from the pack and took them before discarding the blister pack with the remaining pills in Resident #18's room because it was across the hall from the conference room. HS #300 stated she then pretended to have found the blister pack in Resident #18's room.Interview on 08/05/25 at 3:04 P.M. with Human Resources Director (HRD) #12 confirmed HS #300 admitted to taking Resident #35's medication. HRD #12 confirmed HS #300 was terminated. Review of the undated facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property undated revealed the facility would not tolerate the misappropriation of resident property.The deficient practice was corrected on 06/19/25 when the facility implemented the following corrective actions: On 06/13/25, the DON and/or designee investigated and determined Resident #35 had not missed any doses of medication as the medication had been discontinued. On 06/13/25, the DON and/or designee completed initial audits of residents on controlled substances with no other discrepancies identified. By 06/19/25, the Administrator, the DON, and Assistant Director of Nursing (ADON) #14 educated all staff on the abuse, neglect, exploitation, and misappropriation policy. On 06/19/25, HS #300 was terminated. Starting on 08/05/25, the DON and/or designee will monitor/audit residents on controlled substances once weekly as an ongoing part of the facility's performance improvement plan.This deficiency represents noncompliance investigated under Self-Reported Incident Control Number OH00167073 (iQIES Number 1359708.)

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure foods were labeled and dated properly. This had the potential to affect all of the residents residing in the facility. The facility census was 69 residents. Findings include: 1.Observation on 05/18/25 at 9:09 A.M. of the walk-in refrigerator revealed it contained four pre-made salads and one pitcher of orange liquid which were not labeled or dated. Interview on 05/18/25 at 9:15 A.M. with Dietary [NAME] (DC) #342 confirmed the salads and the pitcher of orange liquid were unlabeled and undated. DC #342 confirmed foods should be labeled and dated upon opening. 2.Observation on 05/20/25 at 10:47 A.M. of the walk-in refrigerator revealed it contained two trays of cups filled with orange liquid which were unlabeled and undated. Interview on 05/20/25 at 10:47 A.M. with Kitchen Manager (KM) #334 confirmed the trays of cups filled with orange liquid were unlabeled and undated. KM #334 confirmed foods should be labeled and dated upon opening. Review of facility policy titled Food Receiving and Storage dated November 2022 revealed dry foods and refrigerated/frozen foods should be labeled and dated.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were dated upon opening and discarded on or before the expiration date. This affected eight (Residents #6, #8, #10, #24, #28, #44, #49, and #122) and had the potential to affect all of the residents residing in the facility. The facility census was 69 residents. Findings include: 1.Review of the medical record for Resident #28 revealed an admission date of [DATE] with diagnoses including type two diabetes mellitus, chronic kidney disease, and heart failure. Review of the physician's orders for Resident #28 revealed an order dated [DATE] for artificial tears eye drops to both eyes twice daily. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated [DATE] revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #28 revealed orders dated [DATE] for prednisone eye drops to the left eye twice daily and bromfenac solution eye drops to the left eye at bedtime. Observation on [DATE] at 10:36 A.M. revealed the prednisone eye drops, artificial tears eye drops, and bromfenac eye drops were opened and had not been dated upon opening. Interview on [DATE] at 10:38 A.M. with Licensed Practical Nurse (LPN) #219 confirmed the prednisone eye drops, the artificial tears eye drops, and the bromfenac eye drops for Resident #28 had been opened but had not been dated upon opening. 2.Review of the medical record for Resident #6 revealed an admission date of [DATE] with diagnoses including major depressive disorder, type two diabetes mellitus, and chronic obstructive pulmonary disease (COPD). Review of the physician's orders for Resident #6 revealed an order dated [DATE] for Refresh liquid gel eye drops to the left eye once daily. Review of the MDS assessment for Resident #6 dated [DATE] revealed the resident had intact cognition and required staff assistance with ADLs. Observation on [DATE] at 10:40 A.M. revealed the Refresh liquid gel eye drops for Resident #6 were opened on [DATE]. Interview on [DATE] at 10:41 A.M. with LPN #219 confirmed the Refresh liquid gel eye drops for Resident #6 were expired and should have been discarded. 3.Review of the medical record for Resident #24 revealed an admission date of [DATE] with diagnoses including chronic kidney disease, type one diabetes mellitus, and bipolar disorder. Review of the MDS assessment for Resident #24 dated [DATE] revealed the resident had severe cognitive impairment and required substantial staff assistance with ADLs. Review of the physician's orders for Resident #24 revealed an order dated [DATE] for insulin glargine inject 28 units subcutaneously at bedtime. Observation on [DATE] at 10:42 A.M. revealed Resident #24's bottle of glargine insulin was opened but had not been dated. Interview on [DATE] at 10:43 A.M. with LPN #219 confirmed the bottle of insulin for Resident #24 had been opened but had not been dated. 4. Review of the medical record for Resident #122 revealed an admission date of [DATE] with diagnoses including COPD, type two diabetes mellitus, and glaucoma. Review of the MDS assessment for Resident #122 dated [DATE] revealed the resident had intact cognition and required set up and supervision with ADLs. Review of the physician's orders for Resident #122 revealed an order dated [DATE] latanoprost eye drops to both eyes once daily. Observation on [DATE] at 10:50 A.M. revealed the latanoprost eye drops for Resident #122 were opened but had not been dated. Interview on [DATE] at 10:51 A.M. with LPN #239 confirmed the latanoprost eye drops for Resident #122 were opened but had not been dated. 5.Review of the medical record for Resident #8 revealed an admission date of [DATE] with diagnoses including cerebral infarction, major depressive disorder, and dry eye syndrome. Review of the physician's orders for Resident #8 revealed an order dated [DATE] revealed artificial tears eye drops to both eyes three times daily. Review of the MDS assessment for Resident #8 dated [DATE] revealed the resident had intact cognition and required staff assistance with ADLs. Observation on [DATE] at 11:01 A.M. revealed the bottle of artificial tears eye drops for Resident #8 were opened but had not been dated. Interview on [DATE] at 11:02 A.M. with LPN #245 confirmed the artificial tears eye drops for Resident #8 were opened but had not been dated. 6. Observation on [DATE] at 11:03 A.M. of the north hall medication cart revealed a bottle of docusate sodium with an expiration date of [DATE]. Interview on [DATE] at 11:04 A.M. with LPN #245 confirmed the docusate sodium in the north hall medication cart had expired and should have been discarded. LPN #245 further confirmed Residents #10, #44, and #49 had orders for docusate sodium. Review of the facility policy titled Administering Medications dated 2001 revealed medications should be administered in a safe and timely manner, and as prescribed. The expiration/beyond use date on the medication label should be checked prior to administering. When opening a multi-dose container, staff should record the date opened on the container.

Based on record review, staff interview, and review of the facility policy, the facility failed to complete significant change Minimum Data Set (MDS) assessments in a timely manner. This affected one (Resident #7) of 17 residents reviewed for MDS assessments. The facility census was 69 residents. Findings include: Review of the medical record for Resident #7 revealed an admission date of 11/21/21 with diagnoses including multiple sclerosis, cerebral infarction, and vascular dementia. Review of the physician's orders for Resident #7 revealed an order dated 03/04/25 for the resident to be admitted to hospice. Review of the significant change MDS assessment for Resident #7 dated 05/01/25 revealed the resident had severely impaired cognition and was dependent on staff for assistance with ADLs. Interview on 05/21/25 at 12:35 P.M. with MDS Coordinator #208 confirmed the facility had not completed the significant change MDS assessment for Resident #7 within 14 days as required. Review of the facility policy titled Comprehensive Assessments dated March 2022 revealed comprehensive assessments should be conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) manual.

Based on record review and staff interview, the facility failed to submit Minimum Data Set (MDS) assessments in a timely manner. This affected one (Resident #59) of 17 residents reviewed for assessments. The facility census was 69 residents. Findings include: Review of the medical record for Resident #59 revealed an admission date of 10/03/23 with diagnoses including aphasia, dementia, and atrial fibrillation. Review of the MDS assessment for Resident #59 revealed the MDS for January had a target date of 01/06/25 and a completion date of 01/27/25, and the MDS for April had a target date of 04/07/25 and a completion date of 04/29/25. Interview on 05/21/25 at 01:33 PM with MDS Coordinator #208 confirmed the Resident #59's January 2025 MDS was late and not completed until 01/27/25, and the April 2025 MDS was late and not completed until 04/29/25. MDS Coordinator #208 further confirmed neither of Resident #59's assessments had been transmitted within 14 days as required.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately. This affected one (Resident #66) of 17 residents reviewed for MDS assessments. The facility census was 69 residents. Findings include: Review of the medical record for Resident #66 revealed an admission date of 03/13/25 with diagnoses including cerebral infarction, chronic obstructive pulmonary disease (COPD), dementia, and anxiety disorder. Review of the physician's orders for Resident #66 dated 03/16/25 revealed an order for oxygen two liters per minute (LPM) via nasal cannula (NC) as needed to keep oxygen saturation above 92 percent (%). Review of the Minimum Data Set (MDS) assessment for Resident #66 dated 04/04/25 revealed the resident had severe cognitive impairment and required staff supervision and assistance with activities of daily living (ADLs.) Review of section O for special treatments and procedures for the MDS assessment for Resident #66 dated 04/04/25 revealed the resident was not coded for use of oxygen therapy. Interview on 05/21/25 at 12:50 P.M. with MDS Coordinator #208 confirmed section O of Resident #66's MDS assessment dated [DATE] was not coded correctly as it did not reflect the resident's use of oxygen therapy. Review of the facility policy titled MDS Assessment Coordinator dated November 2019 revealed a licensed nurse should be responsible for conducting and coordinating the development and completion of the resident assessment (MDS). Each individual who completed a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment by dating and signing the assessment and identifying each section completed.

Based on medical record review, staff interview, and review of the facility, the facility failed to ensure staff monitored tube feeding residuals. This affected one (Resident #40) of one resident reviewed for tube feeding. The facility census was 69 residents. Findings include: Review of the medical record for Resident #40 revealed an admission date of 08/23/24 with diagnoses including dysphagia following cerebral infarction, atherosclerotic heart disease, chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 04/02/25 revealed the resident had severely impaired cognition and required substantial staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #40 revealed an order dated 04/30/25 to check tube for residual before each feeding with instructions: if residual is above 60 milliliters (ml) hold for one hour and recheck, and if still above 60 ml to call the doctor. Review of the care plan for Resident #40 revised 05/07/25 revealed the resident required a feeding tube related to dysphagia. Interventions included administering enteral feedings and fluids as ordered, checking placement of tube, flushing tube as ordered, and notifying physician for increased amounts of residual. Review of the Medication Administration Record (MAR) for Resident #40 dated 05/01/25 to 05/21/25 revealed there was no documentation of monitoring the resident for tube feeding residuals. Interview on 05/21/25 at 12:30 P.M. with Assistant Director of Nursing (ADON) #207 confirmed there was no documentation of tube feeding residuals being checked for Resident #40 for 05/01/25 to 05/21/25. ADON #207 confirmed Resident #40 had a physician's order to the check the residual before each feeding. Review of the facility policy titled Checking Gastric Residual Volume (GRV) dated November 2018 revealed staff should measure GRV to assess the resident's tolerance of enteral feeding and minimize the potential for aspiration. The person performing the procedure should record completion of the task on the administration record.

