Every finding on record at Altercare of Wadsworth

Based on observation, interviews and facility policy review, the facility did not ensure food was served at palatable temperatures. This had the potential to affect 64 residents that received meals from the facility. The facility identified one resident (Resident's #9) that received nothing by mouth. The facility census was 65. Findings include: Observation of tray line on 07/23/25 from 4:40 P.M. through 5:34 P.M. revealed food was above 165 degrees Fahrenheit (F) on the tray line. Further observation revealed that the plate warmer was not turned on and the hot bottoms were on but Dietary Aide (DA) #255 did not use them for the entire line. The food truck left the kitchen at 5:23 P.M. and arrived at the unit within a minute. When the last tray on the cart was delivered on 07/22/25 at 5:36 P.M., the Dietary Manager (DM) #246 went to take the temperature of the food and stated that the temperature for the chicken tender was 108 degrees F, French fries were 104.9 degrees F, and the green beans were 106.9 degrees F. DM #246 stated that DA #255 forgot to put on the hot bottom for the test tray. Interviews on 07/22/25 from 11:07 A.M. and 4:30 P.M. with Resident #8 and #19 stated that the food is served cold. Review of the undated facility policy titled, Trayline Food Temperatures and Guidelines, revealed the temperature of the food as it is served to the resident shall be palatable per resident's preference. This deficiency represents non-compliance investigated under Complaint Number 1396911 (OH00166942).

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #4 received activities to meet her needs and preferences. This affected one (Resident #4) of two residents reviewed for activities. The facility census was 65. Findings include: Review of the medical record for Resident #4 revealed an admission date of 11/20/24. Diagnoses included diabetes mellitus, dementia, and major depressive disorder. Review of the care plan for Resident #4 dated 11/27/24 and revised 01/03/25 revealed Resident #4 needed encouragement to participate in activities and needed assistance to and from activities. Interventions included placing an activity calendar for each month in the resident's room, encouraging the resident to explore activity opportunities available and providing regularly scheduled dog therapy visits. Review of Resident #4's activity assessment dated [DATE] revealed music, pets, going outside to get fresh air, and doing things with groups of people was important to the resident Review of the care plan progress note dated 02/09/25 at 12:55 P.M. revealed that a care conference was held for Resident #4 on 02/06/25 at the daughter's request with Licensed Social Worker the Director of Nursing (DON), the Administrator, the daughter of Resident #4 and Resident #4's CareSource Case Manager. Concerns were addressed and multiple departments provided frequent updates to Resident #4's daughter on diet, activities, therapy, medications and blood sugars. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was severely cognitively impaired and was dependent on activities of daily living (ADL). Resident #4 had no behavior problems. Review of the Activity Calendar for July 2025 revealed one-on-one activities were scheduled Monday through Friday at 9:00 A.M. An interview on 07/22/25 at 1:26 P.M. with Resident #4's daughter revealed that she had a concern with her mother not attending activities. Multiple observations of Resident #4 on 07/22/25, 07/23/25 and 07/24/25 revealed Resident #4 was in her room in a wheelchair. Observation on 07/24/25 from 9:00 A.M through 10:00 A.M. revealed no one-on-one room visits occurred, which were scheduled on the calendar. An interview on 07/24/25 at 8:13 A.M. with LSW #242 revealed that Resident #4 was sweet, and her daughter was very involved with her care. Resident #4's daughter had a care conference and voiced concerns about activities. LSW #242 stated that Activities Director (AD) #259 was supposedly keeping a log for the resident's daughter. A phone interview on 07/24/25 at 9:30 A.M. with AD #259 revealed that she had participation sheets in her office, but she was on vacation and not at the facility. AD #259 stated that every time she would go to Resident #4's room, she was sleeping. AD #259 stated that Resident #4 had behaviors when in large groups. AD #259 stated that behaviors were documented on the back of an activity log or progress note in the electronic chart. AD #259 stated that Receptionist #216 and Central Supply #260 would conduct activities while she was on vacation. She stated that she does not have any other staff in the department. The interview on 07/24/25 at 9:45 A.M. with the DON stated that it was the job of activities staff and nursing staff to assist residents to activities. An interview on 07/24/25 at 9:52 A.M. with Central Supply #260 revealed that she was not doing activities because she was pulled to the floor to assist with resident care because she was also a certified nursing assistant (CNA). An interview on 07/24/25 at 10:00 A.M. with Receptionist #216 stated that she only printed out the census and delivered the mail when AD #259 was not in the building. An interview on 07/24/25 at 10:10 A.M. with the Administrator revealed that she could only find activity tracking for Resident #4 for March 2025. She stated that she called in a CNA that does activities on the weekend to come in and have activities and do one-on-one with residents and other activities when she gets to the facility. Review of the facility policy titled, Resident Activity Preferences, dated 03/01/19, revealed resident activity preferences will be readdressed throughout a resident's stay in the facility during care conference process. This deficiency represents noncompliance investigated under Complaint Number 1396911 (OH00166942).

