Every finding on record at Austinwoods Rehab Health Care

Based on record review, observation, interview and review of the facility policy, the facility failed to ensure Resident #85's pain was timely and appropriately addressed. This affected one resident (Resident #85) of four residents observed for timely and appropriate medication administration. The facility census was 83.Findings include:Review of the medical record for Resident #85 revealed an admission date of 11/13/25 with diagnoses including unspecified dislocation of the right hip, unspecified complication of internal orthopedic prosthetic device, implant, and graft, gastroesophageal reflux disease (GERD), hyperlipidemia, primary hypertension, and unspecified glaucoma.Review of the orders revealed a medication order dated 11/13/25 for Resident #85 to have Tylenol 650 milligrams (mg) (analgesic) by mouth every four hours as needed for discomfort or pain. Review of the baseline care plan initiated on 11/13/25 revealed Resident #85 had a right hip injury which resulted in an open reduction internal fixation (ORIF) of the right hip (a surgical procedure to repair a severe hip fracture by surgically realigning the broken bone and then stabilizing it with hardware like screws, plates, or rods) and a recent emergency room visit for a right hip reduction (a medical procedure to realign the hip joint, most commonly following a dislocation). The baseline care plan did not include interventions related to the potential for pain in the right hip or leg secondary from the hip injury or procedures.Review of the Brief Interview for Mental Status (BIMS) summary score from the BIMS completed on 11/14/25 revealed Resident #85 had moderately impaired cognition. Review of the Skilled Charting dated 11/14/25 revealed Resident #85 was alert to person, place, time, and situation. The assessment further revealed Resident #85 was admitted to the facility for post-surgical services, including physical therapy (PT) and occupational therapy (OT), and that medication orders had been received. The assessment did not contain any documentation in the pain evaluation section. Review of the Pain Tool completed on 11/14/25, 11/15/25, and 11/16/25 revealed Resident #85 had right knee pain, rated as hurting a little more on the Faces Pain Scale. Further review of the pain assessment revealed movement made Resident #85's pain worse while the use of rest, ice, and Tylenol helped to make it hurt a little less. Review of the weights and vital signs tab in the electronic medical record (EMR) viewed at 4:59 P.M. revealed Resident #85 had a total of 17 pain assessments documented between 11/13/25 at 10:56 P.M. and 11/17/25 at 9:01 A.M. Further review if the pain assessments revealed the pain was rated using a numerical rating scale from zero to ten, with zero meaning no pain and 10 being the worst pain possible. Of the 17 pain assessments, Resident #85 reported no pain on four occasions, mild pain (rated as one or two) on eight occasions, moderate pain on three occasions (rated as six on 11/13/25 at 10:56 P.M. and five on 11/14/25 at 9:14 P.M. and on 11/16/25 at 11:59 P.M.), and severe pain twice (on 11/17/25 at 8:53 A.M. and at 9:01 A.M.).Review of the Medication Administration Record (MAR) revealed documentation that Resident #85 received Tylenol 650 mg,by mouth on 11/13/25 at 10:56 P.M. for moderate pain, 11/15/25 at 9:14 P.M. for moderate pain, on 11/15/25 at 5:44 A.M. for no pain, and on 11/16/25 at 11:59 P.M. for moderate pain. Further review of the MAR revealed no Tylenol was administered to Resident #85 after reporting severe pain on 11/17/25 at 8:53 A.M. and at 9:01 A.M. Observation on 11/17/25 from 9:00 A.M. to 9:07 A.M. revealed Licensed Practical Nurse (LPN) #313 obtained vital signs from Resident #85, prepared scheduled morning medications, and administered the prepared medications to Resident #85. At 9:01 A.M., Resident #85 was heard telling LPN #313 that her right leg hurt a lot and she then rated the pain level as an eight on a one to 10 numerical rating scale. Further observation revealed Tylenol was not included in the medication cup that was prepared and handed to Resident #85, although LPN #313 informed Resident #85 that there was a little something for her leg pain with the medications that were handed to Resident #85. At the time of the medication observation, two staff from the therapy department were in the room and waiting to take Resident #85 for prescribed therapy.Interview on 11/17/25 at 9:07 A.M. with LPN #313 confirmed that when telling Resident #85 that there was something for her leg pain in the medicine cup, LPN #313 was referring to the meloxicam 15 mg that was ordered daily for arthritis. During the interview, LPN #313 also stated that Resident #85 also had on a patch for pain that was not yet due to be removed (review of the medication orders and the MAR revealed Resident #85 had no orders for, or applications of, topical analgesics or pain patches). Interview on 11/17/25 at 11:48 A.M. with Resident #85 confirmed she usually took Tylenol to help with her right leg pain. During the interview, Resident #85 was uncertain whether she received the Tylenol with her morning medications because there were so many pills and she did not know what all was in the medicine cup, but she thought the nurse told her she gave her something extra for pain. At the time of the interview, Resident #85 stated that her pain was worse than earlier and wanted to see if it was time for more Tylenol. During a follow-up interview on 11/17/25 at 12:08 P.M. with LPN #313, LPN #313 was informed that Resident #85 stated the pain in the right leg was worse. During the interview, LPN #85 was observed looking in Resident #85's medical record before stating that all Resident #85 had for pain was a Tylenol order. Follow-up review of the medical record for Resident #85 at 4:57 P.M., including review of the orders, progress notes, pain assessments, and MAR, revealed no additional pain assessment was completed for Resident #85, and no Tylenol was administered to Resident #85 since the last dose given on 11/16/25 at 11:59 P.M. There were no notes to indicate any non-pharmacological interventions were offered, such as ice (as indicated in the Pain Tool assessments), that Resident #85 was offered and declined Tylenol, or that the medical provider was notified that Resident #85's assessment the morning of 11/17/25 revealed an increase in pain since admission to the facility. Review of the undated policy titled Medication Administration revealed medications were to be given timely, as prescribed, as determined by resident need and benefit. This deficiency represents non-compliance investigated under Complaint Number 2663659.

Based on record reviews, observations, interviews and review of the facility policy, the facility failed to ensure a medication error rate of less than five percent (%) during medication administration on 11/17/25 with four errors of 25 medication administration opportunities resulted in a 16% medication error rate. This affected two residents (Residents #85 and #86) of four residents observed during medication administration. The facility census was 83.Findings include:1. Review of the medical record for Resident #85 revealed an admission date of 11/13/25 with diagnoses including unspecified dislocation of the right hip, unspecified complication of internal orthopedic prosthetic device, implant, and graft, gastroesophageal reflux disease (GERD), hyperlipidemia, primary hypertension, and unspecified glaucoma. Review of the Brief Interview for Mental Status (BIMS) summary score completed on 11/14/25 revealed Resident #85 had moderately impaired cognition. Review of the Skilled Charting dated 11/14/25 revealed Resident #85 was alert to person, place, time, and situation. The assessment further revealed Resident #85 was admitted to the facility for post-surgical services, including physical therapy (PT) and occupational therapy (OT), and that medication orders had been received. Review of the physician orders revealed Resident #85 had one medication scheduled for administration at 8:00 A.M. and a total of twelve medications scheduled for administration at 9:00 A.M. These medications included:1) Cefadroxil oral capsule, 500 milligrams (mg), (antibiotic) give one capsule by mouth two times a day for prophylaxis for seven days, dated 11/14/25, with the morning dose scheduled for 8:00 A.M.2) Amlodipine besylate oral tablet, five milligrams, give one tablet by mouth one time a day for primary hypertension, dated 11/13/25, scheduled at 9:00 A.M.3) Aspirin 81 mg oral delayed release (DR) tablet, give one tablet by mouth two times a day for deep vein thrombosis (DVT) prophylaxis, dated 11/13/25, with the morning dose scheduled at 9:00 A.M.4) Biotin oral tablet, 10,000 mcg, give one tablet by mouth one time a day for supplementation, ordered 11/13/25, scheduled at 9:00 A.M.5) Vitamin D oral tablet 50 micrograms (mcg), give one tablet by mouth once daily for supplement, dated 11/13/25, scheduled at 9:00 A.M.6) Valsartan oral tablet 320 mg, five one tablet by mouth one time a day for hypertension, dated 11/13/25, scheduled at 9:00 A.M.7) Niacin oral tablet, 100 mg, give one tablet by mouth one time a day for anemia, dated 11/13/25, scheduled at 9:00 A.M.8) Meloxicam 15 mg tablet, give one tablet by mouth one time a day for arthritis, dated 11/13/25, scheduled at 9:00 A.M.9) Folic acid 1 mg tablet, give one tablet by mouth one time a day for anemia, dated 11/13/25, scheduled at 9:00 A.M.10) Vitamin E 15 mg oral tablet, one tablet once daily as a supplement, dated 11/14/25, scheduled at 9:00 A.M.11) Culturelle Immunity Support 15B Cell capsule, give one capsule by mouth one time a day for supplement, ordered 11/14/25, scheduled at 9:00 A.M.12) Cranberry juice powder capsule, 425 mg, give one capsule by mouth one time a day for supplementation, dated 11/14/25, scheduled at 9:00 A.M.13) Prevagen oral capsule, 10 mg, give 10 mg my mouth one time a day for supplement, dated 11/14/25, scheduled at 9:00 A.M.Observation on 11/17/25 from 9:00 A.M. to 9:07 A.M. revealed Licensed Practical Nurse (LPN) #313 obtained vital signs from Resident #85, prepared morning medications, and administered the prepared medications to Resident #85. During the observation, LPN #313 confirmed there were nine pills in the medication cup, which included a 5 mg amlodipine tablet, an 81 mg aspirin tablet, a 425 mg cranberry juice powder capsule, a 1,000-mcg folic acid tablet, a 10,000-mcg biotin tablet, a 10 mg prevagen capsule, a 320 mg valsartan tablet, a 50-mcg vitamin D tablet, and a 50 mg meloxicam tablet. During medication preparation, LPN #313 confirmed that there was no Vitamin E available to give to Resident #85 because it was on order. Continued observation revealed Resident #85 took the nine pills that were provided in the medication cup at 9:05 A.M.After the medication administration observation, at 9:49 A.M., review of the medication administration record (MAR) revealed Resident #85 had 11 of the 13 morning medications signed as given by LPN #313 and one morning medication (Vitamin E, 15 mg) signed by LPN #313 with the MAR code 3 for Hold/See Progress Notes (only nine medications were observed as administered. Medications signed as given that were not prepared and administered during the observation included Culturelle Immunity Support 15B Cell capsule (scheduled to be given at 9:00 A.M.), Niacin 100 mg oral tablet (scheduled to be given at 9:00 A.M.), and cefadroxil 500 mg oral capsule (scheduled to be given at 8:00 A.M.). Review of the Medication Administration Audit Report (MAAR) revealed LPN #313 documented administration of the 100 mg of Niacin and 500 mg of cefadroxil at the same time as signing for the nine medications that were observed as administered (between 9:06 A.M. and 9:07 A.M.), directly after the medication was observed being administered to Resident #85. Interview on 11/17/25 at 12:08 P.M. with LPN #313 confirmed the ordered Vitamin E was not given because it was not available. At the time of the interview, LPN #313 pulled out the box of Culturelle Immunity, and reported that she found and gave the ordered Culturelle dose to Resident #85 just after the surveyor left the unit, when it popped up on the MAR as unsigned. When asked about the ordered Niacin and cefadroxil, LPN #313 stated it didn't pop up for me [on the MAR]. Observation at the time of the interview revealed the medication cart contained one blister packet dated 11/14/25 that originally contained seven tablets and one blister packet for the morning medication administration of cefadroxil dated 11/14/25 which originally was dispensed containing seven tablets. Interview with LPN #313 at the time of the observation confirmed there were five of the seven pills left in both packets, with two niacin and two cefadroxil appearing to have been dispensed (the foil backing was torn, and the pills were gone). Another review of the MAR revealed three doses of 100 mg niacin and three doses of the morning 500 mg cefadroxil were signed off, one dose each on 11/15/25, 11/16/25, and 11/17/25, though only two pills (not three) were observed missing from each pharmacy supplied blister packet. Review of the undated policy titled Medication Administration revealed medications were to be administered according to prescriber orders, including within any required timeframes. 2. Review of the medical record for Resident #86 revealed an admission date of 10/22/25 and a re-entry date of 11/03/25. Diagnoses included acute respiratory failure with hypoxia, transfusion-related acute lung injury, anemia, peripheral vascular disease, end stage renal disease, dependence on renal dialysis, and type two diabetes mellitus.Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 10/27/25 revealed Resident #86 had moderately impaired cognition had no behaviors or rejection of care, and received insulin injections, antidepressant, antiplatelet, anticonvulsant, and hypoglycemic medications. The MDS further revealed Resident #86 had complex medical conditions which included diabetes mellitus, and Resident #86 received dialysis.Review of the medication orders revealed an order dated 11/16/25 for sevelamer carbonate oral tablet, 800 mg, (non-absorbable, calcium and metal-free phosphate binder used to treat high phosphate levels) give Resident #86 six tablets by mouth before meals for dialysis. Further review of the order revealed the ordered scheduled administration times were 6:30 A.M., 11:30 A.M., and 4:30 P.M. with an order note changing morning administration to 8:00 A.M. due to resident refusal to take at 6:30 A.M.Review of the MAR revealed the Sevelamer was listed as scheduled to be given at 8:00 A.M., 11:30 A.M., and 4:30 P.M. Further review of the MAR revealed all previous sevelamer orders were listed on the MAR to be given as per the ordered times, which included 6:30 A.M., 11:30 A.M., and 4:30 P.M., with an accompanying electronic MAR (eMAR) note dated 11/16/25 that Resident #86 refused the 6:30 A.M. because it was not to be taken on an empty stomach. Observation on 11/17/25 from 9:10 A.M. to 9:25 A.M. of morning medication preparation and administration for Resident #86 by LPN #313 revealed the ordered oral medications, including sevelamer 800 mg, was administered to Resident #86 at 9:20 A.M. Interview on 11/17/25 at 9:23 A.M. with Resident #86 confirmed he had already eaten breakfast without having the ordered morning medication and that it had been a while since breakfast was served.Interview with LPN #313 on 11/17/25 at 9:25 A.M. confirmed the sevelamer popped up on the MAR for 8:00 A.M. administration and most medications could be given one hour before or one hour after the time it was timed for on the MAR. Further interview with LPN #313 confirmed that the order specified the sevelamer was to be given before meals, it had been more than 30 minutes since residents on the unit ate breakfast, and that the medication was administered more than one hour after the time that was listed on the MAR. Review of the undated policy titled Medication Administration revealed medications were to be administered according to prescriber orders, including within any required timeframes, and that medications were to be administered within one hour of the prescribed time, or in accordance with the specified time within the order, such as before or after meal orders. The policy further revealed that medications times were to be determined by what was best for resident outcome and not staff convenience, such as times that enhanced the optimum therapeutic benefit of the medications and have the least potential negative consequences or interaction with other medications or foods.This deficiency represents non-compliance investigated under Complaint Number 2663659.