Based on review of the medical record review, observation, staff interview, and review of manufacturer's guidelines, the facility failed to ensure the medication error rate was below five percent (%). There were two errors out of 29 medication opportunities resulting in a medication error rate of 6.9%. This affected one (Resident #17) of seven residents reviewed for medication administration. The facility census was 69 residents. Findings include: Review of the medical record for Resident #17 revealed an admission date of 07/08/24 with diagnoses including type two diabetes mellitus, generalized anxiety disorder, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 04/15/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #17 revealed an order dated 05/02/25 Humalog insulin 22 units subcutaneously before meals and an order dated 05/06/25 for Glargine insulin 54 units subcutaneously in the morning. Observation on 05/20/25 at 7:45 A.M. revealed Licensed Practical Nurse (LPN) #245 administered 22 units of Humalog insulin and 54 units of Glargine insulin to Resident #22 with priming the insulin pens prior to administration. Interview on 05/20/25 at 7:47 A.M. with LPN #245 confirmed she did not prime the insulin pens prior to administration to Resident #17. Review of the manufacturer's guidelines for Glargine insulin revised November 2018 revealed a safety test should always be performed prior to each injection. After applying a needle to the pen, the nurse should select a dose of two units by turning the dosage selector and hold the pen with the needle pointing upwards. The nurse should then tap the insulin reservoir so that any air bubbles rise up towards the needle and then press the injection bottom all the way in and ensure insulin came out of the needle tip. Review of the manufacturer's guidelines for Humalog insulin revised 2023 revealed priming the pen meant removing the air from the needle and cartridge that might collect during normal use and ensure the pen was working correctly. If you did not prime before each injection, you might get too much or too little insulin. To prime the pen, turn the dose knob and select two units. Hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top. Push the dose knob in until it stops and zero was seen in the dose window.

Based on review of the medical record review, observation, staff interview, and review of manufacturer's guidelines, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #17) of seven residents reviewed for medication administration. The facility census was 69 residents. Findings include: Review of the medical record for Resident #17 revealed an admission date of 07/08/24 with diagnoses including type two diabetes mellitus, generalized anxiety disorder, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 04/15/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #17 revealed an order dated 05/02/25 Humalog insulin 22 units subcutaneously before meals and an order dated 05/06/25 for Glargine insulin 54 units subcutaneously in the morning. Observation on 05/20/25 at 7:45 A.M. revealed Licensed Practical Nurse (LPN) #245 administered 22 units of Humalog insulin and 54 units of Glargine insulin to Resident #22 with priming the insulin pens prior to administration. Interview on 05/20/25 at 7:47 A.M. with LPN #245 confirmed she did not prime the insulin pens prior to administration to Resident #17. Review of the manufacturer's guidelines for Glargine insulin revised November 2018 revealed a safety test should always be performed prior to each injection. After applying a needle to the pen, the nurse should select a dose of two units by turning the dosage selector and hold the pen with the needle pointing upwards. The nurse should then tap the insulin reservoir so that any air bubbles rise up towards the needle and then press the injection bottom all the way in and ensure insulin came out of the needle tip. Review of the manufacturer's guidelines for Humalog insulin revised 2023 revealed priming the pen meant removing the air from the needle and cartridge that might collect during normal use and ensure the pen was working correctly. If you did not prime before each injection, you might get too much or too little insulin. To prime the pen, turn the dose knob and select two units. Hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top. Push the dose knob in until it stops and zero was seen in the dose window.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff completed proper hand hygiene during medication administration. This affected one (Resident #30) of seven residents observed for medication administration. The facility also failed to ensure staff cleaned glucometers as appropriate after use. This affected one (Resident #3) of one resident with orders for blood sugar checks. Based on medical record review, observation, staff interview, review of the facility policy, and review online guidance per the Centers for Disease Control (CDC) the facility also failed to ensure staff disposed of personal protective equipment (PPE) properly. This affected one (Resident #123) of 15 residents with orders for enhanced barrier precautions (EBP.) The facility census was 69 residents. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 10/31/22 with diagnoses including schizoaffective disorder, type two diabetes mellitus, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #30 dated 03/06/25 revealed the resident had intact cognition and required setup and supervision with activities of daily living (ADLs.) Observation on 05/19/25 at 7:41 A.M. revealed Licensed Practical Nurse (LPN) #219 did not perform hand hygiene before or after medication administration to Resident #30. Interview on 05/19/25 at 7:41 A.M. with LPN #219 confirmed she did not perform hand hygiene before or after medication administration for Resident #30. Review of the facility policy titled Hand Washing Guidelines dated August 2019 revealed staff should perform hand hygiene before and after providing routine resident care. 2. Review of the medical record for Resident #3 revealed an admission date of 12/07/23 with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, and congestive heart failure (CHF). Review of the MDS assessment for Resident #3 dated 03/07/25 revealed the resident had moderate cognitive impairment and required staff assistance with ADLs. Observation on 05/19/25 at 7:45 A.M. revealed LPN #219 did not clean the glucometer after use for Resident #3. Interview on 05/19/25 at 7:47 A.M. with LPN #219 confirmed she did not clean the glucometer after use for Resident #3 and she should have done so. Review of the facility policy titled Medication Administration dated 2001 revealed staff should follow established facility infection control procedures when administering medications. 3. Review of the medical record for Resident #123 revealed an admission date of 05/07/25 with diagnoses including type two diabetes mellitus, CHF, and COPD. Review of the care plan for Resident #123 dated 05/19/25 revealed the resident had two venous/stasis ulcers to the right leg and was placed in enhanced barrier precautions. Observation on 05/21/25 at 11:00 A.M. revealed there was a used yellow disposable gown on an entry table in Resident #123's room. Interview on 05/21/25 at 11:02 A.M. with LPN #238 confirmed Resident #123 was on EBP, and she had used a disposable gown for the resident's care earlier in the day but had not discarded the disposable gown after use and instead left the contaminated gown inside the resident's room. Interview on 05/21/25 at 01:19 P.M. with Assistant Director of Nursing (ADON) #207 confirmed that gowns were to be disposed of after each use and not left anywhere in a resident's room for reuse. Review of the facility policy titled Personal Protective Equipment (PPE) revised May 2023 revealed gowns should be removed and discarded in a dedicated container for waste or linen before leaving the resident room or care area. Review of online guidance per the Centers for Disease Control (CDC) titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) on 05/21/25 at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html revealed for residents on EBP revealed staff should position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.

Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure resident rooms were free from pests. This affected one (Resident #23) of 17 residents reviewed for the physical environment. The facility census was 69 residents. Findings include: Review of the medical record for Resident #23 revealed an admission date of 01/17/25 with diagnoses including e muscular dystrophy, depression, and opioid dependence. Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 04/23/25 revealed the resident #23 had intact cognition and required set up and supervision with activities of daily living (ADLs.) Observation on 05/18/25 at 2:46 P.M. of Resident #23's room revealed there were five ants on bedside table and four ants on windowsill and wall. Observation on 05/20/25 at 9:45 A.M. of Resident #23's room revealed there were 10 ants in total on the bedside table, wall, and windowsill. Interview on 05/20/25 at 9:46 A.M. with Resident #23 confirmed he had ants present in his room for weeks, he had reported it, but the facility had not responded to his concern. Interview on 05/20/25 at 9:49 A.M. with Maintenance Director (MD) #360 confirmed the presence of ants in Resident #23's room. MD #360 further confirmed he would have to call the pest control come out and spray, because he was not allowed to do so. Review of the facility policy titled Pest Control/Pest Surveillance dated 01/03/25 revealed the facility had a policy which promoted pest eradication and the factility would use an outside pest control company for monthly and emergency treatments.

THIS DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of physician standing orders, review of hospital records, staff interview, and policy review, the facility failed to ensure residents were free from constipation and had interventions to prevent constipation on the care plan. This resulted in Actual Harm when Resident #75 did not have a bowel movement for five days before a stool softener was prescribed and was transferred out to the hospital and diagnosed with a fecal impaction. This affected one (Resident #75) of three residents reviewed for constipation. The census was 73. Findings include: Record review revealed Resident #75 was admitted on [DATE] and discharged on [DATE]. Diagnoses included metabolic encephalopathy, coronary artery disease, heart failure, hypertension, peripheral vascular disease, thyroid disorder and osteoporosis. Review of the baseline care plan dated 01/18/25 for Resident #75 revealed she was at risk for bowel and bladder and was continent of bowel. There were no further updates to the care plan. Review of the admission Minimum Data Set (MDS) assessment, dated 01/24/25, revealed she was moderately cognitively impaired. She required supervision/touching assistance for eating, substantial/maximal assistance for toileting, bed mobility, and transfers. She was always continent of bowel. Review of the facility's standing physician orders for constipation, not dated, revealed to give Milk of Magnesia 30 milliliters (ml) by mouth once as needed for constipation and call the physician if there wasn't a bowel movement. Review of the Medication Administration Record (MAR) from 01/18/25 through 03/06/25 revealed no standing orders or stool softeners ordered for Resident #75. Review of the bowel tracker dated 03/07/25 through 03/11/25 revealed no bowel movement documented for Resident #75. Review of therapy notes dated 03/10/25 documented Resident #75 complained of stomach pain, and it was reported to the nursing staff. Review of therapy notes dated 03/11/25 documented Resident #75 had a stomach ache and the family reported constipation issues prior. Therapy staff reported the issue again to the nursing staff. Review of the physician progress note dated 03/11/25 for Resident #75 documented the physician came into the facility and determined the chief complaint was an overall decline. There were also concerns of constipation and straining with bowel movements. There was an order for Sennosides-Docusate Sodium 8.6-50 milligrams (mg) to give two tablets one time a day for constipation. Review of the MAR for Resident #75 from 03/12/25 through 03/15/25 revealed the Senna was given to the resident. Review of the bowel tracker on 03/12/25 revealed Resident #75 had a small bowel movement, on 03/13/25 she had two small bowel movements, and on 03/14/25 she had two large bowel movements. Review of the progress notes from 03/12/25 through 03/15/25 revealed there were no further bowel assessments completed. Review of progress note dated 03/15/25 at 10:00 A.M. documented Resident #75's breathing had increased. Her respirations were 22 breaths per minute, blood pressure 140/80 millimeters of mercury (mmHg), pulse 110 beats per minute, and oxygen saturation was 83 percent (%). Oxygen was applied. The family was notified and wanted the resident sent out to the hospital for evaluation. Review of the hospital records dated 03/15/25 revealed a rectal fecal impaction with thickening of the rectal wall extending proximately into the splenic flexure suggestive of superimposed colitis. Liquefied small bowel enteric content with foci of air in the nondependent bowel right upper quadrant. A soap suds enema was ordered. During an interview on 04/08/25 at 9:45 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated they knew about the unconfirmed impacted bowel from the family, and they started an action plan. They confirmed something happened between 03/11/25 when the doctor reported she had normal bowel sounds and a soft abdomen until 03/15/25 when the resident went out to the hospital. They confirmed there weren't any bowel assessments completed after 03/11/25 since the resident was having bowel movements. They confirmed the only bowel protocol the facility had in place was for milk of magnesia and Resident #75 wasn't given any of that before letting the doctor know on 03/11/25. They confirmed Resident #75 wasn't getting any stool softeners before 03/11/25. During an interview on 04/08/25 at 12:47 P.M., Medical Director (MD) #200 stated she had been notified of Resident #75's constipation but didn't know the constipation had been going on for five days. She stated when she saw Resident #75 on 03/11/25 she assessed her bowel sounds and abdomen and didn't find anything abnormal. She stated she ordered a stool softener and didn't hear back from the facility. She did not know the resident was found to be impacted on 03/15/25 at the hospital and stated the symptoms the resident had upon leaving for the hospital on 03/15/25 with an increased heart rate could have been from her bowel impaction. She stated she would expect to see nursing doing bowel assessments to ensure there wasn't any problems from 03/11/25 through 03/15/25 and not just think because the resident was having bowel movements she was ok. Review of the policy titled Constipation Management Policy, dated 09/10/24 revealed to provide guidelines for the prevention, identification, and management of constipation to ensure patient comfort and health. Prevention 1. Hydration: Encourage patients to drink fluids with each meal/Med pass on an as needed basis, unless contraindicated. 2. Exercise: Recommend regular physical activity to stimulate bowel function as able 3. Routine: Establish regular bowel habits by encouraging patients to use the restroom as able Identification 1. Monitor: Regularly assess patients for signs of constipation. 2. Documentation: Record bowel movement in the patient's medical record, plan of care or activities of daily living flowsheets. Management 1. Initial Interventions: Increase fluid intake with meals/Med Pass, unless contraindicated Encourage physical activity as able 2. Medications: standing orders to be implemented per each facility protocol Bulk-forming agents: e.g., psyllium Osmotic laxatives: e.g., polyethylene glycol Stimulant laxatives: e.g., Bisacodyl (use sparingly) Monitoring and Follow-Up 1. Regular Monitoring: Track patient progress and adjust treatment plans as necessary. Each facility may implement a system for monitoring that best suits their workflow. 2. Patient Education: Provide education on lifestyle modifications and the importance of adherence to treatment plans. The deficient practice was corrected on 04/02/25 when the facility implemented the following corrective actions: On 03/17/25 and 04/01/25, all resident records were audited to see if they had a bowel movement documented and if not, they initiated their bowel protocol which was to give milk of magnesia 30 ml and if no bowel movement, then call the doctor. Auditing is still in progress. Review of the medical records for Residents #18, #4, and #51 revealed they had a bowel tracker in place since 03/17/25 and they didn't have any concerns for constipation in the progress notes. They all had a care plan in place for bowels. On 03/26/25, the nursing staff were educated on abdominal assessment and bowel documentation and there was a video to watch on bowel assessment. During an interview on 04/08/25 at 11:20 A.M., Licensed Practical Nurse (LPN) #122 stated she had been educated on bowel assessment which was a video and on documentation of the bowel tracker. During an interview on 04/08/25 at 11:23 A.M., LPN #201 stated she had been educated on bowel assessment which was a video and on documentation of the bowel tracker. This deficiency represents non-compliance investigated under Complaint Number OH00163923.