Based on record review and interviews with staff and Resident #70's wife, the facility failed to document and adequately address Resident #70's complaints of change in condition. This affected one (Resident #70) out of three residents reviewed for change in condition. The facility census was 65. Findings include: A review of Resident #70's clinical record revealed and admission date of 03/17/23 with diagnoses including hydrocephalus with normal pressure, gastronomy with tube feeding, obstructive sleep apnea, spinal stenosis, chronic sinusitis, low blood pressure, and hypothyroidism.Resident #70's electronic clinical record contained the following documentation on 07/11/25 from 4:41 P.M. to 4:39 A.M. on 07/12/25: 4:41 P.M. the Director of Nursing (DON) checked for tube feed residual. 5:34 P.M. the DON administered medications to Resident #20 and blood pressure (92/52) was documented. The tube feeding rate was signed off and gastronomy placement was checked. Ensured the head of bed (HOB) was elevated. Administered enteral flush. 6:49 P.M. Certified Nursing Assistant (CNA) charted on Resident #70's activities of daily living. 9:10 P.M. Registered Nurse (RN) #291 administered medication. 9:14 P.M. Resident #70's blood pressure (132/74) was documented by RN #291. 12:31 A.M. RN #291 flushed Resident #70's gastronomy tube and administered medication. 4:39 A.M. Resident #70 complained of coughing and unable to catch his breath. The nurse called 9-1-1 and suctioned Resident #70. Resident #70 had a Do Not Resuscitate Comfort Care Arrest (DNRCC-A) advance directive. The emergency medical services (EMS) arrived at 4:46 P.M. and verified Resident #70's absence of vital signs. Resident #70's time of death was 4:46 A.M. The physician and family were notified, and a call was placed to the funeral home. There was no documentation in Resident #70's medical record to indicate he was coughing and producing phlegm, was having behaviors or of a full complement of vital signs was obtained including oxygen saturation levels on 07/11/25 from 5:00 P.M. to 5:00 A.M. on 07/12/25.Interviews on 07/23/25 between 1:45 P.M. and 3:31 P.M. with CNA #288, Licensed Practical Nurse (LPN) #214, DON revealed on 07/11/25 between 5:00 P.M. to 11:00 P.M. Resident #70 had complained of trouble breathing, was coughing and producing clear to brown phlegm. The DON stated she worked on 07/11/25 from 5:00 P.M. to 6:30 P.M. and was informed by a CNA (unnamed) that Resident #70 was coughing and complaining that he was having trouble breathing. The DON stated she listened to Resident #70's lungs and obtained his oxygen saturation which was in the 90s percent range. The DON stated she did not document her assessment or Resident #70's vital signs in Resident #70's electronic record or that Resident #70 did not want to go to the hospital. The DON stated she was not informed Resident #70's wife wanted Resident #70 to go to the hospital. The DON stated the facility did not initiate an investigation of Resident #70's death.An interview with CNA #256 and CNA #231 on 07/23/25 at 3:07 P.M. revealed CNA #256 was assigned to provide care for Resident #70 on 07/11/25 from 3:00 P.M. to 7:00 P.M. CNA #231 stated she answered Resident #70's call light, and he complained of coughing and was struggling to breathe. CNA #231 told the DON that Resident #70 was having a hard time breathing. CNA #231 checked on Resident #70 a little while later and he was still struggling to breathe and had vomited brown phlegm on the floor. CNA #256 stated Resident #70 had vomited brown phlegm on the floor which looked like chocolate. CNA #256 stated she told the DON that Resident #70 was getting worse during the evening hours from 3:00 P.M. to 11:00 P.M., and that Resident #70's wife wanted the facility to send Resident #70 to the hospital.An interview with Hospitality Aide (HA) #271 on 07/23/25 at 3:46 P.M. stated she answered Resident #70's call light two times on 07/11/25 during the evening hours between 6:00 P.M. to 11:00 P.M. Resident #70 was coughing and complaining he was having trouble breathing. HA #271 stated she informed RN #291 that Resident #70 was complaining he was having trouble breathing. RN #291 informed HA #271 that Resident #70 had possibly eaten candy he was not supposed to eat because he had a risk of aspiration, and his oxygen saturation was 95 percent. RN #291 informed HA #271 that Resident #70 was not supposed to consume anything orally. HA #271 stated when she saw Resident #70 a little while later, he was coughing up brown phlegm. Resident #70 then seemed to recover from the coughing jag and told RN #291 he was ready for bed. An interview with RN #291 on 07/24/25 at 8:08 A.M. revealed RN #291 was employed by a staffing agency and was assigned to provide care for Resident #70 on 07/11/25 from 6:30 P.M. to approximately 1:30 A.M. RN #291 stated she received report from the DON of Resident #70's coughing episode and he had possibly eaten candy and was at risk for aspiration. RN #291 stated Resident #70 had a slight cough and was in no distress and thought maybe this was a behavior. RN #291 stated she checked his vital signs, and he was holding a tissue and producing clear phlegm during his coughing episode. RN #291 stated she checked Resident #70 again during the evening medication administration between 8:00 P.M. and 11:00 P.M. and Resident #70 had stopped coughing. At approximately 10:30 P.M. RN #291 told Licensed Practical Nurse (LPN) #272 that Resident #70 might need a chest x-ray and was told that this incident was a behavior of Resident #70. RN #291 stated she did perform an assessment but had not charted the assessment. An interview with Resident #70's wife on 07/24/25 at 8:53 A.M. revealed on 07/11/25 from 5:00 P.M. to 11:00 P.M. Resident #70 was coughing a lot and was in distress. Resident #70's wife was Resident #70's roommate and stated he did not eat any of the candy she had on her over-the-bed table. Resident #70's wife stated Resident #70 was not allowed to consume any food orally. Resident #70's wife stated Resident #70 had phlegm building up and caused him to cough up the phlegm and staff were in and out of the room often during the night to check on him.On 07/24/25 at 9:22 A.M. an interview with LPN #272 revealed RN #291 had informed her of Resident #70's coughing episode. RN #291 had assessed Resident #70 and told her that he may need a chest x-ray in the morning. LPN #272 stated LPN #283 came in to work at approximately 1:15 A.M. and assumed the care of Resident #70. LPN #272 stated RN #291 told LPN #283 that Resident #70 might need a chest x-ray in the morning. LPN #283 stated she did not enter any information regarding Resident #70's change in condition in Resident #70's electronic medical record.An interview with LPN #283 on 07/24/25 at 10:27 A.M. revealed she had worked on 07/12/25 from 1:00 A.M. to 8:15 A.M. and was assigned to care for Resident #70. LPN #283 stated RN #291 had informed her of Resident #70's coughing episodes during the evening on 07/11/25 between 5:00 P.M. and 11:00 P.M. LPN #283 stated she was informed that Resident #70 had been coughing and producing a lot of phlegm and may need an x-ray. Resident #70 may have eaten candy but there was no proof he had consumed the candy. LPN #283 stated she did perform an assessment of Resident #70 but admitted she had not documented her assessment. LPN #283 stated Resident #70 had no coughing episodes until approximately 4:30 A.M. on 07/12/25 when a CNA (unnamed) had alerted her that Resident #70 was coughing/choking and she entered Resident #70's room and turned off his tube feeding solution infusing via his gastronomy tube. LPN #283 stated she told the CNA to stay in Resident #70's room and exited the room and ran to the front of the building to sign a pharmacy invoice to receive narcotic medication for another resident. The CNA (unnamed) yelled for her to come back to Resident #70's room because he had stopped breathing and was turning blue. LPN #283 called 9-1-1 and pushed the code cart down to Resident #70's room. LPN #283 stated she looked at Resident #70's electronic record and located Resident #70's DNRCC-A advance directive and decided to try and suction Resident #70's phlegm orally. LPN #283 stated Resident #70 did not respond to her attempts to suction his secretions, and he died from a sudden heart attack before the EMS personnel arrived. A review of Resident #70's Death Certificate dated 07/17/25 indicated the cause of death was a sudden cardiac event. An interview with DON and Regional RN on 07/24/25 at 9:30 A.M. verified the above information and verified there was no documentation in Resident #70's electronic medical record of Resident #70's complaints of coughing/choking on 07/11/25 or of the assessments the staff performed of Resident #70 on 07/11/25. Review of the facility policy and procedure titled Change in the Residents Condition or Status, dated 05/01/2025, revealed the policy was to ensure the resident's attending physician, and the residents authorized representative or interested family member are notified of changes in the resident's physical, mental, or psychosocial status. 1. Procedure for Notification of Changes The Nurses will immediately notify the resident; consult with the resident's attending physician, on call physician, nurse practitioner, physician assistant or clinical nurse specialist and notify the resident's authorized representative or interested family member when there is: a. An accident or incident involving the resident, which results in an injury and has the potential for requiring physician intervention b. A significant change in the residents' physical, mental, or psychosocial status (i.e. a deterioration in health, mental, or psychosocial status in either life threatening condition or clinical complications). c. Lab, radiology or other diagnostic testing results that fall outside of clinical reference ranges d. A need to alter the resident's medical treatment significantly, i.e. need to discontinue an existing form of treatment due to adverse consequences (e.g. a reaction to a medication), or to commence a new form of treatment (e.g. refusal of treatment or medications (2) or more consecutive times e. A need to transfer or discharge the resident from the facility to a hospital/treatment center (this includes transfers to the hospital as well as discharges against medical advice). 3. Procedure for Documentation of changes in the medical record The nurse will record in the resident's medical record information relating to changes in the resident's medical/mental condition or status (e.g. assessment, appropriate notifications, interventions, and response). 4. Procedure for Significant Change Assessment If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by the RAI instruction Manual 5. Procedure for Updating of Resident Family and Sponsor Information A representative of the business office will periodically update the address, telephone number of the resident's authorized representative or interested family member and notify the resident and the resident's authorized representative or interested family member if there is a change in the resident's billing. This deficiency represents non-compliance investigated under Complaint Number 2565377.