Based on record reviews, observations, interviews, review of facility policies, and review of manufacturer instructions for the facility's blood glucose meter, the facility failed to ensure the blood glucose meter was properly cleaned after use with Resident #86. This affected one (Resident#86) and had the potential to affect three additional (Residents #70 #73, and #81) identified by the facility as having blood sugar level checked with a glucometer. In addition, the facility did not ensure enhanced barrier precautions (EBP) were maintained during medication administration through an enteral feeding tube, affecting Resident #67. The facility identified nine residents who had enteral feeding tubes (Residents #6, #26, #45, #64, #66, #67, #69, #77, and #83). The facility census was 83.Findings include:1. Review of the medical record for Resident #86 revealed an admission date of 10/22/25 and a re-entry date of 11/03/25. Diagnoses included acute respiratory failure with hypoxia, transfusion-related acute lung injury, anemia, peripheral vascular disease, end stage renal disease, dependence on renal dialysis, and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 10/27/25 revealed Resident #86 had moderately impaired cognition and received insulin injections, antidepressant, antiplatelet, anticonvulsant, and hypoglycemic medications. Further review of the MDS revealed Resident #86 had complex medical conditions which included diabetes mellitus and dependence on renal dialysis.Review of the physician's orders revealed an order dated 11/14/25 for Resident #86 to have a blood sugar level checked twice a day. Further review of the order revealed the blood sugar checks were scheduled for 6:00 A.M. and 4:00 P.M.Observation on 11/17/25 from 9:10 A.M. to 9:13 A.M. revealed Licensed Practical Nurse (LPN) #313 used a hand-held, multi-use, blood glucose meter (BGM) to check the blood sugar of Resident #86. Further observation revealed LPN #313 removed the soiled gloves, disposed of the lancet and soiled gloves into the sharps container and trash receptacle on the medication cart, respectively, then removed one standard sized alcohol wipe from the top drawer of the medication cart, opened the wipe, and used the wipe to briskly wipe down the front of the BGM before placing the BGM back into the top drawer of the medication cart and performing hand hygiene. At the end of the observation, LPN #313 stated Resident #87 did not get insulin per sliding scale and did not need the additional fingerstick for blood sugar monitoring that was just performed, but LPN #313 expressed it was her process to check all resident's blood sugars if they were on insulin. Interview on 11/17/25 at 9:25 A.M. with LPN #313 revealed a lack of knowledge of the facility's specific policy for cleaning BGM's between resident use and confirmed the use of one standard alcohol swab to clean the BGM before placing it back into the drawer of the medication cart. Interview on 11/17/25 at 10:05 A.M. with the Director of Nursing (DON) confirmed that use of an alcohol swab to wipe the front of the BGM was not the correct procedure to ensure the device was properly cleaned and disinfected. During the interview, the DON confirmed that the facility used Sani-Cloth Disposable Wipes to clean and disinfect the BGM. During a follow-up interview on 11/17/25 at 10:20 A.M., the DON confirmed the Sani-Cloth Disposable Wipes required a two-minute dry time before the BGM would be considered properly disinfected before drying and placing the BGM back into the drawer of the medication cart.Review of the undated policy titled Performing a Blood Glucose Test revealed the facility was to always ensure that the blood glucose monitoring device was cleaned and disinfected between resident use following manufacturer's instructions.Review of the Assure Prism Multi Blood Glucose Monitoring System Manufacturer's Instructions revealed the device was required to be cleaned prior to disinfection and then disinfected using only specified products with approved Environmental Protection Agency (EPA) registration numbers, which included the following products: Clorox Germicidal Wipes, Super Sani-Cloth Germicidal Disposable Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, and CaviWipes1. The instructions further revealed two of the approved wipes were required, one to clean, and one to disinfect the device. Further review of the manufacturer's instructions revealed the device was to remain wet for the specified amount of time per the wipe manufacturer's instructions in order to be considered properly disinfected. 2. Review of the medical record for Resident #67 revealed an admission date of 04/08/25 and a re-entry date of 09/16/25. Pertinent diagnoses included acute and chronic respiratory failure, spastic quadriplegic cerebral palsy, dysphagia, neuromuscular dysfunction of the bladder, seizures, attention to tracheostomy, dependence on respirator (ventilator) status, tracheostomy status, pressure ulcer of the sacral region, and gastrostomy status. Review of the quarterly MDS 3.0 assessment completed on 10/29/25 revealed Resident #67 had severely impaired cognition. Further review of the MDS revealed Resident #67 had a feeding tube and received more than 51 percent (%) of daily required calories through a feeding tube. Review of the physician's orders revealed an order which specified Resident #67 was to be on EBP per CDC (Centers for Disease Control and Prevention) guidelines.Review of the care plan last reviewed 11/06/25 revealed Resident #67 was on EBP due to having a Foley (an indwelling urinary catheter), a tracheostomy tube (trach), an enteral feeding tube, and wounds. Interventions included keeping gloves and gowns available and using appropriate personal protective equipment (PPE) during direct personal care, including bathing, dressing, transferring, changing bed linen, changing briefs, and any wound care or device use. Observation on 11/17/25 from 11:58 A.M. to 12:02 P.M. revealed Resident #67 received medication through an enteral feeding tube, which was administered by LPN #387. During the observation, LPN #387 did not wear a gown for the medication administration which required close handling of the feeding tube, such as lifting the gown and readjusting the brief to observe the insertion site, leaning in to auscultate feeding tube placement, closing the port to the enteral formula that was hanging on the feeding pump, opening and closing the medication port to attach and detach a syringe for pre and post medication flushes and medication administration, reopening the enteral feeding line port, and readjusting the residents gown and linen once the medication administration was completed. Interview on 11/17/25 at 12:05 P.M. with LPN #387 confirmed Resident #67 was in EBP, and a gown was to be worn during wound care, Foley care, trach care, and probably during administration of medications through Resident #67's feeding tube, but she did not put one on.Interview on 11/17/25 at 3:50 P.M. with the DON confirmed that residents that had enteral feeding tubes were supposed to be in EBP, which required nurses to wear a gown and gloves during medication administration through the feeding tube.Review of the policy titled Enhanced Barrier Precautions (EBP) dated April 2024, revealed EBP was to be implemented for residents with medical devices, including enteral feeding tubes. The facility EBP procedure specified that EBP was to be used consistently throughout the facility and included the use of gowns and gloves during use or care of enteral feeding tubes. This deficiency was an incidental finding identified during the complaint investigation.