Based on record review, review of hospital records, staff interview, and review of facility policy, the facility failed to ensure residents were treated timely for a urinary tract infections (UTI). This resulted in Actual harm when Resident #75 developed signs and symptoms of a UTI and wasn't treated for the UTI for six days. She transferred out to the hospital and it was discovered the resident had a significant distention in the bladder with renal pelvictasis, (renal pelviectasis, is when urine gathers in the center of the kidney, called the pelvis. This makes the kidney larger than normal. This condition can affect one or both kidneys.) This affected one (Resident #75) of one resident reviewed for UTI. There were no other residents in the facility with a UTI. The census was 73. Findings include: Record review revealed Resident #75 was admitted on [DATE] and discharged on [DATE]. Diagnoses included metabolic encephalopathy, coronary artery disease, heart failure, hypertension, peripheral vascular disease, thyroid disorder and osteoporosis. Review of the baseline care plan dated 01/18/25 for Resident #75 revealed she was at risk for bladder incontinence and was incontinent of bladder. There were no further updates to the care plan. Review of the admission Minimum Data Set (MDS) assessment, dated 01/24/25, documented Resident #75 was moderately cognitively impaired. She required supervision/touching assistance for eating, substantial/maximal assistance for toileting, bed mobility, and transfers. She was always continent for bowel and incontinent for bladder. Review of progress note dated 03/07/25 at 6:13 A.M. revealed Resident #75 had foul-smelling urine, burning while urinating, and pain in the abdominal region. The physician was called and made aware with new orders for a urinalysis (UA) with Culture and Sensitivity (C&S). The order was put in the computer system at 8:59 P.M. Review of progress notes dated 03/08/25 at 2:31 P.M. documented the UA and C&S were obtained and the order was changed to STAT (immediate) pickup. At 3:19 P.M. a call was made to the laboratory (lab) to make sure the urine sample was going to be picked up on this day and the lab assured the facility that a representative would be at the facility on that evening to pick up the sample. Review of the pickup time revealed it was 3:19 P.M. The lab results were not reported back to the facility until 03/12/25 at 1:48 P.M. Review of the physician orders dated 03/13/25 at 5:53 A.M. revealed Macrobid 100 milligrams (mg) to give one two times a day for five days. This was started on 03/13/25. The resident was sent to the hospital on 03/15/25 for a fecal impaction. Review of the hospital records dated 03/15/25 revealed Resident #75 had a significant distention in the bladder with renal pelvictasis left greater than the right and no obstruction was noticed. She also tested positive for Influenza A. During an interview on 04/08/25 at 9:45 A.M. the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated they thought the facility executed the orders for the UA and C&S in a timely manner even though it took six days to get the resident an antibiotic and she was exhibiting signs and symptoms of a UTI. They confirmed there wasn't any interventions for the incontinence of bladder. They also confirmed there wasn't any documentation or monitoring of the resident for bladder issues from 03/11/25 through 03/15/25. During an interview on on 04/08/25 at 12:47 P.M., Medical Director (MD) #200 revealed she had no idea the hospital found a significant distention of Resident #75's bladder. She reported it could take up to four days to get the result of a UA and C&S because the UA was just a dip and the C&S was what took the longest to get a result. She revealed when she saw the resident on 03/11/25 she did an assessment on her abdomen and flanks, but there wasn't anything abnormal. She reported the expectation of the nursing staff would be do an assessment on the resident for a distended bladder between 03/11/25 through 03/15/25. She revealed just because the resident was urinating, had a UTI and was on antibiotics for the UTI didn't mean she was ok. She revealed the increased heart rate upon discharge to the hospital on 03/15/25 could have been from the distension of the bladder. Review of policy titled Urinary Tract Infection/Bacteremia, dated 2001, revealed: Assessment and Recognition 1. The physician and staff will identify individuals with a history of symptomatic urinary tract infections, and those who have risk factors (for example, an indwelling urinary catheter, kidney stones, urinary outflow obstruction, etc.) for UTl. 2. The staff and practitioner will identify individuals with possible signs and symptoms of a UTI. a. Signs and symptoms of a UTI may be specific to the urinary tract and/or generalized. The presentation of symptomatic UTl varies. b. Nurses should observe, document, and report signs and symptoms (for example, fever or hematuria) in detail and avoid premature diagnostic conclusions. c. New onset of nonspecific or general symptoms alone (change in mental status, decline in appetite, etc.) is not enough to diagnose a UTI. Urine odor, color and clarity also are not adequate to indicate bacteruria or a UTI. d. Acute deterioration in previously stable chronic urinary symptoms may indicate an acute infection. Multiple concurrent findings such as fever with hematuria or catheter obstruction are more likely to be due to a urinary source. e. A positive urine culture in someone with chronic genitourinary symptoms is not enough to diagnose a symptomatic UTI. The presence of either pyuria or a positive leukocyte esterase test alone are not enough to prove that the individual has a UTI, but the absence of pyuria or a negative leukocyte esterase test is fairly strong evidence that a UTI is not present. Cause Identification 1. The physician will help nursing staff interpret any signs, symptoms, and lab test results. Diagnosis must be based on the entire picture and not just on one or several findings in isolation. a. Before diagnosing a UTI or urosepsis and ordering antibiotics, the physician should consider a resident's overall picture including specific evidence that helps confirm or refute the diagnosis of a UTI (as discussed above). 2. The physician will help identify causes of, and factors contributing to, bacteruria or UTl such as bladder outlet obstruction, kidney stones, neurological impairments, and medications that can cause urinary retention. 3. Because nonspecific or systemic symptoms can be due to diverse factors either instead of or along with a UTI, the staff and practitioner will also consider additional or alternative causes regardless of whether bacteruria or urinary symptoms is present. a. For example, a patient with a UTI could also have confusion caused by fluid and electrolyte imbalance such as hypernatremia as a result of several days of inadequate food and fluid intake. Treatment/Management 1. The physician will order appropriate treatment for verified or suspected UTl and/or urosepsis based on a pertinent assessment. a. Empirical treatment should be based on a documented description of an individual's symptoms and on consideration of relevant test results, co-existing illnesses and conditions, and pertinent risk factors. b. Generally, symptomatic UTl should be treated. Bacteruria alone (an asymptomatic UTI) should not be treated routinely, because treating it does not materially change outcomes, improve longevity, or correct underlying problems. c. In select situations, empirical antimicrobial therapy may be warranted if urosepsis or other complications are suspected. d. In select situations, empirical antimicrobial therapy may be warranted for afebrile individuals with non-specific symptoms. 2. The physician will not treat asymptomatic individuals whose urine is colonized with yeast or with multi-resistant organisms such as methicillin-resistant Staphylococcus aureus or Enterococcus without careful review and clinical rationale. 3. The physician should consider stopping antibiotics or switching parenteral to oral antibiotics in individuals with uncomplicated UTl who have been afebrile and asymptomatic for at least 48 hours. 4. The physician will help the staff identify suspected sepsis related to a UTI and identify whether hospitalization may be warranted. 5. Fever and change in mental status alone do not automatically warrant hospitalization , nor is there compelling evidence that hospitalization improves the ultimate outcomes in individuals with symptomatic UTl. Sepsis, however, may sometimes warrant more aggressive inpatient treatment. Monitoring 1. The physician and nursing staff will review the status of individuals who are being treated for a UTI and adjust treatment accordingly. a. Decisions should be made primarily on the basis of clinical signs and symptoms. The goal of treatment in most cases is to control signs and symptoms of infection, not to eliminate bacteruria. b. Follow-up urine cultures after antibiotic treatment are not indicated routinely, but may be helpful if the symptoms are not resolving or complications are present. 2. When a resident has a persistent or recurrent urinary tract infection after treatment with antibiotics, the physician will review the situation carefully with the nursing staff and consider other or additional issues (such as urinary obstruction or indwelling catheter change or removal) before prescribing additional courses of antibiotics. a. Physicians should justify continuing or resuming antibiotic treatment beyond an initial course. This deficiency represents non-compliance investigated under Complaint Number OH00163923.

