Every finding on record at Austin Trace Health and Rehabilitation

Based on observation, staff interview, review of the facility dishwasher temperature logs, and review of manufacturer's manual, the facility failed to store and label food properly and failed to ensure low temperature dishwasher met proper temperature during the wash cycle. This had the potential to affect all residents in the facility with the exception of 13 facility-identified residents (#7, #9, #10, #26, #38, #44, #50, #67, #87, #90, #98, #102, and #108) who did not receive food from the kitchen. The facility census was 116 residents. Findings include: 1. Observation on 06/08/26 at 8:12 A.M. of the facility refrigerator with [NAME] #143 revealed it contained the following items: a container of coleslaw with use by date of 05/30/26, a container of unlabeled and undated cooked beef, two containers of opened and undated and unlabeled lettuce, a block of cheese with a used by date of 06/06/26. Interview on 06/08/26 at 8:12 A.M. with [NAME] #143 confirmed the container of coleslaw and cheese had use by dates which were prior to 06/08/26 and should have been discarded and the containers with beef and lettuce should have been labeled and dated when opened. 2. Review of the facility dishwasher temperature log dated 06/08/26 revealed the staff had run the dishwasher with the wash cycle temperature reaching 120 degrees Fahrenheit (F.) Interview on 06/08/26 at 8:15 A.M. with Dietary Staff (DS) #143 confirmed the dishwasher temperature log for 06/08/26 read 120 degrees F. Observation on 06/08/26 at 8:21 A.M. with DS #143 revealed he ran the dishwasher three times and the temperature was 110 degrees F. Interview on 06/08/26 at 8:25 A.M. with DS #143 confirmed the wash cycle of the dishwasher was supposed to reach 120 degrees F, but it only reached 110 degrees F during the three observations. Review of the dishwasher manual for Model 5AGES or WS2 page 13 revealed the operating temperature of 120 degrees F at a minimum. 130 to 140 degrees F was recommended. 3. Observation on 06/08/26 at 8:29 A.M. of dry storage with Dietary Manager (DM) #202 revealed there was a large plastic measuring cup inside the plastic flour bin. Interview on 06/08/26 at 8:29 A.M. with DM #202 confirmed the measuring cup should not be stored inside the plastic flour bin.

Based on medical record review, observation, staff interview, and review of manufacturer's guidelines the facility failed to ensure sterile equipment was used for tracheostomy care. This affected one (Resident #30) of 14 residents with tracheostomies. Based on medical record review, observation, and staff interview, the facility failed to follow proper infection control protocols during meal service. This affected one (Resident #79) of 10 residents observed for dining. Based on medical record review, observation, staff interview, review of the facility policy, and review of online guidelines per the Centers for Disease Control (CDC) the facility failed to ensure staff donned appropriate personal protective equipment (PPE) and failed to ensure staff could appropriately discard PPE. This affected two (Residents #107 and #121) of 11 residents with orders for transmission-based precautions (TBP.) The facility census was 116 residents. Findings include: 1.Review of medical record for Resident #30 revealed an admission date of 06/03/25 with diagnoses including nontraumatic intracerebral hemorrhage, contracture left hand, tracheostomy status, and gastrostomy status. Review of the Minimum Data Set (MDS) assessment for Resident #30 dated 06/05/25 revealed the resident had intact cognition and required supervision with activities of daily living (ADLs.) Observation on 06/10/26 at 12:17 P.M. of tracheostomy care for Resident #30 with Respiratory Therapist (RT) #144 revealed RT took the following steps: removed and discarded the tracheostomy dressing, cleansed the area surrounding the tracheostomy with saline and gauze, patted the area dry with gauze, removed a closed suction tracheal catheter from a clear supply bag at bedside, connected the closed suction tracheal catheter to the tubing of the suction machine which was located on the bedside table, attached the suction to the resident's tracheostomy tube, suctioned a small amount of clear secretions using the closed system, removed the closed system from the tracheostomy tube and placed it back into the supply bag, removed the resident's inner cannula and discarded it, replaced a new inner cannula using sterile technique. Interview on 06/10/26 at 12:30 P.M. with RT #144 verified the closed system was stored at bedside in a supply bag. RT #144 verified tracheostomy care was a sterile procedure. She stated the inner cannula used for suctioning was contained in a plastic sheath which was stored approximately one half of an inch from the opening of the hard plastic t-piece of the closed system catheter. RT #144 acknowledged the t-piece was not a closed system and verified the piece which connected to the tracheostomy tube remained open during storage in a non-sterile, unclosed supply bag at bedside. Review of the closed suction tracheal catheter manufacturer's instruction revealed the intended use was for the removal of secretions for ventilator dependent patients. Precautions were to inspect the package prior to use and not to use if the product had been opened or damaged. Non-sterile contents could cause infection. Do not re-sterilize, reuse or repurpose. 2.Review of the medical record for Resident #79 revealed an admission date of 02/26/25 with diagnoses including Alzheimer's disease, peripheral vascular disease, and chronic kidney disease. Review of the MDS assessment for Resident #79 dated 06/01/26 revealed the resident had moderately impaired cognition and required set-up assistance with eating. Observation on 06/08/26 at 11:35 A.M. revealed Certified Nursing Assistant (CNA) #164 removed Resident #79's lunch tray from the meal cart and placed the tray on the table in front of the resident. CNA #164 opened the lid on Resident #79's tray and then grabbed the resident's bread with her bare hands and buttered the bread. Interview on 06/08/26 at 11:43 A.M. with CNA #164 confirmed she used her bare hands and touched Resident #79's bread to butter the bread. 3. Review of the medical record for Resident #107 revealed an admission date of 08/02/25 with diagnoses including nontraumatic intracerebral hemorrhage, diabetes mellitus, and hypertension. Review of the MDS assessment for Resident #107 dated 05/08/26 revealed Resident #107 was cognitively intact and required staff assistance with ADLs. Review of the physician's orders for Resident #107 revealed an order dated 06/07/26 for maintain contact precautions every shift for klebsiella pneumonia, indwelling devices, and wounds. Observation on 06/09/26 at 12:44 P.M. revealed Resident #107's room had a contact precaution sign posted on the door and a personal protective equipment (PPE) cart located outside of his room. CNA #125 knocked on Resident #107's door and entered to deliver the lunch tray and closed the door. CNA #125 had not donned PPE prior to entering Resident #107's room. Interview on 06/09/26 at 12:46 P.M. with CNA #125 confirmed she had not donned PPE prior to entering Resident #107's room to deliver the lunch tray. CNA #125 verified Resident #107 had a contact precaution sign on his room door, and a PPE cart was located outside of his room. 4. Review of medical record for Resident #121 revealed an admission date of 06/04/26 with diagnoses including respiratory failure, heart failure, and type two diabetes mellitus. Review of the physician's orders for Resident #121 revealed an order dated 06/06/26 for contact isolation due to infection with vancomycin-resistant enterococci (VRE.) Observation on 06/08/26 at 11:25 A.M. of Resident #121's room revealed there was a contact isolation sign and a cart containing PPE at the entrance of the resident's room. There were no bins or containers inside the room for staff to discard gowns before leaving the room. Interview on 06/08/26 at 11:36 A.M. with Licensed Practical Nurse #170 verified there were no bins in Resident #121's room for staff to discard used gowns prior to exiting the room. Review of the facility policy titled Standard and Transmission-based Precautions revised 03/24/24 revealed the facility staff would take appropriate precautions, including isolation, to prevent transmission of infectious agents. Contact precautions were measures intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which were spread by direct or indirect contact with the resident or the resident's environment. The policy stated the facility would use standard approaches, as defined by the Centers for Disease Control (CDC) for transmission-based precautions (TBP) including airborne, contact, and droplet precautions. The category of TBP would determine the PPE required. Review of online guidance per the CDC titled Transmission Based Precautions at https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html revealed for resident on contact precautions staff should use PPE appropriately, including gloves and gown. Staff should wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.

