Every finding on record at Ayden Healthcare of Oregon

Based on observation, review of the menu, review of food forum meeting minutes, interview and policy review, the facility failed to ensure food had an appetizing presentation and was palatable to taste. This affected four residents (#100, #36, #83, #35) with the potential to affect all residents receiving meals from the kitchen expect one resident (#15) who received nothing by mouth. The facility census was 78. Findings include: Review of the Food Forum meeting minutes dated 05/20/26 revealed the bananas had been served frozen and the cookies were sometimes too hard. Review of the Food Forum meeting minutes dated 06/17/26 revealed residents were not receiving condiments on their meal trays, not receiving butter and syrup when they had pancakes, and the vegetables were too hard to chew and sometimes overcooked. Review of the Food Forum meeting minutes dated 07/15/26 revealed the resident were tired of peas and carrots and requested numerous new food items. Review of the menu for 08/18/26 revealed the lunch meal included spaghetti with sauce and meatballs, California vegetable blend, bread sticks, peanut butter bar, and a choice of beverages. Observation on 08/18/26 at 12:21 P.M. of a meal test tray with Dietary Supervisor (DS) #203 revealed a plate of spaghetti with meat sauce, a garlic breadstick, and a scoop of mushy California vegetables shaped like a ball, which were dull in color, overcooked, and no longer were in the shape of any vegetable. The presentation of the food on the plate, especially the vegetables, was not visually appealing. Further observation revealed the spaghetti and breadstick were palatable to taste and temperature. The vegetables tasted extremely overcooked, were mushy, watery, and bland. Interview on 08/18/26 at 12:21 P.M., DS #203 verified the poor presentation of the plate due to the smashed pile of vegetables. DS #203 verified the vegetables were unappetizing, mushy, and were overcooked. DS #203 revealed the cook probably started cooking the vegetables too early. Interview on 08/18/26 at 3:45 P.M., Resident #100 revealed she sent her lunch tray back and ordered a sandwich. Resident #100 stated the vegetables were mush.Interview on 08/18/26 at 3:57 P.M., Resident #36 revealed the spaghetti and breadstick were okay, but the vegetables were overcooked and not good. Interview on 08/18/26 at 3:59 P.M., Resident #83 revealed he had not eaten his lunch. Resident #83 revealed the food had not looked good and he had the nursing assistant take away the meal tray. Interview on 08/18/26 at 4:01 P.M., Resident #35 revealed the vegetables at lunch were overcooked. Review of the facility policy titled Food Palatability, dated 03/07/21, revealed residents would receive nourishing and palatable meals served at proper temperatures. Prior to service, food should be tested by the Culinary Services Manager and/or cook to verify taste and temperature. Food would be placed on individual plates neatly with attention to appearance, color palate and presentation.