Based on record review, observation, interview, review of Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to ensure staff performed hand hygiene to prevent possible cross contamination of germs during Resident #1's wound care and Resident #29's incontinence care. This affected one resident (#1) out of two residents reviewed for wound care and one resident (#29) out of three residents reviewed for incontinence care. The facility census was 89. Findings include: 1. Review of the medical record revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnoses including Multiple Sclerosis (MS), anxiety, psychosis, depression, quadriplegia, neuromuscular bladder, gastroesophageal reflux disease (GERD), esophagitis, vitamin B deficiency, joint contracture and osteoporosis. A review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had an indwelling urinary catheter and was incontinent of bowel. A review of Resident #1's medical record revealed a skin/wound note dated 03/24/24 of an assessment of a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.), located on the left posterior thigh/ischium and measuring 9.0 centimeters (cm) long by 8.5 cm wide by 1.1 cm deep. Undermining was present at the 12 o'clock position measuring 2.0 cm. The measured area was 20 percent intact and tissue was within normal limits with 50 percent granular tissue and 10 percent slough. Edges were well defined and irregular in shape with no odor present. The skin/wound note indicated a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling.), located on the right posterior thigh measuring 1.5 cm long by 3.0 cm wide by 0.1 cm deep with 30 percent granular tissue, and 70 percent epithelial tissue. The wound edges were well defined, attached to the wound base, area irregular in shape. A small amount of serosanguinous exudate was noted when the dressing was removed from the wound. A third area of skin breakdown located on the right gluteal area was classified as moisture associated skin damage (MASD) measuring 3.5 cm long by 5.0 cm wide by 0.1 cm deep. The measured area had 60 percent partial thickness skin loss and 40 percent epithelial tissue present. The wound had irregular edges and shape with a small amount of serosanguinous exudate noted when the dressing was removed from the wound. An observation on 03/25/25 at 1:50 P.M. of Licensed Practical Nurse (LPN) #525 perform Resident #1's wound treatment with the assistance of Certified Nurse Aide (CNA) #563 revealed a failure to perform hand hygiene to prevent cross contamination of germs. Both staff entered Resident #1's room and did not perform hand hygiene and donned a pair of gloves. Both staff assisted Resident #1 to roll on her right side, and LPN #525 removed the soiled wound treatments from the three wounds on her sacral area and right/left gluteal areas. The wounds had open areas which had a small amount of serosanguinous drainage present and appeared very red with a tunneling area on the left ischium. LPN #525 cleansed the wounds with wound cleanser and gauze and discarded the soiled supplies in a plastic bag. LPN #525 did not remove her gloves or perform hand hygiene and applied the calcium alginate with silver dressing (a specialized wound care product the merges the absorbent qualities of alginate with the antimicrobial properties of silver) to the left and right gluteal wounds and border foam dressing to the sacral wound. Without removing her gloves, LPN #522 proceeded to assist Resident #1 to reposition using a foam wedge cushion, handling multiple items in the room including Resident #1's call light button and bed remote and moved the over-the bed table close to Resident #1. LPN #525 then removed her gloves and applied another pair of gloves and did not perform hand hygiene and picked up the unused clean wound treatment supplies and exited the room. CNA #563 assisted LPN #525 with repositioning Resident #1 during the wound treatment and used the same gloved hands to place Resident #1's personal items on the over-the-bed table and then exited to room and placed her gown in the soiled utility room. On 03/25/25 at 2:20 P.M. an interview with LPN #525 and CNA #563 verified they failed to perform hand hygiene to prevent the spread of germs during Resident #1's wound treatment. 2. Review of the medical record revealed Resident #29 was admitted n 01/01/25 with diagnoses including nutritional marasmus, bipolar disorder, atrial fibrillation, high cholesterol, lymphedema, high blood pressure, cognitive communication deficit, and left pelvic fracture. A review of Resident #29's MDS assessment dated [DATE] indicated she had bowel and bladder incontinence and needed maximum assistance with toileting. An observation on 03/24/25 at 9:54 A.M. of LPN #522 assist Resident #29 with incontinence care revealed a failure to perform hand hygiene to prevent cross contamination of germs. LPN #522 entered Resident #29's room and did not wash her hands, donned a pair of gloves and proceeded to clean Resident #29's buttock and perineal area of a large amount of feces. Upon completion of the incontinence care, LPN #522 removed her gloves and did not perform hand hygiene. LPN #522 proceeded to touch various surfaces and items in the room including the call light button, bed remote, bedside drawer and other surfaces. LPN #522 was waiting for staff to answer the call light and touched the underside bandage on Resident #29's right temple, Resident #29's bed linens, and repositioned Resident #29. LPN #522 then picked up the package of incontinence wipes which had feces on the outside of the package and set the package on top of Resident #29's clean clothing on top of her bedside table. LPN #522 asked CNA #567 to assist her with turning and repositioning Resident #29 for the incontinence care. CNA #567 entered the room and donned a pair of gloves without performing hand hygiene and proceeded to assist LPN #522 with turning and repositioning Resident #29. LPN #522 then placed Resident #29's call light in reach, picked up the soiled bag of incontinence supplies and soiled linen and exited the room. LPN #522 placed the bag of soiled linen and bag of soiled incontinence supplies in the soiled utility room. LPN #522 removed her gloves and performed hand hygiene. LPN #522 proceeded to obtain a cup, straw and lid and filled the cup with lemonade, walked back to Resident #29's room and assisted her with drinking from the cup of lemonade while holding the straw for her. On 03/24/25 between 10:00 A.M. and 10:30 A.M. an interview with LPN #522 and CNA #567 verified the above findings and agreed they didn't perform hand hygiene to prevent the spread of germs during Resident #29's incontinence care. The facility policy and procedure titled Handwashing revised July 2015 indicated the purpose of the policy was to maintain medical asepsis, for infection control, to reduce transferal of microorganisms from resident to resident, to reduce transferal of microorganisms between staff and residents. The policy indicated proper handwashing technique would be used by all employees to maintain optimal infection control. The Centers for Disease Control and Prevention (CDC) hand hygiene guidance dated 01/30/20 indicated to perform hand hygiene immediately before touching a resident, before performing an aseptic task, before moving from a soiled body site to a clean body site on the same resident, after touching a resident, after contact with blood, body fluids, or contaminated surfaces, after touching a resident's immediate environment. Require healthcare personnel to perform hand hygiene in accordance with CDC recommendations. Ensure healthcare personnel wash their hands with soap and water when hands were visibly soiled.

Based on record review, observation, interview and facility policy review, the facility failed to ensure resident #22 had a physician's order for oxygen use. This affected one resident (#22) of four residents reviewed for oxygen therapy. The facility identified 15 residents (#4, #16, #23, #30, #44, #52, #65, #70, #131, #284, #285, #289, #290, #291, and #294) that required oxygen. The facility census was 89. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included hypertensive heart disease with chronic kidney disease, dementia, type two diabetes mellitus, and asthma. Review of the physician's orders for Resident #22 revealed no orders for oxygen. Review of the care plan dated 03/11/25 revealed Resident #22 had a respiratory diagnosis. Interventions included administering oxygen as ordered by the physician and monitoring the resident's pulse oximetry (a non-invasive medical procedure that measures the oxygen saturation of the blood). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had mild cognitive impairment and required extensive assistance for all activities of daily living. Resident #22 was receiving oxygen therapy. Observations on 03/24/25 from 9:00 A.M. to 10:50 A.M. revealed Residents #22 had and oxygen concentrator and was utilizing the oxygen. Interview on 03/25/25 at 10:53 with Registered Nurse (RN) #504 confirmed Resident #22 did not have a physician's order for oxygen therapy. Review of the facility policy Oxygen Tubing and Nasal Cannula Care, effective 08/01/19, stated to verify physician's order for oxygen.

Based on record review, observation, interview and facility policy review, the facility failed to ensure nasal sprays for Resident #41, who did not have an order to self-administer medications, were not left at the bedside. In addition, the nasal sprays left at the bedside were discontinued by the physician. This affected one resident (#41) of three residents reviewed for medication administration. The facility census was 89. Findings include: Review of the medical record for Resident #41 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, major depressive disorder, and hypertension. Review of the physician's orders for Resident #41 revealed an order for ipratropium bromide nasal solution 0.03% (reduces the amount of mucus produced in the nose) two sprays in each nostril every six hours as needed dated 01/24/25 and discontinued on 03/13/25 and an order for Flonase allergy relief nasal suspension 50 micrograms (mcg) (corticosteroid) two sprays in both nostrils as needed for allergies one time a day dated 04/21/24 and discontinued 03/13/25. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had intact cognition. Resident #41 required standby to moderate assistance for all activities of daily living. Review of the care plan dated 03/11/25 for Resident #41 revealed no focus that Resident #41 was able to self-administer medications or keep them at her bedside. Interview and observation on 03/24/25 at 9:38 A.M. with Resident #41 revealed Flonase nasal spray and ipratropium bromide nasal spray on her bedside table. Resident #41 confirmed the staff let her keep them there and give them to herself when needed. Interview on 03/25/25 at 8:03 A.M. with Registered Nurse (RN) #504 revealed that Resident #41 does keep her nasal sprays at her bedside and administers them to herself. She reported they are trying to keep Resident #41 as independent as possible. Subsequent interview on 03/25/25 at 10:45 A.M. with RN #504 revealed that Resident #41 had no physician's order to self-administer the nasal sprays, and she had brought them back from her bedside table to the medication cart for storage. RN #504 also confirmed that the order for both nasal sprays were discontinued by the physician on 03/13/25 for Resident #41. Review of the facility policy titled Self-Administration of Medication, effective 06/02/15, revealed a decision to permit self-administration is made in the interdisciplinary care plan conference. An order must be received from a physician and placed in the medication administration record. Review of the facility policy titled Medication Storage in the facility, effective 06/02/15, revealed the medication supply is assessable only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on record review, interview and facility policy review, the facility failed to obtain physician ordered laboratory testing for Resident #283. This affected one resident (#283) of five residents reviewed for unnecessary medications. The facility census was 89. Findings include: Review of Residents #283's medical record revealed an admitted [DATE] with diagnoses including infection and inflammatory reaction due to internal left knee prosthesis, atrial fibrillation, peripheral vascular disease, rhabdomyolysis, venous thrombosis, and cognitive deficit. Review of the physician orders start date 02/25/25 end date of 04/03/25 revealed Resident #283 was to receive Cefepime HCL (antibiotic) Intravenous Solution two grams use 2000 milligrams intravenously three times a day for prosthetic infection for 37 days. Review of the physician order dated 02/24/25 revealed an order for C-Reactive Protein (CRP), a protein produced by the liver in response to inflammation) and erythrocyte sedimentation rate (SED Rate), measured the rate to detect inflammation in the body, every Monday and fax to infectious disease. Review of Resident #283 Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive deficit. Resident #283 had received anticoagulant medication and antibiotic medications in the seven days prior to 03/02/25 and had intravenous access. Review of facility document titled Specimen Collected dated 03/03/24 revealed CRP level of 29.7 (high) and SED Rate of 47 (high). Review of facility document titled Specimen Collected dated 03/17/24 revealed CRP level of 8.0 (normal) and SED Rate of 38 (high). Lab results for Monday 03/10/25 were not available to review. Interview on 03/26/25 at 7:58 A.M., the Director of Nursing (DON) confirmed the facility did not have the 03/10/25 specimen results for Resident #283 and verified no lab was drawn on 03/10/25. Review of the facility policy titled Following Physician Order dated February 2022 revealed licensed nursing professionals were to be aware of and follow all physician orders as written.

