Every finding on record at Batavia Nursing Care Center

Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure medications were administered per physician orders. This affected one (#78) of five residents reviewed for medication administration. The facility census was 97.Findings include:Review of Resident #78's medical record revealed an admission date of 04/29/21. Diagnoses included low back pain and chronic pain. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/19/26, revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #78 received a scheduled pain medication regimen. Review of the physician orders revealed Resident #78 had an order dated 11/21/24 for a lidocaine external patch four percent (%), apply to sacrum topically one time a day for pain/discomfort, 12 hours on and 12 hours off, and remove per schedule. Review of the Medication Administration Record (MAR) from 03/01/26 to 03/31/26 revealed the transcription of a physician order dated 11/22/24 to apply a lidocaine external patch to the resident's sacrum one time a day for pain/discomfort, with instructions to apply the lidocaine patch at 9:00 A.M. and remove the lidocaine patch at 9:00 P.M. Further review revealed on 03/09/26 at 9:00 P.M., Licensed Practical Nurse (LPN) #8 initialed the resident's MAR to indicate she removed the resident's lidocaine patch. Observation on 03/10/26 at 8:48 A.M. of medication administration with Registered Nurse (RN) #7 revealed a lidocaine external patch was obtained for administration to Resident #78's sacrum. Continued observation revealed Resident #78 had a lidocaine patch on their sacrum dated 03/09/26. RN #7 removed the lidocaine patch dated 03/09/26 and applied a new lidocaine patch dated 03/10/26 to the resident's sacrum. During an interview on 03/10/26 at 11:40 A.M., RN #7 confirmed she removed a lidocaine patch dated 03/09/26 from Resident #78's sacrum prior to applying a new lidocaine patch this morning. RN #7 stated the lidocaine patch she removed from the resident's sacrum should have been removed during the night shift on 03/09/26.During an interview on 03/10/26 at 7:20 P.M., LPN #8 stated she was assigned to care for Resident #78 on 03/09/26 and did not remember seeing the lidocaine patch, even though she signed the resident's MAR to indicate she removed the lidocaine patch. LPN #8 stated she was expected to remove the lidocaine patch as ordered by the physician. LPN #8 confirmed the lidocaine patch was to be placed on the resident by day shift staff and removed by the night shift staff. During an interview on 03/11/26 at 2:45 P.M., the Director of Nursing (DON) stated staff were expected to remove Resident #78's lidocaine patch as ordered by the physician.During an interview on 03/11/26 at 2:54 P.M., the Administrator stated staff were trained and expected to follow physician orders and to remove any patches accordingly. Review of the facility policy titled, Pain Assessment and Management, dated 03/31/16, revealed pharmacological interventions were provided in accordance with physician orders.

Based on observation, staff interview, and medical record review, the facility failed to ensure accurate medical records. This affected one (#78) of five residents reviewed for medication administration. The facility census was 97. Findings include: Review of Resident #78's medical record revealed an admission date of 04/29/21. Diagnoses included low back pain and chronic pain. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/19/26, revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #78 received a scheduled pain medication regimen. Review of the physician orders revealed Resident #78 had an order dated 11/21/24 for a lidocaine external patch four percent (%), apply to sacrum topically one time a day for pain/discomfort, 12 hours on and 12 hours off, and remove per schedule. Review of the Medication Administration Record (MAR) from 03/01/26 to 03/31/26 revealed the transcription of a physician order dated 11/22/24 to apply a lidocaine external patch to the resident's sacrum one time a day for pain/discomfort, with instructions to apply the lidocaine patch at 9:00 A.M. and remove the lidocaine patch at 9:00 P.M. Further review revealed on 03/09/26 at 9:00 P.M., Licensed Practical Nurse (LPN) #8 initialed the resident's MAR to indicate she removed the resident's lidocaine patch. Observation on 03/10/26 at 8:48 A.M. of medication administration with Registered Nurse (RN) #7 revealed a lidocaine external patch was obtained for administration to Resident #78's sacrum. Continued observation revealed Resident #78 had a lidocaine patch on their sacrum dated 03/09/26. RN #7 removed the lidocaine patch dated 03/09/26 and applied a new lidocaine patch dated 03/10/26 to the resident's sacrum. During an interview on 03/10/26 at 11:40 A.M., RN #7 confirmed she removed a lidocaine patch dated 03/09/26 from Resident #78's sacrum prior to applying a new lidocaine patch this morning. RN #7 stated the lidocaine patch she removed from the resident's sacrum should have been removed during the night shift on 03/09/26.During an interview on 03/10/26 at 7:20 P.M., LPN #8 stated she was assigned to care for Resident #78 on 03/09/26 and did not remember seeing the lidocaine patch, even though she signed the resident's MAR to indicate she removed the lidocaine patch. LPN #8 stated she was expected to remove the lidocaine patch as ordered by the physician. LPN #8 confirmed the lidocaine patch was to be placed on the resident by day shift staff and removed by the night shift staff. During an interview on 03/11/26 at 2:45 P.M., the Director of Nursing (DON) confirmed staff were expected to never sign the MAR if an order had not been completed.

Based on staff interview, observation, record review, and facility policy review, the facility failed to provide care for a peripherally inserted central catheter (PICC) consistent with standards of practice when they did have physician orders for the dressing change of the PICC line, did not flush the catheter per order, and did not change the PICC line dressings weekly. This affected one, (Resident #59) of three residents reviewed for intravenous lines. The facility census was 92. Finding include: Record review for Resident #59 revealed an admitted [DATE] with pertinent diagnoses of cerebral infarction due to thrombosis, dependence on respirator, tracheostomy status, gastrostomy status, persistent vegetative state, chronic respiratory failure with hypoxia, thrombocytopenia, pulmonary embolism, anemia, hypertension, retention of urine, and hirsutism. Review of the 01/10/25 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was in a persistent vegetative state and was dependent for all activities of daily living. The Resident used a ventilator for breathing. Review of Physician Orders dated 02/28/25 revealed Sodium Chloride Solution 0.9 % use 10 milliliters (ml)intravenously every shift for flush. Review of the Physician Orders on 03/26/25 at 11:30 A.M. revealed no order for changing PICC line dressings for Resident #59. Interview with Licensed Practical Nurse (LPN) #22 on 03/26/25 at 11:40 A.M. revealed there were two residents on her hallway with intravenous (IV) lines. She stated she was an LPN but was not IV certified. Observation of Resident #59's PICC line on 03/26/25 at 11:50 A.M. revealed the dressing was dated as changed 03/07/25. Interview with the Director of Nursing (DON) on 03/26/25 at 11:50 A.M. verified the PICC line dressing was dated 03/07/25 and the dressing was suppose to be changed every seven days. Review of the medication administration record for Resident #59 on 03/26/25 at 12:10 P.M. revealed there were nine times the PICC line flush was not signed off as completed during the month of March 2025. Interview with the DON on 03/26/25 at 12:55 P.M. verified there was no Physician Order for PICC line dressing change and there were nine spots on the medication administration record for March 2025 where the every shift PICC lines flushes were not sign off as completed when Licensed Practical Nurse #22 worked as Resident #59's nurse. Review of the facility 10/01/10 midline dressing changes policy revealed change midline catheter dressing 24 hours after catheter insertion, every five to seven days, or if it is wet, dirty, not intact, or compromised in any way. This deficiency represents non-compliance investigated under Complaint Number OH00163050.