Based on record review, observation, interview and facility policy review, the facility failed to ensure staff performed hand hygiene to prevent cross contamination of germs during Resident #1's and Resident #3's medication administration and failed to remove the soiled wound treatment gauze from Resident #2's room after wound care and failed to ensure staff properly cleaned wound care equipment after use during Resident #2's wound treatment procedure. This affected two (Residents #1 and #3) out of three residents observed for medication administration and one (Resident #2) out of three residents reviewed for wound care. The facility census was 65. Findings include: 1. A review of Resident #1's clinical record revealed an admission date of 05/13/25 with diagnoses including [NAME] Syndrome (colonic pseudo-obstruction, is the acute dilatation of the colon in the absence of any mechanical obstruction in severely ill patients), chronic constipation, anemia, vascular implant, deep vein thrombosis, gastrointestinal hemorrhage, duodenal ulcer with hemorrhage, diarrhea, malaise, gastric ulcer with hemorrhage, acute cystitis, schizophrenia, dysphagia, atherosclerosis, respiratory failure, nicotine dependence, cervical disc degeneration, anxiety fibromyalgia, bullous pemphigoid (A rare skin condition causing large, fluid-filled blisters.), esophageal stricture, ileus, chronic obstructive pulmonary disease, pharynx/larynx disease, and neuromuscular bladder. Review of Resident #1's physician orders dated 07/01/25 to 07/30/25 indicated to administer the following medications between 7:00 A.M. and 11:00 A.M.: Acetaminophen 1,000 milligrams (mg) orally (analgesic) Ariprazole 10 mg orally (antipsychotic) Azo D-Mannose 500 mg orally (supplement to support urinary tract health) Vitamin B12 1,000 micrograms (mcg) orally (supplement) Hair, Skin, Nails Biotin 2,500 mg orally (supplement) Hydroxyzine 25 mg orally (antihistamine) Myrbetriq Extended Release 25 mg orally (medication to treat overactive bladder) Multivitamin one tablet orally (supplement) Pantoprazole 40 mg orally (medication to treat excessive stomach acid) Docusate sodium/senna 50 mg/8.6 mg orally (combination of a stool softener and a laxative) Symbicort inhaler one puff (inhaler to treat chronic obstructive pulmonary disease) Potassium chloride 20 milliequivalent (mEq) orally (supplement) Tramadol 25 mg orally (opioid pin medication) Miconazole powder to affected area (antifungal) An observation on 07/23/25 at 7:35 A.M. of Licensed Practical Nurse (LPN) #211 administering the above listed medications to Resident #1 revealed a failure to perform hand hygiene. LPN #211 approached the medications cart and dispensed the medications listed above into a medication cup. LPN #211 then proceeded to enter Resident #1's room and administered the medications to Resident #1. LPN #211 exited the room and did not perform hand hygiene. An interview with LPN #211 on 07/23/25 at 8:32 A.M. verified the above findings and agreed she should have performed hand hygiene before dispensing Resident #1's medications and after administering the medications to Resident #1. 2. A review of Resident #3's clinical record revealed a admission date of 10/24/24 with diagnoses including syncope and collapse, Alzheimer's disease with early onset, diabetes mellitus, high blood pressure, diabetic neuropathy, high cholesterol, dysphagia, obstructive sleep apnea, depression, scoliosis, obesity, kidney disease, heart arrhythmia with cardiac pacemaker, cerebral amyloid angiopathy, and heart failure. Resident #3's physician orders dated 07/01/25 to 07/30/25 indicated to administer the following medications to Resident #3 between 7:00 A.M. and 11:00 A.M.: Acetaminophen 1,00 mg orally Duloxetine 60 mg orally (antidepressant) Lisinopril 20 mg orally (angiotensin-converting enzyme (ACE) inhibitor) Eliquis 5 mg orally (blood thinner) Metformin 500 mg orally (treats high blood sugar) Docusate sodium/senna 50 mg /8.6 mg orally Sotalol 120 mg orally (antiarrhythmic) Gabapentin 600 mg orally (anticonvulsant) An observation of LPN #211 administering the above listed medications to Resident #3 on 07/23/25 at 7:55 A.M. revealed a failure to perform hand hygiene. LPN #211 exited Resident #1's room and did not perform hand hygiene and proceeded to obtain the above listed medications from the medication cart and dispensed the medications in a medication cup. When LPN #211 had completed dispensing the medications into the medication cup LPN #211 was asked to perform hand hygiene prior to entering Resident #3's room to administer the medications. An interview with LPN #211 on 07/23/25 at 8:32 A.M verified the above findings. LPN #211 agreed she should have performed hand hygiene after exiting Resident #1's and before obtaining and dispensing Resident #3' medications. 3. A review of Resident #2's clinical record revealed an admission date of 05/28/25 with diagnoses including diabetes mellitus with diabetic neuropathy/cataracts/polyneuropathy, diverticulosis, cognitive communication deficit, kidney disease, depression and diabetic peripheral angiopathy. Resident #2's physician order dated 07/15/25 revealed indicated to cleanse the left lateral shin wound with wound cleanser, pat dry, apply Skin-Prep (forms a protective barrier) to wound bed, cover with a non-adhesive pad and wrap the leg wound dressing with gauze. An observation on 07/23/25 at 10:30 A.M. of LPN #211 perform Resident #2's wound treatment procedure revealed a failure to perform hand hygiene and clean equipment used for the wound care appropriately. LPN #211 gathered the supplies needed for the wound treatment procedure and placed the supplies on Resident #2's over-the-bed table covered with a clean towel. LPN #211 proceeded to remove Resident #2's wound treatment and applied the physician ordered wound treatment. Upon completion of the task, LPN #211 removed the scissors she used to cut off Resident #2's soiled dressing and placed the scissors in the wound treatment cart without cleaning/sanitizing the scissors. LPN #211 discarded the soiled wound treatment in a waste receptacle lined with a plastic bag and did not remove the soiled wound treatment plastic bag from Resident #2's room upon completion of the task. An interview with LPN #211 on 07/23/25 at 11:02 A.M. verified she had failed to clean/sanitize the scissors she used during Resident #2's wound treatment procedure and failed to remove the soiled wound treatment from Resident #2's room after completing the wound treatment procedure and exiting the room. A review of the facility policy titled: Handwashing-Hygiene, updated 11/2019, revealed the policy was for the employees to conduct proper hand hygiene that will aid in the prevention and transmission of infectious diseases. General guidelines included:Hand washing with soap and water must be performed under the following conditions When hands are visibly dirty or oiled with blood or other body fluids After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin After handling items potentially contaminated with blood, body fluids, or secretions Before eating After using the bathroom Exposure to infectious diarrhea (Clostridium Difficile, Norovirus) If exposure to Bacillus Anthracis is suspected or provenAlcohol/Antimicrobial hand rub may be used in the following situations: Before direct contact with a resident Before donning gloves Before performing any non-surgical invasive procedure Before preparing or handling medications Before moving from a contaminated body site to a clean body site during resident care After contact with resident's intact skin After handling used dressings, contaminated equipment, etc. After contact with inanimate objects (e.g. medical equipment) in the immediate vicinity of the resident After removing gloves.The use of gloves does not replace hand washing or hand sanitizingKeep fingernail tips trimmed to no more than1/4 inch long The Minnesota Department of Health's guidelines titled Wound Care Infection Prevention Recommendations for Long Term Care Facilities followed the Centers for Disease Control's recommendations including for wound care equipment and supplies: Any reusable equipment (e.g., bandage scissors, flashlight, mirror) and supplies that come in contact with non-intact skin, mucous membranes, or any bodily fluids or drainage, including fluids on bedding or gloved health care workers' hands, are considered semi-critical instruments. Either: 1. Perform high-level disinfection (HLD) before use on another residentOR 2. Discard wound care equipment or products when no longer needed for an individual resident. When HLD (or sterilization) is not available and dedicated equipment is used for each resident, it is important to clean and disinfect each piece of equipment after each use on the same resident to reduce bio load per manufacturer's instructions for use.3. Dispose of dedicated equipment (if disposable equipment is used) or arrange to have dedicated equipment appropriately processed after no longer needed for care of the designated resident.This deficiency was an incidental finding identified during the complaint investigation.

Based on record review, observation and interview, the facility failed to ensure Resident #4's wheelchair was maintained in a safe operational condition. This affected one (Resident #4) out of three residents reviewed for wound care. The facility census was 65. Findings include: A review of Resident #4's clinical record revealed an admission date of 11/20/24 with diagnoses including dementia with behaviors, bipolar disorder, depression, anxiety, insomnia, stroke, Alzheimer's disease, peripheral vascular disease, heart disease, gastroenteritis/colitis, diarrhea, malnutrition, osteoarthritis, high blood pressure and cholesterol, cognitive communication deficit, dysphagia and viral wart. Resident #4's occupational therapy notes dated 02/21/25 indicated Resident #4 was provided with a drop seat wheelchair. Resident #4 demonstrated good upright posture at all times utilizing bilateral leg rests. A review of the Concern Log dated 03/03/25 indicated Resident #4's daughter voiced a concern regarding Resident #4's wheelchair. Resident #4's daughter requested an update from therapy regarding Resident #4's wheelchair. The investigation summary revealed therapy had provided a drop seat wheelchair for safety. An interview with Certified Occupational Therapist Assistant (COTA) #295 on 07/24/25 at 10:57 A.M. revealed Resident #4 was provided with a standard wheelchair upon admission to the facility. COTA #295 stated Resident #4 kept throwing herself out of the wheelchair because she wanted to recline. The facility provided a Broda chair. Resident #4's daughter asked to have the Broda chair removed and provide a custom wheelchair. COTA #295 stated Resident #4 was provided with a drop seat wheelchair which would recline for her comfort and safety. An observation of Resident #4's wheelchair with Physical Therapy Director (PTD) #293 and COTA #295 on 07/24/25 at 11:07 A.M. revealed the left arm of the wheelchair was missing the foam padding and was wrapped with an ace bandage wrap. The right leg rest had a missing calf pad with a broken sharp piece of plastic exposed to where the calf pad attached to the leg rest. COTA #295 stated the wheelchair was not in this condition when Resident #4 was provided with the wheelchair. PTD #293 verified the wheelchair needed repair. Both staff indicated they were unaware of the condition of Resident #4's wheelchair or Resident #4's daughter's recent concerns.This deficiency was an incidental finding identified during the complaint investigation.