Based on observation, medical record review, interview and review of the facility policy, the facility failed to ensure pressure ulcer wound dressings were in place and further failed to ensure pressure ulcer preventative interventions were implemented. This affected one (#25) of three residents reviewed for pressure ulcers. The facility census was 86. Findings include:Review of the medical record for Resident #25 revealed an admission date of 09/24/25. Diagnoses included paraplegia, polyneuropathy, pressure ulcer of right buttocks stage IV, and pressure ulcer of sacral region, stage IV.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Resident #25 had two unhealed stage IV pressure ulcers. Review of the care plan dated 05/21/26 revealed Resident #25 was at risk for impaired skin integrity related to incontinence, decreased mobility, current wounds, and osteomyelitis. Interventions included administering wound care treatments as ordered and report any abnormalities to the doctor. Resident #25 was to wear offloading boots while in bed.Review of the physician's orders dated 04/10/26 revealed Resident #25 had an order for wound care to an open area to the sacrum. The area was to be cleansed with wound cleanser, pat dry, apply collagen to the area, and cover with silicone border Zetuvit (advanced, multi-layer superabsorbent wound dressing designed to pull fluid away from the wound to help prevent the skin from getting soggy and breaking down) daily and as needed. Further review revealed Resident #25 had an order dated 04/10/26 for wound care for the posterior thigh. The area was to be cleansed with wound care wash, pat dry, apply collagen to the area and silicone border Zetuvit once daily and as needed. Lastly, Resident #25 had an order dated 05/07/26 to apply Triad cream to the left foot and cover with silicone border dressing once daily on day shift. Resident #25 was to wear a left foot (offloading) boot at nighttime and encourage the resident to wear the boot during the day if lying down.Observation on 06/02/26 at 10:03 A.M. revealed Resident #25 was lying in bed. Further observation revealed there was no wound dressing to the resident's sacrum wound, posterior right thigh wound, or to the left foot. Additional observation revealed Resident #25 was not wearing the offloading boot to the left foot. Concurrent interview with Resident #25 revealed the facility changed his wound dressings daily; however, they often fell off during care, such as incontinence brief changes and getting out of bed, and the staff did not reapply the dressings when they fell off. Resident #25 further stated that the staff never offered to put his offloading boot on and it was sitting in a box next to his bed.Interview on 06/02/26 at 10:25 A.M. with Licensed Practical Nurse (LPN) #158 confirmed she did not check Resident #25 today to ensure his wound dressings were in place. LPN #158 verified Resident #25 did not have a dressing to his coccyx, right posterior thigh, or left foot and was not wearing the offloading boot while in bed. Review of the facility policy titled, Dressings, Dry/Clean, dated September 2013, revealed the nurse should review the resident's plan of care and orders to determine if there were special resident needs. If the resident refused, or there were any issues with the treatment, report to supervisor and document.Review of the facility policy titled, Skin Management Program, dated April 2023, revealed the purpose of the skin management program guide was to provide an approach in the prevention and management of pressure injuries and skin alterations. Staff were to review and follow orders to prevent pressure injuries.This deficiency represents non-compliance investigated under Complaint Number 2981965.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure interventions and wound treatments were implemented as physician ordered and with appropriate technique. This affected two (#1 and #2) of three residents reviewed for wound care. The facility census was 88. Findings include:1. Review of Resident #1's medical record revealed an admission date of 04/04/25, with diagnoses including dementia, acute respiratory failure, Type II diabetes mellitus with diabetic neuropathy, dysphagia, history of aspiration pneumonia, gastrostomy (G-tube), and hypertension.Review of the Minimum Data Set (MDS) assessment, dated 02/04/26, revealed Resident #1 was in a persistent vegetative state, was unable to make needs known, was severely cognitively impaired, was dependent on staff for all activities of daily living (ADLs), was incontinent of bowel and bladder, had no known weight loss, received all nutrition via feeding tube, was at risk for pressure ulcer development with no skin breakdown, and received anticoagulant and antidepressant medications. Review of the plan of care, dated 02/06/26, revealed Resident #1 was at risk for impaired skin integrity related to history of ulcers, diabetes, poor circulation, decreased mobility, side effects of medication use, chronic itching, malnutrition and occasional incontinence. Interventions included skin to be free of breakdown, barrier cream/ointment after each incontinent episode as needed, inspect skin during routine daily care and pressure reducing mattress. Review of the return from hospital assessment dated [DATE] revealed Resident #1 was re-admitted to the facility with skin alterations. Review of the pressure ulcer development risk assessment (Braden) dated 03/11/26 revealed Resident #1 scored an 11, indicating the resident was at high risk for pressure ulcer development. Review of the skin alteration assessment dated [DATE] revealed Resident #1 had a stage II pressure injury to the coccyx, measuring 0.8 centimeters (cm) long by (x) 0.7 cm wide x 0.1 cm deep with serosangous (blood tinged) drainage. A second area of skin alteration, described as excoriation, was documented to the groin and thighs with measurements undetermined and bright red blood drainage. Review of the physician orders revealed an order dated 03/11/26 to cleanse the coccyx with soap and water, pat dry, apply foam dressing, and change daily and as needed (PRN). On 03/12/26, the order was changed to cleanse the coccyx with wound wash, apply zinc cream to foam cover and apply over wounds, and apply zinc cream to rest of buttocks every shift and PRN. Further review revealed an order dated 03/11/26 to cleanse the sacrum and medial thigh/groin area twice daily and apply house barrier cream. Review of a Wound Specialist evaluation dated 03/17/26 revealed Resident #1 admitted with a stage II pressure ulcer measuring 2.0 cm x 1.7 cm x 0.1 with small amount of sero-sanguiuneous drainage. The wound was noted to be improving. Treatment orders to the sacral wound were continued to cleanse with wound cleanser or normal saline, pat dry, apply house barrier cream with zinc to wound bed, cover with dry dressing, and change every shift and PRN if soiled or dislodged. Pressure relief and off-loading. The wound specialist evaluated the resident's right superior buttock to have moisture associated skin damage (MASD), measuring 1.8 cm x 1.7 cm x 0.1 cm with a small amount of sero-sanguineous drainage. Treatment orders were to cleanse with wound cleanser or normal saline, pat dry, apply house barrier cream with zinc to the wound bed, cover with dry dressing, and change every shift and PRN if soiled or dislodged. Pressure relief and off-loading. Observation on 03/18/26 at 7:45 A.M. revealed Certified Nursing Assistant (CNA) #200 and CNA #201 entered Resident #1's room. CNA #200 and CNA #201 proceeded to perform incontinence care and repositioned the resident on his back. Continued observation between 8:00 A.M. and 11:13 A.M. revealed Resident #1 remained positioned on his back. Staff were not observed to check on Resident #1 for incontinence care or reposition the resident between 8:00 A.M. and 11:13 A.M. Continued observation on 03/18/26 at 11:13 A.M. revealed Licensed Practical Nurse (LPN) #300 entered Resident #1's room. LPN #300 exposed Resident #1's G-tube site and discovered Resident #1 was heavily soiled with urine contained in an adult incontinence brief. LPN #300 continued to provide care and treatment to the G-tube and related tube feeding. LPN #300 did not address Resident #1's incontinence care needs. Observation on 03/18/26 at 11:58 A.M. revealed CNA #201 and CNA #202 entered Resident #1's room. CNA #201 and CNA #202 removed Resident #1's incontinence brief and noted the resident was heavily soiled with urine. CNA #201 and CNA #202 proceeded to cleanse the resident using disposable incontinence wipes and incontinence spray cleanser. CNA #201 and CNA #202 positioned Resident #1 to the left side and noted Resident #1 with an area of MASD and a wound to the sacrum. No dressing was applied to the wounds. Concurrent interview with CNA #201 revealed they had assumed care of Resident #1 at 11:00 A.M. and was unaware of when Resident #1 was last checked for incontinence care or repositioned. Both CNA #201 and CNA #202 stated Resident #1 was to be checked, changed for incontinence, and repositioned every two hours. Observation on 03/18/26 at 12:12 P.M., during interview with LPN #300, verified a current physician order was in place for a dressing to be applied to Resident #1's MASD and sacral wound and no dressing was in place as physician ordered. Review of the facility policy titled, Skin Management Program, revised April 2023, revealed, upon completion of the Braden Scale, the nurse would initiate/review the resident's skin alteration plan of care and verify plan of care recognized interventions to assist in reducing the resident's risk of skin breakdown. 2. Review of the medical record revealed Resident #2 admitted to the facility on [DATE], with diagnoses including paraplegia, chronic osteomyelitis, pressure ulcer stage IV to the right buttock and sacral region, anemia, polyneuropathy, hypertension, depression, history of venous thrombosis and embolism, and mild intellectual disabilities.Review of the MDS assessment, dated 12/18/25, revealed Resident #2 had intact cognition, had no behaviors, had bilateral lower extremity range of motion impairment, was dependent on staff for completion of ADLs, required partial to moderate assistance with bed mobility, was incontinent of bowel and bladder, and was at risk for pressure ulcer development. Resident #2 admitted with two stage IV pressure ulcers. Review of the physician orders revealed on 11/19/25, an order was initiated for a open area to Resident #2's right posterior thigh to cleanse the area with liquid antibacterial soap and water, pat dry, and apply Prisma and silicone Border Zetuvit once daily and PRN. Review of the plan of care, revised 02/06/26, revealed Resident #2 was at risk for infection related to communal living and current osteomyelitis. Interventions included administer antibiotics as ordered, complete treatments as ordered, Enhanced Barrier Precautions (EBP), and evaluate for signs and symptoms of infection and report to physician (MD), including redness, swelling, increased pain, purulent drainage, elevated temperature, change in color of sections, cough, congestion, abnormal lungs sounds, diarrhea, and/or vomiting. In addition, on 02/06/26, the nursing plan of care was revised to address the resident being at risk for impaired skin integrity related to incontinence, decreased mobility, current wounds, and chronic osteomyelitis. Goals were noted as skin would be free of breakdown, wound to coccyx would improve by review date, and wound to the right thigh would improve by review date. Interventions included barrier cream/ointment after each incontinent episode as needed, dietary evaluation as needed, explain all procedures prior to care, inspect skin during routine daily care, and pressure reducing mattress. Lastly, on 02/06/26, a nursing plan of care was implemented to address Resident #2's long-term use of antibiotic therapy related to chronic osteomyelitis. Interventions included administer medication as ordered, antibiotics were non-selective and could result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush, colitis, and vaginitis, any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity /allergic reactions, monitor every shift for adverse reaction, ask physician to review medication for possible dose reduction every three months, observe for possible side effects every shift, and report pertinent laboratory test results to the MD. Review of the weekly wound rounds documentation dated 03/18/26 revealed the right gluteal fold wound was discovered on admission. The wound measured 1.5 cm x 0.3 cm x 1.6 cm with a small amount or serous drainage and unchanged wound status. Observation on 03/18/26 at 7:27 A.M. revealed LPN #300 obtained dressing treatment supplies and placed them next to Resident #2 in bed. LPN #300 applied gloves and a gown. LPN #300 positioned Resident #2 on the left side and exposed the right posterior gluteal fold wound, with the dressing dislodged. LPN #300 removed the cover dressing and packing from inside the wound, and disposed of the soiled dressings into a trash bag. LPN #300 then opened the gauze packaging with the soiled gloves and cleansed the wound with wound cleanser spray. No liquid antibacterial soap was used. LPN #300, with the same soiled gloves, proceeded to pat dry the wound with four x four gauze pads. LPN #300 opened a dressing treatment identified as collagen purcol pad with the soiled gloves and packed the pad to the wound. No Prizma wound treatment was applied. LPN #300 then opened a silicone border dressing package with the same gloves and covered the wound. Concurrent interview with LPN #300 verified gloves were not changed between clean and soiled dressings and further confirmed the dressing supplies used to complete the treatment. Interview on 03/18/26 at 1:50 P.M. with the Director of Nursing (DON) verified Resident #2's wound treatment was not administered as ordered by the physician. Review of the facility policy titled, Dressings, Dry/Clean, revised September 2013, revealed the procedure was to clean bedside stand, establish a clean field, place clean equipment on the clean field, arrange supplies so they could be easily reached, wash and dry hands thoroughly, put on gloves, loosen tape and remove soiled dressing, wash and dry hands thoroughly, open dry/clean dressing(s) by pulling corners of the exterior wrapping outward (touching only the exterior surface), using clean technique, open other products (prescribed dressing; dry, clean gauze), wash and dry hands thoroughly, put on clean gloves, assess the wound and surrounding skin for edema/redness/drainage/ tissue healing progress and wound stage, cleanse the wound with ordered cleanser, use clean gauze for each cleansing stroke, clean from the least contaminated area to most contaminated area, use dry gauze to pat the wound dry, apply the ordered dressing and secure with tape or bordered dressing per order, discard disposable items into designated container, remove disposable gloves and discard into container, and wash and dry hands thoroughly. This deficiency represents non-compliance investigated under Master Complaint Number 2803908 and Complaint Number 2800644.