Based on observation, medical record review, staff interview, review of a job description, and facility policy review, the facility failed to maintain infection control practices when handling dirty linens for one (Hall K) of seven halls observed and failed to use proper hand hygiene during incontinence care. This had the potential to affected 16 (#2, #5, #6, #8, #10, #17, #25, #29, #42, #44, #47, #57, #65, #68, #70, and #85) residents who resided on Hall K and one (#83) of two residents observed during incontinence care. The census was 96. Findings included: 1. On 09/23/24 at 10:15 A.M., an observation on Hall K revealed an open resident's door with dirty linens on the floor. State tested Nurse Aide (STNA) #1 was observed throwing linens on the floor and then was observed picking up the linens without wearing gloves and placing them into a bag. During an interview on 09/23/24 at 10:20 A.M., STNA #1 stated she should not have thrown anything on the floor and should have worn gloves when she put the dirty linens in the bag. STNA #1 stated she had infection control education during orientation. On 09/23/24 at 11:13 A.M., STNA #1 was observed carrying unbagged dirty linens down the hallway to the dirty linen room and the dirty linens were observed to be touching the STNA #1's clothing. During an interview on 09/23/24 at 11:16 A.M., STNA #1 stated she should have bagged the dirty linens prior to leaving the resident's room and should not have allowed the linens to touch her clothing. During an interview on 09/25/24 at 10:40 A.M., Registered Nurse Clinical Manager (RN CM) #2 stated linens should go into a bag and should never be placed on the floor. RN CM #2 stated staff should wear gloves when placing dirty linens into a bag, linens should never be carried down the hall unbagged, and should not touch their clothes. RN CM #2 stated it was an infection control issue. During an interview on 09/25/24 at 11:10 A.M., Licensed Practical Nurse Clinical Manager (LPN CM) #3 stated dirty linens should go into a bag and should never be thrown on the floor. LPN CM #3 stated staff should always wear gloves when picking up dirty linens, should bag the linens, and place them into the barrel in the utility room. LPN CM #3 stated dirty linens should never touch the staff's clothing and should always be bagged. She stated she expected staff to bag linens wearing gloves, tie the bag, and not allow the bag to touch their clothing. LPN CM #3 stated she expected dirty linens to never be placed on the floor and stated it was an infection control issue. During an interview on 09/25/24 at 11:47 A.M., the Director of Nursing (DON) stated she expected staff to place dirty linens in a bag. The DON stated that dirty linens should never be on the floor and should never be picked up without gloves or be allowed to touch staff's clothing. She stated infection control was mentioned every month during in-services. During an interview on 09/25/24 at 9:21 A.M., the Administrator stated they did not have a policy about the proper disposal of linens, but she expected staff to put dirty linens in bags and put them into the dirty linen closet. During a follow-up interview on 09/25/24 at 12:19 P.M., the Administrator stated staff should wear gloves and should place the dirty linens in a bag and the bag or linens should not touch the staff's clothing. Review of a facility policy titled, Infection Prevention and Control Program (IPCP), revised 11/28/17, revealed laundry services staff handle, store, and transport linens appropriately including but not limited to; using standard precautions (i.e. [id est, that is], gloves) and minimal agitation for contaminated linen and holding contaminated linen and laundry bags away from his/her clothing/body during transport. Review of an undated nursing assistant and STNA job description document revealed responsibilities and major duties included to adhere to all infection control policies within the assigned facility. 51642 2. Review of an admission record indicated the facility admitted Resident #83 on 10/28/22. According to the admission record, the resident had a medical history that included diagnoses of need for assistance with personal care, tracheostomy status, morbid obesity, and diabetes. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/11/24, revealed Resident #83 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS assessment indicated the resident was always incontinent of urine and required substantial/maximal assistance from staff with toileting hygiene. Review of Resident #83's care plan, included a focus area initiated on 10/12/22, that indicated the resident was at risk for infection related to chronic disease and urinary tract infection (UTI). An intervention was directed for staff to monitor for signs/symptoms of UTI, including foul smelling urine, cloudy urine, sediment, and decreased urine output. The care plan also included a focus area initiated on 10/20/22, that indicated the resident required assistance with activities of daily living. An intervention was directed for staff to provide toileting assistance as needed. During an observation of incontinence care in Resident #83's room on 09/24/24 at 11:12 A.M., STNA #10 donned gloves, a gown, and mask for enhanced barrier precautions (EBP). STNA #10 removed Resident #83's incontinence brief that was soiled with pale-yellow urine. STNA #10 cleansed Resident #83's genitals, groin, buttock, and anal areas with disposable wipes. Without removing her contaminated gloves and without sanitizing or washing her hands, STNA #10 then placed a clean incontinence brief under Resident #83 and placed her gloved hands on the resident's back and assisted the resident with rolling onto their back from their side. STNA #10 then attached both sides of the incontinence brief, removed her gloves, and sanitized her hands. STNA #10 then donned clean gloves and scanned the resident's urine alarm device. STNA #10 then removed her gown, gloves, and mask and placed them in a bag. STNA #10 was interviewed on 09/24/24 at 11:30 A.M. STNA #10 stated she had failed to remove her gloves and sanitize or wash her hands after cleansing the resident's genitals, groin, buttock, and anal areas prior to placing the clean incontinence brief under Resident #83. The Director of Nursing (DON) was interviewed on 09/24/24 at 1:54 P.M. T he DON stated staff were to always change gloves going from dirty to clean tasks such as after cleansing the genitals, buttock, and anal areas and prior to putting a clean brief on the resident. The DON stated it was especially true for Resident #83, who was on EBP. The Administrator was interviewed on 09/25/24 at 11:11 A.M. The Administrator stated staff should remove gloves and wash or sanitize hands prior to placing a clean brief on because going from dirty to clean tasks required washing or sanitizing hands after glove removal and prior to placing a clean brief on a resident. Review of a facility policy titled, Hand Hygiene, revised 11/28/17, indicated staff will perform hand hygiene when indicated, using proper technique. Staff perform hand hygiene (even if gloves are used) in the following situations including; before and after contact with the resident, and after contact with blood, body fluids, or visibly contaminated surfaces or other objects and surfaces in the resident's environment.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure dignity was maintained for one (#73) of four residents observed during care. The census was 96. Findings included: Review of an admission record indicated the facility admitted Resident #73 on 01/25/23. The resident had a medical history that included diagnoses of traumatic brain injury, chronic respiratory failure with hypoxia, and a tracheostomy. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/02/24, revealed Resident #73 had severe impairment in cognitive skills for daily decision-making per a staff assessment of mental status (SAMS). The MDS assessment indicated the resident was dependent on staff with all activities of daily living (ADLs) and required tracheostomy care. Review of Resident #73's care plan, included a focus area initiated 05/28/21, that indicated the resident had altered health maintenance related to a progressive physical and mental status due to a motor vehicle accident resulting in a traumatic brain injury. Interventions directed staff to provide tracheostomy care as ordered. During an observation of tracheostomy care in Resident #73's room on 09/24/24 at 8:40 A.M., Respiratory Therapist (RT) #9 removed Resident #73's inner cannula, placed another inner cannula inside the tracheostomy tube's outer cannula, suctioned a small amount of phlegm, cleansed around the tracheostomy site with a mixture of peroxide and sterile normal saline, and placed split sponges under the flange of the outer cannula. The door to Resident #73's room remained open during the tracheostomy care. During an interview on 09/24/24 at 2:37 P.M., RT #9 stated the staff member forgot to close the door while providing tracheostomy care that morning for Resident #73. RT #9 stated the door should have been closed while providing tracheostomy care for Resident #73. The Director of Nursing (DON) was interviewed on 09/24/24 at 3:03 P.M. and stated Resident #73's door should have been closed during personal care which included tracheostomy care. The Administrator was interviewed on 09/25/24 at 11:11 A.M. and stated Resident #73's door should have been closed during tracheostomy care for dignity. Review of an undated facility policy titled, Resident's [NAME] of Rights, indicated the resident has a right to a dignified existence. Nursing home residents have the right to be free from physical, verbal, mental, and emotional abuse, to be treated with the courtesy and respect in full recognition of dignity and individuality, and privacy during medical examinations and personal care. This deficiency represents non-compliance investigated under Complaint Number OH00157584.