Based on medical record review, staff interview, review of the facility policy, and review of online medication resources, the facility failed to ensure nonpharmacological interventions were attempted prior to administering as needed psychotropic medications. This affected one (Resident #3) of five residents reviewed for unnecessary medications. The facility census was 116 residents. Findings include:Review of the medical record for Resident #3 revealed an admission date of 10/14/24 with diagnoses of acute and chronic respiratory failure with hypoxia, type two diabetes mellitus, major depressive disorder, and chronic kidney disease. Review of the physician's orders for Resident #3 revealed an order dated 11/18/25 revealed an order for Ativan one milligram (mg) give one tablet by mouth every six hours as needed for anxiety with a stop date of 05/19/26. Review of the physician's orders for Resident #3 revealed an order dated 05/30/26 for Ativan one mg give one tablet by mouth every six hours as needed for anxiety. Review of the Medication Administration Record (MAR) for Resident #3 dated November 2025 revealed Ativan was administered seven times without nonpharmacological interventions attempted prior to administration. Review of the MAR for Resident #3 dated December 2025 revealed Ativan was administered 17 times without nonpharmacological interventions attempted prior to administration. Review of the MAR for Resident #3 dated January 2026 revealed Ativan was administered nine times without nonpharmacological interventions attempted prior to administration. Review of the Mar for Resident #3 dated February 2026 revealed Ativan was administered 22 times without nonpharmacological interventions attempted prior to administration. Review of the MAR for Resident #3 dated March 2026 revealed Ativan was administered 22 times without nonpharmacological interventions attempted prior to administration. Review of the MAR for Resident #3 dated April 2026 revealed Ativan was administered 14 times without nonpharmacological interventions attempted prior to administration Review of the MAR for Resident #3 dated May 2026 revealed Ativan was administered five times without nonpharmacological interventions attempted prior to administration. Review of the MAR for Resident #3 dated June 2026 revealed Ativan was administered three times without nonpharmacological interventions being attempted prior to administration. Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 05/15/26 revealed the resident was cognitively intact, required assistance with activities of daily living (ADLs), and took antianxiety medication. Interview on 06/11/26 at 9:13 A.M. with Assistant Director of Nursing (ADON), Licensed Practical Nurse (LPN) #176 confirmed there was no documentation of nonpharmacological interventions being attempted prior to administering as needed Ativan to Resident #3. RN ADON LPN #176 verified nonpharmacological interventions had not been attempted prior to administration of Ativan on multiple dates since 11/18/25. ADON LPN #176 stated the facility expectation was for staff to attempt nonpharmacological interventions prior to administration of any psychotropic medication to include Ativan for Resident #3. Review of the facility policy titled Medication Administration dated 06/21/17 revealed medications should be administered consistent with accepted standards of practice. Review of the online medication resource Medscape at https://reference.medscape.com/drug/ativan-loreev-xr-lorazepam-342906#4edation revealed Ativan had the following potential adverse effects: dizziness, unsteadiness, weakness, fatigue, drowsiness, confusion, disorientation, depression, suicidal ideation, vertigo, ataxia, respiratory depression, seizures, visual disturbances, hypotension, paradoxical reactions (anxiety, excitation, agitation, hostility, aggression, rage.) Ativan was recommended for short term use and carried a black box warning which indicated physical dependence could occur even when taken as prescribed.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure an adequate indication for administration of pain medication. This affected one (Resident #37) of five residents reviewed for unnecessary medications. The facility census was 116 residents. Findings include:Review of medical record for Resident #37 revealed an admission date of 02/23/26 with diagnoses including intraspinal abscess and granuloma, bipolar disorder, schizoaffective disorder and osteomyelitis of vertebra. Review of the Minimum Data Set (MDS) assessment for Resident #37 dated 04/07/26 revealed she the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #37 revealed an order dated 04/30/26 for oxycodone five milligram (mg) tablet every four hours as needed for pain. Review of the Medication Administration Records (MARs) for Resident #37 dated May 2026 and June 2026 revealed oxycodone was given on the following dates for pain documented as zero on a scale of one to 10 with 10 being the worse pain: 05/02/26, 05/03/26, 05/10/26, 05/10/26, 05/16/26, 05/23/26, 05/31/26, 06/06/26. Interview on 06/10/26 at 9:05 A.M. with Registered Nurse Unit Manager (RNUM) #195 verified staff gave oxycodone in May and June 2026 to Resident #37 even though the resident's pain was documented at a pain level of zero. RNUM #195 acknowledged she would not expect pain medication would be given for a pain level of zero. Interview on 06/11/26 at 2:25 P.M. with the Director of Nursing (DON) verified staff documented Resident #37's pain level zero prior to multiple administrations of as needed oxycodone. The DON stated pain medication should be given only when indicated. Review of the facility policy title Pain Assessment and Management dated 03/31/16 documented the alert and oriented resident may be asked to describe pain status and pertinent information may include a numeric rating scale of zero to ten; with zero being no pain and ten being the most severe pain the resident can imagine. Pharmacological interventions would be provided in accordance with physician orders. Review of the facility policy titled Medication Administration dated 06/21/17 revealed medications should be administered consistent with accepted standards of practice.