Based on observation, interview and review of facility policy, the facility failed to ensure insulin pens were dated and labeled after opening. This affected three residents (#9, #16, and #40) of four residents observed for insulin pens during medication administration. The facility census was 66. Findings include: 1. Review of Resident #9's medical records revealed an admitted [DATE] with diagnoses including but not limited to diabetes. Review of Resident #9's physician order for March 2025 revealed resident was ordered Glargine insulin (long-acting insulin) 25 units subcutaneous (SQ) twice a day (BID). Observation during medication administration on 03/13/25 at 8:22 A.M. of the insulin pens with Licensed Practical Nurse (LPN) 154 revealed multiple insulin pens were not dated when opened with expiration date. Resident #9's Glargine insulin pen had no date to indicate when it was opened. Interview on 03/13/25 at 9:03 A.M. with LPN #154 confirmed Resident #9's insulin pen was not dated when opened. LPN #154 reported the insulin pen should be dated when opened and stated she was unsure how long insulin pens were good for after opening. Interview on 03/13/25 at 9:10 A.M. with Director of Nursing (DON) confirmed insulin pens are to be dated when opened. DON confirmed there was no date on the Glargine insulin pen for Resident #9. 2. Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including but not limited to diabetes. Review of Resident #16's physician order for March 2025 revealed an order for Basaglar Kwikpen (Glargine insulin, long-acting insulin) give 12 units SQ once a day (QD). Observation during medication administration on 03/13/25 at 8:22 A.M. of the insulin pens with LPN #154 revealed multiple insulin pens were not dated when opened with expiration date. Resident #16's Basaglar KwikPen, (Glargine insulin) had no date to indicate when it was opened. Interview on 03/13/25 at 9:03 A.M. with LPN #154 confirmed Resident #16's insulin pen was not dated when opened. LPN #154 reported the insulin pen should be dated when opened and stated she was unsure how long insulin pens were good for after opening. Interview on 03/13/25 at 9:10 A.M. with DON confirmed insulin pens are to be dated when opened. DON confirmed there was no date on the Glargine insulin pen for Resident #16. 3. Review of the medical record for Resident #40 revealed an admitted [DATE] with diagnoses including but not limited to diabetes. Review of Resident #40's physician order for March 2025 revealed an order for Fiasp (aspart insulin), (rapid acting insulin) 100 unit/ml, give 6 units sq with meals. Observation during medication administration on 03/13/25 at 8:22 A.M. of the insulin pens with LPN #154 revealed multiple insulin pens were not dated when opened with expiration date. Resident #40's Fiasp (aspart insulin), (rapid acting insulin) 100 unit/ml, give 6 units sq with meals had no date to indicate when it was opened. Interview on 03/13/25 at 9:03 A.M. with LPN #154 confirmed Resident #40'S insulin pen was not dated when opened. LPN #154 reported the insulin pen should be dated when opened and stated she was unsure how long insulin pens were good for after opening. Interview on 03/13/25 at 9:10 A.M. with DON confirmed insulin pens are to be dated when opened. DON confirmed there was no date on the Fiasp insulin pen for Resident #40. Review of facility policy, Medication Storage in the Facility, dated May 2020, revealed mediations are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. Furthermore, all medications dispensed by the pharmacy are stored in the container with the pharmacy label and blood sugar solutions once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency.

Based on observation, interview and record review the facility failed to maintain infection control procedures while administering medications. This affected two residents (#46 and #49) of four residents observed for infection control during medication administration. The facility census was 66. Findings include: 1. Review of the medical record for Resident #49 revealed an admitted [DATE] with diagnosis including but not limited to scoliosis, stage three chronic kidney disease, and hypertension. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had intact cognition. Review of physician orders for March 2025 revealed resident #49 was ordered, Gabapentin 100 milligram (MG) one capsule three times a day (TID) for pain, Metoprolol Succinate Extended Release (ER) 50 mg one tablet once a day (QD) for blood pressure, and Pantoprazole 40 mg one tablet qd for acid reflux. Observation of medication administration on 03/13/25 at 7:27 A.M. with Licensed Practical Nurse (LPN) #122 for Resident #49, revealed three medications to include Gabapentin 100 milligram mg one capsule, Metoprolol Succinate ER 50 mg one tablet, and Pantoprazole 40 mg one tablet were all placed in a medicine cup. LPN #122 handed the medicine cup to Resident #49 who took two of the pills but dropped one pill onto her comforter on her bed. LPN #122 was moving the comforter around to locate the pill and then told Resident #49 to take the pill. Resident #49 picked the pill up off her comforter and ingested it. Interview on 03/13/25 at 7:33 A.M. with LPN #122 confirmed she should have discarded the medication that fell on Resident #49's comforter. Interview on 03/13/25 at 9:10 A.M. with Director of Nursing (DON) confirmed when a medication is dropped on the Resident #49's comforter or bed should be discarded due to infection control concerns. 2. Review of the medical record for Resident #46 revealed an admitted [DATE] with diagnosis including but not limited to type two diabetes mellitus (DM) with diabetic nephropathy, chronic kidney disease and with polyneuropathy, and stage three chronic kidney disease. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had intact cognition. Review of physician orders for March 2025 revealed resident #49 was ordered Lexapro 10 mg to give 15 mg qd. Observation on 03/13/25 at 8:22 A.M. during medication pass revealed LPN #154 take the medication package for Lexapro 10 mg and pop the one and a 1/2 pill from it. The whole pill of Lexapro fell on to the medication cart. LPN #154 picked up the pill with her bare hands and placed it in the medicine cup with all the other pills she had already placed in the medicine cup. LPN #154 proceeded to take the medicine cup into Resident #46's room. LPN #154 handed the medicine cup to Resident #46 who ingested the pills. During medication administration LPN #154 took the glucometer into Resident #46's room and placed it on the over the bed tray with no barrier or disinfecting first. Interview on 03/13/25 at 9:03 A.M. with LPN #154 confirmed she should have discarded the Lexapro medication that fell on the medication cart and not used her bare hands to pick it up and place in the medicine cup. LPN #154 confirmed she should have placed a barrier under the glucometer or disinfected the over the bed tray. Interview on 03/13/25 at 9:10 A.M. with DON confirmed when medication is dropped it is to be discarded, and glucometers required a barrier or disinfect the over the bed tray. Review of the facility policy, Fingerstick Glucose Level, revised 11/2019, revealed policy to obtain blood sample to determine resident's blood glucose level and to prepare a clean field on the bedside stand or overbed table. Review of facility policy, Injectable Medication Administration, revised January 2018, revealed administer medications via subcutaneous route in a safe, accurate and effective manner and use a barrier if supplies or medication will be set down in a resident's room.

Based on record review and interview, the facility failed to have the designated infection control preventionist participate in the quality assurance committee and attend meetings as required. This had the potential to affect all residents. The facility census was 77. Findings include: Review of the certificate of completion of the infection preventionist training course revealed Registered Nurse (RN) #596 completed the course on 03/01/23. Review of the Quality Assurance Performance Improvement (QAPI) Committee members revealed RN #596 was not listed as a member. Review of the QAPI monthly committee meetings for 12/15/23, 01/11/24, 02/23/24 and 03/22/24, revealed RN #596 had not attended the meetings. Interview on 04/22/24 at 9:12 A.M. with RN #596 revealed she was the interim infection preventionist for the facility and had been in that role since December 2023. She stated the Director of Nursing was in the process of completing the infection preventionist training. Follow up interview on 04/24/24 at 10:23 A.M. with RN #596 verified she was not on the document provided by the facility listing the QAPI committee members. Review of the committee meeting sign-in sheets with RN #596 for the meetings held from December 2023 through March of 2024 verified she had not signed that she was present for those meetings. RN #596 stated she went to every meeting, even if she was late, so that she could present her infection control information, but she was unable to provide evidence of her attendance.

Based on record review and interview, the facility failed to invite one resident, Resident #60's, Power of Attorney (POA) to all care plan meetings. This affected one resident (#60) of one resident reviewed for care plan meetings. The facility census was 77. Findings include: Record review for Resident #60 revealed an admitted [DATE]. Diagnoses included muscle weakness, lack of coordination, hemiplegia and hemiparesis following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was severely cognitively impaired and dependent for activities of daily living. Interview on 04/23/24 at 9:39 A.M. with Resident #60's POA revealed she was only invited to two of Resident #60's care plan meetings. Resident #60's POA revealed she would prefer to attend all care conference meetings. Review of the Resident Care Conferences revealed Resident #60 was scheduled to have a quarterly care plan meeting on 05/05/24, 08/04/24, 12/06/24 and 03/10/24. Review of the quarterly Care Conference notes dated 12/06/24 and 03/10/24 revealed Resident #60's representatives were not present. Interview on 04/24/24 at 10:50 A.M. with Licensed Social Worker (LSW) #557 confirmed Resident #60 was scheduled to have a care plan meetings on 12/06/24 and 03/10/24. LSW #557 revealed notification of the scheduled care plan meetings to resident responsible parties were mailed out at the beginning of the previous month prior to when the care plan meeting was scheduled. LSW #557 revealed she made a list for the receptionist. The list consisted of each resident's name who was schedule to have a care plan meeting the following month. The invitation was then sent through the mail by the receptionist to each responsible party. There were no follow up calls made and no further notifications. Review on 04/24/24 at 11:00 A.M. with LSW #557 of the list provided to the receptionist dated as mailed 11/01/23 for the care plan meetings scheduled for the month of December revealed Resident #60's name was not on the list for the receptionist to mail the invitation to the care plan meeting for December 2023. LSW #557 revealed she was unsure what happened and confirmed Resident #60 was not on the list. Review of the list provided to the receptionist dated as mailed 01/19/23 for the care plan meetings scheduled for the month of March revealed Resident #60's name was the last name on the list.