Based on observation, staff interview, and policy review, the facility failed to ensure medications were stored with accurate labeling for safe administration when staff prepped medications and took the medications out of their original packaging. This affected two (#57 and #59) out of four residents observed for medication administration. The facility census was 93. Findings included: 1. Review of the clinical record revealed Resident #59 readmitted to the facility on [DATE]. His diagnoses included but were not limited to paraplegia, urinary tract infection, overactive bladder, neuromuscular dysfunction of the bladder, constipation, anemia, bladder disorder, and chronic pain syndrome. Review of Resident #59's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Observation on 12/28/23 at 5:45 A.M. of Licensed Practical Nurse (LPN) #156 pulling medication for Resident #59 revealed the resident's medications were observed to be in a foam cup with no name or label. The medications stored in the cup included Baclofen 10 milligrams (mg), Baclofen 5 mg, and Gabapentin 300 mg. 2. Review of the clinical record revealed Resident #57 had an admitted [DATE]. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease, hypertension, age-related osteoporosis, major depressive disorder, heart failure, hypothyroidism, peripheral vascular disease, anxiety disorder, anemia, cognitive communication deficit, polyosteoarthritis, and chronic pain syndrome. Review of Resident #57's annual MDS assessment dated [DATE] revealed she had moderate cognitive impairment. Observation on 12/28/23 at 6:26 A.M. of LPN #56 pulling medication for Resident #57 revealed the resident's medications were observed to be in a foam cup with no name or label. The medication stored in the cup included Famotidine 20 mg, Amlodipine 5 mg, Levothyroxine 75 micrograms (mcg), Clopidogrel 75 mg, Benazepril 20 mg, and Venlafaxine Hydorchloride 25 mg. Interview on 12/28/23 at 5:45 A.M. with LPN #156 revealed she set up her medications for the 5:00 A.M. and 6:00 A.M. medication administration ahead of time to make sure all of the ordered medication was in the medication packages. It would give her time to obtain medication from the e-box if needed. An interview with the Administrator on 12/28/23 at 7:20 A.M. verified it was not their policy to have medications set up ahead of time for administration. Review of the facility's policy titled, Medication Storage, dated 06/21/17 revealed the pharmacy dispenses medications in packaging/containers that meet regulatory requirements. It also stated medications shall be kept and stored in these packages/containers. It stated transfer of medications from one container to another is not permitted except by a licensed pharmacist or except as necessary in the event of an unplanned leave of absence of 24 hours duration or less.

Based on observations, record review and staff interviews, the facility failed to ensure recommendations for passive range of motion were implemented upon discharge from Occupational Therapy services to maintain range of motion. Actual harm occurred when Resident #7 did not receive passive range of motion exercises as recommended and subsequently developed contractures of both upper extremities. This affected one (#7) of one residents reviewed for range of motion. The facility identified 25 residents with contractures. The facility identified 30 residents who were on the restorative nursing program. The facility census was 101. Findings include: Review of Resident #7's medical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Rehab Communication Form, dated 05/20/22, revealed passive range of motion to bilateral upper extremities in all functional planes involving shoulders, elbows, wrists, and digits to be performed three times a week. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 05/23/22, revealed range of motion to Resident #7's left and right upper extremities was assessed to be within functional limits with no contractures present. Review of the OT Discharge Summary, dated 05/30/22, revealed discharge recommendations to include Restorative Nursing Program (RNP) for passive range of motion exercises to bilateral upper extremities. Prognosis to maintain current level of function was documented to be good with consistent staff follow through. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/21/22, revealed the resident was rarely/never understood. Resident #7 was assessed to be dependent upon two staff members for bed mobility and toileting. Resident #7 was assessed to have limited range of motion to bilateral upper and lower extremities. Review of the active care plans for this resident revealed there was not a plan of care or interventions in place addressing limitation in range of motion or contractures. Further review of the medical record revealed no documentation of passive range of motion exercises being completed for Resident #7. Observation on 10/25/22 at 10:26 A.M., revealed Resident #7 was lying in bed with no splints or other preventive devices in place to bilateral upper extremities. The resident's fingers, wrists, and elbows were observed to contracted. Interview on 10/27/22 at 9:40 A.M., with Occupational Therapist #170 revealed the employee had assessed and treated Resident #7 in May of 2022. Occupational Therapist #170 verified the resident did not have contractures present at the time of discharge from OT services and recommendations had been made for RNP, which was to include passive range of motion exercises to be completed to the resident's bilateral upper extremities to prevent contractures. Occupational Therapist #170 verified the resident's functional range of motion to bilateral upper extremities were documented to be within functional limits at the time of discharge from OT services. Observation on 10/27/22 at 10:00 A.M., revealed Occupational Therapist #170 entered the room of Resident #7 and assessed the resident's left and right upper extremities for the presence of contractures. Interview with Occupational Therapist #170 at the time of the observation verified the fingers, wrists, and elbows of Resident #7 were currently contracted and passive range of motion exercises being completed may have prevented the development of the contractures. Interview on 10/27/22 at 10:25 A.M., with the Director of Nursing (DON), verified the recommendations for passive range of motion exercises for Resident #7 had not been implemented.

Based on observations, staff interviews, medical record reviews, review of facility policies, and review of the Centers for Disease Control (CDC) prevention online guidance, the facility failed to ensure appropriate isolation precautions and use of Personal Protective Equipment (PPE) were implemented and failed to ensure staff performed adequate hand hygiene when completing care hygienic care. This affected three (#7, #42 and #89) of three residents reviewed for infection control and the potential to affect all residents in the facility. The facility census was 101. Findings include: 1. Review of Resident #7's medical record review revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) assessment, dated 07/21/22, revealed this resident was rarely/never understood. This resident was assessed to be dependent upon two staff members for bed mobility and toileting. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/24/22 at 10:20 A.M., revealed there were isolation signs reading Droplet Precautions present on the room door of Resident #7. Resident #7 was observed to have [CONDITION(S)] appliances in place. Observation on 10/25/22 at 10:53 A.M., revealed Respiratory Therapist (RT) #145 was providing care to Resident #7 inside the resident's room only wearing an N-95 mask and gloves. 2. Review of Resident #42's medical record revealed an admitted [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 09/20/22, revealed this resident had mildly impaired cognition and was assessed to be dependent upon two staff members for bed mobility and toileting. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/24/22 at 10:20 A.M., revealed there were isolation signs reading Droplet Precautions present on the room door of Resident #42. Resident #42 was observed to have a [CONDITION(S)] appliances in place. Observation on 10/25/22 at 9:20 A.M., revealed Licensed Practical Nurse (LPN) #21 was observed to be in the room of Resident #42 providing personal care to the resident while wearing an N-95 respirator mask and gloves with no gown. Interview on 10/25/22 at 9:20 A.M., with LPN #21 verified the employee had not worn a gown while providing personal care to Resident #42. LPN #21 stated staff only had to wear an N-95 and gloves in the room while providing care as the resident was only on droplet precautions. Interview on 10/25/22 at 10:53 A.M., with the Director of Nursing (DON) verified RT #145 was not wearing a gown while in the room of Resident #7. The DON stated Resident #7 and Resident #42 should also be on contact precautions due to their infections and appropriate signage was being added. Review of the policy titled Foundations Health Solutions Infection Control Policy/Procedure Manual, revised 11/28/17, revealed a resident with an infection or communicable disease should be placed on Transmission-based precautions as recommended by current CDC Guidelines for Isolation Precautions. Review of the online CDC guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html), last reviewed 07/12/2022, revealed the document was intended to provide guidance for the use of PPE and room restriction in nursing homes to prevent the spread of MDROs to include [CONDITION(S)] ([CONDITION(S)]) and ESBL producing Enterobacterales. Contact Precautions, to include use of gown and gloves, were recommended during any room entry where there was presence of acute diarrhea, draining wounds or other sites of secretions or excretions that are unable to be covered or contained. Face protection may also be needed if performing activity with risk of splash or spray. 3. Review of Residnet #89's medcial record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/27/22 at 10:56 A.M., revealed State tested Nurse Aide (STNA) #100 completing incontinence care and urinary catheter care for Resident #89. STNA #100 gathered her supplies and put on her gloves. STNA #100 filled a basin with water and then removed her gloves and put on clean gloves. She did not wash her hands after removing her soiled gloves. STNA #100 got disposable wipes and a new adult incontinence brief. Resident #89 had a bowel movement in her adult incontinence brief. STNA #100 cleaned the resident's vaginal area of feces and STNA #100 then used a disposal wipe to clean off her gloves and moved the catheter bag to the other side of the bed and turned Resident #89 over. STNA #100 then cleaned the resident's buttocks of feces with wipes. STNA #100 then removed her soiled gloves put on new gloves and she did not wash her hands between changing gloves. STNA #100 completed Resident #89 care including catheter care then dumped water in the toilet took off her gloves cleaned out basin with water and towel. STNA #100 turned on the water, lathered her hands, washed hands used left forearm to turn on water and rinsed right hand, then used washed right hand to hold button to turn on water and rinsed left hand. Interview on 10/27/22 at 11:10 A.M., with STNA #100 verified she did not wash her hands after removing her gloves multiple times. STNA #100 verified that she wiped off her dirty glove with a disposable wipe and then grabbed the residents catheter bag and turned her over and continued doing care. She also verified that she touched the knob of the sink with her right clean hand and did not rewash her right hand when she had finished all care. Review of the policy titled, Infection Control Policy/Procedure Manual dated 11/28/17, revealed all staff should perform hand hygiene, when coming on duty, after handling contaminated objects, and after personal protective equipment removal. Gloves are worn if potential contact with blood or body fluid, and gloves are removed after contact with blood or body fluids.