Based on medical record review, observation, and staff interview, the facility failed to ensure staff obtained a physician's order to provide wound treatment. This affected one (Resident #89) of 24 residents sampled. Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility also failed to accurately document resident skin condition. This affected two (Residents #8, #37) of three residents reviewed for skin documentation. The facility census was 116 residents. Findings include: 1. Review of the medical record for Resident #89 revealed an admission date of 12/11/24 with diagnoses including epilepsy and mild intellectual disabilities. Review of the Minimum Data Set (MDS) assessment for Resident #89 dated 03/12/26 revealed the resident had intact cognition and required assistance with activities of daily living (ADLs). Review of the progress note for Resident #89 dated 06/06/26 at 9:09 P.M. per Registered Nurse (RN) # 167 revealed the nurse cleansed a laceration to the resident's head with normal saline, applied steri strips and covered with bordered gauze. Review of the physician's orders for Resident #89 revealed an order dated 06/07/26 for wound care to left forehead vertical linear laceration: monitor placement of steri strips, steri strips to remain in place until wound is resolved, notify provider of signs and symptoms of infection or abnormal findings every shift for wound healing. Review of the Treatment Administration Record (TAR) for Resident #89 dated June 2026 revealed staff were signing off completion of the treatment to the resident's left forehead wound every shift. Observation on 06/09/26 at 9:15 A.M. revealed Resident #89 had a laceration to her left forehead with steri strips in place. Interview on 06/10/26 at 2:25 P.M. with Assistant Director of Nursing (ADON) Licensed Practical Nurse (LPN) # 176 confirmed RN #167 had not obtained an order from the physician for the treatment to Resident #89's left forehead laceration and the nurse should have obtained an order for wound care. 2. Review of the medical record for Resident #8 revealed an admission date of 04/30/24 with diagnoses including atherosclerotic heart disease, bipolar disorder, and congestive heart failure. Review of the MDS assessment for Resident #8 dated 05/13/26 revealed the resident had intact cognition and required staff supervision with activities of daily living (ADLs.) Review of the care plan for Resident #8 revealed the resident was at risk for bleeding, bruising and abnormal lab work related to use of anticoagulant (Aspirin) medication. Interventions included to monitor for bruising. Review of recent progress notes for Resident #8 revealed they did not include documentation of bruises or skin tears. Review of the shower sheets for Resident #8 dated 06/02/26, 06/05/26 and 06/09/26 revealed all areas of the skin should be checked, including skin folds, behind the ears, feet and crevices between toes. Any skin impairment, new and old including bruises, red areas, open areas, skin darker than surrounding skin, rashes, scratches, should be noted. There were no bruises or skin tears noted on Resident #8's shower sheets. Review of the non- pressure skin assessment for Resident #8 dated 06/08/26 revealed it did not include documentation of bruises or skin tears. Observation on 06/08/26 at 8:03 A.M. of Resident #8 revealed the resident had multiple bruises of varying sizes in various stages of healing to his upper extremities and two small open areas to his left lower extremity. Interview on 06/08/26 at 8:03 A.M. with Resident #8 confirmed he had bumped into things which resulted in bruises to his arms. Resident #8 stated he bumped his leg which had caused the two skin tears to his left leg, but the resident was unable to recall when this happened. Interview on 06/10/26 at 9:48 A.M. with Registered Nurse Unit Manager (RNUM) #213 verified there were two open skin tears on Resident #8's left leg and multiple bruises to the resident's arms which had not been documented in the resident's medical record. RNUM #213 stated it was the expectation nursing would monitor the bruises to ensure they were not getting worse and acknowledged if the bruises were not documented in a skin assessment there would be no description of the size, location, appearance or number of bruises to determine if a bruise was worsening. There was also no documentation the monitoring was ongoing. RNUM #213 stated Certified Nursing Assistants charted skin concerns on the shower sheets. Interview on 06/10/26 at 11:46 A.M. with Wound Nurse LPN (WNLPN) #155 confirmed staff charted on bruises only if the bruise was bigger than a softball, when it had the risk of opening, or was deep purple in color, and staff did not document bruising, but rather monitored it. WNLPN #155 verified Resident #8 had multiple bruises on his arms and was no documentation of monitoring of bruising per the wound nurse or other staff. Interview on 06/10/26 at 2:30 P.M. with RNUM #213 verified the shower sheets for Resident #8 dated 06/02/26, 06/05/26 and 06/09/26 did not include documentation of bruises or skin tears. 3. Review of medical record for Resident #44 revealed an admission date of 2/18/26 with diagnoses including congestive heart failure (CHF), diabetes mellitus (DM), Parkinson's disease, and dementia. Review of the MDS assessment for Resident #44 dated 05/20/26 revealed the resident had severely impaired cognition and was dependent upon staff assistance with ADLs. Review of the skin assessment for Resident #44 dated 06/08/26 revealed it did not include documentation of a scabbed area to the resident's right second toe. Observation on 06/11/26 at 8:11 A.M. of Resident #44 with RNUM #213 revealed there was a scabbed area of approximately 0.6 centimeter (cm) by 0.6 cm on the middle of the resident's right second toe. Interview on 06/11/26 at 8:11 A.M. with RNUM #213 confirmed the facility was aware of the area but there was no documentation of it in the resident's medical record. Interview on 06/11/26 at 1:45 P.M. with WNLPN #155 revealed she was aware of the scabbed area on Resident #44's right second toe. WNLPN #155 verified there were no measurements of the area, no discovery date, and no documentation of ongoing monitoring in the resident's medical record. Review of the facility policy titled Skin Assessment revised 03/15/24 revealed skin assessments included the collection of objective and subjective data including observation, measurements and comparative analysis of a wound. Areas of altered skin integrity that were present, or which developed subsequently to admission were treated according to medical direction and were conscientiously followed. An assessment of a resident's alterations in skin integrity should be performed and recorded in the resident's medical record at least weekly.

Based on medical record review and staff interview, the facility failed to ensure resident care plans were updated with pertinent changes. This affected one (Resident #89) of two residents reviewed for accidents and hazards. The facility census was 116 residents. Findings include: Review of the medical record for Resident #89 revealed an admission date of 12/11/24 with diagnoses including epilepsy and mild intellectual disabilities. Review of the Minimum Data Set (MDS) assessment for Resident #89 dated 03/12/26 revealed the resident had intact cognition and required assistance with activities of daily living (ADLs). Review of the fall investigation for Resident #89 dated 06/05/26 at 3:45 PM revealed the resident fell while trying on new pants. A new intervention of chair alarm was initiated to prevent further falls. Review of the fall investigation for Resident #89 dated 06/05/26 at 11:05 P.M. revealed the resident fell while trying to move wheelchair and table closer to her reach. New interventions were initiated to prevent recurrence included the following: bed alarm, handrails on sides of toilet, non-slip socks, lock wheels on bed, restorative nursing, assistive device (reacher), low bed. Review of the care plan for Resident #89 revealed the resident was at risk for falls. The care plan was not updated with the following new interventions initiated following the resident's falls on 06/05/26: handrails on sides of toilet, non-slip socks, lock wheels on bed, restorative nursing, assistive device (reacher), low bed. Interview on 06/10/26 at 1:58 P.M. with Regional Director of Clinical Operations (RDOC) #229 confirmed the facility had not updated Resident #89's care plan with the new interventions determined by the facility following the resident's falls on 06/05/26. Review of the facility policy titled Fall Management dated 01/23/25 revealed a plan would be identified and implemented to protect the resident from recurrence of falls and management of the fall would include updating the care plan to reflect the resident's health status and safety needs.

Based on medical record review and staff interview, the facility failed to develop comprehensive resident care plans. This affected one (Resident #30) of 24 residents sampled. The facility census was 116 residents. Findings include: Review of the medical record for Resident #30 revealed an admission date of 06/03/25 with diagnoses including nontraumatic intracerebral hemorrhage, contracture left hand, tracheostomy status, and gastrostomy status. Review of the Minimum Data Set (MDS) assessment for Resident #30 dated 06/05/25 revealed the resident had intact cognition, required staff assistance with activities of daily living (ADLs), and had impairment to one side of his upper extremity. Review of the physician's orders for Resident #30 revealed an order dated 11/14/25 for the resident to wear a left-hand splint at his own discretion and for staff to check under the brace as the resident would allow every dayshift. Review of the care plan for Resident #30 revealed it did not include the resident's left-hand contracture and/or interventions to prevent worsening or decreased range of motion. Interview on 06/11/26 at 2:25 P.M. with the Director of Nursing (DON) confirmed Resident #30 had a left-hand contracture which was not addressed in the resident's care plan.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to notify the physician of a resident fall. This affected one (Resident #89) of 24 residents sampled. The facility census was 116 residents. Findings include:Review of medical record for Resident #89 revealed an admission date of 12/11/24 with diagnoses including epilepsy and mild intellectual disability. Review of the Minimum Data Set (MDS) assessment for Resident #89 dated 03/12/26 revealed the resident was cognitively intact. Review of the fall investigation for Resident #89 revealed the resident had a fall on 06/05/26 at 11:05 P.M. while trying to move the wheelchair and table closer to her reach. Review of the progress notes for Resident #89 revealed the resident's physician was not notified of the fall until 06/06/26 at 5:45 P.M. Interview on 06/10/26 at 2:25 P.M. with Assistant Director of Nursing, Licensed Practical Nurse (LPN) # 176 confirmed the facility did not notify Resident #89's physician of the resident's fall on 06/05/26 at 11:05 P.M. until 06/06/26 at 5:45 P.M. ADON/LPN #176 confirmed the facility should notify physicians immediately of resident falls and accidents. Review of the facility policy titled Fall Management dated 01/23/25 revealed the management of falls included physician notification of falls. This deficiency represents noncompliance investigated under Complaint Number 3022306.

Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure a resident was assessed for the use of a physical restraint. This affected one (21) of the four residents reviewed for falls. The facility census was 114. Findings include: Review of the medical record for Resident #21 revealed an admitted [DATE], with medical diagnoses of peripheral neuropathy, diabetes mellitus, vascular dementia, anxiety, and hypertension. Review of Resident #21's quarterly Minimum Data Set (MDS) assessment, dated 08/29/24, revealed Resident #21 had moderately impaired cognition and required supervision with bathing and transfers, partial/moderate assistance with toileting hygiene, and independent with eating and bed mobility. The MDS indicated Resident #21 had two or more falls with no injuries noted. The MDS also indicated Resident #21 had a bed and chair alarm used daily and another alarm used daily. Review of the medical record for Resident #21 revealed physician order dated 05/23/24 for pressure sensitive alarm (PSA) to chair, an order dated 06/11/24 for alarms to bed, and an order dated 07/24/24 for a pull tab alarm in place at all times. Review of Resident #21's fall care plan dated 04/25/21, stated Resident #21 was at risk for falls and had history of falls. The care plan indicated Resident #21's fall interventions included a chair alarm to wheelchair, a bed alarm, and tab pull alarm in place at all times to chair. Review of the medical record for Resident #21 revealed no documentation to support the facility completed restraint assessments for the use of the alarms to bed and chair. Observation on 10/02/24 at 9:05 A.M., revealed Resident #21 lying in bed with PSA to bed and wheelchair and pull-tab alarm to chair. Resident #21 was observed to have non-skid strips in front of bed, call light within reach, and a low bed with non-skid socks in place were in place. Interview on 10/03/21 at 8:21 A.M., with Corporate Nurse #160 confirmed the facility had not completed restraint use assessments for Resident #21 prior to the use of alarms to bed and chair. Corporate Nurse #160 stated the facility did not consider PSA and pull-tab alarms as physical restraints. Corporate Nurse #160 confirmed Resident #21 had PSA to bed and chair and pull-tab alarm to chair in place. Review of the policy titled, Restraint, dated 06/20/15, stated the facility creates and maintains an environment that fosters minimal use of restraints. The purpose of selective restraint use is to enhance the quality of resident life of resident by assuring safety while promoting an optimal level of function. Stated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The policy stated the need of each resident for restraint use would be assessed upon admission and as needed, a physician's order would be obtained, informed consent for the physical restraint would be obtained from the resident or legal representative. The policy stated a restraint assessment shall be used for the initial and ongoing assessments.

Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure medications were consumed at the time of administration and not left unsecured at the bedside. This affected one (#103) of three residents reviewed for medication administration. The facility census was 114. Findings include: Review of the medical record for Resident #103 revealed an admitted [DATE], with medical diagnoses of amyotrophic lateral sclerosis (ALS), tracheostomy, dependence on ventilator, gastrostomy, atrial fibrillation, and chronic obstructive pulmonary disease. Review of Resident #103's quarterly Minimum Data Set (MDS) assessment, dated 08/02/24, indicated Resident #103 was cognitively intact and required substantial/maximum staff assistance with toilet hygiene, bathing, and bed mobility. The MDS revealed Resident #103 was not transferred out of bed and had a percutaneous endoscopic gastrostomy tube (PEG tube) for enteral feedings. Review of the medical record for Resident #103 revealed no documentation to support a physician order that medications could be left at Resident #103's bedside. Observation with interview on 10/01/24 at 9:06 A.M., of Registered Nurse (RN) #104 administer medications to Resident #103 revealed three medication cups with four white medication tablets inside sitting on Resident #103's bedside table. RN #104 stated she did not know what the medications were sitting in the medications cups and that she was not sure how long the medications were left at her bedside. Observation revealed RN #104 remove the medication cups with the four white medications tablets and discard in the biohazard bin. Interview on 10/01/24 at 9:08 A.M., with Resident #103 confirmed the three medication cups with four white medication tablets had been sitting on her bedside table and she did not know what the medications were in the medication cups. Resident #103 stated the medications had been sitting on the bedside table for a few days. Review of the policy titled, Medication Administration, effective 06/21/17, stated the facility staff are to administer medication and remain with the resident while the medication is swallowed and to never leave a medication in the resident's room without orders to do so.

Based on medical record review, observation, staff and resident interviews, and review of hospital documentation, and policy review, the facility failed to ensure a percutaneous endoscopic gastrostomy tube (PEG) was intact and functioning properly. This affected one (#103) of five residents reviewed for nutrition. The facility census was 114. Findings include: Review of the medical record for Resident #103 revealed an admitted [DATE], with medical diagnoses of amyotrophic lateral sclerosis (ALS), tracheostomy, dependence on ventilator, gastrostomy, atrial fibrillation, and chronic obstructive pulmonary disease. Review of Resident #103's quarterly Minimum Data Set (MDS) assessment, dated 08/02/24, indicated Resident #103 was cognitively intact and required substantial/maximum staff assistance with toilet hygiene, bathing, and bed mobility. The MDS revealed Resident #103 was not transferred out of bed and had a PEG tube for enteral feedings. Review of Resident #103's physician order dated 09/23/24, revealed to flush the PEG tube with 250 milliliters (ml) with water three times per day and an order dated 10/01/24, to send resident non-emergent transport to hospital with PEG tube replacement. Observation with interview, on 10/01/24 at 9:00 A.M., revealed Registered Nurse (RN) #104 prepare Resident #103's PEG tube for medication administration. The observation revealed medical tape to be wrapped around the top portion of Resident #103's PEG tube. The observation revealed the medical tape to be slightly soiled with light brown substance around the edges. Interview on 10/01/24 at 9:02 A.M., with Resident #103 stated the tape was placed on her PEG tube because the PEG tube had a break or hole in the tubing. Resident #103 stated the PEG tube was leaking so staff taped the broken area. Resident #103 stated she was not sure how long the tape had been on her PEG tube but had been there for awhile and that facility staff were aware that there was a hole in the PEG tubing. Resident #103 stated staff would pinch off the tubing when administering flushes and medications and not use the clamp provided on the PEG tube which caused the break in the tube. Interview on 10/01/24 at 9:06 A.M., with RN #104 confirmed Resident #103's PEG tube had medical tape wrapped around the tube and the tape had been there for several days but not sure how long. RN #104 stated she was not aware of any concerns with the PEG tube leaking or having a hole in the tubing. Interview on 10/02/24 at 9:09 A.M., with RN #84 confirmed she had taken care of Resident #103 several days prior to interview and confirmed Resident #103 had medical tape wrapped around her PEG tube. RN #84 stated she thought Resident #103 returned from the hospital with the PEG tube wrapped with medical tape but was not sure. RN #84 stated she did not notice the PEG tube leaking. Review of Resident #103's nurse note dated 10/01/24 at 9:57 A.M., stated the nurse was made aware by the nurse on the floor that the resident's PEG tube was noted to be leaking. The note stated Resident #103 was noted with PEG tube and unable to be replaced in house. Further review of the nurses note stated Resident #103 was sent to the hospital for PEG tube placement and daughter was made aware. Further review, of the nurse's notes revealed a note dated 10/02/24 at 1:57 A.M., which stated Resident #103 returned to the facility with new PEG tube placed in abdomen with redness and scant drainage noted. Review of the hospital emergency room (ER) note, dated 10/01/24, stated Resident #103 was seen in the ER for PEG tube malfunction. The note stated Resident #103's PEG tube was noted to have a crack toward the end of the tube and tape was wrapped around the tube. The ER stated Resident #103's PEG was replaced. Review of the policy titled, Enteral Tube Feeding, dated 06/11/24, stated it was the practice of this facility was to provide enteral nutrition as prescribed and in accordance with current clinical standards of practice. The policy stated to monitor resident for complication including, but not limited to, nausea, vomiting, diarrhea, abdominal cramping, inadequate nutrition or aspiration and to notify healthcare provider.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall interventions were in place as per comprehensive care plan. This affected one (#77) of four residents reviewed for falls. The facility census was 114. Findings include: Review of the medical record for Resident #77 revealed an admitted [DATE], with medical diagnoses of polyneuropathy, arthritis, Alzheimer's disease, hypertension, atrial fibrillation, and chronic kidney disease. Review of Resident #77's annual Minimum Data Set (MDS) assessment, dated 06/27/24, indicated Resident #77 had moderate cognitive impairment and required supervision with toilet hygiene, bed mobility, and transfers. The MDS indicated Resident #77 required partial/moderate assistance with bathing and was independent with eating. The MDS indicated Resident #77 had a history of falls. Review of Resident #77's fall care plan, dated 08/04/22, stated Resident #77 was at risk for falls and had a history of falls with fracture. The fall care plan which indicated Resident #77 had the following fall interventions in place: call light within reach, non-skid strips in front of toilet, visual reminders on walls to remind resident to call for help, visual reminders to bathroom door, and non-skid socks. Observation on 10/02/24 at 8:52 A.M., of Resident #77's room revealed the room did not have non-skid strips to bathroom floor in front of the toilet. The observation also revealed Resident #77's room did not have any visual reminders posted in the room or bathroom. Interview on 10/02/24 at 8:55 A.M., with State tested Nursing Assistant (STNA) #20 confirmed Resident #77's room did not have non-skid strips in front of the toilet or visual reminders posted in the room or bathroom. Review of the policy titled, Fall Management, dated 10/17/16, stated a plan would be identified and implemented as necessary to protect the resident and/or other from recurrence. The policy stated the care plan is developed as necessary to reflect the resident's safety status, needs, and interventions.