Based on observations, staff and resident interviews and policy review, the facility failed ensure meals were palatable. This affected three (Residents #31, #59 and #57) of three residents reviewed for food. The facility identified two residents who couldn't eat anything by mouth. The census was 73. Findings include: Review of the menu dated 04/07/25 revealed lunch consisted of a peppered hamburger patty, buttered noodles, green beans, and white cake. A test tray was obtained on 04/07/25 at 11:50 A.M. The meat was crispy around the edges and was tough. The noodles were over cooked and tasted mushy and the green beans were bland. During an interview on 04/07/25 at 11:55 A.M., Dietary Manager (DM) #171 stated if she cooks the noodles el [NAME], the residents complain they are too hard. This is the way the residents like the noodles. Se said to get the beef pepper patties done and up to temperature they had to be cooked this way. She admitted the foods were over cooked. During an interview on 04/07/25 at 12:55 P.M., Resident #57 stated the buttered noodles and the peppered beef patty were too done at lunch time. During an interview on 04/07/25 at 1:07 P.M., Resident #21 at 1:07 P.M. stated she had a chef salad for lunch but didn't like the food. The food was processed, tough, and didn't taste very good. During an interview on 04/07/25 at 1:15 P.M., Resident #39 stated the food sucked. She said the meat was tough and she called it the mystery meat because it was processed. She stated the noodles for lunch were mushy. She stated when fish was served, it was hard. Review of policy titled Food Palatability, not dated, revealed the facility was committed to serving nutritious, safe, and palatable meals to residents that reflect their choices, cultural backgrounds, and dietary restrictions. Meals will be served in a manner that promotes dignity, socialization, and enjoyment of the dining experience. Palatability is food that is acceptable in taste, appearance, and texture to the resident. This deficiency represents non-compliance investigated under Complaint Number OH00164115.

Based on record review, observation, interviews, and policy / procedures the facility failed to perform incontinence care in a sanitary manner. This affected one (#19) out of three residents reviewed for incontinence care. The facility census was 67. Findings include: Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses of cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery, hypertensive heart disease with heart failure, and obesity. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Resident #19 required setup assistance with eating, substantial assistance with personal hygiene, and was dependent on staff assistance with oral hygiene, toileting hygiene, bathing, dressing, bed mobility. Review of the care plan dated 06/24/22 revealed Resident #19 had bladder and bowel incontinence, with interventions to assist resident to the bathroom as needed and to provide peri care after each incontinence episode. Review of the Auarterly Bowel & Bladder Assessment completed on 10/09/24 revealed resident was incontinent of bladder and bowel. Observation on 11/07/24 at 8:38 A.M. with Certified Nursing Assistant (CNA) #130 and CNA #790 performing incontinence care on Resident #19 revealed the CNA's entered the resident's room, washed their hands, prepared a water basin with wet washcloths, soap, and dry washcloths. CNA #130 and CNA #790 explained the procedure to Resident #19. CNA #130 and CNA #790 washed their hands, applied clean clothes and approached Resident #19. Resident #19's attend was opened in the front and rolled down between her legs. CNA #790 used a clean washcloth with soap to wash Resident #19's right peri-fold, left peri-fold outer labia, and the inner-labia with a clean section of the washcloth with each stroke. CNA #790 used a clean washcloth to rinse Resident #19's right peri-fold, left peri-fold outer labia, and the inner-labia with a clean section of the washcloth with each stroke. CNA #790 used a dry washcloth to dry Resident #19's peri-area. CNA #790 changed her gloves. Resident #19 was positioned onto her right side. CNA #790 used a clean washcloth with soap to wash Resident #19's buttocks/sacrum area. CNA #790 used a clean washcloth to rinse Resident #19's buttocks/sacrum area. CNA #790 used a dry washcloth to dry Resident #19's buttocks/sacrum area. A clean attends was applied, Resident #19 was repositioned in bed, her call light was handed to her, and her oxygen tubing was picked up by the nasal cannula area and handed to her by CNA #790. CNA #130 and CNA #790 removed their gloves and washed their hands prior to exiting the room. Interview on 11/07/24 at 8:48 A.M. with CNA #790 confirmed during incontinence care on Resident #19 she did not change her gloves after performing incontinence care to the resident's buttocks/sacrum area. Interview also confirmed the resident was repositioned, the blankets were placed on the resident, the call light was handed to the resident, and the oxygen tubing was picked up by the nasal cannula area all while continuing to wear the same gloves she used while performing incontinence care. Interview also confirmed she should have removed her soiled gloves and washed her hands prior to covering the resident up, prior to repositioning the resident, prior to handing the call light to the resident, and prior to picking up the nasal cannula for oxygen and handing it to Resident #19. Interview on 11/07/24 at 8:56 A.M. with CNA #130 confirmed while performing incontinence care with CNA #790 they did not change their gloves after incontinence care was complete. Interview also confirmed they should have removed their soiled gloves and washed their hands prior to covering the resident up, prior to repositioning the resident, prior to handing the call light to the resident, and prior to picking up the nasal cannula for oxygen and handing it to Resident #19. Review of the Incontinence Management Standard of Care policy, undated revealed It is the policy of this facility to promote intact skin, maintain dryness and respect the resident's standard and individualized interventions. Review of the Perineal Care procedure, undated revealed the procedure of for providing perineal care is Washes hands, applies disposable gloves, explains procedure to resident. And Cleanse skin folds thoroughly, rinses, and pats dry. And Removes and appropriately discards soiled gloves. Repositions and covers patient. Places call light in reach. This deficiency represents non-compliance investigated under Complaint Number OH00159419.

Based on employee record review, review of the facility Bureau of Criminal Investigation (BCI) log, staff interview, and policy review, the facility to implement their abuse policy to ensure an employee had a background check completed with the results received timely. The had the potential to affect all 67 residents residing in the facility. The facility census was 67. Findings include: Review of the employee record for Certified Nursing Assistant (CNA) #120 was hired on 04/03/24. CNA #120's fingerprint background check was completed on 05/03/24, with facility receiving the results on 05/13/24. Review of the BCI log for the facility revealed CNA #120 was hired on 04/03/24, fingerprints were completed on 05/03/24 and the results were received on 05/13/24. Interview on 11/12/24 at 2:00 P.M. with Human Resource Director #680 confirmed CNA #120 was hired on 04/03/24 and her fingerprint results were not received at the facility until 05/13/24. Interview also confirmed CNA #120 was not terminated and continued to work for the facility after 05/03/24, which was 30 days from her hire date. Interview also confirmed CNA #120 continued to work hours at the facility from 05/03/24 through 05/13/24. Review of the Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy, dated 08/10/23 revealed it is the policy of Facility to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks. The facility will conduct a criminal background check in accordance with State law and Facilities policy. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observations and staff interviews, the facility failed to provide a safe environment for the residents when a window air-conditioning unit in the dining room had exposed wires and coils. This had the potential to affect 41 residents (#102, #107, #109, #110, #112, #116, #118, #119, #120, #122, #125, #126, #127, #128, #129,#130, #131, #134, #135, #136, #138, #139, #142, #143, #144, #145, #146, #147, #149, #151, #152, #153, #154, #156, #158, #159, #161, #162, #163, #164, and #167) who the facility identified who were cognitively impaired and mobile. The facility census was 71. Findings include: Observations on 05/15/24 at 10:20 A.M. in the dining room, was a window air conditioning unit plugged into electrical outlet. The air conditioning unit had exposed coils, wires, and a thick layer of dust with debris and cobwebs covering the exposed internal components of the unit. On the wall in the dining room was a thermostat with no dial with a typed note Do not change setting on the thermostat, and fan, doing so can cause the system to overheat and could cause a fire. For residents rooms the settings must stay on 'cool'. Do not turn the thermostat up, our air conditioner unit is now on, and the system is based on water and not cooled air. Interview on 05/15/24 at 10:25 A.M. with Housekeeping Staff #40 verified the air conditioning unit located in the window of the dining room was plugged into the electrical outlet with the cover that had been broken for a long time. Housekeeping Staff stated, don't touch because she was unsure of the hazard risk because of the layer of dust, grass, and cobwebs on the coils and wires. Housekeeping Staff #40 was unsure when it was cleaned or when it was maintained last. Interview with the Administrator on 05/16/24 at 1:15 P.M. verified the typed letter hanging above thermostat in dining room indicating not to change the thermostat and fan, because of overheating and cause a fire. The Administrator stated she was unsure when or why this letter was placed and removed the letter from the wall. The Administrator stated there was no facility policy regarding the air conditioning system functioning and thermostat controls. Interview with Maintenance Staff #42 on 05/16/24 at 2:30 P.M. verified the air conditioning unit located in the dining room was non-functioning, missing a plastic surround which exposed electrical wires and coils. He verified the unit posed an electrical risk if exposed wires/coils were touched because the unit was plugged into the electrical outlet. He verified that all air conditioning units were to be maintained though the maintenance department but was unsure when that unit was last functioning or maintained. This deficiency represents non-compliance investigated under Complaint Number OH00153796.

Based on observation, record review, review of the facility policy, and resident and staff interview the facility failed to ensure the residents had access to their call light. This affected one (Resident #200) of two residents reviewed for call light accessibility and functioning. The facility census was 71. Findings include: Review of the medical record for Resident #200 revealed an admitted [DATE]. Diagnoses included right hip fracture, seizure disorder, left below the knee amputation, traumatic brain injury, and vascular dementia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had intact cognition. Resident #200 required partial/moderate assistance from staff with oral hygiene and substantial/maximal assistance to dependent on staff for toileting, bathing/shower, upper body dressing, and lower body dressing. Review of the plan of care dated 06/14/22 revealed Resident #200 was at increased for risk for falls with interventions to have commonly used articles within easy reach: water, call light, remote control, and telephone. Interview and observation on 05/16/24 at 8:50 A.M. with Resident #200 in his room stated he was unable to find his television remote and could not call for help because he did not have his call light. No observation of call light within reach of Resident #200. During the interview with Resident #200, Registered Nurse (RN) #31 entered the room. Resident #200 told RN #31 that he was unable to locate his remote and his call light. RN #31 located the call light behind Resident #200's bed approximately five foot up the wall was a light bar and located on top of the light bar was Resident #200 call light. RN #31 removed the call light from above the light bar and gave it to Resident #200. Interview with RN #31 on 05/16/24 at 8:55 A.M. verified call lights were to be within reach of residents, including Resident #200. RN #31 verified Resident #200's call light was not within reach and was unable to call for assistance to find his remote. Review of the facility policy titled Call Lights, revision date 01/2020, revealed the call light is used by a resident to notify staff of the nursing facility that the resident has a need that they would like addressed. Staff will ensure that the resident is in a safe and comfortable position and that the call light is within reach of the resident before leaving the resident's room. This deficiency represents non-compliance investigated under Complaint Number OH00153796.