Based on observation, medical record review, and staff interview the facility failed to ensure timely and effective incontinence care was provided. This affected two (#1 and #2) of three residents reviewed for incontinence care. The facility census was 88. Findings include:1. Review of the medical record revealed Resident #2 admitted to the facility on [DATE], with diagnoses including paraplegia, chronic osteomyelitis, pressure ulcer stage IV to the right buttock and sacral region, anemia, polyneuropathy, hypertension, depression, history of venous thrombosis and embolism, and mild intellectual disabilities.Review of the MDS assessment, dated 12/18/25, revealed Resident #2 had intact cognition, had no behaviors, had bilateral lower extremity range of motion impairment, was dependent on staff for completion of ADLs, required partial to moderate assistance with bed mobility, was incontinent of bowel and bladder, and was at risk for pressure ulcer development. Resident #2 admitted with two stage IV pressure ulcers. Review of the plan of care, revised on 02/06/26, revealed Resident #2 was at risk for alteration in elimination related to urinary retention, paraplegia, weakness, and decreased mobility. Interventions included administer medications as ordered, monitor for signs and symptoms (s/x) of urinary tract infection (UTI), elevated temperature, dysuria, flank pain, hematuria, foul smelling urine/report to physician (MD)/seek diagnosis and promptly treat, and provide incontinence care as needed. Observation on 03/18/26 at 7:10 A.M. revealed Certified Nursing Assistant (CNA) #202 entered Resident #2's room. CNA #202 proceeded to removed Resident #2's urine and bowel movement (BM) soiled incontinence brief and positioned the resident on the left side. CNA #202 cleansed the BM and placed a new adult incontinence brief. However, CNA #202 did not cleanse the Resident's anterior perinium of the soiled urine. CNA #202 discarded the soiled brief in the trash receptacle. Interview on 03/18/26 at 7:20 A.M. with CNA #202 confirmed they did not cleanse the urine from Resident #2's anterior perinium during incontinence care. 2. Review of Resident #1's medical record revealed an admission date of 04/04/25, with diagnoses including dementia, acute respiratory failure, Type II diabetes mellitus with diabetic neuropathy, dysphagia, history of aspiration pneumonia, gastrostomy (G-tube), and hypertension.Review of the Minimum Data Set (MDS) assessment, dated 02/04/26, revealed Resident #1 was in a persistent vegetative state, was unable to make needs known, was severely cognitively impaired, was dependent on staff for all activities of daily living (ADLs), was incontinent of bowel and bladder, had no known weight loss, received all nutrition via feeding tube, was at risk for pressure ulcer development with no skin breakdown, and received anticoagulant and antidepressant medications. Review of the plan of care, revised 02/06/26, revealed Resident #1 was at risk for alteration in elimination related to cognitive deficit, weakness, decreased mobility, lack of core muscles, muscle wasting and atrophy, side effects of medications, and constipation. Intervention included to provide incontinence care as needed. Observation on 03/18/26 at 7:45 A.M. revealed CNA #200 and CNA #201 entered Resident #1's room. CNA #200 and CNA #201 proceeded to perform incontinence care and repositioned the resident. Continued observation between 8:00 A.M. and 11:13 A.M. revealed Resident #1 remained positioned on his back. No staff were observed to check on Resident #1 for incontinence care needs between 8:00 A.M. and 11:13 A.M. Observation on 03/18/26 at 11:13 A.M. revealed Licensed Practical Nurse (LPN) #300 was observed to enter Resident #1's room. LPN #300 exposed Resident #1's G-tube site and discovered the resident was heavily soiled with urine contained in an adult incontinence brief. LPN #300 continued to provide care and treatment to the G-tube and related tube feeding. LPN #300 made no attempt to address Resident #1's incontinence care needs. Observation on 03/18/26 at 11:58 A.M. revealed CNA #201 and CNA #202 entered Resident #1's room. CNA #201 and CNA #202 removed Resident #1's brief and noted the resident was heavily soiled with urine. CNA #201 and CNA #202 proceeded to cleanse the area using disposable incontinence wipes and incontinence spray cleanser. CNA #201 and CNA #202 positioned Resident #1 to the left side. Concurrent interview with CNA #201 revealed they had assumed care of Resident #1 at 11:00 A.M. and was unaware of when the resident was last checked for incontinence care. Both CNA #201 and CNA #202 stated Resident #1 was to be checked and changed for incontinence every two hours. Interview on 03/19/26 at 5:55 A.M. with the Director of Nursing (DON) revealed the facility did not have a policy or procedure in place regarding the provision of incontinence care. The procedure was determined to be a standard of practice task and residents were to be checked, changed, and repositioned every two hours.This deficiency represents non-compliance investigated under Master Complaint Number 2803908 and Complaint Number 2800644.

Based on observation, medical record review, and staff interview, the facility failed to ensure gastrostomy tube (G-tube) care and maintenance were provided as ordered. This affected one (#1) of three residents reviewed for G-tube care. The facility identified two (#24 and #33) additional residents who had a G-tube. The facility census was 88. Findings include:Review of Resident #1's medical record revealed an admission date of 04/04/25, with diagnoses including dementia, acute respiratory failure, Type II diabetes mellitus with diabetic neuropathy, dysphagia, history of aspiration pneumonia, gastrostomy (G-tube), and hypertension.Review of the Minimum Data Set (MDS) assessment, dated 02/04/26, revealed Resident #1 was in a persistent vegetative state, was unable to make needs known, was severely cognitively impaired, was dependent on staff for all activities of daily living (ADLs), was incontinent of bowel and bladder, had no known weight loss, received all nutrition via feeding tube, was at risk for pressure ulcer development with no skin breakdown, and received anticoagulant and antidepressant medications.Review of the plan of care, revised 01/30/26, revealed Resident #1 had potential for alteration in nutrition/hydration related to diagnoses of dementia, diabetes mellitus Type II, and hypertension. Resident #1 received nothing by mouth (NPO) and was dependent on tube feeding (TF)/flushes to meet nutrition/hydration needs. Interventions included administer medications as ordered, elevate head of bed (HOB) as ordered, and evaluate tube feed tolerance. Review of the physician orders revealed an order dated 03/11/26 for Resident #1 to receive NPO and tube feeding (Glucerna 1.2) via G-tube every shift off at 12:00 A.M. and on at 4:00 A.M. for 20 hours or until 1500 milliliters (ml) had been infused at a infusion rate of 75 ml per (/) hour (hr) for 20 hours with a 175 ml water flush every six hours. In addition, a physician treatment order was implemented to cleanse area around G-tube with soap and water, then apply new sponge daily and as needed (PRN). Observation on 03/18/26 at 11:13 A.M. revealed Licensed Practical Nurse (LPN) #300 entered Resident #1's room. LPN #300 exposed Resident #1's G-tube site. No dressing (sponge) was in place. LPN #300 proceeded to cleanse a small amount of brown/red dried drainage from the G-tube insertion site. Concurrent interview with LPN #300 verified a dressing should have been applied to Resident #1's G-tube site. Interview on 03/19/26 at 5:55 A.M. with the Director of Nursing (DON) revealed the facility did not have a policy or procedure in place regarding the provision of G-tube care and maintenance. The procedure was determined to be a standard of practice task. This deficiency was an incidental finding discovered during the complaint investigation.

Based on observation, review of the medical record, staff interview, and review of facility policy, the facility failed to ensure enhanced barriers precautions (EBP) were implemented. This affected two (#1, #3) of three residents reviewed for infection control. The facility identified 26 (#1, #2, #3, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, and #37) residents on EBP. The facility census was 88. Findings include:1. Review of the medical record revealed Resident #1 admitted to the facility on [DATE], with diagnoses including dementia, acute respiratory failure, Type II diabetes mellitus with diabetic neuropathy, dysphagia, history of aspiration pneumonia, gastrostomy (G-tube), and hypertension.Review of the Minimum Data Set (MDS) assessment, dated 02/04/26, revealed Resident #1 was in a persistent vegetative state, was unable to make needs known, had severe cognitive impairment, was dependent on staff for all activities of daily living (ADLs), was incontinent of bowel and bladder, had no known weight loss, received all nutrition via feeding tube, was at risk for pressure ulcer development with no skin breakdown, and received anticoagulant and antidepressant medications. Review of the physician orders revealed Resident #1 had an order dated 03/11/26 to receive nothing by mouth (NPO) and tube feeding (Glucerna 1.2) via G-tube every shift, off at 12:00 A.M. and on at 4:00 A.M., for 20 hours or until 1500 milliliters (ml) had been infused at a infusion rate of 75 ml per hour for 20 hours, with a 175 ml water flush every six Hours. In addition, physician wound treatment orders were modified on 03/17/26 as follows: right buttock moisture associated skin damage (MASD) - cleanse with wound cleanser or normal saline, pat dry, apply house barrier cream with zinc to wound bed, cover with dry dressing, and change every shift and as needed (PRN) if soiled or dislodged and sacral wound - cleanse with wound cleanser or normal saline, pat dry, apply house barrier cream with zinc to wound bed, cover with dry dressing, and change every shift and PRN if soiled or dislodged. The medical record lacked a physician order or nursing plan of care for the implementation of EBP. Observation on 03/18/26 at 6:59 A.M. revealed Resident #1 was in bed with the tube feeding infusing. Further observation revealed no signage near the entry of Resident #1's room instructing staff that EBP were in place or personal protective equipment (PPE) located near the resident's room. Observation on 03/18/26 at 7:45 A.M. revealed Certified Nursing Assistant (CNA) #200 and CNA #201 entered Resident #1's room. Neither staff donned PPE. CNA #200 and CNA #201 proceeded to perform incontinence care and repositioned the resident. Interview on 03/18/26 at 8:00 A.M. with CNA #200 confirmed no PPE was applied during care for Resident #1. CNA #200 verified they were unaware Resident #1 was in EBP and PPE was to be applied during direct contact with the resident. Interview on 03/18/26 at 10:40 A.M. with the Director of Nursing (DON) verified there was no signage or PPE at Resident #1's room entry to alert staff that the resident was on EBP. 2. Review of the medical record revealed Resident #3 admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV), Type II diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, necrotizing fasciitis, peripheral vascular disease, lymphedema, and nutritional anemia.Review of the MDS assessment, dated 03/11/26, revealed Resident #3 had moderately impaired cognition, no resistive behaviors, range of motion impairment to bilateral lower extremities, was dependent on staff for completion of ADLs, was incontinent of bowel and bladder, and was at risk for pressure ulcer development. Resident #3 admitted with one stage III pressure ulcer and one stage IV pressure ulcer. Review of the physician orders revealed orders dated 03/09/26 to cleanse Resident #3's left hip wound with wound cleanser, pat dry, apply skin prep to periwound, lightly pack wound with collagen rope with silver, apply collagen with silver to the wound bed, cover wound with dry dressing, and change daily and as needed (PRN) and to cleanse the left shoulder wound with wound cleanser, pat dry, apply skin prep to periwound, apply collagen powder to wound bed, cover with calcium alginate and dry dressing, and change daily and PRN. Observation on 03/18/26 at 6:56 A.M. revealed Resident #3's call light was active. Further observation revealed no EBP signage or PPE was located near the entry to Resident #3's room. Continued observation revealed at 6:58 A.M., CNA #200 and CNA #201 entered Resident #3's room. Neither staff donned PPE. CNA #200 and CNA #201 proceeded to perform incontinence care and repositioned the resident. Interview on 03/18/26 at 7:10 A.M. with CNA #202 revealed they assumed care of Resident #3 at 6:00 A.M. CNA #202 verified they were unaware Resident #3 required EBP and confirmed no sign was in place at the resident's room to alert staff to EBP and no PPE was readily accessible. Interview on 03/19/26 at 5:58 A.M. with the DON revealed the facility policy did not contain instructions to include or require a physician order or plan of care to place or maintain a resident in EBP. Review of the facility policy, Enhanced Barrier Precautions (EBP), dated August 2022, revealed EBP were an infection control intervention designed to reduce the transmission of resistant organisms that employed the use of a gown and gloves during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices (for example, G-tube, catheter, et cetera) were at especially high risk for both acquisition and colonization with multi drug resistant organisms (MDRO). The use of a gown and gloves for high contact resident care activities was indicated when contact precautions did not otherwise apply. Examples of high contact activities included: dressing, bathing, transferring, providing personal hygiene, changing briefs, and wound care. This deficiency was an incidental finding discovered during the complaint investigation.