Based on record review, observation and interview, the facility failed to ensure the resident and/or responsible party was notified of changes in wound treatment and skin injury. This affected two (#26 and #60) of three residents reviewed for wounds. The facility census was 77. Findings include: 1. Record review for Resident #60 revealed an admitted [DATE]. Diagnoses included muscle weakness, lack of coordination, hemiplegia and hemiparesis following cerebral infarction. Review of Resident #60's face sheet revealed Resident #60 had a Power of Attorney (POA) for Health Care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was severely cognitively impaired, dependent for activities of daily living, and had no ulcers, wounds or skin problems. Review of the care plan for Resident #60 dated 05/04/23 revealed Resident #60 was incontinent of bowel and bladder and was at risk for skin breakdown. Interventions included to observe and report any noted redness, excoriation, or open areas with incontinence care. Observe protective pads, briefs for skin tolerance if used. Review of the physician order for Resident #60 dated 04/19/24 revealed to cleanse the right upper and anterior thigh with wound cleanser, pat dry, apply Xeroform (petroleum based gauze) and dry clean dressing, change every Tuesday, Thursday and Saturday. Review of the wound grid dated 04/16/24 completed by Assistant Director of Nursing (ADON)/Wound Care Nurse #505 revealed Resident #60 had an in-house wound observed 04/16/24 to the right upper lateral thigh. Further record review revealed the POA was not notified. Observation on 04/23/24 at 9:22 A.M. of wound care for Resident #60 completed by Wound Care Physician #599 and ADON/Wound Care Nurse #505 confirmed Resident #60 had wounds to the right thigh. Interview on 04/23/24 at 9:39 A.M. with Resident #60's POA revealed she was not made aware Resident #60 had any wounds. Interview and review of Resident #60's medical record including the wound grid (dated 04/16/24) on 04/23/24 at 2:25 P.M. with ADON/Wound Care Nurse #505 revealed the tape from Residents #60's incontinence brief was placed directly on Resident #60's skin and when removed caused abrasions. ADON/Wound Care Nurse #505 confirmed Resident #60's POA was not notified of the wounds to the right upper and anterior thigh. Per ADON/Wound Care Nurse #505 she had not had time to notify the POA yet. Interview on 04/23/24 at 03:36 P.M. with the Director of Nursing revealed residents' responsible parties should be notified of any changes in condition immediately if they were serious or within a shift if the change was not serious. Review of the facility's undated Change in Resident's Conditions or Status policy revealed the nurse was to immediately notify the resident, consult with the resident's attending physician or on-call physician, and notify the resident's Authorized Representative or an interested family member when there was an accident or incident involving the resident which resulted in injury and had the potential for requiring physician intervention. 43063 2. Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, chronic kidney disease and diabetes mellitus. Review of the wound provider's progress note dated 03/21/24 revealed Nurse Practitioner #597 was there to re-evaluate Resident #26's wound healing process and the resident's condition to define the treatments that would help the wounds continue the healing process. Wound #1 was to his right buttock and was noted to be a healed stage three pressure ulcer that was closed and intact. Nurse Practitioner #597 ordered a preventative treatment with Medihoney (has antibacterial properties and hastens the healing of wounds through anti-inflammatory effects) to the wound bed and to continue the treatment for a preventative dressing. Review of the physician's orders revealed Resident #26 had an order dated 03/23/24 for treatment to his buttocks, cleanse with wound cleanser, pat dry, apply Medihoney, and cover with a dry dressing. He also had an order dated 03/23/24 for Medihoney treatment to buttocks dated 03/23/24. Review of Resident #26's nursing assessments revealed there were no nursing assessments dated for 03/21/24 through 03/23/24 that would have included an update to the resident or his responsible party. Review of the nursing progress notes for Resident #26 revealed no documentation that Resident #26 or his responsible party were notified of the new physician's orders for treatment to buttocks. Interview on 04/22/24 at 3:36 P.M. with Assistant Director of Nursing (ADON) #505 verified staff did not notify Resident #26 and his responsible party of the new physician's orders for treatment to his buttocks on 03/23/24. Interview on 04/23/24 at 3:37 P.M. with the Director of Nursing verified notifications on changes with residents should be made timely and should be made within the same shift. Review of the facility policy titled, Change in Resident's Conditions or Status, undated, revealed the nurse would immediately notify the resident and notify the resident's authorized representative when there was a new form of treatment.

Based on record review and interview, the facility failed to ensure residents were ambulated per physician order to maintain function abilities. This affected one (Resident #65) of two residents reviewed for restorative programs. The facility census was 77. Findings include: Review of the medical record for Resident #65 revealed an admitted [DATE] with diagnoses including Parkinsonism (having the same symptoms of Parkinson's Disease), muscle weakness and age-related physical debility. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] for Resident #65 revealed he had intact cognition, had no behaviors or refusals of care and was able to understand staff and be understood. Review of the Restorative Program Initial Observation dated 03/25/24 authored by Assistant Director of Nursing (ADON) #505 revealed therapy had referred Resident #65 for a restorative ambulation program related to weakness. Review of the physician's order dated 03/25/24 revealed a restorative program, staff were to encourage and assist Resident #65 to ambulate up to 326 feet with his walker with one staff member for 15 minutes a day, four to seven days a week as tolerated. Review of the point of care history (documentation completed by the aides) for April 2024 revealed Resident #65 was not offered to ambulate or there was no documentation for 04/03/24, 04/09/24, 04/10/24, 04/12/24, 04/13/24, 04/14/24, 04/15/24, 04/16/24, 04/17/24, 04/19/24, 04/21/24, 04/22/24 and 04/23/24. He was assisted with his ambulation restorative program only three days the week of 04/07/24 and two days the week of 04/14/24. Interview on 04/22/24 at 10:29 A.M. with Resident #65 revealed he was no longer receiving skilled therapy services from the facility. He stated since then, staff would not assist him to ambulate with his walker. Resident #65 stated he wanted to maintain his walking ability as long as possible. Interview on 04/24/24 at 10:05 A.M. with ADON #505 revealed therapy made recommendations and a physician's order was obtained for the restorative programs. The programs were to assist in maintaining a resident's abilities such as range of motion and ambulation. She verified the staff were not following the physician's order for Resident #65 on the dates listed above. Review of the facility policy titled, Restorative Nursing Care, updated April 2024, revealed the restorative program was provided for each resident, as indicated, to maintain their highest level of physical functioning. The restorative nursing program would be performed four to seven days a week as tolerated for residents who required those services.