Based on observation, staff interview and policy review, the facility failed to ensure food storage was maintained in a clean manner to prevent potential food contamination or food borne illness. This had the potential to affect 50 of 50 resident who reside on the affected units. The facility census was 101. Findings include: Observation on [DATE] from 9:50 A.M. through 10:15 A.M., revealed the in the E/F Unit resident refrigerator: the outside of the freezer casket pull away from the top side and corner edge of the door exposing debris; inside the freezer, there was a built up of ice where the door closed, preventing the door from completely shutting and making a complete seal; there was and outside handle missing from the refrigerator door exposing two holes in the door; two large, insulated lunch containers with no name or date; two open containers of fluids with no open date and opened and partially served ice cream cake in freezer with no open date. In the J/K Unit resident refrigerator an opened and partially served resident identified gallon of milk with expiration date [DATE]; an opened and partially used liter of pop with no open date; an outside refrigerator handle lose in the middle, taped with heavy taping material and soiled with debris and two open containers of fluids with no open date. Interview on [DATE] from 9:50 A.M. through 10:15 A.M., with Dietary Manager (DM) #90 verified the refrigerators on the units were for resident food storage only. She verified the open containers of fluids, pop and ice cream cake should have been dated with an open date. She verified the expired food should have been discarded within seven days of opening. She stated the insulated bags should have been labeled and dated or stored elsewhere if the bags contained employees' meals. DM #90 verified E/F refrigerator gasket was in disrepair and did not make contact with the freezer surface to prevent ice build up and the door handle tape and holes were not cleanable surfaces. Review of the policy titled, Food Storage-labeling and Dating dated [DATE], revealed items must be dated after opening with an open date. All foods should be discarded prior to or on day seven.

Based on record review, staff interview and policy review, the facility failed to respond timely to pharmacy recommendations after being acknowledge by the physician. This affected one (#96) of five residents reviewed for pharmacy recommendations. The total facility census was 101. Findings include: Review of Resident #96's medical record revealed an admitted [DATE], with diagnoses including: diabetes, [CONDITION(S)], chronic ulcer in foot, pressure hypertension, open wound, [CONDITION(S)], suprapubic catheter, oxygen via nasal cannula and anxiety. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was receiving the medication, [MEDICATION(S)] tablet 10 milligrams every eight hours for [CONDITION(S)]. Review of the pharmacy recommendation dated 03/15/22, revealed the pharmacist recommended the [MEDICATION(S)] order should include parameters to ensure it is only given when clinically appropriate. The physician signed the pharmacy recommendation on 03/23/22, with revised clarification to hold [MEDICATION(S)] with systolic blood pressure greater than 110. Review of physician orders of October 2022 revealed the [MEDICATION(S)] clarification was ordered on 10/26/22 to give 2 tablets by mouth every 8 hours as needed for [CONDITION(S)] and hold [MEDICATION(S)] with systolic blood pressure greater than 110. Interview on 10/27/22 at 11:03 A.M., with the Director of Nursing, (DON) verified the [MEDICATION(S)] pharmacy recommendation order was not ordered as a clarification by the physician until 10/26/22 after the surveyor had requested the pharmacist medication recommendations. The DON verified the new clarification should have been ordered when the physician approved the clarification. Review of the policy titled Medication Monitoring, dated 06/21/17 revealed the facility must act on the reports in a manner that meets the needs of the residents.

Based on medical record review and staff interview the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one resident (Resident #106) out of three residents reviewed for hydration status related to feeding tubes. The facility census was 105. Findings included: Review of the medical record for Resident #106 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day admission minimum data set (MDS) assessment for Resident #106 revealed the resident had an impaired cognition. No hallucinations, delusions, or rejection of care was noted in the assessment. Resident #106 required total dependence for all activities of daily living (ADL's). The assessment listed the resident as having an indwelling catheter, feeding tube, and therapeutic diet. Resident #106 received 51% or more of his total calories and 501 milliliters (ml) or more per day through his feeding tube. Review of the hospital discharge paperwork for Resident #106 dated 02/28/22 revealed the resident was to receive water flushes at 100 ml's every four hours through his feeding tube. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 03/29/22 at 1:45 P.M. with the Director of Nursing (DON) confirmed there was no order written for Resident #106 to be flushed with 100 ml's of water every four hours through his feeding tube from his admission on 02/28/22 through 03/03/22. The DON confirmed that flush orders would normally accompany the nutritional supplement or tube feedings for the resident. The resident received many medications from staff members throughout the day. The DON stated that with the staff following correct medication administration techniques, the resident would have received as much fluid if not more water even without the order for the flushes. This deficiency substantiates Complaint Number OH 968.