Based on observation, and staff interview, the facility failed to maintain a safe and sanitary environment by containing cigarettes in approved extinguishment receptacles. This affected 17 residents (#1, #3, #22, #23, #29, #34, #38, #40, #41, #51, #52, #53, #55, #56, #57, #66, #70) identified as independent of unsupervised smokers and an additional 32 residents (#2, #6, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #47, #48, #49, #50, #54, #57, #58, #59, #60, #61, #62, #63, #64, #65, #67, #68, #69, #71, #72) residing on the south end of the building. Facility census 79. Findings include:Observation of the south 300 resident community room on 02/23/26 at 8:54 A.M. revealed four extinguished cigarette butts on the carpeted floor. A plastic trash can was identified inside the building near the outside exit door to the designated independent smoking area. The trash can had multiple paper and styrofoam items inside with multiple extinguished cigarettes inside. Continued observation located outside the community room exit door discovered greater than 17 extinguished cigarettes were observed on the ground and in vicinity of the combustible wood building exterior. On 02/23/26 at 8:58 A.M. observation with Unit Manager Licensed Practical Nurse (LPN) #301 verified the discarded cigarettes located in the community room, plastic trash can and outside designated independent resident smoking area. On 02/23/26 at 1:10 P.M. the facility Administrator provided a list of residents whom smoke. The facility identified 17 residents (#1, #3, #22, #23, #29, #34, #38, #40, #41, #51, #52, #53, #55, #56, #57, #66, #70) as independent of unsupervised smokers. In addition 32 residents (#2, #6, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #47, #48, #49, #50, #54, #57, #58, #59, #60, #61, #62, #63, #64, #65, #67, #68, #69, #71, #72) were identified to reside on the south end of the building.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure proper hand sanitation was maintained during meal preparation and dining service. This affected 78 current residents identified to receive meals from the facility kitchen excluding one resident (#18) receiving nutrition via feeding tube. Findings include: On 02/23/26 at 12:09 P.M. observation during the lunch meal service noted Dietary Aide (DA) #201 wearing single use plastic gloves while handling empty individual meal trays. DA #201 proceeded to handle soiled meal trays and handled the commercial dishwasher while placing the soiled trays inside. DA #201 removed the clean trays and returned to the serving line without changing gloves or washing hands. DA #201 began handling clean utensils and placing meal tickets to the clean meal trays without changing the gloves. At 12:14 P.M. DA #201 handled tray meal tickets with gloves and the tickets fell to the floor. DA #201 proceeded to pick the tickets off the floor and placed them to the clean meal trays on the meal service line. DA #201 changed gloves. However, no hand washing was observed. On 02/23/26 at 12:39 P.M. interview with DA #201 verified when gloves are cross contaminated. Staff are to removed the soiled gloves and wash hands before donning a new pair. On 02/23/26 observation during the lunch meal service noted at 11:55 A.M. [NAME] #200 exited the kitchen wearing plastic single use gloves. [NAME] #200 placed hands on the kitchen entry door, placed hands on the walk-in cooler and obtained various food items. [NAME] #200 used the gloved hand to close the cooler door and reentered the kitchen using the door handle. [NAME] #200 proceeded to handle food and clean plates without changing gloves or washing hands. At 12:00 P.M. [NAME] #200 exited the kitchen wearing single use plastic gloves and placed hands on the door handle exiting the kitchen and door handle to walk-in cooler. [NAME] #200 proceeded to close the walk-in cooler with the gloved hand while carrying a tray of tuna fish sandwiches and re-entered the kitchen handling the door knob with the gloved hand. [NAME] #200 then proceeded to handle the sandwiches with the soiled gloves placing them to plates. At 12:03 P.M. [NAME] #200 exited the kitchen with single use plastic gloved hands and handled the door knob to the kitchen entry door and walk-in cooler door. [NAME] #200 returned to the kitchen with food items while placing the gloved hands on the door knobs. At 12:30 P.M. [NAME] #200 exited the kitchen through the front kitchen entry door. [NAME] #200 had gloved hands and handled the entry door knob without changing gloves or washing hands. [NAME] #200 returned to the kitchen with the same gloves applied and handled food items, making grilled sandwiches wearing the same soiled gloves. On 02/23/26 at 12:40 P.M. interview with [NAME] #200 verified the lack of changing gloves and related hand washing when handling food. On 02/23/26 at 1:23 P.M. interview with Dietary Manager (DM) #500 during a review of facility gloving and hand washing policy verified hands are to be washed between glove changes. DM #500 identified one of 79 residents (#18) not receiving food from the facility kitchen. Review of facility single use glove policy updated 11/22/20. Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from food handlers hands to the food product being served. Gloved hands are considered food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Hands are to be washed when entering the kitchen and before putting on the single use gloves and after removing single use gloves. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed: After handling soiled trays or dishes. After handling anything soiled. After handling boxes, crates, packages. After picking up any item from the floor. Any time a contaminated surface is touched. Wash hands after removing gloves. Review of hand washing policy updated 11/22/20. Hands and exposed portions of arms should be washed immediately before engaging in food preparation. When to wash hands: When entering the kitchen at the start of a shift. After handling soiled equipment or utensils. During food preparation, as often as necessary to remove soil or contamination and prevent cross contamination when changing tasks. Before donning disposable gloves for working with food and after gloves are removed. After engaging in other activities that contaminate the hands. Food preparation and/or pot sinks will not be used for hand washing.