Based on observations, staff interviews, medical record reviews, and policy reviews, the facility failed to implement their infection control policies when they allowed a resident positive with Coronavirus Disease 2019 (COVID-19) to share a room with a non-COVID-19 positive resident. This affected one (#59) out of five residents reviewed for infection control procedures related to COVID-19. Additionally, the facility failed to follow infection control guidelines when performing incontinence care. This affected one (#1) out of the three resident reviewed for incontinence care. Facility census was 108. Findings included: 1. Review of the medical record for Resident #60 revealed an admitted [DATE] with medical diagnoses of asthma, hypertension (HTN), cystic disease of the liver, rheumatoid arthritis, and hyperlipidemia. Review of the medical record for Resident #60 revealed an annual Minimum Data Set (MDS), dated [DATE], which indicated Resident #60 had moderate cognitive impairment and was dependent upon staff for eating, toileting, bathing, bed mobility, and transfers. Review of the medical record for Resident #60 revealed a physician order dated 02/21/24 for contact and droplet precautions for COVID-19. Review of the medical record revealed Resident #60 shared a room with Resident #59. Observation on 02/22/23 at 11:07 A.M. of Resident #60 revealed a personal protective equipment (PPE) cart and droplet isolation sign located outside of Resident #60's room. Resident #60 was observed lying in bed sleeping. Observation of Resident #60's room revealed the bed was located on the right side of the room and there was a wall that went from ceiling to floor and was half the length of the room as a divide between Resident #60's side of the room and roommates' side of the room. Resident #60's roommate, Resident #59, was observed wheeling herself around the room, to the bathroom and to the door of the room to the hallway. The door to the room was observed to be open at all times during the investigation. Resident #60 was unable to answer questions due to impaired cognition. Review of the medical record for Resident #59 revealed an admitted [DATE] with medical diagnoses of chronic obstructive pulmonary disease (COPD), heart failure, schizoaffective disorder, Alzheimer's disease, and anxiety. Review of the medial record for Resident #59 revealed a significant change MDS, dated [DATE], which indicated Resident #59 had short- and long-term memory loss and was independent with eating and bed mobility, required supervision for toilet hygiene and transfers, and was dependent for bathing. Review of the medical record for Resident #59 revealed Resident #59 was up to date on influenza and pneumococcal vaccinations but had refused a COVID-19 booster vaccination. Review of the medical record for Resident #59 revealed she shared a room with Resident #60. Review of the medical record did not contain documentation to support Resident #59 was COVID-19 positive or that Resident #59's representative was notified Resident #59 was sharing a room with a resident who was COVID-19 positive. Observation on 02/22/23 at 11:07 A.M. of Resident #59 shared a room with Resident #60. The observation revealed Resident #59 was in her wheelchair wheeling herself to the door to the room. Resident #59 was not able to answer questions due to impaired cognition. Interview on 02/22/24 at 2:05 P.M. with Administrator confirmed the facility had private rooms available to move residents who were COVID-19 positive into so they did not have to share rooms with a resident who was not COVID-19 positive. Administrator confirmed Resident #60 tested positive for COVID-19 and shared a room with Resident #59 who was not COVID-19 positive. Administrator confirmed Resident #60 and Resident #59's room had a wall that was in the middle of the room to divide the space but confirmed Resident #59 had the ability to wheel herself over to Resident #60's side of the room and be exposed to COVID-19. Review of facility policy titled COVID-19, dated 05/11/23, stated residents with symptoms of COVID-19 should not be cohorted with residents with confirmed COVID-19 unless they are confirmed to have COVID-19 through testing. 2. Review of the medical record for Resident #1 revealed an admitted [DATE] with medical diagnoses of respiratory failure, anxiety, diabetes mellitus, HTN, paraplegia, and atrial fibrillation. Review of the medical record for Resident #1 revealed a quarterly MDS, dated [DATE], which indicated Resident #1 was cognitively intact and was dependent for toilet hygiene, bathing, bed mobility, and transfers. The MDS indicated Resident #1 was always incontinent of bladder and had a colostomy. Review of the medical record for Resident #1 revealed a physician order dated 09/14/23 to apply versetime to right gluteus and sacrum every shift and with incontinence cares and an order dated 02/22/24 for contact precautions for carbapenem-resistant enterobacterales (CRE) in the urine. Observation on 02/22/4 at 10:43 A.M. of State tested Nursing Assistant (STNA) #237 providing incontinence care for Resident #1. The observation revealed STNA #237 cleansed Resident #1 with cleansing wipes, removed the soiled depends and pad from underneath Resident #1 and discarded the items in the trash. STNA #237 was observed applying protective skin barrier cream to Resident #1 and then applied clean depends. STNA #237 was observed to reposition Resident #1 in bed and then removed her gloves and washed her hands. During the observation, STNA #327 did not change her gloves or perform hand hygiene after they became soiled. Interview on 02/22/24 at 10:55 A.M. with STNA #237 confirmed she did not change her gloves or perform hand hygiene after she cleansed Resident #1's peri area and removed the soiled items or prior to applying the protective skin barrier or applying clean depends. Review of the facility policy titled, Infection Control, dated 11/28/17 stated all staff are to perform hand hygiene between resident contact, after handling contaminated objects, after PPE removal and before and after performing resident care procedures. This deficiency represents non-compliance investigated under Complaint Number OH00151260.