Based on medical record review, staff interviews, and policy review, the facility failed to complete an assessment and implement a treatment for a newly developed pressure ulcer. This affected one (#43) out of three residents reviewed for pressure ulcers. The facility census was 65. Findings included: Review of the medical record Resident #43 revealed an admitted [DATE] with medical diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, peripheral vascular disease, and hypertension. Review of the medical record for Resident #43 revealed an annual Minimum Data Set (MDS), dated [DATE], which indicated Resident #43 was cognitively intact and required substantial/maximum staff assistance for bed mobility, bathing, transfers, and toileting. The MDS indicated Resident #43 was always incontinence of bladder and frequently incontinent of bowel. The MDS indicated Resident #43 did not have any pressure ulcers. Review of the medical record for Resident #43 revealed a nurse's note dated 02/15/24 at 5:50 P.M., written by Registered Nurse (RN) #217 which stated the nurse observed small pressure sore to the residents buttocks. The note continued to state the State tested Nursing Assistant (STNA) informed her the area was present last week but had opened since then. The note stated the area was cleaned, ointment was applied, and the Assistance Director of Nursing (ADON) was notified. Further review of the medical record revealed a nurse's note, dated 02/16/24 at 11:40 A.M. which stated the nurse assessed the open area to resident's sacrum which measured 1.1 centimeters (cm) by 1.4 cm by 0.1 cm. The note stated the wound bed was dark red in the center and pink toward the outer edges and no drainage or odor was noted. The note continued to state the Physician Assistant, the wound Nurse Practitioner (NP), resident's power of attorney, and the dietician were notified. Review of the medical record for Resident #43 revealed a physician order dated 02/16/24 to cleanse sacrum with wound cleanser, pat dry, apply medi-honey to wound bed, cover with bordered gauze and to change daily and as needed. The medical record did not contain documentation to support a treatment to the sacrum was ordered prior to 02/16/24. Review of the medical record for Resident #43 revealed weekly skin assessments dated 02/05/24 and 02/12/24 which stated Resident #43 had no skin issues. The weekly skin assessment dated [DATE] stated Resident #43 had a small pressure sore to buttocks. Further review of the medical record revealed a pressure skin grid assessment dated [DATE] which stated Resident #43 was noted to have a Stage II pressure ulcer to the sacrum area on 02/15/24. The wound measured 1.1 cm by 1.4 cm by 0.1 cm. The medical record for Resident #43 revealed a pressure skin grid assessment, dated 02/27/24, which indicated the Stage II pressure ulcer to Resident #43's sacrum was healing and measured 1.0 cm by 1.5 cm by 0.1 cm. Review of the medical record for Resident #43 revealed wound NP note, dated 02/20/24 which stated Resident #43 was evaluated for Stage II pressure ulcer to sacrum which was found on 02/16/24. The note indicated the wound measured 1.8 cm by 1.8 cm by 0.1 cm and was debrided during the evaluation. Review of the wound NP note, dated 02/27/24, stated the Stage II pressure ulcer to the sacrum had improved and measured 1 cm by 1.5 cm by 0.1 cm. Interview on 02/29/24 at 12:48 P.M. with RN #217 confirmed she was the nurse who took care of Resident #43 when the pressure ulcer to the sacrum was found on 02/15/24. RN #217 stated STNA #204 informed her the pressure ulcer was present the week before but was not open at that time. RN #217 stated she notified the Assistant Director of Nursing (ADON) #233 of the area to the sacrum for further assessment. RN #217 stated ADON #233 completed the pressure skin grid and notified physician for treatment orders. Interview on 02/29/24 at 2:09 P.M. with STNA #204 confirmed she informed RN #217 that the pressure ulcer to Resident #43's sacrum was present a week prior to 02/15/24. STNA #204 stated she notified Licensed Practical Nurse (LPN) #211 on 02/09/24 that Resident #43 had a small area to the sacrum. STNA #204 stated she was not aware if LPN #217 assessed the area or notified the physician for treatment orders. Interview on 02/29/24 at 2:25 P.M. with LPN #217 confirmed he was notified by STNA #204 that Resident #43 had an area on her sacrum. LPN #217 stated he assessed the area to Resident #43's sacrum and the area was red, was not open, and was not blanchable. LPN #217 stated he applied barrier cream and a bordered gauze and informed STNA #204 to notify the ADON the next day of the area to Resident #43's sacrum. LPN #217 confirmed he did not measure the area or notify the physician of the area for treatment orders. Review of the facility policy titled, Wound Care, revised November 2018, stated wounds would be monitored for location, size (measure length, width, and depth), undermining, tunneling, exudates, necrotic tissue, and the presence or absence of granulation tissue and epithelialization. The policy also stated to notify the physician upon discovery of new skin area and when delay in healing is noted and to obtain physician orders for treatment to begin at the time of discovery. This deficiency represents non-compliance investigated under Complaint Number OH00150850.

Based on record review, observation and resident and staff interviews, the facility failed to ensure residents were treated with dignity by ensuring the residents indwelling (Foley) urinary catheter collection bag was covered. This affected one (#11) of three residents reviewed for indwelling (Foley) urinary catheters. The facility census was 71. Findings include: Review of medical record for Resident #11 revealed admitted . 10/31/22. Diagnoses included depression, schizophrenia, Crohn's disease and ulcerative colitis. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had Brief Interview Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Resident #11 required extensive two person transfers, toileting, one person assistance for bed mobility and supervision for eating. Resident #11 had an indwelling (Foley) urinary catheter. Observation and interview on 06/07/23 at 10:14 A. M with Resident #11 revealed he was sitting just inside the doorway to his room with the collection bag for his indwelling (Foley) urinary catheter hooked to his wheelchair. Resident #11's collection bag was observed to be uncovered and contain approximately 100 milliliters of urine. Resident #11 verified he would like the indwelling (Foley) urinary catheter it to be covered. Interview on 06/07/23 at 10:14 A.M. with Physical Therapy Assistant (PTA) #13 verified the collection bag for Resident #11's indwelling (Foley) urinary catheter bag was uncovered. Interview on 06/07/23 at 9:47 A.M. with State tested Nursing Assistant #12 and on 06/08/23 at 10:52 A.M. with STNA #22 revealed they were unaware the facility had covers for residents indwelling (Foley) urinary catheter collection bags. STNA #12 and #22 both stated they sometimes use a pillowcase. This deficiency represents non-compliance investigated under Complaint Number OH00143060.

Based on record review, observation, resident and staff interviews, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement physician-ordered interventions for residents with pressure ulcers, failed to thoroughly assess resident's skin and failed to identify pressure ulcers until they had already reached an advanced stage. This resulted in Actual Harm when Resident #76 developed an avoidable unstageable pressure ulcer to the left heel on 09/16/22 and Resident #55 developed an avoidable unstageable pressure ulcer to the right heel on 11/17/22. This affected two (#55 and #76) of three residents reviewed for pressure ulcers. The facility census was 84. Findings include: 1. Review of the medical record for Resident #55 revealed an admitted [DATE] with a diagnoses including vascular dementia, hypertension, and Alzheimer's disease. Review of the Minimum Data Set 3.0 (MDS) for Resident #55 dated 09/04/22 revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL's). Further review of the MDS revealed Resident #55 was coded as negative for the presence of pressure ulcers and was coded as being at risk for the development of pressure ulcers. Review of the pressure ulcer risk assessment for Resident #55 dated 08/26/22 revealed the resident was at risk for the development of pressure ulcers. Review of the admission skin assessment for Resident #55 dated 08/26/22 revealed resident's skin was intact. Review of the care plan for Resident #55 initiated 08/31/22 revealed the resident was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included the following: administer medication as ordered, assist resident to the bathroom as needed, provide peri care after each incontinence episode, apply barrier cream after incontinence care, assist the resident with turning and repositioning, pressure redistribution mattress to bed. Review of the care plan for Resident #55 dated 09/14/22 revealed the resident has an actual pressure wound to the coccyx. Interventions included: administer medications as ordered, administer treatment as ordered, assist resident with turning and repositioning, measure wounds weekly as ordered, observe for signs of infection: redness, purulent drainage, warmth, foul odor, obtain lab work as ordered, notify physician of abnormal lab values. Review of the pressure ulcer assessment for Resident #55 dated 09/15/22 revealed the resident developed a Stage I pressure ulcer to her coccyx which measured 2.1 centimeters (cm) in length by 0.6 cm in width and 0.1 cm in depth which was first identified on 09/09/22. Review of the pressure ulcer assessment for Resident #55 dated 09/22/22 revealed the pressure ulcer to the coccyx now measured 2.3 cm in length by 0.9 cm in width and 0.2 cm in depth and was now classified as a Stage III pressure ulcer. Review of the weekly skin assessments per licensed nurses for Resident #55 revealed the facility had completed one skin assessment for the resident on 09/16/22 which indicated the weekly skin assessment included previously identified pressure areas and no new areas of skin impairment. Review of the shower sheets for Resident #55 completed by the state tested nursing assistants (STNAs) and signed by licensed nurses for the following dates revealed there were no new areas of skin impairment notes for Resident #55: 09/02/22, 09/09/22, 09/16/22, 09/23/22, 09/30/22, 10/07/22, 10/14/22, 10/23/22, 10/28/22, 11/04/22, 11/11/22. Review of the nurse progress note for Resident #55 dated 11/12/22 revealed the STNA notified the nurse the resident had a black blister to her right heel. The nurse went into the resident's room and checked the resident's heel. A large black blister was noted to right heel. Area was cleansed gently, patted dry, skin prep applied, and heel was placed in a heel cup. Review of the pressure ulcer assessment for Resident #55 dated 11/17/22 revealed the resident had an unstageable pressure ulcer to her right heel which was purple in color and measured 6.0 cm in length by 2.7 cm in width. Review of a wound physician note for Resident #55 dated 11/17/22 revealed the resident had a new onset wound to the right heel which was classified as a deep tissue injury (DTI) which measured 6.0 cm in length by 2.7 cm in width. Review of the November 2022 monthly physician orders for Resident #55 revealed orders dated 11/17/22 for the resident to wear moon boots while in bed and an order to cleanse the right heel with normal saline (NS), pat dry, apply Betadine, apply heel cup, and apply the moon boots once daily and as needed. Review of the November 2022 Treatment Administration Record (TAR) for Resident #55 revealed the treatment to the right heel and the order for the moon boots was not implemented until 11/19/22. Observation on 11/21/22 at 2:18 P.M. revealed Resident #55 was resting in bed and was not wearing moon boots. One moon boot was observed in the resident's room resting on the windowsill. Resident #55 was not interviewable. Interview on 11/21/22 at 2:20 P.M. with STNA #370 confirmed Resident #55 did not have a pair of moon boots. STNA #370 further confirmed Resident #55 was not able to don or doff the moon boot herself. STNA #370 confirmed she had not placed the moon boot on the resident's right foot when she put the resident in bed after lunch because she thought the moon boot was only supposed to be placed when the resident was in bed for the night. Observation on 11/22/22 at 9:34 A.M. revealed Resident #55 was up in a geri chair and had a moon boot on the right foot. Interview on 11/22/22 at 9:34 A.M. with Licensed Practical Nurse (LPN) #200 confirmed the facility only had one moon boot for Resident #55 which they applied to the right foot because she had a pressure ulcer on that foot. Observation on 11/22/22 at 10:15 A.M. with LPN #200 revealed Resident #55 had a blackened area to the medial aspect of her right heel which was the size of two quarters placed next to one another. There was no drainage and the wound appeared to be covered with eschar. Interview on 11/22/22 at 10:15 A.M. with LPN #200 confirmed Resident #55 had an unstageable pressure ulcer to her right heel which was first identified on 11/17/22. LPN #200 further confirmed licensed nurses were supposed to conduct a head-to-toe skin assessment for each resident weekly. LPN #200 further confirmed the facility had not conducted regular weekly skin assessments for Resident #55. Interview on 11/22/22 at 1:08 P.M. with the Director of Nursing (DON) confirmed the facility staff first identified an area of impaired skin integrity to Resident #55's heel on 11/11/22. The DON confirmed the facility, and the wound physician identified a DTI to resident's right heel on 11/17/22. The DON confirmed the treatment to the wound was not implemented until 11/19/22. The DON further confirmed the licensed nurses were supposed to conduct weekly skin assessments and document them in the electronic medical record and there was only one weekly skin assessment for Resident #55 which was dated 09/16/22. The DON further confirmed the pressure ulcer to Resident #55's heel was avoidable. 2. Review of the medical record for Resident #76 revealed an admitted [DATE] with diagnoses including atherosclerotic heart disease, anemia, chronic kidney disease and hypertension. Review of the MDS for Resident #76 dated 11/10/22 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Review of the care plan for Resident #76 initiated 02/18/22 revealed the resident was at risk for the development of pressure ulcers due to decreased mobility and incontinence. Interventions included the following: administer medication as ordered, apply lotion to dry skin as needed, assist resident to the bathroom as needed, provide peri care after each incontinence episode and wheelchair cushion as ordered. Review of the weekly skin assessments per licensed nurses for Resident #76 revealed the most recent skin assessment for the resident was conducted on 07/07/22 and indicated the resident had no areas of impaired skin integrity. Review of the care plan for Resident #76 dated 09/16/22 revealed the resident has an actual pressure wound to the left heel. Interventions included: administer medications as ordered, administer treatment as ordered, assist resident with turning and repositioning, measure wounds weekly as ordered, observe for signs of infection: redness, purulent drainage, warmth, foul odor, obtain lab work as ordered, notify physician of abnormal lab values. Review of the shower sheets for Resident #76 completed by the STNAs and signed by licensed nurses for the following dates revealed there were no new areas of skin impairment notes for the resident on 09/01/22 and 09/08/22. Shower sheet dated 09/15/22 revealed heels were soft and were an abnormal color (purple). Review of the pressure ulcer assessment for Resident #76 dated 09/16/22 revealed the resident had a pressure ulcer to her left heel that measured 2.5 cm in length by 2.0 cm in width. Review of the September 2022 monthly physician orders for Resident #76 revealed orders dated 09/16/22 for moon boots while in bed and to apply Betadine to left heel every shift. Review of a wound physician note for Resident #76 dated 09/29/22 revealed the resident had an unstageable pressure injury to the left heel, covered with dark colored eschar and had no drainage which measured 4.8 cm in length by 2.5 cm in width. The physician recommended boots for offloading the wound. Review of the wound physician note for Resident #76 dated 11/17/22 revealed the pressure ulcer to the resident's left heel was now classified as a Stage III and had 25 percent (%) yellow slough to the wound bed with a moderate amount of serous drainage. The wound measured 1.0 cm in length by 0.3 cm in width by 0.1 cm in depth. The physician recommended boots for offloading the wound. Review of the November 2022 monthly physician orders for Resident #76 revealed orders dated 11/17/22 for the resident to wear moon boots while in bed and an order to cleanse the left heel with normal saline (NS), pat dry, apply Calcium alginate and collagen and secure with an ABD pad once daily and as needed. Observation on 11/22/22 at 8:35 A.M. revealed Resident #76 was resting in bed and was not wearing moon boots. Interview on 11/22/22 at 8:35 A.M. with Resident #76 confirmed she had developed a pressure ulcer to her left heel a couple months ago and it was painful. Resident #76 further confirmed she had moon boots which she was supposed to wear when she was in bed, but she was not sure where the moon boots were. Resident #76 confirmed she was unable to don or doff the moon boots herself and she had not worn them the night before. Interview on 11/22/22 at 8:37 A.M. with STNA #300 confirmed Resident #76's moon boots were not on her feet. STNA #300 confirmed night shift must have not put them on. Interview on 11/22/22 at 9:35 A.M. with LPN #200 confirmed Resident #76's moon boots were available in her closet and should have been placed on her feet while resident was in bed. Observation of wound care for Resident #76 on 11/22/22 at 9:36 A.M. per LPN #200 revealed the resident had a dime-sized darkened area to her left heel. The upper portion of the wound was yellow in color. Interview on 11/22/22 at 9:36 A.M. with LPN #200 confirmed Resident #76 had a pressure ulcer to her left heel which was first identified as an unstageable deep tissue injury on 09/16/22. LPN #200 confirmed the wound physician now classified the wound as a Stage III pressure ulcer due to the presence of slough in the wound bed. LPN #200 further confirmed the facility had not conducted regular weekly skin assessments for Resident #76. Interview on 11/22/22 at 1:08 P.M. with the DON confirmed the facility staff first identified an area of impaired skin integrity to Resident #76's heel on 09/16/22. The DON confirmed the wound physician identified a DTI to the resident's right heel on 09/29/22. The DON further confirmed the most recent weekly skin assessment for Resident #76 was dated 07/07/22. The DON further confirmed the pressure ulcer to Resident #76's heel was avoidable. Review of the facility policy titled Skin Care Pressure Prevention dated 11/2018 revealed the facility would ensure resident skin was observed routinely and preventative care plans completed upon admission and developed and implemented for each resident based on resident's risk factors for the development of skin breakdown. Review of the facility policy titled Assessments undated revealed a skin assessment should be completed upon admission and skin inspections should be conducted weekly and recorded in the resident's record. Review of the NPUAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Review of the NPUAP guidelines dated 2014 page 115 revealed ideally, heels should be free of all pressure, a state sometimes called floating heels. Pressure can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure. This deficiency represents non-compliance investigated under Complaint Number OH00136575.