Based on medical record review, observation, staff interview, review of facility policies, and review of online resources per the Center for Medicare and Medicaid Services (CMS) and the Centers for Disease Control (CDC), the facility failed to ensure staff wore appropriate personal protective equipment (PPE) in resident areas to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect the residents residing in Unit E (#13, #14, #15, #16, #17, #18, #19, #20, #21, #22 and #23). Additionally, the facility also failed to clearly indicate residents with orders for transmission based precautions ordered by the physician. This affected two (#14 and #25) of 17 facility-identified residents on transmission-based precautions. The census was 100. Findings include: 1. Review of the medical record for Resident #14 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of November 2021 monthly physician orders for Resident #14 revealed an order dated 09/30/21 for resident to be on droplet and contact isolation for an indefinite period of time due to Carbapenem-Resistant Acinetobacter Baumannii (CRAB) infection in her sputum. Review of the nurse progress notes for Resident #14 dated 11/19/21 and 11/21/21 revealed resident continued on transmission based precautions due to her CRAB infection. Observation on 11/18/21 at 11:10 A.M. of Resident #14's room revealed there was no signage or indicator outside the resident's room to alert staff and/or visitors of transmission based precautions ordered by the physician. Further observation revealed there were three isolation carts containing personal protective equipment (PPE) positioned throughout the hallway but there was no cart directly adjacent to Resident #14's room. Review of the medical record for Resident #25 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of admission physician orders for Resident #25 dated 11/11/21 revealed resident should be on contact and droplet isolation for 14 days. Review of the immunization record for Resident #25 revealed it was uncertain if resident had been vaccinated against COVID-19. Observation on 11/18/21 at 9:25 A.M. of Resident #25's room revealed there was no signage or indicator outside the resident's room to alert staff and/or visitors of transmission based precautions ordered by the physician. There was no isolation cart with PPE located adjacent to resident's room. Interview on 11/18/21 9:26 A.M. with Licensed Practical Nurse (LPN) #250 revealed Resident #25 was unvaccinated and was a new admission to the facility and should be on contact and droplet isolation. LPN #250 confirmed there should be signage on the door indicating the isolation ordered by the physician but there was no such signage. Interview on 11/18//21 at 7:10 A.M. with the Director of Nursing (DON) confirmed she was also the Infection Preventionist (IP) for the facility and staff were notified of which residents were on transmission based precautions by the signage on the resident's door. DON further confirmed the facility kept PPE carts in the hallway at all times and it could be used as needed by staff. The Surveyor requested a list of all residents on isolation precautions at 7:10 A.M. Review of facility list of residents on isolation provided by the DON on 11/18/21 at 9:10 A.M. revealed Residents #14 and #25 were not on the list of residents with orders for isolation precautions. Interview on 11/18/21 at 11:00 A.M. with the DON confirmed Resident #14 should be on contact and droplet precautions due to CRAB infection and Resident #25 should be on contact and droplet precautions due to being unvaccinated and newly admitted . DON confirmed Resident #14 and #25's names were not on the isolation list provided to the Surveyor at 9:10 A.M. but their names should have been included. DON further confirmed Residents #14 and #25 did not have signage on their doors to alert staff and visitors of their isolation status. Review of the facility policy titled Novel Coronavirus Prevention and Response dated 04/09/20 revealed the facility would post applicable signage regarding transmission based precaution. Review of online resource per the CDC titled Increase in Hospital-Acquired Carbapenem-Resistant Acinetobacter baumannii Infection and Colonization in an Acute Care Hospital During a Surge in COVID-19 Admissions - New Jersey, February-July 2020 at https://www.cdc.gov/mmwr/volumes/69/wr/mm6948e1.htm revealed CRAB was an opportunistic pathogen primarily associated with hospital-acquired infections and was an urgent public health threat in health care facilities. Further review revealed CRAB readily contaminates the patient care environment and health care providers 'hands, survives for extended periods on dry surfaces, and causes health care-associated infections that are challenging to contain and often linked to infection prevention and control (IPC) breaches. 2. Review of the medical record for Resident #20 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the immunization record for Resident #20 revealed resident had refused vaccination against COVID-19. Observation on 11/18/21 at 6:35 A.M. of State tested Nursing Assistant (STNA) #300 was exiting Resident #20's room and was not wearing eye protection. Interview on 11/18/21 at 6:36 A.M. with STNA #300 confirmed she was not wearing eye protection and the staff were not currently required to wear eye protection. Observation on 11/18/21 at 6:40 A.M. of Housekeeper #350 revealed she was working on Unit E, the unit where Resident #20's room was situated and was not wearing eye protection. Interview on 11/18/21 at 6:41 A.M. with Housekeeper #350 confirmed she was not wearing eye protection and the staff were not currently required to wear eye protection. Observation on 11/18/21 at 6:59 A.M. of Housekeeper #350 revealed she was still not wearing eye protection. Interview on 11/18/21 at 7:10 A.M. with the DON confirmed all staff were supposed to wear eye protection in resident areas at this time due to the moderate county positivity rate for COVID-19. Review of the facility policy dated Novel Coronavirus Prevention and Response dated 04/09/20 revealed the facility would educate staff on proper use of personal protective equipment and application of standard, contact and droplet transmission precautions, including eye protection. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/covid-19/covid-19-nursing-home-data revealed the county in which the facility was situated was experiencing a high spread (red) of COVID 19 with a positivity rate of 10.6 % and the county was identified as red for the week ending in 11/16/21. Review of an online resource per the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. 3. Observation on 11/18/21 at 10:28 A.M. of LPN #250 revealed she was sitting at the nurses' station desk adjacent to Unit E which was in a resident area and was not wearing her mask or eye protection. Further observation revealed LPN #250 was eating food and drinking a beverage. Interview on 11/18/21 at 10:29 A.M. with LPN #250 confirmed she was not wearing a mask or eye protection and was eating at the nurses' station desk. LPN #250 further confirmed the facility provided break areas for staff to eat and drink where they could remove their PPE without residents present. LPN #250 confirmed staff were supposed to wear a mask and eye protection at all times in resident areas. Interview on 11/18/21 at 11:00 A.M. with the DON confirmed the facility provided break areas for staff to eat and drink where they could remove their PPE without residents present and staff were supposed to wear a mask and eye protection at all times in resident areas. The DON confirmed there are 11 residents (#13, #14, #15, #16, #17, #18, #19, #20, #21, #22 and #23) residing on Unit E. Review of an online resource from the CDC (https://www.cdc.gov/Coronavirus/2019-ncov/hcp/long-term-care-strategies.html) revealed the following guidance regarding facemasks: ensure all healthcare care personnel (HCP) wear a facemask while in the facility. This deficiency substantiates Complaint Number OH 220.

Based on medical record review, review of self-reported incidents, review of written statements, review of punch details, staff interview, and review of facility policy, the facility failed to ensure a staff member alleged of resident abuse was removed from the facility immediately while the abuse investigation was in progress. This affected one (#4) out of two residents review for abuse and had the potential to affect 19 (#4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22) residents who the alleged staff had access to following an abuse allegation. Facility census was 111. Findings include: Review of the medical record revealed Resident #4 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) for Resident #4 dated 12/28/19 revealed resident was cognitively intact and required extensive assistance of two staff with activities of daily living. Review of care plan for Resident #4 dated 11/19/18 revealed resident experienced alterations in mood and/or behavior and had a history of [REDACTED]. Review of facility SRI revealed and incident report was initiated at 9:00 P.M. on 12/24/19 and was closed on 12/31/19. Further review of SRI revealed Resident #4 alleged abuse per a staff member, but the facility did not substantiate abuse. Review of handwritten witness statement per State tested Nursing Assistant (STNA) #70 dated 12/24/19 revealed Resident #4 accused STNA #60 of hitting her in the face with a pillow during care. STNA #70's statement further revealed she was present during care and did not believe STNA #60 hit the resident. Review of handwritten witness statement per STNA #60 (alleged perpetrator) dated 12/24/19 revealed Resident #4 accused STNA #60 of hitting her in the face with a pillow during care. STNA #60's statement further revealed she denied hitting the resident in the face, and she reported the resident's allegation immediately to the nurse. Review of handwritten statement per Administrator dated 12/26/19 revealed Administrator interviewed Resident #4 regarding the allegation of abuse against STNA #60. Administrator's statement revealed Resident #4 reported STNA #60 rubbed her face when moving the pillow during care but did not hit the resident. Review of punch detail for STNA #60 revealed aide worked from 6:10 P.M. on 12/24/19 to 12:46 [NAME]M. on 12/25/19. Interview with Licensed Practical Nurse (LPN) # 80 on 01/21/20 at 3:07 P.M. confirmed staff notified her by phone on 12/24/19 at approximately 9:00 P.M. that Resident #4 had alleged abuse occurred during care. LPN #80 further confirmed she directed the staff who had worked with the resident to complete handwritten witness statements and she called the Administrator at home to report Resident #4's allegation. Interview with the Administrator on 01/21/20 at confirmed LPN #80 called her at home on 12/24/19 at 9:00 P.M. and reported Resident #4 had alleged staff were inappropriate during care but resident was not descriptive of the incident. Administrator further confirmed she was unaware on 12/24/19 Resident #4 had alleged STNA #60 hit her in the face with a pillow. Administrator confirmed STNA #60 was not suspended during the investigation and continued to work on 12/24/19 until her shift ended. The facility confirmed this had the potential to affect 19 (#4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22) resident who STNA #60 had access to following the abuse allegation and while continuing to work. Review of facility policy titled Abuse Neglect and Misappropriation dated 11/21/16 revealed if a staff member is suspected or accused of abuse, they will be removed from the facility and the schedule pending the outcome of the investigation. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, staff interview, and review of facility policy, the facility failed to date open vials of Influenza vaccine and [MEDICATION NAME] Purified Protein Derivative(PPD) and the facility failed to dispose of outdated Prostat (protein supplement). This had the potential to affect all 107 residents residing in the facility. Findings include: Medication storage observation and interview conducted on 11/20/19 at 8:58 [NAME]M. with Licensed Practical Nurse (LPN) #486 revealed an open/undated vial of influenza vaccine noted in the L-Hall medication storage refrigerator. LPN #486 verified the vial was open and undated, and should have been dated when it was opened. Medication storage observation and interview conducted on 11/20/19 at 10:37 [NAME]M. with LPN # 480 revealed two bottle of Prostat (protein supplement) expiration dated 06/06/19 and the other dated 10/02/19 in the F-Hall medication cart, and a open/undated insulin pen. LPN #480 verified the Prostat was out of expiration date, and should had been disposed of, and the insulin pen should have been dated when opened. Further review of medication storage conducted at 10:52 [NAME]M. with LPN #480, of the E/F medication storage room, revealed two bottles of [MEDICATION NAME] PPD. LPN #480 stated the [MEDICATION NAME] PPD was used on resident's and staff member to check for [MEDICAL CONDITION] when they are admitted /hired to the facility. LPN #480 verified the bottles were both opened and undated, and should have been dated upon opening. Interview conducted on 11/20/19 at 12:23 P.M. with Registered Nurse (RN) #656 stated she would expect all vial medications to be dated upon opening and disposed of within the required time frames, as applicable. Review of the facility policy titled, Medication Storage, dated (MONTH) (YEAR), revealed outdated medication are immediately removed from stock, and disposed of accordingly. Staff should ensure the opened date is documented on the vial or pen.