Based on observation, and staff interview, the facility failed to ensure resident common showers, and common area corridors were properly cleaned and maintained. This affected 68 current residents excluding 11 residents (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16) residing on the medbridge unit. Facility census 79. Findings include:1. Observation on 02/24/26 at 6:09 A.M. noted the north common shower room left stall with a black substance along the edge of the floor and wall. Next to the wall mounted seat on the left revealed an approximate one foot by 8 inch section of missing ceramic tile which exposed the structural backing or [NAME] board, and a one inch diameter hole through the wall ([NAME] board). 2. Observation on 02/24/26 at 6:14 A.M. noted the south common shower room with a soiled brief on the floor in front of the sink. A brown substance with pealing caulk was identified around the base of the toilet. Inside the left shower stall revealed a black substance between the shower stall floor and tile. In addition inside the shower stall noted a black substance between the wall shower tiles, four holes penetrated the wall through the ceramic tile with a black brown substance around the holes, and a broken soap dispenser in the stall leaving jagged edges. 3. On 02/24/26 between 6:15 A.M. and 6:25 A.M. observation of corridor floor tiles revealed a brown/black residue covering various tiles, along corridor walls and at resident room thresholds. These areas were between the following rooms; 101-109, 110-122, 201-210, 301-312, 314-326. 4. On 02/24/26 between 6:15 A.M. and 6:25 A.M. observation located between resident rooms 206-208, 314-327 identified multiple broken floor tiles in the corridor. On 02/24/26 at 6:23 A.M. interview with Licensed Practical Nurse (LPN) #300 revealed the floors had been observed in the same condition since beginning employment at the facility. On 02/24/26 at 6:25 A.M. tour of the facility with Director of Housekeeping Services (DHS) #600 verified the condition of facility flooring, and resident common showers. DHS #600 stated attempts had been implemented to remove the flooring stains which were unsuccessful. DHS #600 verified the tile floors were installed in all facility corridors excluding the Medbridge unit rooms 330-341, which were carpeted and included 11 current residents (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16). This deficiency represents non-compliance investigated under Complaint Number 2720626.

Based on observation, medical record review, staff interview, review of medication refrigerator temperature logs, and review of a facility policy, the facility failed to ensure medications were stored in a safe and secure manner. This had the potential to affect all 90 residents residing in the facility. The facility census was 90.Findings include:1. Observation on 12/22/25 at 9:55 A.M. of the medication refrigerator located at the North nurse station revealed the current temperature check log was incomplete as there were no temperatures recorded on 12/05/25, 12/09/25, 12/15/25, 12/16/25, and 12/19/25. Review of a facility temperature log for November 2025 for the medication refrigerator located at the North nurse station revealed temperatures had not been recorded on 11/07/25, 11/10/25, 11/11/25, and 11/28/25. Review of a facility temperature log for October 2025 for the medication refrigerator located at the North nurse station revealed temperatures had not been recorded on 10/03/25, 10/06/25, 10/07/25, 10/09/25, 10/10/25, 10/13/25, 10/14/25, 10/17/25, 10/20/25, 10/21/25, 10/24/25, 10/27/25, 10/28/25, and 10/31/25. Review of a facility temperature log for December 2025 for the medication refrigerator located at the South nurse station revealed temperatures had not been recorded on 12/03/25, 12/04/25, 12/06/25, 12/10/25, 12/11/25, 12/14/25, and 12/18/25. Review of a facility temperature log for November 2025 for the medication refrigerator located at the South nurse station revealed temperatures had not been recorded on 11/01/25, 11/02/25, 11/06/25, 11/08/25, 11/09/25, 11/13/25, 11/14/25, 11/15/25, 11/16/25, 11/19/25, 11/20/25, 11/26/25, 11/27/25, 11/28/25, 11/29/25, and 11/30/25. Review of a facility temperature log for October 2025 for the medication refrigerator located at the South nurse station revealed temperatures had not been recorded on 10/07/25, 10/10/25, 10/11/25, 10/28/25, and 10/31/25 Interview on 12/22/25 at 11:30 A.M. with the Director of Nursing (DON) confirmed temperatures had not been monitored daily for the medication refrigerators at the North and South Nurse stations and confirmed the missing dates from the refrigerator temperature logs from the North and South nurse station refrigerators for October, November, and December 2025 as listed above. The DON confirmed medication refrigerator temperatures should be monitored and logged daily.Review of facility policy titled, PCU027 - Medication Storage in the Facility, dated 2022, revealed medications requiring refrigeration would be stored in a refrigerator with a thermometer to allow for daily temperature monitoring.2. Review of the medical record for Resident #263 revealed he was admitted on [DATE] with diagnoses including emphysema, hypertension, viral hepatitis C, alcohol dependence, cocaine use, and toxic encephalopathy.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #263 was cognitively impaired and did not exhibit behaviors at the time of the assessment. The resident utilized a walker and a wheelchair and required moderate assistance with activities of daily living, personal hygiene, bed mobility, and transfers.Review of physician orders for Resident #263 revealed he was ordered amlodipine besylate 2.5 milligrams (mg) by mouth once daily for hypertension on 11/10/25, Eliquis five (5) mg by mouth once daily for deep vein thrombosis prophylaxis on 11/07/25, tamsulosin hydrochloride 0.4 mg by mouth once daily for prostate health on 10/23/25, budesonide-formoterol fumarate dihydrate (Symbicort) 160-4.5 micrograms per actuation (mcg/act)two puffs inhaled orally every 12 hours for shortness of breath on 10/23/25, and albuterol sulfate (Ventolin) 108 (90 base) mcg/act two puffs inhaled orally every 12 hours for shortness of breath on 10/23/25.Observation on 12/22/25 at 10:02 A.M. of medication administration for Resident #263 completed by Licensed Practical Nurse (LPN) #652 revealed LPN #652 did not secure three medication cards while taking the prepared medications to Resident #263's room. Resident #263's amlodipine besylate, Eliquis, and tamsulosin hydrochloride medication cards were left on top of the medication cart in the hallway; each card had nine doses remaining. The medication cart with was out of LPN #652's view from 10:10 A.M. until 10:16 A.M. leaving the medication cards unsecured.Interview on 12/22/25 at 10:16 A.M. with LPN #652 confirmed she left Resident #263's amlodipine besylate, Eliquis, and tamsulosin hydrochloride medication cards, each with nine doses, unsecured on top of the medication cart in the hallway while she was in Resident #263's room.Observation on 12/22/25 at 3:20 P.M. of Resident #263 revealed he was lying in bed in his room and was awake and conversational. Further observation revealed one Ventolin inhaler and one Symbicort inhaler by the pillow in his bed.Interview on 12/22/25 at 3:30 P.M. with LPN #650 confirmed Resident #263 was not permitted to have Symbicort and Ventolin stored in his room and confirmed the presence of both medications in the resident's room.Interview on 12/22/25 at 4:00 P.M. with the DON confirmed Resident #263 was not permitted to self-administer medications.Review of facility policy titled, PCU027 - Medication Storage in the Facility, dated 2022, revealed the facility would securely store medication so it is accessible only to licensed nursing personnel.This deficiency represents non-compliance investigated under Complaint Number 2614307.

Based on observation, medical record review, resident and staff interview, and review of a facility policy, the facility failed to maintain a clean and homelike environment. This affected two (#268 and #269) of 15 residents residing on the 200 hall. The facility census was 90.Findings include:Review of the medical record for Resident #268 revealed she was admitted on [DATE] with diagnoses that included urinary retention, chronic pulmonary embolism, depression, hyperlipidemia, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #268 was cognitively intact and did not exhibit behaviors at the time of the assessment.Review of the medical record for Resident #269 revealed she was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, atrial fibrillation, anxiety, depression, and hypertension Review of the MDS assessment dated [DATE] revealed Resident #269 was cognitively intact and did not exhibit behaviors at the time of the assessment.Observation on 12/22/25 at 9:40 A.M. of the 200 hall revealed, between room [ROOM NUMBER] and room [ROOM NUMBER], there was a metal ceiling tile support track hanging down approximately three inches and two ceiling tiles with round orange-brown stains approximately three inches in diameter. Continued observation revealed two ceiling tiles with round orange-brown stains approximately six inches in diameter between room [ROOM NUMBER] and room [ROOM NUMBER], and outside room [ROOM NUMBER] and room [ROOM NUMBER] was an excess amount of dust buildup on the vents and surrounding ceiling tiles.Interview on 12/22/25 at 9:55 A.M. with Licensed Practical Nurse (LPN) #650 confirmed the observations of the stained ceiling tiles, the ceiling tile metal support track hanging, and the excess dust build up on the vents on the 200 hall ceiling.Interview on 12/22/25 at 3:40 P.M. with Resident #268 and Resident #269 revealed they were aware of the conditions of the ceiling on the 200 hall and found the conditions to be bothersome and not homelike.Review of facility policy titled, Quality of Life - Homelike Environment, dated May 2017, revealed the facility would provide a safe, clean, and homelike environment.This deficiency represents non-compliance investigated under Complaint Number 2642376.