Based on record review, staff interview, and review of facility policy, the facility failed to conduct a thorough investigation to determine potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in Actual Harm when Resident #87 experienced a fall on 11/06/22 which was not investigated to implement effective interventions. Resident#87 sustained a right comminuted hip fracture from the fall. This affected one (#87) of three residents reviewed for falls. The census was 84. Finding include: Review of the medical record for Resident #87 revealed an admitted [DATE] with a diagnosis of Alzheimer's disease. Review of the Minimum Data Set 3.0 (MDS) for Resident #87 dated 10/10/22 revealed the resident was cognitively impaired and required limited assistance of one staff with activities of daily living (ADLs). Review of the fall risk assessment for Resident #87 dated 06/01/22 revealed the resident was at high risk for falls. Review of the care plan for Resident #87 last updated 05/27/22 revealed the resident was at risk for falls related to memory impairment and schizophrenia. Interventions included the following: display a use call light sign in room, hipsters to be worn at all times when out of bed may remove for care, keep bed in lowest position except during care, keep call light within reach, non-skid strips to floor next to bed, offer to lay down after lunch, offer toileting every two hours, room modification, staff to anticipate resident's needs, therapy screen as needed, wheelchair removed from room. Review of the nurse progress note for Resident #87 dated 11/06/22 timed at 4:25 A.M. per an agency nurse revealed Resident #87 was found on the floor, had a fall and was complaining of pain to her right hip. The nurse administered Tylenol per order and gave witness statement forms to the two aides working on the unit. Review of witness statement per State tested Nursing Assistant (STNA) #225 revealed she saw Resident #87 on the floor near her bed on 11/06/22 at approximately 4:15 A.M. Review of witness statement per STNA #380 dated 11/06/22 revealed the aide saw Resident #87 in her bed at 2:00 A.M. when the aide was performing rounds. Further review of the statement revealed at the time of the fall the aide walked by the resident's room, she saw the resident sitting on the floor with no bottoms on. The floor was a little wet and the resident was helped up off the floor, cleaned up, and helped back into bed. Review of the nurse progress note for Resident #87 dated 11/09/22 revealed the facility obtained a stat (immediate) x-ray of the right hip and it was positive for hip fracture. The resident was sent to the hospital via ambulance. Review of hospital notes for Resident #87 dated 11/09/22 revealed the resident presented in the emergency roiagnom on [DATE] after a fall on 11/06/22. The hospital obtained a computerized tomography (CT) scan which showed a comminuted fracture of the resident's right hip and pelvis attributed to the fall. Further review of the hospital notes revealed Resident #87 was not a surgical candidate due to advanced dementia. Interview on 11/22/22 at 1:08 P.M. with the Director of Nursing (DON) confirmed the facility had not completed an investigation of Resident #87's fall on 11/06/22 to determine the root cause of the fall and if care planned fall interventions were in place at the time of the fall nor had the facility reviewed the resident's care plan following the fall. The DON confirmed the facility medical director examined Resident #87 on 11/09/22 after the facility informed the physician of the resident's fall on 11/06/22. The DON stated Resident #87 complained of right hip pain, and the physician ordered a stat x-ray. The x-ray was positive for an acute fracture due to the fall on 11/06/22. The DON confirmed Resident #87 was transferred to the hospital per ambulance. Review of the facility policy titled Fall Policy dated October 2018 revealed an investigation will be completed after an incident where a resident investigation will be done on an incident where a resident, visitor, or staff member says a fall has occurred, a resident is observed on the floor, or a resident is lowered to the floor with or without an injury. Current interventions will be reviewed, and a new intervention implemented to reduce the risk of a fall. Relevant information will be documented regarding the fall, assessment, notifications and interventions. This deficiency represents non-compliance investigated under Complaint Number OH00137573 and OH00137574

Based on medical record review, staff interview and policy review, the facility failed to implement the bowel protocol for a resident who had not had a bowel movement in three days. Actual harm occurred when Resident #39 was not documented to have a bowel movement for four days and was subsequently sent to the hospital for abdominal distention, pain, and constipation. This affected one (Resident #39) and had the potential to affect all 65 residents residing in the facility. The facility census was 65. Findings include: Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This resident had no known allergies. Review of the active physicians order, dated 07/21/21, revealed orders to record bowel movements every shift for monitoring. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/02/21, revealed this resident was rarely/never understood. This resident was dependent on two staff members for bed mobility, transfers, and toileting. This resident was assessed to always be incontinent of bowel and bladder. Review of the Treatment Administration Record (TAR) for December 2021 revealed no bowel movements were documented on day or night shift on 12/05/21, 12/06/21, 12/07/21, and 12/08/21 and day shift on 12/09/21. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note, dated 12/09/21 at 9:26 A.M., revealed Resident #39's abdomen was hard and distended and no bowel sounds were present in the lower quadrants. No bowel movement was recorded for the last three days. Nurse Practitioner (NP) #100 was notified and ordered a STAT KUB (an urgent x-ray of the kidneys, ureters, and bladder). Review of the nursing progress note dated 12/09/21 at 11:00 A.M. revealed NP #100 gave orders to administer as needed pain medication due to Resident #39 yelling out in pain. Review of the nurses progress note, dated 12/09/21 at 12:30 P.M., revealed the results of the KUB showed a likely bowel obstruction. NP #100 was notified and gave orders for the resident to be sent to the hospital. Review of the Hospital Visit Note, dated 12/09/21, revealed the resident presented to the hospital with abdominal distention and moaning. A Computed Tomography (CT) test of the abdomen and pelvis was performed and results showed a large amount of stool was present in the colon with no evidence of obstruction. The final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent back to the facility with orders for [MEDICATION(S)] and and magnesium [MEDICATION(S)] (both laxatives to treat constipation). During interview on 12/09/21 at 11:50 A.M., Registered Nurse (RN) #195 stated Resident #39 had no documentation of having a bowel movement in more than three days according to the MAR. RN #195 stated Resident #39 was experiencing pain and had abdominal distention during morning care. RN #195 stated Resident #39 did not have any bowel sounds active in the lower abdomen upon auscultation. RN #195 stated the NP had been notified and gave orders for Resident #39 to be sent to the emergency room (ER) for evaluation due to the results of an x-ray showing a possible bowel obstruction. RN #195 stated she had administered pain medication to Resident #39 due to the resident yelling out and crying in pain which was made worse when her abdomen was palpated. Review of the facility policy titled Bowel Protocol, revised January 2020, revealed residents bowel movements were to be recorded in the medical record and bowel patterns would be monitored by nursing staff. If the resident had no had a bowel movement in three day staff were to follow physician orders for constipation, if there were not order, staff were to notify the physician for direction. This is an incidental deficiency discovered during the course of this complaint investigation.