Based on observation, interview and Centers for Disease Control and Prevention guidelines the facility failed to ensure staff performed hand hygiene to prevent possible cross contamination of germs during Resident #1's wound care and Resident #29's incontinence care. This affected one out of three residents reviewed for incontinence care. The facility census was 89. Findings include: Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnoses including multiple sclerosis, anxiety, psychosis, depression, quadriplegia, neuromuscular bladder, gastroesophageal reflux disease, esophagitis, vitamin B deficiency, joint contracture and osteoporosis. A review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had an indwelling urinary catheter and was incontinent of bowel. A review of Resident #1's clinical record revealed a skin/wound note dated 03/24/24 of an assessment of a stage IV pressure ulcer (Sores that extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments.), located on the left posterior thigh/ischium and measuring 9 centimeters (cm) long by 8.5 cm wide by 1.1 cm deep. Undermining present at the 12 o'clock position measuring 2 cm. The measured area had 20 percent intact and tissue within normal limits with 50 percent granular tissue and 10 percent slough. Edges were well defined and irregular in shape with no odor present. The skin/wound note indicated a stage III pressure ulcer (Sores that have broken completely through the top two layers of the skin and into the fatty tissue below.) located on the right posterior thigh measuring 1.5 cm long by 3 cm wide by 0.1 cm deep with 30 percent granular tissue, and 70 percent epithelial tissue. The wound edges were well defined, attached to the wound base and the area was irregular in shape. A small amount of serosanguinous exudate was noted when the dressing was removed from the wound. A third area of skin breakdown located on the right gluteal area was classified as moisture associated skin damage measuring 3.5 cm long by 5 cm wide by 0.1 cm deep. The measured area had 60 percent partial thickness skin loss and 40 percent epithelial tissue present. The wound had irregular edges and shape with a small amount of serosanguinous exudate noted when the dressing was removed from the wound. An observation on 03/25/25 at 1:50 P.M. of Licensed Practical Nurse (LPN) #525 perform Resident #1's wound treatment with the assistance of Certified Nurse Aide (CNA) #563 revealed a failure to perform hand hygiene to prevent cross contamination of germs. Both staff entered Resident #1's room and did not perform hand hygiene and donned a pair of gloves. Both staff assisted Resident #1 to roll on her right side and LPN #525 removed the soiled wound treatments from the three wounds on her sacral area and right/left gluteal areas. The wounds had open areas which had a small amount of serosanguinous drainage present and appeared very red with a tunneling area on the left ischium. LPN #525 cleaned the wounds with wound cleanser and gauze and discarded the soiled supplies in a plastic bag. LPN #525 did not remove her gloves or perform hand hygiene and applied the calcium alginate with silver dressing to the left and right gluteal wounds and border foam dressing to the sacral wound. Without removing her gloves LPN #522 proceeded to assist Resident #1 to reposition using a foam wedge cushion, handling multiple items in the room including Resident #1's call light button and bed remote and moved the over-the bed table close to Resident #1. LPN #525 then removed her gloves and applied another pair of gloves and did not perform hand hygiene and picked up the unused clean wound treatment supplies and exited the room. CNA #563 assisted LPN #525 with repositioning Resident #1 during the wound treatment and used the same gloved hands to place Resident #1's personal items on the over-the-bed table and then exited to room and placed her gown in the soiled utility room. On 03/25/25 at 2:20 P.M. an interview with LPN #525 and CNA #563 verified they failed to perform hand hygiene to prevent the spread of germs during Resident #1's wound treatment. 2. Resident #29 was admitted n 01/01/25 with diagnoses including nutritional marasmus, bipolar disorder, atrial fibrillation, high cholesterol, lymphedema, high blood pressure, cognitive communication deficit, and left pelvic fracture. A review of Resident #29's MDS assessment dated [DATE] indicated she bowel and bladder incontinence and needed maximum assistance with toileting. An observation on 03/24/25 at 9:54 A.M. of Licensed Practical Nurse (LPN) #522 assist Resident #29 with incontinence care revealed a failure to perform hand hygiene to prevent cross contamination of germs. LPN #522 entered Resident #29's room and did not wash her hands, donned a pair of gloves and proceeded to clean Resident #29's buttock and perineal area of a large amount of feces. Upon completion of the incontinence care, LPN #522 removed her gloves and did not perform hand hygiene. LPN #522 proceeded to touch various surfaces and items in the room including the call light button, bed remote, bed side drawer and other surfaces. LPN #522 was waiting for staff to answer the call light and touched the underside bandage on Resident #29's right temple, Resident #29's bed linens, and repositioned Resident #29. LPN #522 then picked up the package of incontinence wipes which had feces on the outside of the package and set the package on top of Resident #29's clean clothing on top of her bed side table. LPN #522 asked CNA #567 to assist her with turning and repositioning Resident #29 for the incontinence care. CNA #567 entered the room and donned a pair of gloves without performing hand hygiene and proceeded to assist LPN #522 with turning and repositioning Resident #29. LPN #522 then placed Resident #29's call light in reach, picked up the soiled bag of incontinence supplies and soiled linen and exited the room. LPN #522 placed the bag of soiled linen and bag of soiled incontinence supplies in the soiled utility room. LPN #522 removed her gloves and did perform hand hygiene. LPN #522 proceeded to obtain a cup, straw and lid and filled the cup with lemonade, walked back to Resident #29's room and assisted her with drinking from the cup of lemonade while holding the straw for her. On 03/24/25 between 10:00 A.M. and 10:30 A.M. interview with LPN #522 and CNA #567 verified the above findings and agreed they didn't perform hand hygiene to prevent the spread of germs during Resident #29's incontinence care. The facility policy and procedure titled Handwashing revised July 2015 indicated the purpose of the policy was to maintain medical asepsis, for infection control, to reduce transferal of microorganisms from resident to resident, to reduce transferal of microorganisms between staff and residents. The policy indicated proper handwashing technique would be used by all employees to maintain optimal infection control. The Centers for Disease Control and Prevention (CDC) hand hygiene guidance dated 01/30/20 indicated to perform hand hygiene immediately before touching a resident, before performing an aseptic task, before moving from a soiled body site to a clean body site on the same resident, after touching a resident, after contact with blood, body fluids, or contaminated surfaces, after touching a resident's immediate environment. Require healthcare personnel to perform hand hygiene in accordance with CDC recommendations. Ensure healthcare personnel wash their hands with soap and water when hands were visibly soiled.

Based on medical record review, hospital record review, facility policy review and interview, the facility failed to provide adequate two-person assistance with bed mobility for Resident #36 as assessed/planned resulting in an injury. Actual harm occurred on 10/05/24 when Resident #36 sustained a fractured hip when one staff member (State tested Nursing Assistant, (STNA) #110) was providing personal care for Resident #36. The resident had been assessed/planned to require two staff members for bed mobility prior to the incident. During care, the resident complained of extreme pain when the STNA lifted the left side of her body. On 10/07/24, the resident was transferred to the hospital for follow-up care. An x-ray obtained on 10/07/24 identified the fracture which the facility determined was caused by the single person bed mobility procedures with STNA #110 on 10/05/24. This affected one resident (#36) of three residents reviewed for accidents. The census was 90. Findings include: Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, anxiety disorder, psychosis, major depressive disorder, quadriplegia, neuromuscular dysfunction of bladder, vitamin B deficiency, contracture, insomnia, glaucoma, and osteoporosis. Review of Resident #36's care card dated 09/20/24 revealed the resident required two-person assistance with bed mobility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact. The assessment indicated the resident was dependent on staff for bed mobility, rolling left and right in bed. Review of Resident #36's current care plan revealed the resident needed (staff) assistance with activities of daily living (ADL). One intervention within the care plan revealed she needed assistance with bed mobility. Another intervention within the care plan was for staff to follow the resident care card for assistance with her ADLs. Review of Resident #36's hospital records dated 10/07/24 revealed Resident #36 mentioned to the hospital staff that when she was being transferred/moved in her bed on 10/05/24 when she felt a sharp pain to her left hip. An x-ray was completed on 10/07/24, and confirmed she had a impacted displaced subcapital left femoral neck fracture. Review of a facility Self-Reported Incident (SRI) dated 10/07/24, revealed Resident #36 was lying in bed on 10/05/24, and used her call light to request assistance with moving from one side to the other while in bed. State tested Nursing Aide (STNA) #110 arrived to the resident's room and attempted to assist Resident #36 with shifting her body from the left side to the right side. STNA #110 lifted Resident #36's left side of her body by herself, so she could remove the pillow and move it to the right side of the resident's body. During that time, Resident #36 expressed extreme pain when STNA #110 lifted the left side of her body. STNA #110 asked if she wanted the nurse to assess her, but Resident #36 declined. From 10/05/24 to 10/07/24, the resident received pain medication as ordered. An x-ray was not completed until 10/07/24. The results of the x-ray at the facility were inconclusive, so the resident was transferred to the hospital, where those x-rays confirmed she had a fractured hip, which was caused during the single person bed mobility procedures with STNA #110 on 10/05/24. Review of Licensed Practical Nurse (LPN) #107's interview statement dated 10/06/24 revealed Resident #36 told her about the incident the night before (on 10/05/24). She stated the aide turned her hard and quick, to the point that her left leg was not positioned correctly. LPN #107 confirmed she was still in pain. LPN #107 asked Resident #36 would like an x-ray in the morning. She also told the nurse she did not think she could attend her wound care appointment the next morning as it would be too painful to get on and off the gurney. She was given medication for pain at that time and stated she would let the daytime nurse know the next morning that they should get an x-ray. Review of LPN #105's interview statement dated 10/07/24 confirmed Resident #36 told her about the incident that happened on Saturday (10/05/24). She confirmed she had pain to her left side during the incident. LPN #105 documented she assessed her left and found no evidence of visible injury. But she contacted the nurse practitioner to report the incident and the pain; an x-ray was ordered for that day. Review of STNA #110's investigation statement dated 10/08/24 confirmed she was assisting Resident #36 with moving a pillow from underneath her left side and was going to move it to her right side as part of her turning schedule. She confirmed she was attempting to move the pillow from Resident #36 left side, and Resident #36 yelled in pain. She did not move her anymore. She ended her statement with, I was not told that 'Resident #36' required two people to assist her. Review of STNA #106's interview statement dated 10/10/24 revealed she worked the morning shift of Saturday, 10/06/24. She confirmed she was told by Resident #36 about the incident that happened the night before (10/05/24) and how her leg was hurting. She reported the incident and pain to the nurse that was working. She confirmed there was discomfort throughout her shift when they propped her up or moved her for care. There was nothing listed in the statement that the physician was notified about the incident or the resident's pain. Interview with Resident #36 on 11/09/24 at 12:00 P.M. confirmed one staff person was assisting her when she had requested to be turned/propped to the other side in bed. She stated it's usually two staff that would come in and help, but she didn't know this aide and didn't know if she could do it by herself. She confirmed she felt severe pain in her left leg/hip area as soon as the staff person (STNA #110) lifted her left side to remove the pillow. Resident #36 confirmed she was in severe pain after the incident. She stated she did not see a doctor, a doctor was not offered to her, and she did not receive an x-ray regarding her hip pain until 10/07/24. She confirmed she would have liked an x-ray sooner had it been offered. She stated the pain didn't really stop, but she received her pain medication as she typically takes it. Interview with Licensed Practical Nurse (LPN) #105 and STNA #101 on 11/09/24 at 12:10 P.M. and 12:18 P.M. confirmed each time they go in to assist Resident #36 with transferring or moving in bed, they have two people to assist. They confirmed that one person would lift the sheet that was underneath Resident #36, and the other staff would grab/move the pillow. Interview with STNA #106 on 11/09/24 at 12:46 P.M. confirmed Resident #36 told her about the incident that happened with STNA #110 and how it caused her a lot of pain. She confirmed she told the on-shift nurse about the incident and the pain. She was not certain what all the nurse did, but the nurse did give the resident as needed pain medication. She stated Resident #36 had pain, but in her opinion, she was always in pain, so she didn't feel it was different than her typical pain. But she did confirm the pain seemed to be more frequent than her typical pain, which was why she reported it to the nurse. She does not know if the physician was notified during that shift; that would be the responsibility of the nurse. Interview with LPN #107 on 11/09/24 at 12:49 P.M. confirmed she was told about the incident that happened on 10/05/24 regarding Resident #36. She asked Resident #36 if she wanted to get an x-ray the next morning; Resident #36 confirmed she would like that. She also stated she offered to send Resident #36 to the hospital that night, but stated Resident #36 declined because getting on a gurney would hurt too much. LPN #107 stated she was not given any information from the morning shift nurse at shift change about an incident with Resident #36 or any extra pain. But LPN #107 stated she did not contact the nurse practitioner or physician that night because, the x-ray technicians would not come to a facility on a Sunday night. Review of facility Condition Change Reporting, Residents policy, dated July 2015, revealed communication with the physician, the resident, and/or the responsible party was maintained when there was a significant change in condition and/or treatment. The physician, resident, and/or responsible party were notified when the resident's physical, communicative, psychosocial, or functional status changes unexpectedly, the resident is injured, or if treatment was significantly altered. This deficiency represents non-compliance investigated under Complaint Number OH00159103.