Based on observation, medical record review, staff interview, and review of drug manufacturer instructions for use, the facility failed to ensure a resident was encouraged to use and offered an oral rinse after administration of an orally inhaled medication containing a steroid. This affected one (#263) of three residents reviewed for medication administration. The facility census was 90.Findings include:Review of the medical record for Resident #263 revealed he was admitted on [DATE] with diagnoses including emphysema, hypertension, viral hepatitis C, alcohol dependence, cocaine use, and toxic encephalopathy.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #263 was cognitively impaired and did not exhibit behaviors at the time of the assessment. Resident #263 utilized a walker and a wheelchair and required moderate assistance with activities of daily living, personal hygiene, bed mobility, and transfers.Review of physician orders for Resident #263 revealed the resident was ordered budesonide-formoterol fumarate dihydrate (Symbicort, a combination drug containing a steroid and a long-acting beta-agonist) 160-4.5 micrograms per actuation (mcg/act), two puffs inhaled orally every 12 hours for shortness of breath.Observation on 12/22/25 at 10:02 A.M. of Licensed Practical Nurse (LPN) #652 administering medications to Resident #263 revealed she administered Symbicort and did not instruct nor encourage Resident #263 to rinse his mouth after the administration of the inhaled medication.Interview on 12/22/25 at 10:15 A.M. with LPN #652 confirmed residents should rinse their mouths after using a steroid inhaler, and confirmed Resident #263 was not offered or encouraged to rinse his mouth following administration of Symbicort.Interview on 12/22/25 at 12:55 P.M. with Registered Nurse (RN) #660 revealed residents should rinse their mouths with water after using a steroid inhaler.Review of the manufacturer's instructions for Symbicort inhaler usage, dated 2018, revealed one of the ingredients was an inhaled corticosteroid budesonide. Further review revealed after inhaling the medication, the user was instructed to rinse their mouth out with water and spit the water out.This deficiency represents an incidental finding discovered during the complaint investigation.

Based on personnel record review, staff interview, review of policy, and review of the facility's Tuberculin (TB) Risk Assessment, the facility failed to ensure all new hire employees had current TB testing results in their employee files. This had the potential to affect all 80 residents. The facility census was 80. Findings include: Review of the facility's TB Risk assessment dated [DATE] revealed the facility had a TB screening program for all employees that required a baseline skin test with a two-step skin test for all healthcare workers. 1. Review of the personnel file for Licensed Practical Nurse (LPN) #460 revealed a hire date of 02/05/25. Further review of the personnel file for LPN #460 revealed no TB skin test results in the file. Interview on 09/09/25 at 4:50 P.M. ,with Human Resource Director (HRD) #410 verified there were no TB skin test results in the personnel file for LPN #460. 2. Review of the personnel file for Housekeeper #400 revealed a hire date of 09/11/24. Further review of the personnel file for Housekeeper #400 revealed a one step TB test was completed on 09/11/24 and read as a negative result on 09/14/24. Further review of the TB skin test form revealed a second step TB skin test was due to be completed one to three weeks following the first step and the form was blank. 3. Review of the personnel file for Certified Nursing Assistant (CNA) #450 revealed a hire date of 06/25/25. Further review of the personnel file for CNA #450 revealed a one step TB test was completed on 06/25/25 and read as a negative result on 06/27/25. Further review of the TB skin test form revealed a second step TB skin test was due to be completed one to three weeks following the first step and the form was blank. Interview on 09/09/25 at 5:05 P.M., with HRD #410 verified Housekeeper #400 and CNA #450 completed only the first step of the required two step TB skin test upon hire. Interview on 09/09/25 at 5:19 P.M., with Regional Director of Operations (RDO) #440 stated new employees should have the two-step TB skin test upon hire. RDO #440 further stated there have not been any TB infections in the facility. Review of the policy titled, Tuberculosis, Employee Screening for, revised August 2019 revealed all employees are screen for latent tuberculosis infection (LTBI) and active tuberculosis (TB) disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening, prior to beginning employment. This deficiency represents non-compliance investigated under Complaint Number 2612082.

Based on observation, staff interview, resident interview and review of facility policy, the facility failed to ensure treatments for pressure wounds were completed as physician ordered. This affected one (#52) of three residents reviewed for wound care. The facility census was 74. Findings include: Review of medical record for Resident #52 revealed admitted [DATE]. Diagnoses included quadriplegia, pressure ulcer of the left heel, stage four pressure ulcer of the sacral and pressure induced deep tissue damage of right the buttocks. Review of the Minimum Data Set (MDS) assessment, dated 01/31/25, revealed Resident #52 had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed Resident #52 had bilateral impairment to the upper and lower extremities and was staff dependent on all activities of daily living (ADLs). Additionally, Resident #52 had two stage three pressure ulcers and five stage four pressure ulcers. Review of Resident #52's care plan, dated 01/27/25, revealed the resident had non-compliance related to wound care treatments and side to side positioning in bed. Further review revealed on 01/14/25, the resident stated wound care was not completed by staff; however, the resident was refusing at times wound care treatment was to be provided. The interventions included educational attempts made with residents and family related to non-compliance and notifying the physician of non-compliance. Additional review of the care plan revealed Resident #52 had stage four pressure ulcers to the coccyx related to immobility, paraplegia and weakness. The interventions included wound care treatments as ordered, monitoring dressing to ensure it was intact and adhering and report loose dressing to the nurse. Review of Resident #52's current physician orders revealed treatment for the sacrum and bilateral ischium wounds included to cleanse with saline or antibacterial soap and water, pack wounds with Vashe moistened kerlix, apply abdominal pad and secure with Mefix or silicone tape or alternative, every night shift for wound care. Review of the Treatment Administration Record (TAR) for February 2025 revealed the treatment for the sacrum and bilateral ischium was not documented as completed on 02/02/25, 02/03/25, 02/07/25, 02/08/25, 02/17/25, 02/20/25, 02/23/25 and 02/24/ 25. Review of the nursing progress notes revealed no evidence Resident #52 refused these wound treatments. Observation on 02/25/25 at 7:05 A.M. of wound treatment for Resident #52, completed by Licensed Practical Nurse (LPN) #225 and Certified Nurse Aide (CNA) #140 revealed the dressing on the wound was dated 02/22/25. Coinciding interview with LPN #225 verified the date on the dressing was 02/22/25 (three days prior) and the order was for the treatment to be completed daily. Interview on 02/25/25 at 7:10 A.M. with Resident #52 revealed wound treatments were not completed daily. Interview on 02/25/25 at 8:30 A.M. with the Director of Nursing (DON) verified there was no evidence Resident #52's wound treatments had been completed or refused on 02/02/25, 02/03/25, 02/07/25, 02/08/25, 02/17/25, 02/20/25, 02/23/25 and 02/24/ 25. Review of the facility policy titled, Skin Management, dated April 2023, revealed the purpose was to provide an approach in the prevention and management of pressure injuries. This deficiency represents non-compliance investigated under Complaint Number OH00161936.

Based on observation, staff interview, and policy review, the facility failed to maintain the North and South shower rooms in a clean and sanitary manner. This had the potential to affect all residents except 24 (#3, #8, #9, #10, #15, #17, #18, #19, #20, #26, #27, #31, #33, #44, #47, #51, #52, #55, #56, #57, #58, #59, #62, and #70) residents identified as not using the shower rooms. The facility census was 70. Findings include: Observation on 07/10/24 beginning at 9:07 A.M., revealed there was a debris and a buildup of a dark colored substance around the perimeter of the shower floor tiles in both the North and South shower rooms. Interview on 07/10/24 at 9:11 A.M., with Housekeeping and Laundry Supervisor (HLS) #250 verified the dark colored substance on the floor tiles in both the North and South shower rooms. Review of the policy titled, Floors, last revised 2009, revealed floors would be maintained in a clean, safe, and sanitary manner. Review of the policy titled, Quality of Life-Homelike Environment, last revised 05/2017, revealed the facility would maintain a clean, sanitary and orderly environment. This deficiency represents non-compliance investigated under Complaint Number OH00154998.