Based on observation, staff interviews, and medical record review, the facility failed to provide assistance for eating to a dependent resident. This affected one (#74) out of three residents reviewed for activities of daily living (ADL's). The facility census was 108. Findings included: Review of the medical record for Resident #74 revealed an admitted [DATE] with medical diagnoses of dementia, DM, chronic obstructive pulmonary disease (COPD), hypertension (HTN), and atherosclerotic heart disease (ASHD). Review of the medical record for Resident #74 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #74 had impaired cognition and was rarely/never understood. The MDS indicated Resident #74 was dependent for eating, bathing, toileting, and transfers. Observation on 02/22/24 at 11:16 A.M. revealed Resident #74 sleeping in bed with her breakfast tray sitting on the bedside table. The observation revealed the lids to the drinks had not been removed, the lid to meal had not been opened, and there was not any silverware on the tray. The observation revealed the meal had not been eaten by the resident. Interview on 02/22/24 at 11:18 A.M. with Licensed Practical Nurse (LPN) #302 confirmed Resident #74 required staff assistance for eating and that the breakfast tray had not been set-up and staff did not feed Resident #74 breakfast. Interview on 02/22/24 at 1:50 P.M. with State tested Nursing Assistant (STNA) #300 confirmed she was the STNA taking care of Resident #74 and that she was not aware Resident #74 required assistance with her meals. STNA #300 confirmed she did not feed Resident #74 her breakfast. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, staff interview, and policy review, the facility failed to ensure refrigerator temperature logs in resident's rooms were accurately completed accurately. This affected five (#14, #15, #16, #17, and #18) out of five residents reviewed for having refrigerators in their rooms. The facility census was 97. Findings include: 1) Review of the medical record for Resident #14 revealed he was admitted to the facility on [DATE]. Diagnoses included respiratory failure unspecified with hypercapnia, chronic kidney disease stage three, anemia, major depressive disorder, hyperlipidemia, type two diabetes mellitus with diabetic neuropathic arthropathy, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #14 revealed the resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require extensive assistance with bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and was totally dependent on staff for transfer. Review of the refrigerator temperature logs from 09/01/23 through 09/30/23 for the refrigerator in Resident #14's room revealed Former Housekeeping Aide (FHA) #200's initials were listed and crossed out by Housekeeping Supervisor (HS) #140's initials on 09/12/23, 09/13/23, and 09/20/23. 2) Review of the medical record for Resident #15 revealed she was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, anemia, congestive heart failure, dementia, and chronic obstructive pulmonary disease. Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #15, revealed the resident had intact cognition evidenced by a BIMS score of 15. This resident was assessed to require extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, and was totally dependent on staff for eating and transfer. Review of the refrigerator temperature logs from 09/01/23 through 09/30/23 for the refrigerator in Resident #15's room revealed FHA #200's initials were listed and crossed out by HS #140's initials on 09/12/23, 09/13/23, and 09/20/23. 3) Review of the medical record for Resident #16 revealed he was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, quadriplegia, and type two diabetes mellitus without complications. Review of the quarterly MDS 3.0 assessment, dated 09/22/23 for Resident #16 revealed this resident had severely impaired cognition evidenced by a BIMS score of 03. This resident was assessed to require extensive assistance for bed mobility, and was totally dependent on staff for transfer, dressing, eating, toilet use, and personal hygiene. Review of the refrigerator temperature logs from 09/01/23 through 09/30/23 for the refrigerator in Resident #16's room revealed FHA #200's initials were listed and crossed out by HS #140's initials on 09/05/23, 09/06/23, 09/17/23, 09/18/23, and 09/20/23. 4) Review of the medical record for Resident #17 revealed she was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, paranoid schizophrenia, generalized anxiety disorder, type two diabetes mellitus without complications, anemia, and congestive heart failure. Review of the quarterly MDS 3.0 assessment, dated 09/08/23 for Resident #17 revealed this resident had severely impaired cognition evidenced by a BIMS score of 99. This resident was assessed to require extensive assistance for bed mobility and transfer, and was totally dependent on staff for personal hygiene, toilet use, eating, and dressing. Review of the refrigerator temperature logs from 09/01/23 through 09/30/23 for the refrigerator in Resident #17's room revealed FHA #200's initials were listed and crossed out by HS #140's initials on 09/08/23, 09/12/23, 09/13/23, 09/19/23, and 09/20/23. 5) Review of the medical record for Resident #18 revealed she was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, aphasia, schizoaffective disorder, hyperlipidemia, congestive heart failure, and type two diabetes mellitus with other skin ulcers. Review of the quarterly MDS 3.0 assessment, dated 09/21/23, revealed this resident had severely impaired cognition evidenced by a BIMS score of 99. This resident was assessed to require extensive assistance for bed mobility, and was totally dependent on staff for personal hygiene, toilet use, dressing, and eating. Review of the refrigerator temperature logs from 09/01/23 through 09/30/23 for the refrigerator in Resident #18's room revealed FHA #200's initials were listed and crossed out by HS #140's initials on 09/12/23, 09/13/23, 09/19/23, and 09/20/23. Review of the refrigerator temperature logs from 09/01/23 to 09/30/23 revealed FHA #200's initials were listed and crossed out by HS #140's initials for the refrigerator located in the physical therapy room on 09/19/23. Interview on 11/17/23 at 1:22 P.M. with HS #140 revealed FHA #200 informed her that FHA's initials were on the refrigerator logs for days that she had not worked. HS #140 stated FHA #200 was upset, which prompted HS #140 to write her own initials on top of FHA #200's initials. HS #140 confirmed she had not checked the refrigerator temperatures herself and just initialed that she had done so. HS #140 reported she had educated her staff and conducted audits three times a week since the end of September 2023 to ensure housekeeping staff were recording daily refrigerator temperatures. HS #140 stated she had no documentation regarding the staff education she provided to housekeeping employees. Interview on 11/17/23 at 3:53 P.M. with the Administrator confirmed FHA #200 had not worked on 09/19/23. Review of the undated facility policy titled Guidelines Regarding Refrigerators in Resident Rooms revealed a designated staff member would monitor the temperature of the refrigerator using the refrigerator log. This deficiency represents non-compliance investigated under Complaint Number OH00147173.

Based on observation, staff interview, and record review, the facility failed to properly store food and failed to properly test the sanitizer buckets. This had the potential to affect all residents who received meals from the kitchen. The facility identified eight residents who did not receive meals from the kitchen (Residents #13, #46, #59, #60, #66, #70, #77, and #80). The facility census was 77. Findings include: Observation on 12/05/22 at 9:01 A.M. of the facility kitchen revealed two scoops were observed in the flour bin. Observation of the walk-in cooler revealed a partially opened bag of ham cubes that was not dated and was spilling ham cubes to the tray on the shelf below. In the walk-in cooler, there was a partially unwrapped and undated sleeve of American cheese. Interview on 12/05/22 at 9:13 A.M. with Dietary Staff (DS) #44 confirmed the observation of the flour, ham cubes, and cheese. DS #44 confirmed the scoops were not to remain in the flour. DS #44 confirmed the ham and cheese were not dated and not properly wrapped. Observation and interview on 12/06/22 at 10:29 A.M. with Dietary Manager (DM) #500 revealed DM #500 was not able to locate test strips to test the sanitizer buckets. DM #500 confirmed the facility did not have the ability to test the sanitary buckets. Review of the facility's list of residents and diets revealed Residents #13, #46, #59, #60, #66, #70, #77, and #80 were nothing by mouth and did not receive food from the kitchen.