Based on medical record review and staff interview, the facility failed to develop and implement baseline care plans that were person centered and included the minimum healthcare information necessary to care for the residents. This affected three (Residents #3, #12 and #88) reviewed during the annual survey. The facility census was 107. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognition was severely impaired and the resident was comatose. Review of Resident #3's medical chart revealed no baseline care plan. Interview on 11/21/19 at 12:19 P.M. with the Director of Nursing (DON) who stated the facility could not locate a baseline care plan for Resident #3. 2. Review of the medical record for Resident #12 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12's cognition was intact. Interview on 11/21/19 at 12:19 P.M. with the Director of Nursing (DON) who stated the facility could not locate a baseline care plan for Resident #12. 3. Review of the medical record for Resident #88 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] revealed Resident #88's cognition was intact. Resident #88 was noted on the MDS under Section O to have received [MEDICAL TREATMENT]. Interview on 11/21/19 at 8:56 [NAME]M. with the Assistant Director of Nursing (ADON) who reviewed the baseline care plan which was in the resident's chart and he verified he did not see that the baseline care plan addressed the resident's [MEDICAL TREATMENT] needs.

Based on medical record review, staff and resident interviews and review of facility policy, the facility failed to conduct appropriate interdisciplinary team (IDT) care plan meetings (care conferences) as required. This affected five (Residents #4, #7, #12, #30, and #97) of five reviewed for care planning during the annual survey. The facility census was 107. Findings include: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact with rejection of care behaviors one to three days during the seven day look back period. Review of Social Services Progress Notes dated 11/19/19, 08/21/19, 08/14/19, 04/12/19, 01/10/19 revealed the care conference offered to resident and the resident declined. On 10/10/19, the care conference was offered to resident and brother, and both declined. Further review of the medical record revealed no documentation the IDT still conducted the required comprehensive assessments, with the required staff, to review appropriate care. Interview conducted on 11/19/19 at 11:16 [NAME]M., Resident #7 stated he use to be invited to care conference meetings, but he was unsure of when they last had one. Interview conducted on 11/20/19 at 2:48 P.M. the facility Administrator verified the facility did not hold IDT care conference for Resident #7 with a appropriate staff. 2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 09/18/19 revealed Resident #30 was cognitively intact with rejection of care noted one to three days during the look back period. Review of the Social Service Progress Notes dated 09/18/19, 05/01/19, 02/22/19, and 11/22/18 revealed the resident was offered a care conference and declined. The medical record contained no documentation verification the facility held an IDT care plan meeting with the required staff, to review Resident #30's care. Interview conducted on 11/19/19 at 9:50 [NAME]M., Resident #30 stated the facility use to have care conferences, but she had no been invited to one in a long time. Interview conducted on 11/20/19 at 2:47 P.M. the Administrator stated the facility conducted a care conference on 11/04/19 that the resident and her mother were invited to, however also verified the conference held did not include the required staff including but not limited to, the attending physician and/or non-physician practitioner, and nurse aid with responsibility for the resident. 3. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitive intact, with noted delusions, behavioral symptoms not directed towards others and rejection of care noted one to three days during the look back period. Interview conducted on 11/19/19 at 10:57 [NAME]M., Resident #97 stated she had not been invited to attend a care plan meeting and/or care conference since admission to the facility. Review of Nursing progress Note dated 11/12/19 revealed a care conference was held, over the phone, with Resident #97's son and the social worker. Interview conducted on 11/20/19 at 3:09 P.M., the facility Administrator stated Resident #97's son is very specific, and had requested weekly conferences over the phone. Administrator verified Resident #97 was cognitively intact, and the facility was unable to provide any verification the resident was invited or even addressed regarding care conferences, and/or care conferences only with her son. 4. Medical record review for Resident #12 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of Resident #12's quarterly MDS assessment dated [DATE] revealed Resident #12's cognition was intact. Review of the medical record for Resident #12 revealed no care conferences had been held. Interview on 11/20/19 at 4:56 P.M. with the Administrator) who stated the facility did not have the care conferences for this resident. The facility was not able to reach her family via telephone but that did not impact the resident. 5. Review of Resident #4's medical records revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of minimum data set ((MDS) dated [DATE] revealed resident had moderate cognitive impairment. Resident #4 required extensive to total assistance of one or two people for all activities of daily living. Review of resident's social work records and progress notes revealed no documentation of care conferences being held for the resident. Interview on 11/20/19 at 8:00 [NAME]M. Administrator stated the facility had a new social services staff and they had discovered care conferences were not being done consistently. The Administrator further verified that the facility did not have and care conference documentation for Resident #4.

Based on observation, interview, and record review the facility failed to have advanced directives properly documented. This affected two (Resident #4 and Resident #12) of 22 residents reviewed for advanced directives. The census was 107. Findings include: 1. Review of Resident #4's medical records revealed an admission date of [DATE]. Review of the electronic health record revealed a Do Not Resuscitate - Comfort Care Arrest (DNRCCA) order entered on [DATE]. Observation on [DATE] at 12:39 P.M. revealed no physician signed DNRCCA form nor any other indication in the resident chart. Interview on [DATE] at 12:55 P.M. Licensed Practical Nurse (LPN) #480 stated if the resident coded she would look in the electronic health record for the code status, then verify signed DNRCCA in the hard chart. LPN #480 verified there was no signed DNRCCA form completed in the resident chart. LPN #480 further stated the signed copy should be in the chart. As a result LPN #480 stated she would then perform chest compressions and attempt to resuscitate the resident due to the lack of signed DNRCCA form in the hard chart. 2. Medical record review for Resident #12 revealed an admission date of [DATE]. Review of the electronic medical record revealed Resident #12 had physician orders [REDACTED]. Review of the hard chart revealed the resident had no signed DNRCC form in the medical record. Interview conducted on [DATE] at 1:00 P.M. with Registered Nurse (RN) #462 stated the resident was a DNRCC. RN #462 stated if the resident coded at that time, she would verify in the Electronic Health Record (EHR) the resident code status and look in the hard chart to verify signed form. RN #462 verified there was no signed form in the resident hard chart and if the resident coded at that time, she would perform Cardiopulmonary Resuscitation (CPR) due to no signed DNR form in the medical record. Review of policy titled Social Services Policy/Procedure Manual, dated [DATE], stated Upon admission, should the resident have an Advance Directive, copies will be made and placed on the chart as well as communicated to the staff.