Based on medical record review, review of controlled substance records, review of pharmacy receipts, resident and staff interview, and policy review, the facility failed to timely obtain pharmacy services when resident medication was needed for administration. This affected one (#73) of three residents review for medications. The facility census was 70. Findings include: Review of the medical record for Resident #73 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included type two diabetes mellitus, osteoarthritis of the knee, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had intact cognition. Review of the hospital discharge medication orders revealed Resident #73 was ordered the narcotic pain medication oxycodone-acetaminophen 5-325 milligrams (mg) per tablet with instructions to take one tablet by mouth every eight hours as needed for pain for two days. Review of a pharmacy receipt dated 06/14/24 revealed the facility received five oxycodone-acetaminophen 5-325 mg. On 06/19/24, the facility received one card of 56 tablets of oxycodone-acetaminophen 5-325 mg and one card of 29 tablets of oxycodone-acetaminophen. Review of a control drug record revealed on 06/14/24 Resident #73 had 20 oxycodone-acetaminophen tablets brought in from home. Further review of the control drug record revealed the resident was given ten doses of the medication from 06/14/24 through 06/19/24 before the medication was sent home with the resident's family member. Review of a physician order dated 06/14/24 revealed an order for oxycodone-acetaminophen oral tablet 5-325 mg one tablet by mouth every eight hours as needed for pain for two days. Review of a physician order dated 06/15/24 revealed an order for oxycodone-acetaminophen oral tablet 5-325 mg one tablet by mouth every six hours as needed for pain for two days. Review of a physician order dated 06/18/24 revealed an order for oxycodone-acetaminophen oral tablet 5-325 mg one tablet by mouth every eight hours as needed for pain. Review of a physician order dated 06/19/24 revealed an order for oxycodone-acetaminophen oral tablet 5-325 mg one tablet by mouth every six hours as needed for pain. Review of the active inventory of medications on hand at the facility revealed oxycodone-acetaminophen 5-235 mg was available for administration. Interview on 07/10/24 at 1:26 P.M., the Director of Nursing (DON) stated nursing staff pulled Resident #73's oxycodone-acetaminophen 5-325 mg from her own stock of medications brought from home, and stated the nursing staff should have pulled the oxycodone-acetaminophen from the facility's contingent stock. Interview on 07/10/24 at 2:09 P.M., Resident #73 stated she had her home medications with her when she admitted to the facility. Resident #73 revealed the facility took her medications including her oxycodone-acetaminophen and used the medication without her permission. Resident #73 revealed the nurse told her the facility had no oxycodone-acetaminophen and had to use the medication the resident brought from home. Interview on 07/11/24 at 10:31 A.M., Unit Manager Registered Nurse (UMRN) #215 revealed Resident #73 brought medications from home and was educated she could not have the medications in her room. UMRN #215 revealed she never instructed the nursing staff to use the resident's home medications. Review of the policy titled, Emergency Medication Kit, dated 2022, revealed a specialized code could be obtained by the nurse from the pharmacist upon verification of receipt of a valid prescription before gaining access to controlled substances. This deficiency represents non-compliance investigated under Complaint Number OH00155011.

Based on observations, staff interviews, and review of the facility policies, the facility failed to ensure safe food handling occurred during meal service, failed to ensure the thermometer used to check food temperatures was sanitized between food items, and failed to ensure the high-temperature dishwasher washed and/or rinsed at the proper temperatures. This affected two residents (#9 and #70) who received a cheeseburger and the potential to affect all 82 residents residing in the facility. The facility identified all 82 residents in the facility received food from the kitchen. Findings include: 1. Observation prior to meal service on 04/30/24 at approximately 11:20 A.M. revealed Cook #553 was preparing to take food temperatures. Cook #553 removed a cloth soaking in a red sanitizer bucket and wrung it out and placed it on the counter near the steam table. Cook #553 then used the cloth to wipe the thermometer, placed the cloth back on the counter, and tested the temperature of mashed potatoes. Cook #553 then picked up the cloth and wiped off the thermometer and placed the cloth back on the counter, and tested the temperature of the pork chops. Cook #553 continued to use the cloth to wipe the thermometer before testing the green beans, the pureed pork, the pureed green beans, the pureed mashed potatoes, and the mechanical soft pork. Observation on 04/30/24 at approximately 11:24 A.M. revealed Cook #553 testing the sanitation level of the water in the sanitation bucket revealed the color of the test strip remained nearly unchanged. Interview with Cook #553 at that time confirmed the test strip should have turned green to show adequate sanitizing levels of 200 parts per million (PPM). Cook #553 confirmed the test strip on 04/30/24 at approximately 11:24 A.M. revealed the liquid in the sanitizer bucket was approximately 100 PPM and further confirmed he used the cloth from that sanitizer bucket to wipe the thermometer he used to complete food temperatures. Cook #553 confirmed the test strip indicated the liquid in the sanitizer bucket was not concentrated to the required amount. Interview on 04/30/24 at 11:25 A.M. with Dietary Manager (DM) #569 confirmed the sanitizing solution should be 200 PPM and the test strip would turn green when it was at the proper concentration. Review of the policy Taking Accurate Temperatures, updated 03/07/21, revealed the thermometer should be cleaned, rinsed, sanitized and air-dried prior to use. Additionally, the thermometer should again be cleaned, rinsed, sanitized and air-dried between foods. 2. Observation during meal service on 04/30/24 beginning at approximately 11:30 A.M. revealed Cook #553 wearing plastic gloves and touching serving utensils, covers for the steam table, and utensil drawers while plating resident meals. Cook #553 continued to wear the same gloves and picked up a piece of cheese and placed it on a burger, and picked up the top of the bun and put it over the cheese and handed the plate to the dietary aide to put on the tray. Staff identified the cheeseburger was for Resident #9. Continued observation revealed Cook #553 continued to touch serving utensils and steam table lids before opening a package of hamburger buns, reaching into the buns with his gloved hand, placing the bun on a plate, using tongs to place a burger on the bun, then used his gloved hand to pick up a slice of cheese, place it on the burger and place the bun on top. Staff identified the cheeseburger was for Resident #70. Interview on 04/30/24 at 11:40 A.M. with Cook #553 confirmed he did not change his gloves or perform hand hygiene before touching the ready-to-eat cheese and buns for Residents #9 and #70. Interview on 05/02/24 at approximately 2:30 P.M. with Dietary Manager (DM) #569 confirmed ready-to-eat food should be touched with a clean pair of gloves. Review of the policy titled Employee Sanitary Food Practices, updated 03/07/21, revealed disposable gloves were a single-use item and should be discarded after each use and gloves must be worn if raw food was handled. 3. Observation and interview on 04/30/24 at 1:47 P.M. with Cook #553 revealed the high-temperature dishwasher had a label indicating the wash temperature should be at least 160 degrees Fahrenheit (F) and the rinse temperature should be at least 180 degrees F. Observation of the dishwasher, after running a wash cycle three times, revealed a wash temperature of 142 degrees F and a rinse temperature of 181 degrees F. Cook #553 confirmed the wash temperature did not reach the minimum temperature indicated by the label on the machine. Observation on 04/30/24 at approximately 4:40 P.M. revealed the facility served dinner using standard plates and silverware. Observation on 05/01/24 at approximately 8:00 A.M. revealed the facility served breakfast using styrofoam plates and plastic silverware. Interview and observation on 05/01/24 at 9:19 A.M. revealed an outside repair company was fixing the dish machine. The repair person stated they attempted and failed to repair the dish machine the previous evening. Interview and observation on 05/01/24 at 10:33 A.M. with Dietary Aide (DA) #548, who was actively running the dish machine, confirmed the wash temperature was 165 degrees F and the rinse temperature was 172 degrees F. Observation on 05/01/24 at approximately 1:00 P.M. revealed the facility served dishes on standard plates and silverware.

Based on observation, staff interview, and review of the menu portion spreadsheet, the facility failed to provide adequate protein portions for residents on a mechanical soft diet. This affected five (#15, #16, #22, #33, and #40) of six residents identified on a mechanical soft diet. The facility census was 82. Findings include: Review of the dietary menu spreadsheet for lunch on 04/30/24 revealed the portion for mechanical soft pork chop should have been six ounces. Observation during meal service on 04/30/24 beginning at 11:30 A.M. revealed Cook #553 used a size 20 scoop (equivalent to 1.52 ounces) to serve mechanical soft pork chops. Interview on 04/30/24 at 12:30 P.M. with Cook #553 confirmed some mechanical soft pork chop was leftover. Cook #553 stated it was because some residents on a mechanical soft diet chose the alternative menu option. Cook #553 confirmed he used the 20 scoop to serve mechanical soft pork to the residents on a mechanical soft diet. Interview and observation on 05/01/24 at 10:00 A.M. with Dietary Manager (DM) #569 confirmed the size 20 scoop held 1 5/8 ounces. DM #569, while reviewing the menu portion spreadsheet, confirmed the mechanical soft pork serving size should have been six ounces.

Based on observations, staff interviews, and review of the facility policy, the facility failed to provide clean resident rooms. This affected four (#21, #27, #55, and #59) of four residents reviewed for environment. The facility census was 82. Findings include: 1. Observation on 04/30/24 at 8:51 A.M. revealed Resident #27 sitting in their room wearing a shirt with food on it and the floor of room was dirty and sticky and an area of dry yellowish fluid was noted under Resident #27's bed. Interview on 04/30/24 at 8:55 A.M. with Occupational Therapy Assistant (OTA) #564 verified Resident #27 was sitting in their room wearing a shirt with food on it and the floor of the room was dirty and sticky and a dried yellowish fluid was noted under Resident #27's bed. 2. Observation on 04/30/24 at 9:26 A.M. revealed the floor of the resident room, shared by Residents #55 and #59, was dirty and sticky. Subsequent observation on 04/30/24 at 2:44 P.M. revealed the floor of the resident room, shared by Residents #55 and #59, continued to be dirty and sticky. Interview on 04/30/24 at 4:05 P.M. with State tested Nursing Assistant (STNA) #507 verified the floor of the resident room, shared by Residents #55 and #59, was dirty and sticky. Review of the facility policy titled Cleaning and Disinfecting Residents' Rooms, dated August 2013, revealed housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visible soiled. 47057 3. Observation on 04/29/24 at 12:05 P.M. revealed a stool soiled and uncovered bed pan under Resident #21's bed. Resident #21 stated he used it and put it under his bed yesterday. Interview on 04/29/24 at 12:10 P.M. with State tested Nursing Aide (STNA) #551 verified the stool soiled and uncovered bed ban under Resident #21's bed. Review of the facility policy titled Quality of Life-Homelike Environment, revised 05/2017, revealed the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting that includes a clean, sanitary, and orderly environment.