Based on observation, review of the facility policy, record review, and staff interview, the facility failed to ensure nasal cannula oxygen tubing was dated and changed per the physician's order. This affected three (Residents #40, #50, and #55) of six residents observed with oxygen. The facility census was 77. Findings included: 1. Review of Resident #50's medical record revealed an admitted [DATE]. Diagnoses included dementia, anxiety, and seizure disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had impaired cognition. Review of the plan of care dated 09/27/21 revealed Resident #50 was at risk for impaired respiratory infection related to potential COVID-19. The care plan did not have any goals or interventions related to oxygen administration. Review of Resident #50's physician order dated 11/20/22 revealed oxygen to be administered at two liters per minute per nasal cannula continuously. The physician order dated 10/30/22 revealed to change the oxygen cannula tubing weekly. Interview and observation on 12/05/22 at 2:40 P.M. with Licensed Practical Nurse (LPN) #70 confirmed the date on the resident's oxygen tubing was labeled in green marker with a date of 11/21/22. LPN #70 confirmed the oxygen tubing was to be replaced weekly. LPN #70 confirmed the oxygen tubing had not been changed as per the physician's order. 42492 2. Review of the medical record for Resident #40 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD). Review of the MDS 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of the care plan dated 01/18/22 revealed Resident #40 required oxygen related to end stage COPD and respiratory failure. Interventions included to administer oxygen as ordered, monitor lung sounds/oxygen saturation levels as ordered, and observe/report signs of dyspnea. Review of the physician orders dated 03/12/22 revealed an order for oxygen administration per face mask - triturate to keep saturation levels above 90% and an order dated 06/12/22 to change oxygen tubing/cannula/mask weekly every Sunday night shift. Observation and interview on 12/04/22 at 2:25 P.M. with Licensed Practical Nurse (LPN) #64 verified the date on Resident #40's oxygen mask was 11/21/22. LPN #64 verified there was a physician order to change the oxygen mask weekly. 3. Review of the medical record for Resident #55 revealed an admitted [DATE]. Diagnoses included COPD. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #55 had impaired cognition and was on oxygen therapy. Review of the care plan dated 01/17/22 revealed Resident #55 required oxygen therapy related to respiratory failure and COPD. Interventions included to administer oxygen as ordered, monitor lung sounds/oxygen saturation levels as ordered, and observe/reports signs of dyspnea. Review of the physician orders dated 01/10/22 revealed an order for oxygen administration at two liters per minute per nasal cannula continuous and on 09/11/22, an order to change the oxygen tubing/cannula/mask weekly every Sunday on night shift. Observation and interview on 12/04/22 at 12:02 P.M. with State tested Nursing Aide (STNA) #32 revealed Resident #55 was lying in her bed an oxygen was being administered at two liter per minute per nasal cannula. The nasal cannula was labeled with the date of 09/12/22 and there were initials on it. STNA #32 verified Resident #55's nasal cannula was labeled with tape and dated 09/12/22. Interview on 12/06/22 at 3:51 P.M. with LPN #16 stated oxygen tubing was changed once weekly on night shift and was labeled either directly on tubing or with a label taped on. Review of the facility's policy titled Respiratory Policy/Procedure Manual, dated 08/25/12, revealed to label nasal cannula and humidifier with date.

Based on observation, record review, review of the facility policy, and staff interview, the facility failed to ensure the resident's care plan was accurate to reflect the use of oxygen and advance directives. This affected three residents (#4, #31, and #50) of twenty-four residents reviewed during the annual recertification. The facility census was 77. Findings include: 1. Review of Resident #50's medical record revealed an admitted [DATE]. Diagnoses included dementia, hemiplegia, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had impaired cognition. Review of the plan of care dated 09/27/21 revealed Resident #50 was at risk for impaired respiratory infection related to potential COVID-19. Further review of the resident's plan of care revealed no goals or interventions related to oxygen administration and Resident #50 frequently removed her oxygen. Review of Resident #50's physician order dated 11/20/22 revealed oxygen was to be administered at two liters per minute per nasal cannula continuously. Observation on 12/06/22 at 2:30 P.M. with Licensed Practical Nurse (LPN) #70 in Resident #50's room revealed the resident's oxygen concentrator was on two liters per minute. The resident's oxygen tubing was on the floor tangled in the bed frame. LPN #70 attempted to replace the resident's oxygen, as the resident was pushing the oxygen away. The LPN #70 educated the resident on the importance of the oxygen. Interview on 12/06/22 at 2:40 P.M. with LPN #70 revealed Resident #50 frequently would remove her oxygen. Interview on 12/07/22 at 2:40 P.M. with the Director of Nursing (DON) confirmed Resident #50's plan of care made no mention of oxygen administration. 2. Review of Resident #31's medical record revealed an admitted [DATE]. Diagnoses included diabetes mellitus, multiple sclerosis, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had intact cognition. Review of the plan of care dated 09/17/22 revealed Resident #31 Advanced Care planning was reviewed and the code status was Full Code. This was not consistent with Resident #31's physician order or the signed advance directives. Review of Resident #31's Ohio Comfort Care Do Not Resuscitate Order form dated 10/06/22 revealed the resident's code status was Do Not Resuscitate Comfort Care (DNRCC). Review of Resident #31's profile page in the electronic charting revealed the resident's code status was DNRCC. Review of the physician order dated 10/11/22 revealed an order Resident #31's code status to be DNRCC. Interview on 12/05/22 at 5:22 P.M. with the Director of Nursing (DON) confirmed Resident #31's care plan was not accurate and did not reflect the correct advance directives for Resident #31. The DON confirmed it was the facility's expectation to update the care plan when the order was received. 42492 3. Review of the medical record for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had impaired cognition. Review of the care plan dated 01/24/22 revealed Resident #4's code status was a Full code. This was not consistent with Resident #4's physician order or the signed advance directives. Review of the physician orders dated 12/02/22 revealed Resident #4 had physician orders for the code status to be Do Not Resuscitate Comfort Care Arrest (DNRCCA). Review of the DNR Order Form revealed Resident #4's code status was DNRCCA and it was signed on 12/02/22. Interview on 12/06/22 at 8:37 A.M. with the Administrator verified Resident #4 had physician orders for DNRCCA written on 12/02/22 and the care plan was not accurate to reflect the change in code status to DNRCCA. Review of the facility policy titled Advance Care Planning, dated 05/05/14, revealed residents are given the opportunity to discuss their goals for care, including their preference for advanced care planning.

Based on medical record review, observation, staff interview, review of information from the Centers for Disease Control (CDC) and policy review, the facility failed to ensure newly admitted residents who were not up-to-date with their Coronavirus Disease 2019 (COVID-19) vaccine were quarantine and failed to ensure staff wore appropriate personal protective equipment (PPE) when entering quarantine residents room, to potentially prevent the spread of COVID-19. This had the potential to affect all 77 residents residing in the facility. Additionally, the facility failed to ensure staff washed their hands or performed hand hygiene appropriately after changing gloves during a dressing change for Resident #32. This affected one (#32) out of three residents sampled for skin breakdown. Facility census was 77. Findings include: 1. Record review for Resident #56 revealed an admitted [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/07/22 at 9:02 A.M. revealed Resident #56 was in her room and there was no signs indicating the resident was on isolation and droplet precautions due to her being a new admission. There also was no PPE posted outside Resident #56's room. Observation on 04/07/22 at 11:50 A.M. revealed Resident #56 now had signs indicating she was on droplet/contact precautions and there was a plastic container with PPE outside the resident's room. Interview with Licensed Practical Nurse (LPN) #11 on 04/07/22 at 11:50 A.M. verified there was now signs on Resident #56 room indicating she was on contact and droplet precautions and there was now PPE out in front of her room. LPN #11 verified there was no PPE or signs up earlier in the morning. Interview with State tested Nurse Aide (STNA) #12 on 04/07/22 at 11:56 A.M. revealed she worked yesterday and there was no isolation precaution signs or PPE posted outside Resident #56 room. STNA #12 verified there are droplet and contact precautions and PPE outside Resident #56 door now. Interview with the Director of Nursing (DON) on 04/07/22 at 12:15 P.M. revealed the facility follows the CDC policy and guidelines for quarantining new admissions. The DON verified per the CDC residents who are not up to date with their vaccine including having a booster shot should quarantine for seven days with testing. The DON verified Resident #56 was admitted on [DATE] was not up to date with her vaccine booster and should be on quarantine until 04/08/22. Observation on 04/07/22 at 12:27 P.M. revealed STNA #12 was in Resident #56 room standing next to the resident talking to her about her meal tray for approximately a minute. STNA #12 did not have on any PPE besides a surgical mask. STNA #12 was not wearing a gown, an N95-mask, gloves, or eye protection. Interview with STNA #12 on 04/07/22 at 12:28 P.M. verified she was only wearing a surgical mask in Resident #56 room. STNA #12 stated she was unaware she had to put on PPE equipment if she was only passing trays to residents on isolation precautions. Review of information from the CDC website at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html updated 02/02/22 revealed in general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission. Patients placed in empiric Transmission-Based Precautions are based on close contact with someone with [CONDITION(S)]-CoV-2 infection should be maintained in Transmission-Based Precautions for the following time periods. Patients can be removed from Transmission-Based Precautions after day seven following the exposure (day 0) if a [CONDITION(S)] test is negative for [CONDITION(S)]-CoV-2 and they do not develop symptoms. The specimen should be collected and tested within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. Review of the CDC website updated 02/02/22 titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic revealed Health Care Providers who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of a facility policy titled Infection Control Initiating Transmission Based Precautions dated 10/18/01 revealed Transmission-Based Precautions are implemented by a nurse in charge of the resident's care or the Infection Preventionist. Applicable Transmission-Based Precautions sign will be placed at the doorway to the resident's room. An isolation bin or cart stocked with required PPE, supplies and equipment will be placed near the outside of the doorway to the resident's room. Review of a facility policy titled Standard and Transmission-based Precautions dated 11/28/17 revealed the facility will use standard approaches, as defined by the CDC, for Transmission-Based Precautions: airborne, contact, and droplet precautions. The category of Transmission-Based Precautions will determine the type of PPE to be used. 2. Record review of Resident #32 revealed an admitted [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply hydroconductive and bordered foam daily and as needed. Observation of Resident #32 dressing change on 04/07/22 at 1:00 P.M. revealed Registered Nurse (RN) #13 washed her hands then put on gloves. RN #13 removed the old dressing to the residents sacrum and then RN #13 took off her gloves and put on new gloves, she did not wash her hands. RN #13 cleansed the wound with normal saline and gauze, she then pat dried the wound with a four by four and put on hydroconductive dressing and a border gauze. Interview with RN #13 on 04/07/22 at 1:10 P.M. verified she did not wash her hands after removing her gloves and putting on new gloves after she cleaned Resident #32 wound. Review of a facility policy titled Hand Hygiene dated 11/28/17 revealed Staff perform hand hygiene (even if gloves are used) in the following situations: before and after contact with the resident, after contact with blood, body fluids, or visibly contaminated surfaces or other objects and surfaces in the resident's environment, after removing personal protective equipment (e.g., gloves, gown, facemask). This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observations and staff interview, the facility failed to ensure a residents gastrostomy enteral feeding was running at the rate ordered by the physician. This affected one (#7) of three reviewed for enteral feeding. Facility census was 77. Findings include: Record review of Resident #7 revealed an admitted [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/07/22 at 9:30 A.M. revealed Resident #7 tube feeding was [MEDICATION(S)] 1.5 and was running at 50 ml/hour. Observation on 04/07/22 at 12:00 P.M. revealed Resident #7 tube feeding was [MEDICATION(S)] 1.5 and was still running at 50 ml/hour. Interview with Registered Nurse (RN) #10 on 04/07/22 at 12:03 P.M. verified Resident #7 [MEDICATION(S)] 1.5 tube feeding was running at 50 ml/hour and it should be running at 55 ml/hour. RN #10 was unsure how long the tube feeding had been running at the incorrect rate. This deficiency substantiates Complaint Number OH 323.