Based on observation, interview, and record review, the facility failed to follow physician orders regarding application of Tubigrip (a tubular stocking that provides compression) and elevation of an extremity and failed to ensure incontinence briefs fit appropriately and did not cause skin injury. This affected one (#60) of three residents reviewed for activities of daily living and one of four residents (#60) reviewed for incontinence care. The facility census was 77. Findings include: 1. Record review for Resident #60 revealed an admitted [DATE]. Diagnoses included muscle weakness, lack of coordination, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and aphasia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was severely cognitively impaired and dependent for activities of daily living. Review of the care plan dated 05/04/23 revealed Resident #60 had potential for fluid imbalance/complications related to edema. Interventions included to evaluate edema. Review of the physician orders for Resident #60 revealed orders dated 03/18/24 to elevate right arm and Tubigrip to right upper extremity, on in A.M. and off at hs (night) also dated 03/18/24. Observation on 04/23/24 at 9:22 A.M. of wound care for Resident #60 with Wound Care Physician #599 and Assistant Director of Nursing (ADON)/Wound Care Nurse #505 revealed Resident #60's right hand was swollen. Resident #60's right hand was not elevated and there was no Tubigrip on the right upper extremity. ADON/Wound Care Nurse #505 confirmed the arm was not elevated, it was swollen and there was no Tubigrip on. ADON/Wound Care Nurse #505 revealed Resident #60's arm was paralyzed and he was unable to apply the Tubigrip or elevate the arm himself. Observation and interview on 04/23/24 at 3:12 P.M. with State tested Nursing Assistant (STNA) #513 confirmed Resident #60's right arm was not elevated and he did not have the Tubigrip on to the right upper extremity. Observation on 04/24/24 at 8:36 A.M. revealed Resident #60's right arm was not elevated and he did not have the Tubigrip on to the right upper extremity. Resident #60's right hand was very swollen. Observation and interview on 04/24/24 at 8:44 A.M. with Licensed Practical Nurse (LPN) #594 confirmed Resident #60's right arm was not elevated and he did not have the Tubigrip on to the right upper extremity. Resident #60's right hand was very swollen. LPN #594 revealed his hand was always like that, then left the room without attempting to elevate the arm or apply the Tubigrip. Interview at the nurses station with LPN #594 confirmed she did not attempt to elevate the arm or apply the Tubigrip. LPN #594 revealed Resident #60 did not like it. LPN #594 re-entered Resident #60's room and asked Resident #60 if she could elevate his arm. Resident #60 said, yes. LPN #594 elevated the right arm on a pillow and asked Resident #60 if he was comfortable. Resident #60 said, yes. LPN #594 then stated, Well I am just agency. LPN #594 did not offer or attempt to apply the Tubigrip. Observation and interview on 04/24/24 at 1:45 P.M. with State tested Nursing Assistant (STNA) #524 revealed she did not know Resident #60 was supposed to wear a Tubigrip. STNA #524 confirmed she was Resident #60's caregiver and worked with him frequently. After applying the Tubigrip, STNA #524 confirmed Resident #60 did not refuse the Tubigrip. Interview on 04/25/24 at 7:36 A.M. with the Director of Nursing (DON) confirmed Resident #60 had physician orders to include elevating the right arm and Tubigrip to right upper extremity, on in A.M. and off at hs, both dated 03/18/24. The DON revealed the order to elevate the right arm only showed up in the aids profile for Resident #60 and confirmed it did not require them to sign it off. The DON revealed the Tubigrip order was on the treatment record and was signed off in the A.M. and hs by the nurses daily as completed. 2. Record review for Resident #60 revealed an admitted [DATE]. Diagnoses included muscle weakness, lack of coordination, hemiplegia and hemiparesis following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was severely cognitively impaired, dependent for activities of daily living, had no ulcers, wounds or skin problems, and was always incontinent of bowel and bladder. Review of the care plan for Resident #60 dated 05/04/23 revealed Resident #60 was incontinent of bowel and bladder and was at risk for skin breakdown. Interventions included to observe and report any noted redness, excoriation, or open areas with incontinence care. Observe protective pads, briefs for skin tolerance if used. Review of the physician orders for Resident #60 dated 04/12/24 revealed cleanse right hip with wound cleanser, pat dry, apply chamosyn, clean dry dressing, do not tape to secure. Review of the physician order dated 04/18/24 revealed treatment to right upper and anterior thigh included cleanse with wound cleanser, pat dry, apply Xeroform (petroleum based gauze) clean dry dressing once a day on Tuesday, Thursday and Saturday and as needed. Observation on 04/23/24 at 9:22 A.M. of wound care for Resident #60 with Wound Care Physician #599 and Assistant Director of Nursing (ADON)/Wound Care Nurse #505 revealed three wounds to the right thigh. Observation revealed there were also eight healed scarred areas surrounding the three open areas. ADON/Wound Care Nurse #505 revealed the scarred areas and open areas were caused from the tape on Resident #60's incontinence briefs. Interview on 04/23/24 at 2:25 P.M. with ADON/Wound Care Nurse #505 revealed the wounds to Resident #60's thigh were caused by the tape on the briefs being placed directly on Resident #60's skin. When the tape was removed it caused abrasions to his skin. ADON/Wound Care Nurse #505 revealed nothing had been done to prevent further injury caused by the tape from the incontinence briefs and confirmed the briefs were not looked at for resizing and there was no education completed to staff regarding placing the tape on the brief, not the skin. Observation on 04/23/24 at 3:12 P.M. with State tested Nursing Assistant (STNA) #513 revealed Resident #60 was wearing a medium incontinence brief and the brief on the right side was taped to Resident #60's skin right on top of a current red area. Interview on 04/23/24 at 3:36 P.M. with Director of Nursing (DON) confirmed there was no education provided to staff within the last four months or since Resident #60 had repeated abrasions related to the tape on the briefs applied to his skin. The DON revealed he would have expected staff to address the cause of the wounds to prevent continued injuries. The DON was unsure of the process for sizing briefs Observation, interview, and review of Resident #60's record on 04/23/24 at 4:03 P.M. with the DON revealed the packaging on the incontinence briefs (provided by the facility) had a height and weight chart on the back of the package. The DON confirmed Resident #60's briefs were provided by the facility and according to Resident #60's height and weight, Resident #60 should have been wearing a large brief.

Based on observation, interview and record review, the facility failed to follow orders and implement new orders for a resting hand splint for one resident (#60) of one resident reviewed for splints. The facility census was 77. Findings include: Record review for Resident #60 revealed an admitted [DATE]. Diagnoses included muscle weakness, lack of coordination, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was severely cognitively impaired and dependent for activities of daily living. Review of the care plan dated 05/04/23 revealed Resident #60 had potential for fluid imbalance/complications related to edema. Interventions included to evaluate edema. Review of the physician orders for Resident #60 revealed an order dated 05/23/23 for a resting hand splint to the right hand during hours of sleep four to six hours every shift. Observation on 04/23/24 at 9:22 A.M. of wound care for Resident #60 with Wound Care Physician #599 and Assistant Director of Nursing (ADON)/Wound Care Nurse #505 revealed Resident #60 did not have a resting hand splint on the right hand. ADON/Wound Care Nurse #505 confirmed Resident #60 was unable to move his right arm and was unable to apply the splint himself. Observation on 04/24/24 at 8:36 A.M. of Resident #60 revealed the resting hand splint to the right hand was not on. Interview on 04/24/24 at 9:09 A.M. with State tested Nursing Assistant (STNA) #524 confirmed Resident #60 did not have a resting hand splint on the right hand. STNA #524 revealed the hand splint was to be applied at 12:00 P.M. and removed when she left her shift at 3:00 P.M. Observation and interview on 04/24/24 at 1:45 P.M. with STNA #524 confirmed Resident #60 did not have his right hand splint on. STNA #524 revealed she forgot to apply the hand splint. Interview on 04/24/24 at 1:47 P.M. with Licensed Practical Nurse (LPN) #594 confirmed Resident #60 did not have the right hand splint on and revealed she thought it was to be worn during the night shift only. LPN #594 verified the order was for every shift. Interview on 04/24/24 at 2:15 P.M. with LPN #594 revealed she again read the order for Resident #60 wrong for the right hand splint. LPN #594 revealed the order read while sleeping so she would have to wait until he was sleeping then she could put it on but if he woke up while she was putting it on, she would have to stop because she could not put it on because he was awake because the order read while sleeping. Interview on 04/24/24 at 2:30 P.M. with the Director of Nursing (DON) verified the order for Resident #60 for the right hand splint was written for every shift on 05/23/23. The DON revealed Resident #60 did not get out of bed and he slept on and off throughout the day taking frequent naps. The DON confirmed he was unable to find the original recommendation from therapy to confirm the splint should be on every shift. Interview and record review for Resident #60 on 04/24/24 at 2:30 P.M. with the DON and Occupational Therapy Assistant (COTA) #604 revealed per COTA #604 that the order for Resident #60's resting hand splint to the right hand written 05/23/23 was no longer in place. COTA #604 revealed that splint was discontinued on 04/10/24 and a new order was written for a different splint. COTA #604 presented a copy of the form titled Inservice/Meeting for Resident #60 dated 04/10/24 which revealed Resident #60 was to utilize right volar inflatable resting hand splint at night up to six hours. Perform passive range of motion to entire upper extremity prior to donning and at removal, skin check every two hours with wear. Place forearm on flat part of splint, wrap fingers around inflated portion of the splint. Strap over knuckles with slit allowing access to inflate valve. Wrap remaining two straps around the forearm. The form was signed on the 7:00 A.M. to the 3:00 P.M. shift by two unknown staff members. The DON confirmed they were nursing staff members. COTA #604 verified Occupational Therapist (OTR) #606 signed and verified the order to be implemented 04/10/24. COTA #604 revealed and the DON confirmed this was how the therapy orders were completed, the new order was written on the form, given to the nurse, the nurse put the new order in to the electronic medical system as the order to be followed. The DON confirmed the order was not completed by the nursing staff who signed the form which resulted in the order not being implemented as it should have been on 04/10/24.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure Resident #21's urinary catheter bag was placed below his bladder at all times. This affected one (#21) of four residents reviewed for bowel and bladder/incontinence care. The facility census was 77. Findings include: Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnosis included neuromuscular dysfunction of the bladder. Review of the physician order with a start dated on 03/30/24 revealed suprapubic catheter to straight drain for neuromuscular dysfunction of bladder. Review of the plan of care dated 01/09/24 revealed interventions included resident would not develop complications related to Foley (urinary) catheter such as urinary tract infection. Keep drainage bag below bladder and off of the floor. Observation of Resident #21 on 04/22/24 at 11:27 A.M. revealed his urinary catheter drainage bag was lying on the bed with clear yellow urine in the tubing and in the drainage bag. The urinary catheter drainage bag was not positioned below Resident #21's bladder. Observation of Resident #21 on 04/22/24 at 3:20 P.M. revealed Resident #21 resting in bed with eyes closed with the urinary catheter drainage bag lying on the bed above Resident #21's bladder. The catheter drainage bag was full of clear yellow urine. Interview on 04/23/24 at 11:11 A.M. with Licensed Practical Nurse (LPN) #538 revealed Resident #21 had a urinary catheter related to a neuromuscular neurogenic bladder. Resident #21 had a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) and his urinary drainage bag laid on his bed all the time. LPN #538 indicated the urinary drainage bag should be hanging below his bladder. LPN #538 stated if the catheter bag was not kept below the bladder the urine would back up in his bladder and could cause an infection. Interview on 04/23/24 at 2:07 P.M. with Resident #21 revealed he had a Foley catheter for [AGE] years and he knew the drainage bag should be below the bladder. Resident #21 stated the suprapubic catheter was created three weeks ago and since then the drainage bag had always been positioned on the bed and not below his bladder. Interview on 04/23/24 at 2:15 P.M. with Director of Nursing (DON) verified Resident #21's suprapubic catheter drainage bag was laying on Resident #21's bed, and above his bladder. The DON indicated urinary catheter drainage bags should be below the bladder, hanging off the side of the bed. Review of the facility's undated policy Catheter Care, Urinary, revealed the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview, record review, and policy review, the facility failed to provide enteral nutrition per physician's order. This affected one (#60) of one resident reviewed for enteral nutrition. The facility census was 77. Findings include: Record review for Resident #60 revealed an admitted [DATE]. Diagnoses included esophagitis, gastroparesis, and dysphagia, oropharyngeal phase, and hemiplegia and hemiparesis following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was severely cognitively impaired, dependent for activities of daily living, and received tube feeding. Review of the care plan dated 05/05/23 for Resident #60 revealed Resident #60 was at risk for altered nutrition related to a diagnosis of recent stroke with percutaneous endoscopic gastrostomy (peg) tube placement (feeding tube). Resident #60 received nothing by mouth (NPO) and was dependent on tube feed for nutrition and hydration. Interventions included to provide diet per physician order, NPO, see tube feed and water flush orders. Review of the physician order dated 11/13/23 for Resident #60 revealed enteral feeding formula Peptamen 1.5 to run at 65 milliliters (ml) per hour (hr) to run for 18 hours, on at 6:00 A.M. until 12:00 A.M., off six hours 12:00 A.M. until 6:00 A.M. Observation on 04/25/24 at 7:30 A.M. revealed Resident #60 was lying in bed. Resident #60's tube feeding was not running. Interview on 04/25/24 at 7:31 A.M. with Licensed Practical Nurse (LPN) #515 verified she was Resident #60's nurse. LPN #515 confirmed Resident #60's tube feeding was not running. Observation on 04/25/24 at 9:11 A.M. revealed Resident #60 was lying in bed and his lips and mouth had a thick, dry, pasty film. Resident #60's tube feeding was not running. Interview with LPN #515 at the time of the observation revealed Resident #60's tube feeding was only to run from 12:00 A.M. to 6:00 A.M. LPN #515 confirmed Resident #60's lips and mouth had a thick, dry, pasty film. Upon review of Resident #60's physician orders with LPN #515, LPN #515 confirmed Resident #60's tube feeding was to run from 6:00 A.M. until 12:00 A.M., off six hours 12:00 A.M. until 6:00 A.M. Review of the facility's undated policy Enteral Nutrition revealed it was the facility policy to ensure adequate nutrition support through enteral feeding would be provided to residents unable to consume adequate nutritional intake by mouth. Enteral feeding orders would be written to consistent volume infusion.