Based on observation, medical record review, facility policy review and interview, the facility failed to develop and implement an effective and individualized pressure ulcer prevention program to prevent the worsening of a pressure ulcer to the coccyx for Resident #37. Actual harm occurred on 05/01/24 when the facility Wound Nurse (WN) #318 identified Resident #37, who was at risk for pressure ulcer development and dependent on staff for turning and repositioning, had an unstageable (full thickness loss of tissue completely covered by dead tissue) pressure ulcer to the coccyx. The resident had been admitted to the facility on [DATE] with a Stage I (skin intact and redness to skin over a bony prominence) pressure ulcer to the coccyx. The facility failed to ensure adequate and effective interventions (including turning and repositioning) were provided to prevent the deterioration of the ulcer to an unstageable pressure ulcer. This affected one resident (#37) of three residents reviewed for change of condition. The facility census was 81. Findings include: Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including end stage renal disease, arteriovenous fistula, hyperparathyroidism, disorder of plasma protein metabolism, iron deficiency anemia, hypotension of dialysis, atrial fibrillation, anxiety disorder, hypertrophic disorder of the skin unspecified, coagulation defect, angina pectoris, anemia, gallstone ileus and hip fracture with surgical intervention. Review of the facility document titled Baseline Care Plan, dated 04/19/24, revealed Resident #37 was alert and at times confused, required assistance from two staff for bed mobility, transfers, walking and toileting and used a wheelchair for mobility. Resident #37 was continent of bowel and bladder and had a Stage I pressure wound to her coccyx. Interventions included turning and repositioning every two hours, pressure reducing mattress to the bed, pressure reducing cushion to the wheelchair and a zinc cream with foam dressing to the coccyx wound. Resident #37 had pain present in her right hip (status post fracture with surgical intervention) and coccyx with oxy (oxycodone: a narcotic pain medication) as the pharmacological intervention for the pain. Review of the facility document titled Skin Grid, dated 04/19/24 and authored by Licensed Practical Nurse (LPN) #337, revealed Resident #37 was admitted with a Stage I pressure ulcer to the coccyx. The epithelial tissue was pink, there was no drainage and no odor. There were no wound measurements noted on the skin grid. Review of the facility document titled Braden Scale for Predicting Pressure Ulcers, dated 04/19/24, revealed Resident #37 was at risk for development of pressure ulcers. Review of the Medication Administration Record (MAR) dated 04/01/24 to 04/30/24, for Resident #37 revealed she was being medicated for pain with Oxycodone-Acetaminophen oral tablet 5-325 milligrams one tablet every six hours as needed for pain which ranged between a pain level of four to seven (the pain scale was zero to 10 with ten being the worst pain) on 11 out of 12 occasions for assessment of pain. The pain medication was noted to be effective at treating the pain. The documentation on the MAR did not specify the location of the pain or specify there was an associated nurse's note to reflect the location of the resident's pain. In addition, review of the medical record/MAR revealed no documented evidence of turning and repositioning being provided for the resident every two hours. Review of the Treatment Administration Record (TAR) dated 04/01/24 to 04/30/24 revealed an order dated 04/19/24 for zinc to the coccyx, pad and protect with silicone border every night shift and every other day. The treatments were signed off as being completed as ordered. Review of the TAR revealed no documented evidence of turning and repositioning being provided for the resident every two hours. Review of the progress notes dated 04/19/24 to 04/30/24 revealed on 04/19/24 Resident #37 was admitted to the facility with a reddened area to coccyx. Zinc was applied and a pad and foam border dressing placed. On 04/25/24 at 6:10 A.M. it was noted Resident #37 was sent to the hospital emergency room due to low blood pressure and increased nausea and vomiting. On 04/25/24 at 5:15 P.M. Resident #37 returned to the facility with no new orders. Further review of the progress notes and medical record revealed a skin assessment was not completed on 04/25/24 upon the resident's return from the emergency room . Review of a progress note dated 04/26/24 at 6:05 P.M. revealed the dressing to the resident's coccyx was soiled. New foam dressing applied. Daughter in facility and concerned about coccyx wound. The note documented the area was present from recent hospital stay. Small slit in skin observed with small amount of redness noted to area. Advised daughter this nurse would notify facility wound nurse. Patient education given on interventions to promote wound healing. There was no information in the progress notes to indicate the resident was noncompliant with wound care or turning and repositioning. In addition, there was no evidence the facility wound nurse had assessed this wound from 04/19/24 through 04/26/24. Review of the facility document titled Skin Grid, dated 05/01/24 and authored by (facility) Wound Nurse (WN) #318 revealed this was the first observation by WN #318. Resident #37 was admitted with a Stage I pressure ulcer and currently had an unstageable pressure ulcer. The description of the wound included the wound had 100 percent light yellow slough (dead skin that impedes healing) covering the wound base. There was a small amount of serosanguinous (fluid containing both blood and liquid part of blood) drainage and no odor. The wound edges were well defined, well attached to the wound base and irregular in shape. The area around the wound had slow blanching (skin that remains white or pale for longer than normal when pressed) erythema (redness) without temperature change. The wound measured 2.0 centimeters (cm) in length, 0.5 cm in width and depth was 0.1 cm. Treatment was changed to cleanse with normal saline, apply Santyl (medication that removes dead tissue from wounds) ointment to the wound base and cover with adaptive dressing and secure with silicon dressing. Review of the physician order dated 05/01/24 revealed wound treatment orders for Santyl external ointment 250 units per gram (collagenase); apply to sacrum topically every night for wound care and cleanse open area with normal saline solution, apply Santyl to wound base, cover with adaptic, secure with sacral size foam dressing every night shift for open area. Review of a progress note dated 05/01/24 at 11:10 A.M. and authored by WN #318 revealed she saw Resident # 37 due to worsening area to sacrum (coccyx) present on admission. The resident's daughter stated the area started as a skin tear in the hospital before coming to the facility. Resident #37 expressed slight discomfort when sitting for long periods of time. Resident #37 had expressed discomfort when sitting for long periods in dialysis. The nurse practitioner was notified. Low air loss mattress was to be placed (recommended on 05/01/24) and a gel wheelchair cushion was in place (present from admission). Resident was on a turning schedule, and incontinence program. Resident's daughter agreed. Review of the MAR and TAR for May 2024 revealed on 05/01/24 an order to cleanse open area to sacrum with normal saline solution, apply Santyl to wound base, cover with adaptic, secure with sacral size foam dressing every night shift for open area and Santyl ointment to sacral area every night shift. The treatments were signed off as completed as ordered. The resident's pain level was assessed between a level two to four with Oxycodone-Acetaminophen noted to be effective treatment for the pain. Further review of the medical record revealed no documented evidence of turning and repositioning being provided for the resident every two hours. Interview on 05/01/24 at 11:30 A.M. with facility WN #318 revealed she was not aware of Resident #37's Stage I pressure ulcer that had been present on 04/19/24. WN #318 revealed she was notified by phone to look at Resident #37's skin on 04/26/24 but felt it was not a priority, therefore WN #318 assessed Resident #37's skin on 05/01/24. WN #318 stated because there was not a comprehensive assessment completed upon admission she could not assess if the wound had become better or worse. WN #318 also verified the dialysis center had not been notified Resident #37 had a pressure ulcer and there had been no communication to the dialysis center as to what interventions were needed during treatment. WN #318 also verified she was unaware if Resident #37 was compliant with every two hour turns. Interview with the Director of Nursing (DON) on 05/01/24 at 2:31 P.M. verified WN #318 was notified on 04/26/24 of wound concerns for Resident #37, but the resident was not assessed by the wound nurse until 05/01/24. The DON verified Resident #37 was admitted to the facility with a pressure ulcer Stage I, but a complete skin assessment was not done on 04/19/24. Interview on 05/01/24 at 3:30 P.M. with Director of Dialysis #422 revealed since admission, Resident #37 had received five treatments of dialysis lasting three hours each. Director of Dialysis #422 revealed the facility did not communicate Resident #37 had a pressure ulcer or interventions that were needed. Interview on 05/01/24 at 5:30 P.M. with Resident 37's family member revealed she had requested the wound nurse to evaluate Resident #37 since admission on 04/19/24 because Resident #37 had a tear on the buttocks during the hospital stay before admission. Resident #37's family member stated Resident #37 was not observed to be turned every two hours, and she visited the resident daily. Interview with Resident #37 on 05/01/24 at 5:30 P.M. revealed she had pain in her tailbone and felt like her wound was not getting better. Interview on 05/02/24 at 9:45 A.M. with LPN #311 revealed skin should be assessed twice a week with a full assessment and documentation on the Skin Grid assessment in the electronic medical record. LPN #311 revealed she notified WN # 318 by phone on 04/26/24 after Resident #37's family approached her with concerns and Resident #37's dressing was soiled. LPN #311 stated she did not think the wound was concerning so she did not do any measurements on it at that time. LPN #311 verified she did not notify any physician regarding Resident #37's skin. LPN #311 said Resident #37 was compliant with the turning and repositioning, but the aides were not required to document when this intervention was performed. Interview on 05/02/24 at 11:00 A.M. with State tested Nursing Assistant (STNA) #420 revealed Resident #37 was compliant with turning and repositioning, but stated staff were not required to document the provision of turning and repositioning. Interview on 05/02/24 at 11:50 A.M. with LPN #337 revealed she did not notify the wound nurse or the physician of Resident #37's Stage I pressure ulcer on admission. LPN #337 also verified she did not document measurements of the wound on admission. Observation on 05/02/24 at 4:30 P.M. with WN #318 revealed Resident #37 had a pressure ulcer to the coccyx. The ulcer contained yellow slough and the dressing in place was observed to be soiled. Review of the facility policy titled Pressure Ulcers Identification and Suggested Treatment Protocols, dated June 2015, revealed pressure ulcers would be identified and treatments would be ordered for proper healing of the wound. This deficiency represents noncompliance investigated under Master Complaint Number OH00153187.

Based on observation, medical record review, policy reviews and interview, the facility failed to implement Enhanced Barrier Precautions while providing wound care and incontinence care for Resident #37, and failed to appropriately use Personal Protective Equipment (PPE) while caring for Resident #44. This affected two residents (#37 and #44) out of three residents reviewed for infection control. The facility census was 81. Findings include: 1. Review of Resident #37's medical record revealed diagnoses including end stage renal disease and dependence on renal dialysis. On 05/01/24 an order was written to cleanse an open area on Resident #37's sacrum with normal saline, apply santyl (debriding agent) to the wound base, cover with adaptic and secure with a sacral size dressing every night shift. A wound assessment dated [DATE] revealed the open area was an unstageable pressure ulcer and was not infected. On 05/02/24 at 4:15 P.M., State tested Nursing Assistant (STNA) #376 was observed providing incontinence care to Resident #37. No gown was worn. On 05/02/24 directly after incontinence care was provided Licensed Practical Nurse (LPN) #393 (the infection control preventionist and wound nurse) was observed changing the dressing which was placed across the buttocks and coccygeal area. An unstageable pressure ulcer with the wound bed covered with slough (dead tissue). The dressing change was performed without the use of a gown. On 05/02/24 at 4:20 P.M., LPN #393 verified gowns had not been worn during incontinence care and wound care. LPN #393 indicated the facility used a Quality and Safety Oversight group(QSO) memo in determining when to initiate Enhanced Barrier Precautions. Review of QSO-24-08-NH memo dated 03/20/24 revealed in July 2022 the Centers for Disease Control (CDC) released updated enhanced barrier precaution recommendations for implementation of personal protective equipment (PPE) use in nursing homes to prevent the spread of multi-drug resistant organisms. The new recommendations now included the use of enhanced barrier precautions during high contact care activities for residents with chronic wounds or indwelling medical devices regardless of their multi-drug resistant organism status. Wounds included chronic wounds. Examples of chronic wounds were pressure ulcers. Examples of indwelling medical devices included feeding tubes. Review of the Implementation of PPE from CDC dated 07/12/22 revealed examples of high contact care activities such as changing briefs and providing wound care required the use of gowns and gloves at a minimum. 2. During the interview with LPN #393 on 05/02/24 at 4:20 P.M., a non-pervious gown was observed hanging on the door of Resident #44. Resident #44 was observed lying in her bed with a feeding tube pump. LPN #393 indicated Resident #44 was on enhanced barrier precautions and the gown was on the outside of the door so staff could use the gown for more than one use. LPN #393 stated she believed guidance from CDC was unclear regarding the re-use of gowns. Review of Resident #44's medical record revealed diagnoses of moderate protein calorie malnutrition and gastrostomy status. Review of Resident #44's care plan initiated 11/24/20 revealed Resident #44 had anoxic brain injury, inability to receive anything by mouth, and enteral nutrition use (tube feeding). Resident #44 did not have any urinary or bowel infections. A care plan dated 12/04/20 indicated Resident #44 was totally incontinent of bowel and bladder. On 05/02/24 at 4:30 P.M., LPN #393 informed the Administrator of discussions about non-compliance related to the re-use of gowns for multiple encounters for residents on enhanced barrier precautions. The Administrator insisted the facility could re-use gowns multiple times because CDC guidelines were unclear. Review of CDC Updated Guidance of Enhanced Barrier Precautions for Nursing Homes published 07/12/22 revealed one of the sources related to the guidance was a CDC Letter to nursing home staff which indicated the gown and gloves used for each resident during high contact resident care activities should be removed and discarded after each resident care encounter. This deficiency identified noncompliance as an incidental finding during the investigation of Master Complaint Number OH00153187.