Based on observation, medical record review, staff interview, interview with the wound certified nurse practitioner, policy review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to timely identify/assess facility acquired pressure ulcers and to ensure pressure ulcer treatments were initiated as ordered. This resulted in actual harm when the facility failed to assess Resident #22's facility acquired pressure ulcer to the coccyx and two days later the pressure ulcer was noted to be an unstageable pressure ulcer. This affected two (#22 and #12) out of three residents reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. The facility census was 68. Findings include: 1. Review of Resident #22's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) assessment dated [DATE] identified the resident as having moderate cognitive impairment as indicated by a brief interview for mental status score of nine out of 15. The MDS identified the resident as requiring total dependence with one assist with bed mobility; total dependence with two person assist with transfers; total dependence with one assist with toilet use. The MDS identified the resident as being frequently incontinent of urine and frequently incontinent of bowel. The MDS identified the resident as having one stage three pressure ulcer that was not present upon admission and a deep tissue injury that was not present upon admission. Review of Resident #22's skin care plan, revised 09/19/18, revealed the resident is at risk for impaired skin integrity due to impaired cognition, impaired and decreased mobility, requiring assistance with activity of daily living, incontinence, falls, and complaints of pain. It identified on 06/25/18 the resident had a Stage 3 to the sacrum. Interventions included to assess skin for signs and symptoms of skin breakdown every shift, initiated 11/18/16. Further review of Resident #22's skin care plan, revised 09/19/18, revealed the resident is at risk for impaired skin integrity due to impaired cognition, impaired and decreased mobility, requiring assistance with activity of daily living, incontinence, falls, and complaints of pain. The care plan identified on 06/25/18 the resident had a Stage 3 to the sacrum. Interventions included to complete topical's and treatments as ordered, initiated 03/24/17. Review of the skin report sheet dated 06/18/18 revealed if something is noticed on a client while providing care place an X on the body diagram and in the appropriate category. On this skin report sheet for Resident #22 revealed there was an X placed on the left buttock area. This shower sheet was then signed off by Licensed Practical Nurse (LPN) #108. Review of the weekly skin assessment dated [DATE] at 2:06 A.M. revealed the resident has an old and new pressure area. It revealed the coccyx area was open with discoloration. There was no complaints of pain. Cleansed with saline and covered with a dry dressing and referred to wound nurse. Review of the nurses notes dated 06/24/18 at 5:54 A.M. revealed the resident has a Kennedy ulcer above coccyx with new order to clean with normal saline, pat dry and apply wound gel and dry dressing. Further review of information from the NPUAP revealed a Kennedy ulcer is usually found on the coccyx/sacrum, they are usually pear shaped, they appear red, yellow and black in color, there is a sudden onset and death is imminent. Review of the medical record revealed there was no further indication this alteration in skin integrity was a Kennedy ulcer. Review of the Wound Management Service notes dated 06/25/18 revealed they were referred for a new onset of altered skin integrity. It revealed nursing found a sacral wound and complaints of pain noted with wound care. It revealed the resident had a unstageable pressure ulcer to the sacrum, measuring 3.0 centimeters (cm) x 4 cm x 0.1 cm. It identified the wound as having 75-100% adherent soft, black eschar (dead tissue). It revealed there was a small amount of thin, watery, clear exudate (drainage). Review of the treatment orders revealed an order for [REDACTED]. Review of the physicians orders and treatment administration record (TAR) revealed the treatments that was ordered by the wound center were not implemented as ordered. Review of the physician's order revealed an order to cleanse site to buttock with normal saline, apply calcium alginate, and cover with foam border dressing every night, initiated 06/26/18 and discontinued 07/02/18. Review of the TAR from 06/26/18 through 07/02/18 revealed the dressing that was signed off as being completed was to cleanse the buttock with normal saline, apply calcium alginate, and cover with foam border dressing. Review of the Wound Care notes dated 08/06/18 revealed a new order to cleanse the sacral region with normal saline, apply calcium alginate to the wound base, and cover with bordered foam dressing, every day and as needed. Review of the physician's order revealed an order to cleanse site to sacrum with normal saline pat to dry apply Santyl ([MEDICATION NAME] agent), cover with calcium alginate and cover with foam dressing every shift. This was ordered 07/14/18 and discontinued 09/18/18. Review of the TAR's from 07/14/18 through 09/18/18 revealed the dressing change that the staff were completing for Resident #22 not the correct treatment. The treatment that was being signed off was to cleanse site to the sacrum with normal saline pat to dry apply Santyl, cover with calcium alginate and cover with foam dressing every shift. Review of the Wound Management Service notes dated 09/18/18 revealed the resident has 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) pressure ulcer to the sacral region measuring 0.3 cm x 0.2 cm x 0.1 cm. The notes revealed the wound base was 100% granular and without slough noted. Observation on 09/19/19 at 11:53 A.M. revealed LPN #108 completed Resident #22's dressing change. Observation at this time revealed Resident #22 had an open area on her sacrum and then a slightly larger open area to the right upper inner part of her buttock. The open area on the sacrum was 100% granulation tissue, without odor and without slough or eschar present. The open area to the right upper inner part of the buttock was a Stage 2 with the wound bed pink, and without slough or eschar present. LPN #108 did not measure either of these areas at this time. LPN #108 cleansed both of these areas with normal saline and pat them dry. She then applied calcium alginate to both areas and covered them with bordered foam gauze. Interview with the Assistant Director of Nursing (ADON) #105 on 09/19/18 at 1:29 P.M. confirmed when Resident #22's pressure area was found on 06/23/18. When the area was found there was no further description provided or measurement of the wound. She voiced the first time she had seen it was on 06/25/18 and the wound was 75-100% necrotic. Further interview with the ADON #105 confirmed the wound center orders were not implemented on 06/25/18 and 08/06/18, and during this time the wrong dressing changes were being completed. ADON #105 confirmed they were still using the Santyl on the residents wounds up until yesterday, 09/18/18. Interview with LPN #108 on 09/19/18 at 3:02 P.M. confirmed on 06/18/18 the aide had identified the resident had an area to her buttock and she has signed off on this shower sheet. Phone interview with LPN #104 on 09/19/18 at 3:06 P.M. confirmed she had found the area to Resident #22's coccyx on 06/23/18. She described this area as a bright red open area, and not being that big in size. She voiced there was no necrotic tissue and no drainage. She voiced she had applied a dressing, notified the physician by fax and notified the wound nurse. During an interview with Wound Certified Nurse Practitioner (WCNP) #80 on 09/19/18 at 3:21 P.M. she was asked if it is possible for an open area to turn necrotic within two days. WCNP #80 voiced it is unusual for an open area to turn necrotic that quick. However, she voiced I'm not saying it couldn't happen. Interview with State tested Nursing Assistant (STNA) #121 on 09/19/18 at 4:07 P.M. revealed she completed Resident #22's shower sheet on 06/18/18. STNA #121 voiced she had circled the area on the shower sheet because at this time the resident had an open area to her buttock. Observation of Resident #22's open areas on 09/20/18 at 9:45 A.M. with Minimum Data Set Nurse (MDSN) #130 and ADON #105 revealed the resident has the open area to the upper sacrum that WCNP #80 has been assessing. At this time MDSN #130 and ADON #105 assessed Resident #22's buttocks and confirmed the resident also had an open area to the right upper part of her buttocks, that they had identified as a Stage 2. ADON #105 measured this area as measuring 0.6 cm x 0.4 cm x 0.1 cm. ADON #105 voiced she had called WCNP #80 and she had confirmed when she was here last on 09/18/18 the resident only had the one area to the sacrum that they were assessing. ADON #105 confirmed prior to today, there was no assessment and no measurements of this area. Review of the facility policy titled Skin: Skin Assessment Monitoring or Healing Process Policy and Procedure dated 01/01/16 revealed the purpose of this policy is to provide guidelines for the proper procedures for qualified nursing staff to monitor pressure ulcers on a daily basis. A nurse will also assess ulcers and wounds at the time of admission, re-admission, with a significant change to the resident's condition and weekly thereafter until healed. The objectives indicated to determine the stage of the ulcer and describe and monitor the ulcer's characteristics. The procedures revealed that the nurses should monitor pressure ulcers/dressing daily including: 1. an evaluation of the ulcer if no dressing is present 2. an evaluation of the status of the dressing 3. the status of the area surrounding the ulcer 4. the presence of possible complications 5. whether pain, if present is adequately controlled. Additionally, the procedure included that with weekly assessment or wound changes the following should be documented: 1. location and staging 2. size, length, width, depth 3. presence, location and extent of any undermining or tunneling/sinus tract 4. exudate if present 5. pain, if present, nature and frequency 6. wound bed: color and type of tissue/character including evidence of healing (granulation) 7. description of the wound edges and surround tissue. Review of information from the NPUAP revealed an unstageable pressure ulcer is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the annual minimum data set (MDS), dated [DATE], revealed a brief interview for mental status (BIMS) of 15 out of 15, indicating no cognitive impairment. Further review revealed the resident had no pressure ulcer. Review of physician's order, dated 07/15/18, revealed to clean the area on coccyx with wound cleanser, pat dry, apply hydrogel, and cover with a foam border dressing daily for open area. Review of physician's order, dated 07/24/18, revealed to cleanse area on coccyx with normal saline, pat dry, apply honey alginate, and cover with a foam border dressing. Review of progress note, dated 07/30/18, revealed Resident #12's wound measured 1.0 centimeter (cm) length by 0.6 cm width by 0.2 cm depth. Review of wound care note, dated 07/31/18, revealed Resident #12 was seen for evaluation and management of coccyx ulcer. The resident had been seen for a coccyx ulcer in the past and states the wound re-opened on 07/18/18. The ulcer was described as partial thickness ulceration of the coccyx, re-opened on 07/18/18, stage II pressure ulcer, measuring 1.0 cm length by 0.6 cm width by 0.2 cm depth. Observation on 09/19/18 at 12:10 P.M. revealed a stage II pressure ulcer to Resident #12's coccyx measuring 2.2 cm length by 1.0 cm width by 1.0 cm depth. LPN #116 completed the dressing change per physician's order with no concerns. Interview on 09/19/18 at 4:04 P.M. with the Director of Nursing (DON) confirmed Resident #12's pressure ulcer on the coccyx was first identified on 07/15/18 when orders for dressing changes were obtained. The DON further confirmed there was no assessment or measurement of the area until 07/30/18.