Based on observation, interview and record review, the facility failed to monitor oxygen saturation levels for residents receiving continuous and as needed oxygen. This affected three residents, Residents #26, #31 and #60 of six residents reviewed for oxygen therapy. The facility census was 77. Findings include: 1. Record review for Resident #60 revealed an admitted [DATE]. Diagnoses included muscle weakness, esophagitis, lack of coordination, hemiplegia and hemiparesis following cerebral infarction, atherosclerotic heart disease and emphysema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was severely cognitively impaired, dependent for activities of daily living, and had medically complex conditions. Review of the care plan for Resident #60 dated 05/04/23 revealed Resident #60 had alteration in respiratory function related to emphysema and former smoker. Interventions included to administer oxygen as ordered. Review of the physician orders dated 03/25/24 for Resident #60 revealed an order for oxygen at two liters per nasal cannula as needed (PRN) to keep saturation of peripheral oxygen (SP02) greater than 92 percent. Review of Resident #60's medical records revealed two oxygen saturation levels were assessed for the month of April 2024, 04/16/24 and 04/11/24. Interview on 04/24/24 at 5:00 P.M. with the Director of Nursing (DON) verified Resident #60's order for oxygen at two liters per nasal cannula PRN to keep SP02 greater than 92 percent. The DON revealed oxygen saturation levels were to be assessed every shift for residents with an as needed order to keep the SP02 above the ordered given level. Observation on 04/24/24 at 5:07 P.M. revealed the DON obtained Resident #60's SPO2 level which was 90 percent on room air. Interview on 04/25/24 at 9:38 A.M. with Certified Nurse Practitioner (CNP) #595 revealed she only wrote as needed oxygen orders for residents to keep there oxygen saturation level above a specified level if the resident was having problems. CNP #595 confirmed saturation levels were to be checked every shift to assess and monitor the saturation level. 36650 2. Review of the medical record for Resident #31 revealed Resident #31 had intact cognition. Diagnoses included chronic obstructive pulmonary disease with (acute) exacerbation, acute bronchitis, unspecified, and dependence on supplemental oxygen. Review of the physician orders from 04/01/24 through 04/25/24 revealed an order for continuous oxygen at two to four liters per nasal cannula, check placement, record oxygen saturation every shift. Review of the vital signs documentation from 04/01/24 through 04/25/24 revealed Resident #31's oxygen saturation was last documented on 04/05/24. Review of Treatment Administration Record (TAR) for April 2024 revealed continuous oxygen at two to four liters per nasal cannula, check placement, record oxygen saturation every shift. The TAR did not include a record of Resident #31's oxygen saturation every shift. Interview on 04/24/24 at 5:00 P.M. with the Director of Nursing (DON) verified Resident #31 physician order for oxygen continuous at two to four liters, per nasal cannula, check placement and record oxygen saturation every shift. The DON also verified Resident #31's oxygen saturation was not being checked and recorded in the medical record as ordered. The DON indicated oxygen saturation levels were to be assessed every shift to monitor oxygen saturation for residents with orders for continuous or as needed oxygen. Interview and observation on 04/25/24 at 10:15 A.M. with Resident #31 revealed the nurses did not check his oxygen saturation every shift, maybe once a day. Interview on 04/25/24 at 10:18 A.M. with Licensed Practical Nurse (LPN) #595 confirmed Resident #31 had an order for continuous oxygen and to check his oxygen saturation every shift; however it was not being done and there was no place to record the oxygen saturation levels. 43063 3. Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, chronic kidney disease and diabetes mellitus. Review of the care plan for Resident #26 dated 12/21/18 revealed he was at risk for cardiovascular impairment due to diagnoses of hypertension and atrial fibrillation. Interventions included to administer oxygen as ordered. Review of the physician's orders revealed Resident #26 had an order dated 12/01/20 for oxygen one to four liters nasal cannula as needed if pulse oximeter was below 92 percent or shortness of breath. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2024 revealed nursing had not documented a pulse oximeter reading since 04/03/24. Review of the vitals record from 04/05/24 through 04/25/24 for Resident #26 revealed nursing staff had not assessed his oxygen saturation level since 04/05/24. Interview on 04/24/24 at 5:00 P.M. with the Director of Nursing (DON) verified Resident #26 had an order for oxygen one to four liters nasal cannula as needed if pulse oximeter was below 92 percent or shortness of breath. The DON stated oxygen saturation should be assessed every shift to monitor oxygen saturation levels for residents on oxygen as needed.