Based on medical record review, observation, staff and resident interviews, the facility failed to fully complete the required quarterly Minimum Data Set (MDS) assessment. This affected one (Resident #79) of twenty-two residents reviewed during the investigation stage of the annual survey. The facility census was 107. Findings include: Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of last quarterly MDS assessment dated [DATE] revealed Section C- Cognitive Patterns including the Brief Interview of Mental Status (BIMS) was not completed and noted as not assessed on all sections of the mental status assessment. Review of the Social Service Progress Note dated 10/25/19, competed by Social Services (SS) #474 documented the psychosocial assessment for the quarterly MDS dated [DATE] was attempted on 10/25/19 and Resident #79 was receiving ventilator treatment, is non-verbal and unable to complete BIMS. Observation and interview conducted on 11/20/19 at 5:05 P.M., Resident #79 was observed in bed, with ventilator in place. Resident #79 was interviewed during the annual survey, and was observed to answer questions appropriately and a reliable source of information. Interview conducted on 11/21/19 at 8:01 [NAME]M. with the facility Director of Nursing (DON) verified Resident #79's MDS Section C assessment dated [DATE] was noted as not assessed. The DON verified Resident #79's medical record contained no documentation that additional attempts were made to complete assessment prior to SS #474's attempt on 10/25/19. DON verified Resident #79 was typically alert and able to answer questions with no issues. During interview conducted on 11/21/19 at 8:30 [NAME]M., SS #466 stated she was aware BIMS assessments are required to be completed fully for residents. SS #466 stated she had attempted to complete the assessment for the resident, however had no documentation of verification and/or completed the required assessment. SS #474 stated he was new to the facility and attempted to see the resident on 10/25/19. SS #474 verified he did not complete the assessment as required, stating the resident was not able to talk to him, so the assessment wasn't completed. SS #474 stated he was not trained on who to complete the assessment, if they resident is non-interviewable/or unable to complete the assessment.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to administer medication to residents within an error rate less than five percent. This affected one (Residents #353) of five residents reviewed for medication administration during the annual survey. The facility census was 107. Findings include: During medication administration reviews, twenty-five medication administration opportunities were observed with two noted errors, resulting in a medication administration facility error rate of 8 percent. Review of the medical record revealed Resident #353 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders revealed the resident was ordered [MEDICATION NAME] 5 milligram (mg) tablet with meals, for [MEDICAL CONDITION] and hold if the systolic blood pressure is greater than 110 mm/Hg. Resident #353 was also ordered insulin five units with meals, and additional sliding scale insulin dependent on blood sugar. Observation and interview conducted on 11/20/19 at 11:43 [NAME]M. during medication administration review revealed Resident #353 was observed in his room with her lunch tray on the overbed table. Resident #353 was eating his lunch meal. LPN #408 was observed at that time, checking Resident #353's blood sugar with a glucometer and providing the ordered Humalog (insulin) with additional six units sliding scale for blood sugar of 206. When questioned regarding LPN #408 checking resident's blood sugars after they had already began eating and providing ordered insulin, LPN #408 stated she does them when they are scheduled, whatever time they are due. LPN #408 was also observed during that time, checking Resident #353's blood pressure and providing his ordered [MEDICATION NAME]. During Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Interview conducted on 11/20/19 at 12:23 P.M. with Registered Nurse (RN) #656 state she would expect for the staff to check blood sugars prior to the resident eating, when providing insulin. Review of the facility policy titled Medication Administration, dated (MONTH) (YEAR) revealed insulin is a high risk drug and warrants additional precautions for the safe and effective administration. Medication will be administered within accepted standards of practice.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to check blood sugars and give ordered insulin prior to meals and failed to provide [MEDICATION NAME] (used to increase blood pressure) within the required parameters, both resulting in significant medication errors. This affected two (Residents #73 and #353) of 26 resident the facility identified as receiving insulin, and also affected one (Resident #353) of nine residents the facility identified as receiving [MEDICATION NAME]. The facility census was 107. Findings include: 1. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders revealed Resident #73 was ordered [MEDICATION NAME] Insulin, 4 units injection before meals. Observation and interview conducted on 11/20/19 at 11:27 [NAME]M. during medication administration review revealed Resident #73 was observed in her room with her lunch tray on her overbed table. Resident #73 stated she was finished with her meal. Licensed Practical Nurse (LPN) #408 was observed at that time, checking Resident #73's blood sugar with a glucometer and providing the ordered [MEDICATION NAME] insulin. 2. Review of the medical record revealed Resident #353 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders revealed Resident #353 was ordered [MEDICATION NAME] 5 milligram (mg) tablet with meals for [MEDICAL CONDITION], and to hold if the systolic blood pressure is greater than 110. Resident #353 was also ordered insulin 5 unit with meals, and additional sliding scale insulin dependent on blood sugar. Observation and interview conducted on 11/20/19 at 11:43 [NAME]M. during medication administration review revealed Resident #353 was observed in his room eating his lunch meal. LPN #408 was observed at that time, checking Resident #353's blood sugar with a glucometer and providing the ordered Humalog (insulin) with additional six units sliding scale for blood sugar of 206. When questioned regarding LPN #408 checking residents blood sugars after they had already began eating and providing ordered insulin, LPN #408 stated she does them when they are scheduled, whatever time they are due. LPN #408 was also observed during that time, checking Resident #353's blood pressure and providing his ordered [MEDICATION NAME]. During Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Interview conducted on 11/20/19 at 12:23 P.M. with Registered Nurse (RN) #656 state she would expect for the staff to check blood sugars prior to the resident eating, when providing insulin. Review of the facility policy titled Medication Administration, dated (MONTH) (YEAR), revealed insulin is a high risk drug and warrants additional precautions for the safe and effective administration. Medication will be administered within accepted standards of practice.

Based on medical record review and staff interviews, the facility failed to ensure a resident's wheelchair was equipped with two foot rests during transport. Resident #42 suffered actual harm when the resident was being transported in the hallway by staff with only the left foot rest on the wheelchair. The resident's right foot made contact with the floor, resulting in an abrupt stop, ejecting the resident from the wheelchair. The resident sustained [REDACTED]. This affected one (Resident #42) of three residents reviewed for falls The facility census was 105. Findings include: Record review for Resident #42 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident had a chronic ulcer of left lower leg and foot which and was receiving wound treatment. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance of two people for bed mobility, transfer, and toilet use. The resident did not walk in room or the corridor during the seven day look back period. She required extensive assistance of one person for locomotion on and off the unit which includes self sufficiency once in the wheelchair. The resident used a wheelchair to aid in mobility. Review of the occupational therapy note dated 05/29/19 revealed Resident #42 had requested a second foot foot rest, as her wheelchair only had one. The Occupational Therapist found a matching foot rest, put it on the resident's wheelchair and adjusted it. Review of the progress notes dated 06/05/19 at 9:45 [NAME]M. revealed State tested Nurse Aide (STNA) came to the nursing station and stated that Resident #42 had fallen out of her wheelchair on the way back from [MEDICAL TREATMENT]. Resident #42 was awake and alert to self and situation the wheelchair was sitting directly behind the resident on the floor. The resident stated that her feet dropped and she fell forward out of the wheelchair. She stated that she had gotten tired. Review of the hospital record dated 06/05/19 revealed an oblique nondisplaced [MEDICAL CONDITION] shaft of the left tibia and midshaft of the left fibula. The reason for the X-ray was a fall and the resident told hospital staff the STNA was pushing her too fast in the wheelchair. The resident was ejected from wheelchair landing on right elbow and left leg. Interview with Resident #42 on 06/20/19 at 12:55 P.M. revealed that the facility broke her leg when they were pushing her back from [MEDICAL TREATMENT]. The resident stated STNA #10 was pushing her too fast and that she must have fallen asleep. The wheelchair flipped over and she broke both bones in her left leg. She stated that there was not a foot pedal on the wheelchair and that they expected her to hold her feet up while they pushed her in the wheelchair back to her room, which was a long way from [MEDICAL TREATMENT]. Interview with STNA #10 on 06/20/19 at 2:15 P.M. revealed that she was pushing Resident #42 back from the onsite [MEDICAL TREATMENT] center on 06/05/19. She stated the residents are usually pretty tired when they come back from [MEDICAL TREATMENT] and that the [MEDICAL TREATMENT] center usually calls someone to get the residents. She and STNA #13 were bringing the resident back. She was asleep in the wheelchair. She dropped her feet suddenly and she didn't have her foot rests on the wheelchair. The resident fell on the ground, but she did not fall on her face. The resident was awake when she started pushing her and stated she was going at a normal speed. Interview with the Director of Nursing (DON) on 06/20/19 at 1:35 P.M. revealed the resident was at risk for falls and had previous falls on 05/04/19 and 05/26/19. The DON stated that they did not discipline the STNA because they believed nothing she did impacted the fall. She stated she did not know if there were foot rests on the wheelchair. The DON stated the facility completed a fall investigation. The [MEDICAL TREATMENT] unit called for STNA #10 to pick up the resident on 06/05/19 at about 9:45 [NAME]M. The Resident was to be transferred from [MEDICAL TREATMENT] back to her room. The resident gave three different scenarios about the incident. She told one doctor she heard a snap when she fell out of the wheelchair. The DON stated any training about transporting residents would have been provided during STNA training. During a follow up interview on 06/20/19 at 3:40 P.M., STNA #10 then stated the resident had one foot rest on the left side of the wheelchair. This statement was inconsistent with what was stated during the first interview. Interview with STNA #13 on 06/20/19 at 3:50 P.M. revealed she was present when Resident #42 fell on [DATE] and that the resident was holding her foot up during transport by STNA #10. She must have gotten tired and put her right foot down and it caused her to fall. STNA #13 stated there was only had one foot rest on the wheelchair and it was the left one. Review of the State of Ohio Nurse Aide Training and Competency Evaluation Program Standards and Guidelines, dated 11/01/16, revealed Safety precautions for Wheelchair and Geriatric Chair Safety includes to make sure casters point forward. This keeps the wheelchair balanced and stable. Position the resident's feet on the footplates. Make sure the resident's feet are on the footplates before pushing or repositioning the chair. The resident 's feet must not touch or drag on the floor when the chair is moving This is an incidental deficiency discovered during the investigation of complaint number OH 826.