Based on medical record review, review of job responsibilities and interview, the facility failed to ensure nurse practitioners provided visit notes in a timely manner and dated notes in a consistent manner to permit the determination of when the visit was made. This affected one (Resident #88) of three residents reviewed for change in condition. The facility census was 81. Findings include: Review of Resident #88's closed medical record revealed diagnoses including acute pulmonary edema, type two diabetes mellitus, end stage renal disease, hypotension, chronic congestive heart failure, dependence on renal dialysis, hypercholesterolemia, paroxysmal atrial fibrillation, hypothyroidism, hyperlipidemia, difficulty walking, obesity, thrombocytopenia, non-rheumatic aortic valve disorder, aneurysm of the ascending aorta without rupture, atrial flutter, non-pressure chronic ulcer of the foot, acute kidney failure, aortic valve stenosis, dizziness, cellulitis, anemia and a history of gastrointestinal hemorrhage. During an interview on 05/02/24 at 10:20 A.M., the Director of Nursing (DON) verified there was only one progress note from Nurse Practitioner (NP) #501 dated 01/31/24 in the medical record. The DON stated she knew NP #501 visited Resident #88 more often than that and she would call and have her load her notes into the electronic health record. The DON verified when NP #501 or the doctor visited the resident the date of the visit should be recorded. On 05/02/24 additional notes from NP #501 regarding Resident #88 were loaded into the electronic health record including two from a previous stay at the facility (12/01/23 and 12/06/23), four notes which did not contain the date of the visit, and notes from 02/05/24, 02/12/24, 02/19/24, 12/21/24, 02/28/24, 03/01/24, 03/06/24, and 03/13/24. On 05/02/24 at 1:33 P.M., the DON verified although multiple notes from NP #501 had been put into the system that day multiple notes did not reveal the dates of the visits. Review of the facility's Physician Services Policy, effective August 2015, indicated the physician was responsible for reviewing each resident's total program of care during visits, including medications and treatments at each visit. The physician should also sign and date all orders and write, sign new orders and date progress notes at each visit, so care and services were provided according to the most recent order. This deficiency identified noncompliance as an incidental finding during the investigation of Master Complaint Number OH00153187.

Based on medical record review, review or residents' rights and interview, the facility failed to ensure they honored a resident's right to choose their plan of treatment. This affected one (Resident #88) of three residents reviewed for change in condition. The facility census was 81. Findings include: Review of Resident #88's closed medical record revealed diagnoses including acute pulmonary edema, type two diabetes mellitus, end stage renal disease, hypotension, chronic congestive heart failure, dependence on renal dialysis, hypercholesterolemia, paroxysmal atrial fibrillation, hypothyroidism, hyperlipidemia, difficulty walking, obesity, thrombocytopenia, non-rheumatic aortic valve disorder, aneurysm of the ascending aorta without rupture, atrial flutter, non-pressure chronic ulcer of the foot, acute kidney failure, aortic valve stenosis, dizziness, cellulitis, anemia and a history of gastrointestinal hemorrhage. Review of a nurse practitioner note revealed on 03/13/24 Resident #88 was alert and in no obvious distress. Resident #88 was sitting in her wheelchair and had no complaints of weakness to her bilateral lower extremities but continued to complain of burning discomfort to both legs. Gabapentin (medication used for neuropathic pain) had been increased recently but nephrology wanted no additional increases of the gabapentin. Resident #88 was concerned her weakness would increase. Treatment options were discussed. Resident #88 did not want to go to the hospital at that time. Nurses would let the physician, nurse practitioner or physician assistant know of any changes. A nursing note dated 03/14/24 at 12:27 A.M. revealed Resident #88 was insisting on going to the hospital to get a Computed Tomography (CT) scan. Resident #88 stated she could have had a stroke days ago. The doctor was already aware. A neurology appointment was scheduled and Resident #88 would continue to be monitored. There was no indication the physician was made aware of the request at that time although that was an option discussed with the nurse practitioner on 03/13/24. A nursing note dated 03/14/24 at 8:23 A.M. revealed Resident #88 was requesting to be sent to the emergency room (ER) for a CT and reported I'm just not feeling right. A nursing note dated 03/14/24 at 9:14 A.M. indicated Resident #88 was transported to the hospital for evaluation. A message was left for Resident #88's daughter. A nursing note dated 03/14/24 at 2:26 P.M. indicated Resident #88 was being transferred back to the facility. A straight catheterization was done and she had a urinary tract infection. An order was received for Omnicef (antibiotic) with the first dose given in the ER. A CT was negative. Review of the Nursing Home Resident's [NAME] of Rights revealed residents had the right to have all reasonable requests and inquiries responded to promptly. During an interview on 05/01/24 at 3:33 P.M., the Administrator stated staff were taught residents and families had the right to have wishes honored regarding treatment, including transfers to the hospital. On 05/01/24 at 4:05 P.M., the Administrator stated the nurse who did not send Resident #88 to the hospital when she was insisting on going worked for agency and the facility no longer permitted her to work at the facility. This deficiency identified noncompliance as an incidental finding during the investigation of Master Complaint Number OH00153187.

Based on medical record review, review of a laboratory agreement, and interview, the facility failed to obtain laboratory tests in a timely manner. This affected one (Resident #88) of three residents reviewed for change in status. The facility census was 81. Findings include: Review of Resident #88's closed medical record revealed diagnoses including acute pulmonary edema, type two diabetes mellitus, end stage renal disease, hypotension, chronic congestive heart failure, dependence on renal dialysis, hypercholesterolemia, paroxysmal atrial fibrillation, hypothyroidism, hyperlipidemia, difficulty walking, obesity, thrombocytopenia, non-rheumatic aortic valve disorder, aneurysm of the ascending aorta without rupture, atrial flutter, non-pressure chronic ulcer of the foot, acute kidney failure, aortic valve stenosis, dizziness, cellulitis, anemia and a history of gastrointestinal hemorrhage. On 03/01/24 an order was written STAT (one time order which that should be prioritized because it was of urgent nature) to obtain labwork including a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP). Review of a nursing note dated 03/02/24 at 12:29 A.M. indicated at the beginning of the shift ( 7:00 P.M. - 7:00 A.M.) Resident #88 complained of pain and nausea. A blood pressure of 100/50 was recorded. Resident #88's daughter was at bedside concerned Resident #88's sodium level might be low. A call was placed to the nurse practitioner with new orders for a stat CBC and CMP or offer to send Resident #88 to the emergency room (ER). Resident #88 refused to go to the ER. Lab had not been in to draw the bloodwork for the laboratory tests. Review of a nursing note dated 03/02/24 at 2:58 P.M. revealed Resident #88's daughter called to inquire about pending blood work. Review of a nursing note dated 03/02/24 at 3:38 P.M. indicated a call was placed to the lab regarding the stat CBC and CMP. The lab stated they never received the order so the stat lab was ordered at that time. Review of the laboratory report from 03/02/24 revealed the stat lab was drawn on 03/02/24 at 4:50 P.M. Review of a nursing note dated 03/02/24 at 6:32 P.M. revealed laboratory results were returned with results including a hemoglobin value of 6.2 grams per deciliter (reference range 11.5-15.5) and hematocrit of 20.3% (reference range of 34-48). A new order was received to send Resident #88 to the ER for evaluation and treatment. Resident #88 and her daughter were aware. A nursing note dated 03/02/24 at 8:19 P.M. revealed Resident #88 left the facility via stretcher for transfer to the hospital at 7:40 P.M. Review of a Laboratory Services Agreement revealed the agreement was made on 05/02/22 and STAT phlebotomy services would be available/provided seven days a week, 24 hours a day within four hours of the request. During an interview on 04/30/24 at 3:02 P.M., the Director of Nursing (DON) stated when stat labs were ordered the expectation was they would be obtained within four hours. The DON verified the stat labs ordered 03/01/24 were not obtained until 03/02/24 at 4:50 P.M. On 04/30/24 at 4:36 P.M., the Director of Nursing (DON) verified the stat lab orders received on 03/01/24 were not obtained timely. This deficiency represents noncompliance as an incidental finding during the investigation of Master Complaint Number OH00153187.

Based on resident interview, medical record review, staff interview and facility policy review the facility failed to ensure residents were provided showers as per their preference. This affected one (Resident #49) of three residents reviewed for showers. The facility census was 86. Findings include: Interview 11/17/23 at 9:40 A.M. with Resident #49 confirmed she had not had a shower or bath for several weeks. Review of Resident #49's medical record revealed an admitted [DATE] with admission diagnoses that included multiple sclerosis and chronic obstructive pulmonary disease. Review of Resident #49's Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 08/01/23 revealed the resident had an independent and intact cognition level and required extensive staff assistance with bathing. Review of the State tested Nurse Aide (STNA) Tasks documentation for Resident #49 revealed there was no documentation indicating a bath or shower was provided for the resident for the 30-day period prior to the survey. There was no documentation of Resident #49 refusing a shower or bath during the time frame. Review of the progress notes for Resident #49 for the 30-day period prior to the survey revealed they did not include documentation regarding refusals of baths or showers for the resident. Interview with the Director of Nursing (DON) on 11/17/23 at 11:50 A.M. confirmed the facility had no documentation of a shower or bath or a refusal of a shower or bath for Resident #49 for the 30-day period prior the survey. Review of the facility policy titled Bath (Complete, Partial, Shower, Tub) with a revision date of June 2015 revealed residents will be bathed per resident request to promote cleanliness and overall psychosocial well-being. This deficiency represents non-compliance investigated under Complaint Number OH00148310.

Based on record review and interview the facility failed to ensure the code status in the hard chart/medical record matched the electronic medical record for two (Resident's #13 and #24) of 24 resident records reviewed. The facility census was 79. Finding Include: 1. Review of the medical record for Resident #13 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had intact cognition. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's electronic chart revealed the code status matched the physician order. Review of Resident #13's hard chart on 08/23/22 at 10:14 A.M. revealed the code status form in the chart was marked Do Not Resuscitate Comfort Care (DNRCC). There was a Do Not Resuscitate (DNR) sticker on the outside of chart. Interview on 08/23/22 at 1:01 P.M. the Director of Nursing (DON) verified the hard chart code status form did not match the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Review of the medical record for Resident #24 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #24 had severely impaired cognition. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's electronic chart revealed the code status matched the physician order. Review of Resident #24's hard chart on 08/23/22 at 10:33 A.M. revealed the code status form was marked for both DNRCC and DNRCC-A. Interview on 08/23/22 at 10:24 A.M. the DON verified the hard chart was marked for two different code statuses.