Based on record review and interview, the facility failed to ensure dialysis residents were monitored after dialysis treatments. The facility also failed to maintain communication with the dialysis center. This affected one ( #16) of one resident reviewed for dialysis. The facility census was 77. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including end stage renal disease. Review of the physician's order dated 03/30/24 revealed Resident #16 received dialysis on Tuesdays, Thursdays and Saturdays. Review of Resident #16's dialysis assessments revealed he did not have post-dialysis assessments on 04/06/24, 04/09/24, 04/11/24, 04/18/24 and 04/20/24. Review of Resident #16's medical record revealed there was no documentation received from the dialysis center for Resident #16 from 03/30/24 through 04/22/24. Interview on 04/23/24 at 2:44 P.M. with Dialysis Nurse #598 revealed the facility did not send communication with Resident #16 at times and never required any information to be sent back to the facility from the dialysis center. Interview on 04/23/24 at 3:08 P.M. with the Director of Nursing (DON) verified the nursing staff were to perform dialysis assessments prior to the residents going to dialysis and after returning. The post-dialysis assessments were to include the residents return date and time to the facility, mental status, vitals signs, skin assessment, dialysis access site assessment, lung sounds, edema, if pain was present and if there were any new orders from the dialysis center. The DON verified the nursing staff had not performed assessments on the dates listed above and verified there was no documentation received from the dialysis center for Resident #16 since 03/30/24. Review of dialysis center documentation provided by Registered Nurse (RN) #596 on 04/23/24 at 3:44 P.M. for Resident #16 revealed the facility had received the documentation from the dialysis center via fax on 04/23/24 at 3:44 P.M. Review of the facility policy titled, Dialysis Care Planning Policy, undated, revealed the dialysis center would send reports from the resident's dialysis treatments to the facility after each visit. Upon return to the facility following dialysis, the nurse was to perform a complete body check and observe the dialysis site for any complications.

Based on record review, interview, and review of facility policy, the facility failed to ensure the physician's order for an as needed psychotropic medication had a time-frame for usage for Resident #13. This affected one resident (#13) of six residents reviewed for unnecessary medications. The facility census was 77. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including schizoaffective disorder, dementia with anxiety, major depressive disorder, and psychotic disorder with delusions. Review of the Psychotropic Medication Regimen Evaluation, dated 03/04/24, revealed a gradual dose reduction (GDR) would be attempted for Ativan. Resident #13's new orders included Change routine Ativan to 0.5 milligrams (mg) twice daily (BID) and add Ativan 0.5 mg as needed (PRN) with no stop date to monitor PRN usage and GDR attempt. Review of the physician's orders for April 2024 identified orders for Ativan 0.5 mg as needed ordered on 03/04/24 with no end date. On 04/24/24 at 11:19 A.M., interview with Registered Nurse (RN) #545 verified Resident #13 had a PRN order for Ativan and stated she had never administered the PRN dose of Ativan for Resident #13. On 04/24/24 at 4:30 P.M., interview with the Director of Nursing (DON) verified Resident #13's PRN order for Ativan did not have an end date and stated the physician had discontinued the order on 04/24/24. Review of facility policy titled Behavior Management Policy, not dated, revealed PRN orders for psychotropic medications would be limited to 14 days unless the prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days. Their rationale would be documented in the medical record and the duration for the PRN order would be indicated.

Based on record review and interview, the facility failed to ensure accurate documentation in the medical record for residents. This affected two ( #26 and #40) of 26 residents reviewed. The facility census was 77. Findings include: 1. Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, chronic kidney disease and diabetes mellitus. Review of the physician's orders revealed Resident #26 had an order dated 11/09/23 for Medihoney to his left buttock, cleanse with wound cleanser, pat dry, apply Medihoney and cover with dry dressing twice a day. This order had a discontinue date of 01/16/24. Review of the wound provider's progress note dated 12/14/23 revealed Nurse Practitioner (NP) #597 had assessed Resident #26 for a left buttock abrasion. NP #597 documented the wound was intact and healed. NP #597 provided an order for staff to gently cleanse the wound, pat dry, apply Medihoney (treatment for the management of wounds and burns that help in the management of chronic and stalled wounds and to assist in debridement of necrotic tissue) to the wound bed and place a dry clean dressing twice daily and as needed for one week as a preventative. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #26 revealed staff continued to perform treatments to the left buttock 12/21/23 until 01/16/24 when the order was discontinued. Review of the nursing progress notes for Resident #26 revealed no documentation as to why Resident #26's treatment to the left buttock with Medihoney continued when NP #597 had indicated the treatment should be discontinued one week after her assessment on 12/14/23. Review of the wound provider's progress notes dated 03/21/24 and 03/28/24 revealed NP #597 signed and reviewed the progress notes on 04/22/24 at 4:54 P.M. The provider's progress notes were provided on 04/23/24 at 8:49 A.M. by Registered Nurse (RN) #596. Review of the physician's orders from April 2024 revealed Resident #26 had an order dated 03/23/24 for treatment to his buttocks, cleanse with wound cleanser, pat dry, apply Medihoney, and cover with a dry dressing. He also had an order dated 03/23/24 for Medihoney treatment to buttocks dated 03/23/24. Review of Resident #26's nursing assessments (observations) revealed there were no nursing assessments dated for 03/21/24 through 04/22/24 to indicate why he had a physician's order for Medihoney to his buttocks. Review of Resident #26's nursing progress notes dated from 03/04/24 through 04/11/24 revealed no indication as to why he had an order dated 03/23/24 for Medihoney to his buttocks. There were no progress notes dated from 04/11/24 through 04/23/24 when the report was ran on 04/23/24 at 9:09 A.M. Interview on 04/23/24 at 1:30 P.M. with Assistant Director of Nursing (ADON) #505 verified NP #597's order had not been followed to discontinue the preventative treatment for Medihoney to Resident #26's left buttock wound one week after her assessment on 12/14/23. She was unsure why the order had continued until 01/16/24. Additional interview on 04/22/24 at 3:36 P.M. with ADON #505 verified Resident #26 had a stage two pressure ulcer that had been identified on 04/19/24. ADON #505 stated she had not placed any documentation into his medical record as she had not had time. Interview on 04/23/24 at 1:30 P.M. with RN #596 verified NP #597's wound progress notes were not in the electronic medical record for 03/21/24 and 03/28/24. 36650 2. Review of the medical record for Resident #40 revealed an admitted [DATE]. Diagnosis included Alzheimer's disease and weakness. Review of the physician orders for April 2024 revealed cleanse left buttock with normal saline, pat dry, apply Medihoney, alginate silver, lightly fill wound bed with alginate silver and cover with dry dressing. Another order indicated cleanse sacrum with normal saline, pat dry, apply alginate lightly fill wound, do not pack and cover with dry dressing. Review of the April 2024 Treatment Administration Record (TAR) revealed both treatments were signed off as being completed. Observation on 04/23/24 at 10:34 A.M. of Resident #40's wound with Registered Nurse (RN) #505 and Wound Physician #599 revealed there was one pressure ulcer on the sacrum. There was not a pressure ulcer on the left buttock. Interview on 04/23/24 at 10:42 A.M. with RN #505 revealed the left buttock and sacrum were the same pressure ulcer; the left buttock ulcer was renamed a sacrum ulcer. RN #505 stated when the pressure ulcer got changed to sacrum the treatment order for the left buttock was not discontinued, so there were two different orders for the same area. RN #505 verified the current treatment orders were not correct because she forgot to discontinue the left buttock order and staff were marking both treatments as being completed. RN #505 verified Resident #40 medical record was not accurate.

Based on observations, interview and record review, the facility failed to ensure that the kitchen was clean and sanitary. This had the potential to affect 72 out of 73 residents in the facility. Resident #69 was identified as being nothing by mouth (NPO). Findings include: A tour of the kitchen on 06/25/23 from 8:06 A.M. through 8:25 A.M. with Dietary Manager (DM) #833 revealed there was ice buildup in the walk-in freezer that had ice forming on the boxes of frozen supplements and a container of Canadian bacon. In the walk-in refrigerator there was cole slaw not labeled or dated. The ceiling was peeling in the dry storage room. In the kitchen area, there was paper, food residue, dishes, and a steam table lid was on the floor behind the cooking equipment, the dish [NAME], where clean plate lids were stored, had dried food residue on it, and the microwave was dirty with food residue inside. Interview on 06/25/23 at 11:30 A.M. with Dietary Manager (DM) #833 revealed that dietary had been short staffed lately and there were no sanitation policies for the kitchen. DM #833 stated that there was one resident (#69) that was NPO. Review of the facility policy dated 01/2021 titled, Dietary Manager Responsibilities revealed that the facility must store, prepare distribute and serve food in accordance with professional standards for food safety. Review of the facility policy dated 08/12/20 titled, Dating Foods revealed that opened items and leftovers will be labeled and dated.