Based on medical record review, observations, staff interview and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement appropriate pressure ulcer preventative measures for Resident #66 who was identified as being at high risk for skin breakdown. This resulted in actual harm when Resident #66 developed multiple avoidable stage II pressure ulcers on the right and left heel, these pressure ulcers further required debridement therefore progressing to stage III pressure ulcers and the resident further developed a drug resistant infection in the left heel. This affected one (#66) of three residents reviewed for pressure ulcers. The facility identified 11 residents with pressure ulcers. Facility census was 93. Findings include: Review of Resident #66's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #66's annual minimum data set (MDS) assessment dated [DATE] revealed the resident was total dependent of one staff member for bed mobility and transfers; the resident does not ambulate; the resident has impairment of range of motion of the lower extremities on one side of the body and the resident received diuretics. Further review of the annual MDS revealed Resident #66 had no existing pressure ulcers, however, the resident was at high risk for pressure ulcers. Review of Resident #66's Braden Scale- for predicting pressure sore risk dated 06/18/13 revealed the resident scored a "17" indicating he was not at risk according to the scoring system; however, the assessment documented the resident was chair-fast, very limited with mobility and had a potential problem with friction. Resident #66's comprehensive care plan dated 06/18/13 entitled "resident at risk for skin integrity due to decrease mobility, has [MEDICAL CONDITION], and [MEDICAL CONDITION], is incontinent; presently he has a stage III ulcer on his right heel and one on his left heel; he also has a stage I ulcer on proximal left buttocks as well as left distal buttock" was reviewed. The care plan instructed staff to elevate Resident #66's bilateral heels off bed with pillows and to measure the resident bilateral calves (lower legs) every shift and record measurements in inches. Further review revealed a lack of intervention regarding how pressure relief to the heels would be obtained while the resident was in his wheelchair or geri-chair. Further review of Resident #66's nurse's notes dated 06/23/13 at 12:00 P.M., revealed the discovery of a 5 centimeter (cm) by 5 cm blister on the resident's right heel. Review of Wound Care Flow Sheets revealed Resident #66's right heel pressure ulcer required debridement on 10/23/13 and continued without healing to the time of the survey. According to the Wound Care Flow Sheets, Resident #66 developed another fluid filled blister on the left heel on 07/24/13 that measured 2.5 cm by 1.0 cm. The blistered area on the left heel healed on 08/28/13; however, a new blister re-developed on 09/24/13 that measured 5.0 cm by 4.6 cm by a depth of 0.1 cm. The left heel blister that developed on 09/24/13 required debridement by the wound clinic on 10/23/13 according to the flow sheets and the pressure ulcer continued to the time of the survey. According to a physician progress notes [REDACTED].#66 lower extremities had [MEDICAL CONDITION], the residents heels were wrapped and the ulcers would be treated aggressively. Resident #66's record revealed the wound clinic was consulted for specialty treatment beginning on 09/03/13. Resident #66 received further bilateral Doppler arterial studies of the bilateral lower extremities on 09/18/13, which concluded Resident #66 had no definite arterial obstruction shown in the study. Physician orders [REDACTED].#66 on [MEDICATION NAME] 100 milligrams (mg) one orally twice daily for 14 days for a buttock wound. On 10/23/13 a physician order [REDACTED]. However, a physician order [REDACTED].#66 in contact isolation for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) in the left foot. On 11/13/13 at 10:15 A.M. to 11:00 A.M., Licensed Practical Nurse (LPN) #11 and Registered Nurse (RN) #12 was observed during Resident #66's pressure ulcer treatment. During the observations LPN #11 and RN #12 worn gowns and gloves and stated that Resident #66 was in isolation due [MEDICAL CONDITION] infection in the left heel and the surveyor was further instructed to wear gowns and gloves during the observation. LPN #11 stated Resident #66 was assisted to bed not long before entering the room, so she could measure the residents bilateral heel pressure ulcers and change the dressing. Upon entering the room Resident #66's leg/ heel positioning was observed. LPN #11 confirmed that two pillows were under Resident #66's bilateral lower extremities; however, the resident's legs were so swollen that the extra weight from the [MEDICAL CONDITION] was compressing the two pillows being used and the residents heels were resting directly on the mattress. LPN #11 proceeded with Resident #66's treatment and cleansed an open area on the right heel with soap and water gauze; LPN #11 measured the right heel as being 6.0 cm by 3.5 cm by a depth of 0.3 cm; the right heel wound was noted to be draining a large amount of yellow/ reddish colored drainage and the wound bed contained eschar. LPN #11 further applied Santyl ointment to the right heel wound area, covered the area with an ABD pad and wrapped the foot/ heel/ lower leg with Kerlix and an ACE wrap. LPN #11 then proceeded to cleansed the left heel area with soap and water gauze; LPN #11 measured the left heel as being 2.5 cm by 2.0 cm by a depth of 0.3 cm; the left heel wound was draining a small amount of yellow/ reddish drainage and the wound bed contained eschar. LPN #11 applied [MEDICATION NAME] dressing cut to fit the left heel wound covered the area with an ABD pad and then wrapped the foot/ heel/ lower leg with Kerlix and an ACE wrap. During the observations LPN #11 further described Resident #66's pressure ulcers on the heels as stage III. Furthermore, LPN #11 confirmed Resident #66 was unable to move his bilateral lower extremities and required staff assistance to move them. Resident #66 was observed in his wheelchair in the activity room on 11/13/13 at 6:10 P.M. During the observation Resident #66's right heel was resting directly on the edge of the right foot rest. LPN #11 was interviewed on 11/14/13 at 2:13 P.M. regarding Resident #66's in house acquired pressure ulcers to the right and left heel. LPN #11 confirmed the source of Resident #66's ulcers was related to pressure and that she felt the lower leg swelling contributed to the ulcers. LPN #11 confirmed the facilities intervention regarding heel pressure relief was to use pillows to elevate the heel and she was further interviewed regarding the appropriateness of the use of these pillows because of the resident's [MEDICAL CONDITION]. LPN #11 confirmed Resident #66 had excessive swelling of the lower extremities. LPN #11 stated as of today (11/14/13) they are going to start using a wedge and they have ordered boots to suspend the heels. LPN #11 was also interviewed regarding the source of the pressure to the heels and she further stated that this could be due to Resident #66's heels resting on the bed because of the resident's lower leg/ feet swelling. LPN #11 confirmed the facility had not attempted to suspend Resident #66's heels with something more effective than pillows such as boots or a wedge up until today (11/14/13). Furthermore, LPN #11 confirmed that Resident #66 left heel was recently cultured by the wound clinic and the wound was positive [MEDICAL CONDITION] infection which was why the resident was in contact isolation and why the resident required [MEDICATION NAME](an oral antibiotic). LPN #11 was interviewed regarding the care plan intervention to measure the bilateral calves and she stated this intervention was done due to Resident #66's lower leg [MEDICAL CONDITION]; however, LPN #11 stated she believes this intervention was discontinued a while ago but was unable to find a discontinued order and was unable to provide record that the calves were currently being measured. LPN #11 stated the facility was going to start measuring Resident #66's bilateral calves again and documenting the measurements. Information from the NPUAP obtained at www.npuap.org was reviewed. According to the NPUAP, consider all bed-bound and chair-bound persons, or those whose ability to reposition is impaired, to be at risk for pressure ulcers. The NPUAP provided preventative points which indicated to provide pressure redistribution when positioning persons in chairs or wheelchairs. Furthermore, the NPUAP provided preventative points as using devices that eliminate pressure on the heels; for short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed and place heel suspension boots for long-term use.

Based on observation, record review and staff interview the facility failed to identify one resident who developed in house pressure until the wounds were unstageable which resulted in actual harm. This affected one resident (#54) of six reviewed for pressure sores/ulcers. The facility identified four residents with in facility acquired pressure sores. Findings included; Record review for Resident #54 revealed a [DIAGNOSES REDACTED]. Resident #54 had a cardiovascular accident (stroke) with right sided weakness. Review of the nursing assessment revealed the resident was admitted to the facility on [DATE] from a local hospital. Upon admission, the resident had a pressure area on her coccyx which healed soon after admission. The resident was assessed as high risk for skin breakdown. An at risk Plan of Care (POC) was initiated on 10/21/10. The prevention interventions put into place at that time included turn and reposition every two hours, monitor nutritional status, incontinence care, elevate heels while in bed, and provide pressure relief mattress. On 11/12/10 an open area was was found on the resident's right ankle during care. Additional interventions put into place at that time included side to side turns, float heels (put legs and feet on a pillow so the heels do not touch the laying or sitting surface) and skin sweeps every week. A physician order [REDACTED]. A review of the Treatment Record for January 2011 revealed staff were to check the right foot splint every four hours during the night for pressure area and circulations issues remove if noted and documented findings, notify the physician and wound nurse in the morning. On 1/15/11, a nursing note was written at 10:00 A.M. revealed "New areas noted to right heel and outer foot, note was left for wound nurse by 10 - 6 nurse to assess the areas. Wound nurse was notified. will assess." At 11:00 A.M. a nursing note revealed the physician was notified of the open areas and an order was given for a treatment to be done until the wound nurse could assess. On 1/18/11 the POC was revised to include the pressure areas discovered on 1/15/11. The POC stated that areas on right outer foot and heel found on 1/15/11 "due possibly to splint on foot too tight." At that time a Podus boot was added. A Podus boot is a boot that suspends the foot and relieves pressure to the heel. A note, written on 1/18/11 written by RN #8 stated," Notified by staff of areas on res (resident) right heel and outer right foot by little toe joint. Res has [MEDICAL CONDITION](stroke) and this is non functioning side but has good movement on left. Moves left foot around and pushes right foot off pillow but also has had recent placement of splint in November. POC revised Monitoring splint and need to put on hold/use different interventions. Strap fastens over area on outer foot. Res unable to voice discomfort but has non-verbal communication facially and indicates pain." The Wound Evaluation Flow Sheet revealed the wound on the right heel was first measured on 1/18/11, three days after it was discovered. The measurements were 3.2 centimeters (cm) by 2.1 cm. It was described as being unstageable. The ulcer was a 100% firm dark bluish area. The ulcer on the outer side of the right foot below the fifth toe joint was first measured on 1/18/11. The area was 2.7 cm by 2.0 cm and was 100% blue/purple irregular shape. It also stated the wound was possible from rubbing from the splint. Review of the current Minimum Data Set assessment, dated 2/02/11, revealed the resident's cognitive level could not be assessed due to physical condition. She was unable to make decisions. The resident was dependent on one staff for all transfers, ambulation, dressing, eating, hygiene, and toileting. The resident was fed per gastrostomy tube. She had a Foley catheter in place to straight drain. She had a [MEDICAL CONDITION] in place with oxygen. A review of the Wound Evaluation Flow sheet revealed on 2/4/11 the ulcer on the right heel was 0.4 cm by 0.8 cm and was 100% semi firm black eschar. On 2/04/11 the ulcer on the right foot outer side lateral was described as 1.5 cm by 2.0 cm and had firm black eschar with pink granulating tissue. The POC was rewritten on 3/15/11 and again it stated the areas on the right heel and outer right foot by toe joint found during care on 1/15/11- splint to foot put on by OT (Occupational Therapy) possibly too tight. On 3/31/11 the resident was seen by the podiatrist for a wound consultation. He described the wound bed as approximately 50 -60% eschar with mild to moderate serous drainage. Full thickness depth with intact periwound edges. He recommended sharp debridement every 10 -14 days to try to eliminate the eschar and promote granulation. On 4/4/11 the right heel ulcer was 1.3 cm by 0.9 cm and was 100% dark blue-red soft tissue. On 4/05/11 the wound was described as 2.0 cm by 3.0 cm by .3 cm and was 90% red clean beefy tissue with gray yellow tissue. At this time the ulcer was positive for a Methacillinase resistant staphylococcus aureus. Observation of Resident #54 was observed on 04/06/11 at 2:00 P.M. as staff completed the dressing change to the residents right outer foot ulcer. The treatment was completed as ordered and no splint was on. During an interview with registered nurse (RN) #8 on 04/07/11 at 4:45 P.M. she affirmed the treatment record directed staff to check the right foot splint every four hours during the night for pressure area and circulations issues remove splint if noted and staff did not remove the splint and then check the foot to see if there were any pressure areas under the splint or under the straps. RN #8 affirmed the area on the right outer foot was not identified until it had become an unstageable area.