Based on record review, interview and review of a medication reference website; the facility failed to ensure an unresponsive resident's blood glucose level was assessed prior to administering insulin, resulting in actual harm when the resident was admitted to the hospital for [CONDITION(S)] and blood sugar monitoring. This affected one (Resident #1) of three residents reviewed for medication administration. The census was 48. Findings include: Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Plan/Orders revealed documentation of A1C 5.9, watch insulin (referenced from the Centers for Disease Control and Prevention website, cdc.gov, A1C is a laboratory test that reflects an average blood sugar for the past three months, a normal A1C is below 5.7 percent). There were no other notes related to insulin or glucose monitoring. Review of an admission minimum data set (MDS) assessment dated [DATE], revealed Resident #1 had short and long-term memory problems. The resident was not able to recall current season, location of own room, staff names/faces, or that he/she was in a nursing home. The resident required extensive assistance of two people for bed mobility and toilet use, extensive assistance of one person for dressing and eating, was totally dependent of one person for locomotion and hygiene, and totally dependent of two people for transfers. Review of a progress note dated 06/04/21 at 12:21 A.M. (late entry for 06/03/21 at 9:11 P.M.) revealed Licensed Practical Nurse (LPN) #50 attempted to administer the evening medication to Resident #1. The resident was unresponsive to the nurse. The nurse attempted to arouse the resident by turning on the room light and raising the head of bed. The resident did not open eyes or verbally respond to the nurse. Vital signs were documented as blood pressure 107/45 millimeters of mercury (mmHg), temperature 97 degrees Fahrenheit (F), pulse 68, and oxygen saturation 95 percent. The medication [MEDICATION(S)] was administered; the resident was non-reactive. The nurse attempted to obtain a blood glucose reading but the attempt was unsuccessful due to the resident pulling hand away. Review of a progress note dated 06/04/21 at 12:31 A.M. (late entry for 06/03/21 at 10:47 P.M.) revealed the representative for Resident #1 called the facility to request the resident status. The representative reported the resident was not acting normal earlier in the shift. The representative was informed the resident continued to be lethargic and missed evening medication. The representative requested the nurse to call another representative of Resident #1 (Representative #2) to notify of the resident's lethargy. Representative #2 requested Resident #1 be sent to the hospital for evaluation. Review of a progress note dated 06/04/21 at 12:54 A.M. Resident #1 was transported to the hospital on 06/04/21 at approximately 12:28 P.M. Review of a progress note dated 06/04/21 at 5:00 A.M. (effective date 06/04/21 at 4:57 A.M.) revealed the hospital nurse call the facility to report the resident was transferred to another hospital due to low blood glucose. The blood glucose was documented at 49 milligrams (mg) per deciliter (dl), when the resident arrived to the hospital (per cdc.gov the American Diabetes Association (ADA) target for blood sugar before meals was 80 to 130 mg/dl and one to two hours after a meal was below 180 mg/dl). The resident was being transferred to another hospital for observation to ensure the resident blood glucose was steady. During telephone interview on 06/28/21 at 3:27 P.M. with LPN #50 revealed she attempted to administer oral medication to Resident #1 in the evening on 06/03/21. LPN #50 reported the resident was unresponsive and attempts to arouse the resident were unsuccessful. The oral medication was not given because the nurse did not want the resident to choke on the medication, however the injectable medication [MEDICATION(S)] was administered. LPN #50 revealed he/she did not routinely provide care for Resident #1, this was the second time to work with this resident. LPN #50 reported the resident baseline was lethargic and the nurse did not have concerns when the resident was unresponsive. The resident's representative called to check on the resident some time after the [MEDICATION(S)] had been administered and voiced concerns of the resident being lethargic during the day. The representative requested Resident #1 to be sent to the hospital for evaluation of the lethargy. After talking with the representative the nurse became concerned and attempted to obtain a finger stick blood sugar. LPN #50 stated the resident pulled away while the nurse was attempting to get blood from the resident's finger and a blood sugar was not obtained. The resident was sent out to the hospital for evaluation per the family's request. LPN #50 verified blood sugar monitoring was not attempted prior to administering [MEDICATION(S)]. LPN #50 verified Resident #1 was unresponsive at the time of [MEDICATION(S)] administration. During interview on 06/29/21 at 10:53 A.M. with Nurse Practitioner (NP) #110, the resident's primary care provider, revealed the baseline for Resident #1 was confusion. NP #110 revealed Resident #1 slept a lot but was able to be aroused and would interact with staff. Interview with NP #110 revealed it was the NP's expectation if any resident was unresponsive, the nurse would assess the resident to find out why the resident was not responding prior to administering any medication, including insulin such as [MEDICATION(S)]. Review of the medication reference website, Medscape, revealed [MEDICATION(S)] was a long acting insulin indicated to improve glycemic control. Dose must be individualized based on clinical response; blood glucose monitoring is essential in all patients receiving insulin therapy. Increased frequency of glucose monitoring with changes of meal pattern, physical activity, and [CONDITION(S)] unawareness. This deficiency substantiates Complaint Numbers OH 613 and OH 552.