Based on observation, medical record review, staff and resident interview, and facility policy review, the facility failed to ensure residents had access to their call lights and their bed mobility equipment. This affected three (#12, #48, and #67) of three residents reviewed for accommodation of needs. The facility census was 82. Findings include: 1. Review of the medical record revealed Resident #12 was admitted on [DATE]. Diagnoses included early-onset cerebellar ataxia, type two diabetes mellitus without complications, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 03/09/24, revealed Resident #12 was cognitively intact. Resident #12 was dependent on staff for shower/bathing, lower body extremity, personal hygiene, and always incontinent of bowel and bladder. Observation on 04/29/24 at 2:05 P.M. revealed Resident #12 was sitting in a wheelchair next to the bedside. Resident #12 reported she wanted to go back to bed. Resident #12's call light was observed to be under the bed and inaccessible to the resident. Interview on 04/29/24 at 2:09 P.M. with State tested Nursing Assistant (STNA) #626 verified the call light was inaccessible to Resident #12. 2. Review of the medical record revealed Resident #67 was admitted on [DATE]. Diagnoses included type two diabetes mellitus, coronary artery disease, hypertension, and depression. Review of the Minimum Data Set (MDS) assessment, dated 01/27/24, revealed Resident #67 was severely cognitively impaired, required partial to moderate assistance from staff for mobility, and always incontinent of bowel and bladder. Observation on 04/29/24 at 2:07 P.M. revealed Resident #67 was sitting in a wheelchair near the end of the resident's bed. Resident #67's call light was observed to be clipped to the top of the bed near the pillow and was inaccessible to the resident. Interview on 04/29/24 at 2:09 P.M. with State tested Nursing Assistant (STNA) #626 verified the call light was inaccessible to Resident #67. Review of the facility's undated policy titled Call Light Policy and Procedure revealed staff will ensure the resident is in a comfortable position and the call light is within reach of the resident before leaving the resident's room. 49742 3. Review of Resident #48's medical records revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), morbid obesity, muscle weakness, acute on chronic congestive heart failure (CHF), and muscle wasting and atrophy. Review of the Minimum Data Set (MDS) assessment, dated 04/08/24 revealed Resident #48 was cognitively intact. Review of the most recent care plan revealed Resident #48 was at risk for decline in activities of daily living (ADL) function and required extensive assistance with interventions including an overbed trapeze to assist with bed mobility. Interview and observation with Resident #48 on 04/30/24 at 11:14 A.M. revealed the resident did not have an overbed trapeze on her bed in approximately one month. Resident #48 indicated she utilized the over bed trapeze extensively to reposition herself in bed. There was no over bed trapeze for Resident #48 in her room Interview with Director of Rehabilitation #504 on 05/01/24 at 8:17 A.M. revealed Resident #48 has participated in 23 sessions of Occupational Therapy (OT) and was discharged from OT on 11/29/23. Director of Rehabilitation #504 indicated Resident #48 had an overbed trapeze for bed mobility. Interview with State tested Nursing Aide (STNA) #597 on 05/01/24 at 8:36 A.M. verified there was no overbed trapeze on Resident #48's bed.

Based on closed medical record review, staff interview, facility treatment administration guidelines, and review of the National Pressure Ulcer Advisory Panel (NPUAP) information on pressure ulcers, the facility failed to implement preventative measures to ensure a resident did not develop pressure ulcers. Actual harm occurred to Resident #1 when the resident developed one unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) and two deep tissue injuries (purple or maroon localized area or discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). This affected one (#1) of three residents reviewed for pressure ulcers. The facility identified two residents currently residing in the facility who had pressure ulcers (#5 and #6). The facility census was 99. Findings include: Closed record review revealed Resident #1 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's most current Minimum Data Set (MDS) assessment, dated 04/03/18, identified the resident as alert, able to make needs known, continent of bowel and bladder, requiring the extensive physical assistance of two staff for bed mobility, transfers, and toileting. The assessment noted the resident without skin breakdown and at risk for developing a pressure ulcer. Review of admission orders [REDACTED]. Review of the nurse's notes on 03/27/18 at 11:50 P.M., the resident was admitted to the facility and assessed with [REDACTED]. On 03/28/18, a nursing plan of care was developed to address the resident's risk for skin breakdown related to mobility alteration due to poor endurance, pain, chronic [MEDICAL CONDITION] to bilateral lower extremities, diabetes mellitus, positioning challenges related to pain. Interventions included diet and supplements as ordered, elevate heels as able, encourage, educate, provide staff assistance to reposition as needed, observe skin condition with activities of daily living daily and report abnormalities, therapy evaluation and treatment per physician orders, and use pillows/positioning devices as needed. Further review of the resident's medical record revealed [REDACTED]. Review of the nurse's notes, dated 04/13/18 at 12:30 P.M., revealed the nurse documented the resident had an open area to the coccyx assessed as unstageable (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar). The wound was described as measuring 3.5 centimeters (cm.) long by (x) 3.5 cm. wide with 25 percent (%) slough and 75% center of the wound appeared as dark purple, no drainage noted, no odor, tenderness to the area reported by resident, edges of wound were soft, defined, no tunneling or undermining noted. The coccyx wound was reddened but blanchable. Additionally, the right heel presented as scattered pale purple area with entire site measuring 2.5 cm. x 1.0 cm. and no open areas, and was slightly tender to touch. The left heel presented as one area of dark purple, closed, measuring 2.0 cm. x 2.0 cm. and was painful to touch. The physician was notified and a treatment was obtained and applied to all three areas. Interventions included a specialty air mattress placed on the resident's bed, the resident was assessed as alert and oriented, able to make needs known, and was independent for bed mobility. The resident was educated on the need to offload wounds and encouraged to do so. Additional interventions included to elevate heels off the mattress with pillows as tolerated. Review of physician orders, dated 04/13/18, revealed a [MEDICATION NAME] agent named Santyl ointment was to be applied to the coccyx wound every day, every night and as needed (prn). Wound care to the right heel deep tissue injury (DTI) included cleansing with wound wash, pat dry, apply skin prep, two x two gauze, then [MEDICATION NAME] dressing daily and every night. On 04/13/18 wound care to the left and right heel DTI's included cleansing with wound wash, pat dry, apply skin prep, 2 x 2 gauze, [MEDICATION NAME] dressing daily and every night. On 04/14/18, the wound treatment to the coccyx was modified to include cleansing with wound wash, pat dry, apply Santyl ointment and foam dressing every day, every night and as need (prn). Review of the resident's treatment administration records noted the dressing change to the coccyx was completed once on 04/13/18 at 10:30 A.M. and the bilateral heel treatments were recorded as completed on 04/13/18 and 04/14/18 at 10:30 A.M. No documentation indicated the dressings were administered as ordered twice daily on 04/14/18 or any treatment administered to the three areas on 04/15/18. According to nurse's notes on 04/15/18 at 3:36 P.M., the resident was transferred to another skilled nursing facility. On 04/26/18 at 11:30 A.M., an interview with the Administrator and Director of Nursing (DON) verified there was no documented evidence in the resident's medical record indicating interventions were consistently implemented to prevent the unstageable pressure ulcer and deep tissue injuries. Additionally, the Administrator and DON verified there was no documentation available indicating the dressing change were completed in accordance with physician orders. Review of the facility's list of resident who have pressure ulcers revealed Resident #5 and #6 had pressure ulcers at the time of the survey. Review of information from the National Pressure Ulcer Advisory Panel (NPUAP), 2014 defined pressure ulcers as a localized injury to the skin and/or underlying tissue over a bony prominence, as a result of pressure, or pressure in combination with shear. The NPUAP indicated that early assessment of risk factors and the implementation of preventative measures were key. Review of the facility's treatment administration guidelines, updated 03/2018, revealed treatments were to be documented immediately following administration. This deficiency substantiates Master Complaint Number OH 537.