Based on interview and record review, the facility failed to notify Resident #30's family of the discovery of an unstageable pressure ulcer. This affected one (Resident #30) of three residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #30 revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #30 expired at the facility on [DATE]. Review of Resident #30's Minimum Data Set (MDS) 3.0 dated [DATE], revealed the resident was severely cognitively impaired, with fluctuating periods of inattention and altered level of consciousness, required total dependence of two for most activities of daily living (ADL), used a wheelchair, was always incontinent of bladder and bowels, had no falls, had significant weight loss, and had an unstageable pressure ulcers. Review of Resident #30's late entry progress note entered [DATE] for [DATE], revealed the identification of an unstageable sacral pressure ulcer measuring 2.5 centimeters (cm) by 2.5 cm by 0.5 cm. Treatment was initiated and the nurse practitioner, Director of Nursing (DON), and floor nurse was made aware. The note did not indicate Resident #30's family was notified. Review of Resident #30's profile revealed the resident's daughter was listed as emergency contact and responsible party and the medical record was silent of the daughter being notified of the pressure ulcer discovered on [DATE]. Interview on [DATE] at 2:36 P.M. with LPN #203 verified Resident #30's family should have been notified when the pressure ulcer was discovered. LPN #203 could not confirm Resident #30's family was notified. Documentation that Resident #30's family was notified of a change in condition upon development of the unstageable pressure ulcer was requested and was not provided by the facility. This deficiency substantiates Complaint Number OH 427.

Based on observation, interview and record review the facility failed to ensure contact and droplet isolation precautions were followed for Resident #2. This affected two residents (Resident's #2 and #3) of three residents reviewed for infection control. The facility census was 84. Findings include: Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. This infection required contact isolation precautions to prevent the bacterial infection, Extended Spectrum Beta-Lactamase (ESBL) from spreading to others. The resident was also in a 14 day quarantine (droplet precautions) for COVID 19 due to being a new admission. Review of the baseline care plan revealed Resident #2 was to be in contact isolation for ESBL in her urine. Review of the physicians orders dated 06/13/20 revealed Resident #2 was to receive an intravenous (IV) antibiotic three times a day for a total of 20 doses. On 06/17/20 at 11:00 A.M., observation of Resident #2's outside doorway had signs for contact and droplet isolation precautions with a bin containing personal protective equipment (PPE). A sign read to not enter room without having on the following PPE: gown, gloves, masks and/or face shield. Looking into the room revealed State tested Nurse Aide (STNA) #5 was at Resident #2's bed side and picked up a Styrofoam cup with a straw in it and exited the room. STNA #5 only had on a home made face covering which was not secured around his nose, exposing his nose. STNA #5 was observed walking down the hall and then returned to Resident #2's room with the same Styrofoam cup with the straw still in the lid and placed the cup on the resident's bed side table without donning any PPE. STNA #5 then left the room and entered Resident #3's room which was across the hall, put on gloves, grabbed Resident #3's walker and assisted the resident to the bathroom, removed his gloves and exited the room, never washing or sanitizing his hands at any point during the entire observation. On 06/17/20 at 11:10 A.M., interview with STNA #6 revealed Resident #2 was in isolation but she thought she only needed to don PPE when performing care and could enter the room for other reasons without donning any PPE. STNA #6 had on a home make face covering that was not secure around her nose. On 06/17/20 at 11:12 A.M., interview with the Director of Nursing (DON) verified Resident #2 was in contact isolation for ESBL and droplet isolation due to being a new admission and monitoring for COVID 19. The DON verified any time anyone entered the room they needed to don full PPE as the sign indicated to prevent the transfer of the ESBL infection and preventative for COVID 19. The surveyor informed the DON of the above observation and interview. On 06/17/20 at 11:15 A.M., interview with STNA #5, with the DON present, verified his home made face covering did not fit properly and he was not able to keep his nose covered. The DON requested STNA #5 remove the mask and obtain a surgical mask to ensure both his mouth and nose were covered at all times. The surveyor reviewed the above observations and STNA #5 verified he took the used Styrofoam cup to the ice bin and filled it with ice using another Styrofoam cup that was near the bin, then replaced the used lid and straw and returned the used Styrofoam cup to Resident #2 without wearing gloves or washing his hands at any point. STNA #5 verified as he was returning the cup to Resident #2, Resident #3's call light was activated and he entered Resident #3's room without washing or sanitizing his hands, put on gloves and assisted Resident #3 to the bathroom, removed his gloves and still did not wash his hands and his home made face covering was not covering his nose at any point when he was in contact with both residents. STNA #5 verified he entered Resident #2's room multiple times without donning any PPE because he thought he only needed to when performing care. On 06/17/20 at 11:25 A.M., interview with Licensed Practical Nurse (LPN) #7 verified any time anyone enters Resident #2's room they should have on full PPE including a surgical mask and not a home made face covering. Review of the 02/26/20 contact precautions policy revealed for any known infection anyone entering the room should wear a gown, gloves and change the gloves when come in contact with the infective materials. Also perform hand hygiene prior to leaving the room. Review of the 02/26/20 droplet precautions policy revealed for any suspected infections anyone entering the room should wear disposable gown, gloves and surgical mask, remove the PPE and perform hand hygiene prior to leaving the room. Review of the updated policy, 03/16/20, for COVID 19 revealed anyone admitted to the facility would be placed in quarantine and placed on droplet precautions for 14 days, anyone entering the room should don PPE as above and also including face shield and/or goggles and use disposable plates and cups.

Based on observation, record review and interview the facility failed to maintain adequate infection control practices during incontinence care for Resident #1 to prevent the spread of infection. This affected one resident (Resident #1) of seven residents observed for infection control. Findings include: An observation of incontinence care for Resident #1 was completed on 07/02/18 at 11:03 A.M. State tested Nurse Aide (STNA) #102 and STNA #103 washed their hands and applied gloves. STNA #103 positioned Resident #1 on her back. STNA #102 cleansed the resident's perineal area including the groin and labia. STNA #103 positioned Resident #1 on her right side. STNA #102 cleansed the resident's buttocks, rectum, and gluteal crease. STNA #102 discarded the disposable wipes. Without removing her gloves and washing her hands, STNA #102 picked up the package of disposable wipes from the resident's bed and placed it on the resident's over bed table. STNA #102 crossed the room and picked up the resident's mechanical lift pad and placed it under Resident #1. STNA #102 assisted Resident #1 with adjusting her T-shirt. Then, STNA #102 removed and discarded her gloves. STNA #102 did not wash her hands. STNA #102 exited the room and returned with the mechanical lift. An interview was completed with STNA #102 immediately following the observation. STNA #102 verified the above observation. Review of the Infection Control Log dated 04/24/18 revealed Resident #1 received antibiotic therapy for a urinary tract infection. The infection resolved 05/01/18. Review of the Infection Control Log dated 05/23/18 revealed Resident #1 received antibiotic therapy for a urinary tract infection. The infection resolved 06/02/18. Review of the Handwashing policy dated 07/2015 revealed a policy for proper handwashing technique will be used by all employees to maintain optimal infection control. The purpose of the policy was: To maintain medical asepsis, for infection control; to reduce transferal of microorganisms from resident to resident; to reduce transferal of microorganisms from staff to residents. Review of the facility policy for Perineal Care dated (MONTH) (YEAR) revealed the care will be performed, as needed, to keep the perineum clean, dry and free of odor and infection. Review of the procedure for female perineal care revealed gloves should be removed after cleansing and positioning the resident back on her back, and prior to covering the resident and making the resident comfortable. This deficiency substantiates Complaint Number OH 634.

Based on observation, record review and interview the facility failed to ensure timely assistance with the placement of hearing aids was provided for Resident #1. This affected one resident (Resident #1) of three residents reviewed for the use of hearing aids. Findings include: Record review revealed Resident #1 had a physician order, dated 05/23/18 for hearing aids, which were to be worn daily, from morning until bedtime. The hearing aids were to be kept in a case in the medication cart, inserted by the day shift staff and removed by the night shift staff. Review of the Medication Administration Record [REDACTED].M. and removed at 9:00 P.M. Review of a resident care plan revealed Resident #1 had impaired communication related to poor cognition and a hearing deficit. The goal of the plan of care was Resident #1 would continue to make her needs known. Resident #1 would have her needs met without undue frustration through next review. The care plan interventions included assessing for understanding of what was being said, and wearing hearing aids as ordered by the physician. Resident #1 was observed in bed on 07/02/18 at 8:48 A.M. Resident #1 was alert, sitting upright, and eating breakfast. Upon introduction, Resident #1 leaned slightly forward, tilted her head and asked this surveyor to repeat what was said. An interview was completed at the time of the observation. During the interview, Resident #1 revealed she was hard of hearing. Resident #1 verified she had hearing aids. Resident #1 revealed the nurses kept her hearing aids because she was not able to insert them without assistance. Resident #1 revealed she had not had her hearing aids in place for maybe three days. Resident #1 revealed she does ask the staff for her hearing aids and sometimes they responded and sometimes, not. Resident #1 said maybe they forget when I ask, but I'm not sure. Resident #1 verified she did have some hearing but it was not very clear. An observation of hygiene care was observed the same morning at 11:03 A.M. State tested Nurse Aide (STNA) #102 and STNA #103 provided verbal directions and physical prompting throughout the procedure. Each STNA would repeat the cues and directions in a louder voice when Resident #1 indicated she did not hear them. A mechanical lift transfer from the bed to the wheelchair was completed by the same STNAs at 11:20 A.M. Again, each STNA provided verbal directions and physical prompting throughout the procedure. Each STNA would repeat the cues and directions in a louder voice when Resident #1 indicated she did not hear them. An interview was completed with STNA #102 and #103 immediately following the observation. Each verified Resident #1 did wear hearing aids. STNA #102 and #103 revealed the hearing aids were kept in the medication cart and it was the nurses responsibility to insert the hearing aids. An interview was completed with Licensed Practical Nurse (LPN) #104 at 11:30 A.M. LPN #104 verified it was her responsibility to insert the resident's hearing aids every morning. However, she was busy with additional tasks and it slipped her mind. This deficiency substantiates Complaint Number OH 634. This deficiency is also an example of continued non-compliance from the survey dated 06/14/18.

Based on interview, record review and policy and procedure review, the facility failed to provide adequate supervision and assistance during a transfer. This resulted in Actual Harm when Resident #50 sustained a displaced spiral fracture of the arm humeral shaft. This affected one of three residents reviewed for accidents. Findings include: Review of the clinical record revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 assessment dated [DATE] indicated the resident was independent in daily decision making ability and displayed no behavioral symptoms, required the extensive assistance of two plus persons for bed mobility and transfers, and had no falls since her admission or prior assessment. Review of the fall risk assessment dated [DATE] identified her as high risk for falls. Review of Resident #50's falls plan of care indicated she was high risk due to fluctuating blood sugars, pain/psychotropic/narcotic medication use/visual impairment, throwing her leg over the side of the bed and left above knee amputation. Review of the nurse's progress notes authored by Registered Nurse (RN) #40 on 08/02/17 at 6:36 A.M. indicated at 6:10 A.M. she was alerted by State tested Nurse Aide (STNA) #41 that Resident #50 had fallen out of bed by swinging her right leg over to reposition. RN #40 immediately went into the room and found Resident #50 was face down between the bed and window wall. Resident #50 complained of head and left arm pain. RN #40 called 911 for emergency assistance with getting her up off the floor. No vital signs were able to be obtained because her left arm was in severe pain and her right arm was under her body. The physician was notified immediately and ordered Resident #50 be sent to the hospital for an evaluation and treatment. The family was notified. On 08/02/17 at 11:18 P.M. Resident #50 returned to the facility wearing a sling and with orders to follow up with an orthopedic surgeon. She had sustained a displaced spiral fracture of the humerus shaft of the left arm. Interview with the Director of Nursing and the Administrator on 08/10/17 at 1:25 P.M. verified STNA #41 attempted to turn Resident #50 by herself instead of using two staff, as the resident was assessed to need, and the resident rolled out of bed onto the floor sustaining a fractured arm. They said Resident #50 flipped her leg out as she always did and rolled out of bed onto the floor. STNA #41 was not a new STNA and should have followed the care card. Review of the Fall policy and procedure dated October 2015 indicated falls would be reported, investigated, evaluate current interventions, interdisciplinary review and implement appropriate interventions to prevent further falls. This deficiency substantiates Complaint Number OH 876.

Based on medical record review and interview, the facility failed to promptly notify Resident #2's physician of her ongoing nausea and vomiting, poor oral intakes, poor urine output and refusals of medications. Actual Harm resulted when Resident #2 was sent to the hospital on [DATE] as a result of laboratory testing revealing critically high levels of sodium and chloride, indicating dehydration. Resident #2 was admitted to intensive care and did not return to the facility until 05/07/15. This affected one (Resident #2) of four residents reviewed for a change in condition. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Resident #2 had a nutritional care plan initiated on 10/26/14 which indicated she had a poor appetite, gastrointestinal distress and was at risk for dehydration. Interventions included notifying the physician of any significant problems. Review of the nurse's note dated 04/15/15 at 6:19 A.M. revealed [MEDICATION NAME], a medication for nausea/vomiting was administered. On 04/16/15 at 5:39 A.M., the nurse's note indicated Resident #2 refused all of her medications, including medications for nausea, due to complaints of nausea and vomiting. On 04/16/15 at 6:19 A.M., Resident #2 did take [MEDICATION NAME] medication for nausea. Review of the nurse's notes dated 04/19/15 revealed Resident #2's 10:00 A.M. medications were held due to nausea. At 2:51 P.M., [MEDICATION NAME] was administered for nausea. On 04/22/15 at 9:52 A.M., nurse's notes indicated [MEDICATION NAME] was given for nausea and the 10:00 A.M. medications were held due to Resident #2's nausea. The nurse's note dated 04/22/15 at 2:05 P.M. indicated another medication was held due to nausea. Review of the nurse's notes dated 04/24/15 at 9:16 A.M. revealed Resident #2 was vomiting. At 9:20 A.M., the nurse's note indicated Resident #2 had an emesis and refused all of her medications except [MEDICATION NAME] for nausea. Review of the nurse's notes dated 04/27/15 at 2:06 P.M. indicated Resident #2 refused all of her medications, including medications for nausea, due to nausea. The note at 6:40 P.M. identified Resident #2 ate a couple bites of jello and had a small emesis. Resident #2 had one urination which was described as very dark in color and with a strong odor, which could indicate dehydration. This note also indicated Resident #2 refused all of her medications, including the ones for nausea. Review of meal intake records from 04/22/15 through 04/28/15 revealed nine documented meal refusals, and seven documented meals with intakes of 0-25%. There was only documentation for one meal on 04/25/15 and no documentation for any meals on 04/26/15. Review of the urine output record for Resident #2 revealed she had no documented urine output on 04/25/15 and 04/26/15 on the 7:00 AM to 7:00 PM, 12 hour shift and no urine output at all for the entire day on 04/27/15 or on 04/28/15 on the 7:00 AM to 7:00 PM shift, the day she was sent to the hospital. Review of the medical record revealed there was no evidence of physician notification of Resident #2's continued nausea and vomiting, refusal of meals and medications and low urine output until 04/28/15. Review of a nurse's note dated 04/28/15 at 12:52 P.M. revealed the physician ordered stat (immediate) lab testing to be completed for Resident #2 as well as intravenous fluids of 0.9% sodium chloride to be started at 50 cubic centimeters (cc) an hour continuously. The nurse's note at 6:52 P.M., revealed abnormal lab results were called to the physician and the resident was then ordered to be sent to the hospital. Resident #2 left the facility at 7:30 P.M. The nurse's note dated 04/28/15 at 10:41 P.M. indicated Resident #2 was admitted to the hospital with [REDACTED]. Review of the laboratory test results from 04/28/15 revealed a critically elevated sodium level of 166 (normal 136-145), a critically high chloride level of 136 (normal 98-107) and a critically high blood urea nitrogen (BUN) of 173 (normal 7-19). Review of the emergency room evaluation and treatment record dated 04/28/15 revealed Resident #2 had an elevated heart rate of 119, her white blood count was 22.2, indicating the presence of infection, had an elevated sodium of 168, elevated chloride of 133 and an elevated BUN of 171. Interventions included an intravenous (IV) bolus of fluids, a continuous IV infusion, cardiac monitoring and monitoring of her oxygen level. Her admitting [DIAGNOSES REDACTED]. She was admitted to an intensive care unit. On 05/28/15 at 1:40 P.M., interview of the Director of Nursing (DON) and the Administrator verified that from 04/15/15 to 04/28/15, there was no evidence the physician was notified of inadequate oral intakes, repeated complaints of nausea and little or no urine output. When the physician was notified on 04/28/15, the resident was transferred to the hospital with critical lab results. The DON indicated the physician ordered the labs on 04/28/15 and had seen the resident. The DON provided documentation of a physician visit dated 04/27/15. The physician documented Resident #2 as being lethargic, weak, having nausea and vomiting and having a dry mouth. The physician indicated intravenous fluids (IV) would be ordered and lab testing would be ordered. Although this document was dated 04/27/15, no written physician orders [REDACTED]. This was verified with the Administrator, Staff Development Registered Nurse #10 and the DON on 05/28/15 at 3:20 P.M. This deficiency substantiates Complaint Number OH 126.

Based on record review and interview, the facility failed to promptly address Resident #2's ongoing nausea and vomiting, poor oral intakes, poor urine output and refusals of medications. Actual Harm resulted when Resident #2 was sent to the hospital on [DATE] as a result of emergency laboratory testing which revealed critically high levels of sodium and chloride, indicating dehydration. Resident #2 was admitted to the intensive care unit with dehydration. This affected one (Resident #2) of one resident reviewed for hydration, of one resident identified by the facility with hydration concerns. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Resident #2 had a nutritional care plan initiated on 10/26/14 which indicated she had a poor appetite, gastrointestinal distress and was at risk for dehydration. Interventions included notifying the physician of any significant problems. Review of the resident care card dated 04/03/15 indicated Resident #2 was alert and oriented to person, place and time and always understood. She required supervision to eat and was continent of urine. Review of the nurse's note dated 04/15/15 at 6:19 A.M. revealed [MEDICATION NAME], a medication for nausea/vomiting was administered. On 04/16/15 at 5:39 A.M., the nurse's note indicated Resident #2 refused all of her medications, including medications for nausea, due to complaints of nausea and vomiting. On 04/16/15 at 6:19 AM, Resident #2 did take [MEDICATION NAME] medication for nausea. Review of the nurse's notes dated 04/19/15 revealed Resident #2's 10:00 A.M. medications were held due to nausea. At 2:51 P.M., [MEDICATION NAME] was administered for nausea. On 04/22/15 at 9:52 A.M., nurse's notes indicated [MEDICATION NAME] was given for nausea and the 10:00 A.M. medications were held due to Resident #2's nausea. The nurse's note dated 04/22/15 at 2:05 P.M. indicated another medication was held due to nausea. Review of the nurse's notes dated 04/24/15 at 9:16 A.M. revealed Resident #2 was vomiting. At 9:20 A.M., the nurse's note indicated Resident #2 had an emesis and refused all of her medications except [MEDICATION NAME] for nausea. Review of the nurse's notes dated 04/27/15 at 2:06 P.M. indicated Resident #2 refused all of her medications, including medications for nausea, due to nausea. The note at 6:40 P.M. said Resident #2 ate a couple bites of jello and had a small emesis. Resident #2 had one urination which was described as very dark in color and with a strong odor, which could indicate dehydration. This note also indicated Resident #2 refused all of her medications, including the ones for nausea. Review of meal intake records from 04/22/15 through 04/28/15 revealed nine documented meal refusals, and seven documented meals with intakes of 0-25%. There was only documentation for one meal on 04/25/15 and no documentation for any meals on 04/26/15. Review of the urine output record for Resident #2 revealed she had no documented urine output on 04/25/15 and 04/26/15 on the 7:00 AM to 7:00 PM, 12 hour shift and no urine output at all for the entire day on 04/27/15 or on 04/28/15 on the 7:00 AM to 7:00 PM shift, the day she was sent to the hospital. Review of a nurse's note dated 04/28/15 at 12:52 P.M. revealed the physician ordered stat (immediate) lab testing to be completed for Resident #2 and for intravenous fluids of 0.9%, sodium chloride, to be started at 50 cubic centimeters (cc) an hour continuous. The nurse's note dated 04/28/15 at 1:19 P.M., indicated Resident #2 ate only bites of food and took sips of her supplement. She refused to eat. The nurse's note at 6:52 P.M., revealed abnormal lab results were called to the physician and the resident was ordered to be sent to the hospital. Resident #2 left the facility at 7:30 P.M. The nurse's note dated 04/28/15 at 10:41 P.M. indicated Resident #2 was admitted to the hospital with [REDACTED]. Review of the laboratory test results from 04/28/15 revealed a critically elevated sodium level of 166 (normal 136-145), a critically high chloride level of 136 (normal 98-107) and a critically high blood urea nitrogen (BUN) of 173 (normal 7-19). Review of the emergency room evaluation and treatment record dated 04/28/15 revealed Resident #2 had an elevated heart rate of 119, her white blood count was 22.2, indicating the presence of infection, had an elevated sodium of 168, elevated chloride of 133 and an elevated BUN of 171. Interventions included an intravenous (IV) bolus of fluids, a continuous IV infusion, cardiac monitoring and monitoring of her oxygen level. Her admitting [DIAGNOSES REDACTED]. She was admitted to one of the intensive care units. Review of the transfer form dated 05/07/15 when Resident #2 returned to the facility revealed she had a feeding tube inserted on 05/05/15. On 05/28/15 at 1:40 PM, interview of the Director of Nursing (DON) and the Administrator verified that from 04/15/15 to 04/28/15, there was no evidence the physician was notified of inadequate oral intakes, repeated complaints of nausea and little or no urine output. When the physician was notified on 04/28/15, the resident was sent to and admitted to the hospital with [REDACTED]. The DON provided documentation of a physician visit dated 04/27/15. The physician documented Resident #2 as being lethargic, weak, having nausea and vomiting and having a dry mouth. The physician indicated intravenous fluids (IV) would be ordered and lab testing would be ordered. The comments section also indicated Resident #2 may need a gastrostomy (feeding) tube and they would check for other test results. Although this document was dated 04/27/15, no written physician orders [REDACTED]. This was verified with the Administrator, Staff Development Registered Nurse #10 and the DON on 05/28/15 at 3:20 P.M. They also verified Resident #2's poor urine output and absence of urine output recorded. This deficiency substantiates Complaint Number OH 126.