Based on medical record review, observations, staff interviews, review of hospital report, review of video surveillance and review of the facility smoking policy the facility failed to supervise and ensure safety for residents who required supervision for smoking. This affected one Resident (#2) of three reviewed for supervision. This resulted in actual harm when Resident #2 lit himself on fire and obtained facial burns, singed eyelashes and eyebrows and burnt hair on the left side of his face. The facility identified 28 residents who required supervision for smoking. The census was 118. Findings include : Review of the medical record for Resident #2 revealed [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) dated on 10/23/17 revealed the resident had no cognitive impairments as far as person, place and time; however, the resident did have impulse control issues and poor judgement. According to the MDS the resident required total assistance with care. Review of the residents plan of care updated on 10/23/17 revealed the resident was non compliant with most aspects of his care. Review of Resident #2's smoking assessment dated [DATE] revealed the resident did not need any adaptive equipment to smoke. Review of the nurses notes from admission to 12/04/17 revealed several entries where the resident was non compliant with care including medications, eating, incontinence care, bathing, having X-rays completed and going to the hospital. Review of the nurses notes dated 12/04/17 at 6:45 P.M. revealed a resident came to the nurses station and stated Resident #2's hair had been on fire. The nurse and the State tested Nursing Assistant (STNA) immediately went to the front of the building to check on the resident. Upon observation Resident #2 was noted to [MEDICAL CONDITION] the left side of his forehead. Resident #2's hair was burnt from his mid forehead to the left ear area. Staff called nine-one-one (911) and notified the Director of Nursing (DON). Resident #2 stated he wasn't going to the hospital and he had the right to die, he did finally consent to being transported. Review of the hospital note for 12/04/17 revealed the resident presented with [MEDICAL CONDITION] the entire left side of his hair was burned. His eye lashes and eye brows were also singed. He told the doctor it was an accident, that the wind blew ashes into his face. The emergency room (ER) doctor noted he felt [MEDICAL CONDITION] self inflicted due to the size of the burn and the fact the resident told him he thought of killing himself earlier that day. On exam it was noted the resident was in pain and was given [MEDICATION NAME] (narcotic pain medication). Resident #2 was sent back to the facility that evening and placed on suicide watch. The resident was sent to a psychiatric facility on 12/05/17 after he threatened to burn the building down the next time he had the chance. Review of the facility video of the incident that occurred on 12/04/17 revealed a resident was on the porch drinking coffee and in the back ground Resident #2 was seen. The video was somewhat dark, but it was noted Resident #2 was on fire and another resident's patted the fire out while another resident went for help. Observations on 12/11/17 at 10:00 A.M. revealed two residents were smoking on the front porch which was deemed a non smoking area. Staff was not present with the residents. This was reported to the Administrator upon entrance to the facility. Interview with the Administrator on 12/11/17 at 2:00 P.M. revealed during investigation of the incident it was noted the residents guardian gave Resident #2 cigarettes and a lighter. The Administrator noted the guardian knew of the residents history and the facility policy and still gave the resident the smoking materials. Interview with the DON on 12/12/17 at 11:00 A.M. revealed Resident #2 had a lighter and the staff was not aware of it. Phone interview with STNA #7 on 12/12/17 at 1:00 P.M. revealed she assisted the resident outside on 12/04/17, but she was unaware the resident had cigarettes or a lighter. Review of the facility smoking policy revised dated of 11/28/17 revealed all residents were to be supervised during smoking. No residents were to have lighters or cigarettes. The residents were to smoke at designated smoke times in designated areas. This is an example of continued non-compliance from the survey dated 11/16/17.

Based on closed record review, hospital documentation and staff interviews the facility failed to ensure residents were transferred in a safe manner. Staff failed to apply and use a gait belt appropriately. This resulted in actual harm for one Resident (#120) when staff had to lower her to the floor and she suffered a closed fracture of the sacrum. This affected one Resident (#120) of three sampled for falls. The census was 119. Findings include: Review of the medical record revealed Resident #120 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the care plan cover (Kardex) dated [DATE] indicated the resident was at risk for falls but did not contain how to transfer the resident. Review of the care plan for falls dated [DATE] did not have an intervention listed on how to transfer the resident. Review of the five day Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident was alert and oriented and required the extensive assistance to dependence on staff for her activities of daily living. Per the MDS she was dependent on two staff for transfers. Review of a skilled progress note dated [DATE] at 10:15 A.M. revealed the resident had no cognitive impairment. Further review revealed the resident required two assist with bed mobility. Resident required two person assist for transfers and for transfers to be done per a mechanical lift. Resident required one assist for toileting. Review of a skilled progress note dated [DATE] at 1:48 A.M. revealed the resident required no help at all from staff for bed mobility. Assisted resident into wheelchair/chair/bed (extensive assist). Resident required two person assist for transfers and for transfers to be done per a mechanical lift. Assisted resident on and off the bedpan with extensive assistance. Staff changed the incontinence pad or brief with extensive assist. Resident required one assist for toileting. Review of an incident note dated [DATE] at 9:05 A.M. revealed the writer was called to the shower room by an State tested Nurse Aide (STNA). Resident observed sitting on the floor in front of her wheelchair. No apparent injuries noted. Resident stated her legs gave out during transfer. Resident assessed and no injuries were noted. Resident denied hitting her head, two STNA's were present during change in plane and confirmed the resident did not hit her head. Vitals assessed temperature 98.2 degrees Fahrenheit, pulse 91, respiratory rate 21, blood pressure ,[DATE] and oxygen saturation 97% on room air. Resident denied pain and the resident was transferred from the floor to the wheelchair with two assist. Range of motion was within normal limits. New intervention in place for bath blanket under resident's feet when in shower room to prevent slipping. The physician was notified. Review of health status note dated [DATE] at 5:59 P.M. revealed the resident complained of pain this morning. Writer administered as needed (PRN) pain medication with no success noted. Resident with complaint of mouth pain 9:00 A.M. At 11:00 A.M., the resident with complaint of pain in abdomen, stated she could not have a bowel movement. Writer offered suppository, stated resident had Miralax as well as stool softener with morning medications. Resident refused suppository and stated she wanted to wait and see what happened. Writer returned to the room with resident complaining of lower abdominal pain from the waist down and it was intolerable. Writer explained to resident that it was too early for pain medication at which time resident stated she wanted to see a doctor now and wanted to go to the hospital. Vital signs were assessed and were normal. Called for transport to pick resident up. Resident picked up at 4:20 P.M. and she complained to the emergency medical technician (EMT) of pain in her tail bone. Resident stated to the EMT it was her tailbone hurting the whole time. Review of health status note dated [DATE] at 6:32 P.M., revealed the writer called the emergency room (ER) to check on the resident and was informed the resident had a fractured sacrum and would be returning to the facility. Review of an x-ray report dated [DATE] revealed there was a suspected acute mildly displaced fracture of the lower sacrum. Review of the hospital documentation dated [DATE] revealed a [DIAGNOSES REDACTED]. On [DATE] at 9:32 A.M. an interview was conducted with the Director of Nursing (DON), Licensed Practical Nurse (LPN) #23 and Registered Nurse (RN) #33. The DON said Resident #120 was in the shower room, the staff went to adjust her in the wheelchair and her feet slid out beneath her. The transfer was from the toilet to the wheelchair and she was assessed to require two staff assistance which she did. The facility said Resident #120's legs were giving out and the STNA guided her to the floor. At the time of the incident, there was no complaint of pain. Resident #120 legs gave out during the transfer. When staff asked if the resident was hurt the resident said only her pride. The new intervention was to put a bath blanket under her feet when she was in the shower room to prevent her from sliding or slipping. On [DATE] Resident #120 began to complain of pain and having lower back/hip pain. The nurse assessed her and the physician ordered to send her to the hospital for evaluation and treatment. The resident was sent to the emergency room (ER) and returned the same day with a [DIAGNOSES REDACTED]. However, the hospital x-ray report documented a possible fracture. The hospital did not do a computed tomography (CT) scan, magnetic resonance imaging (MRI) or follow up to confirm a fracture. There was no follow up ordered. The facility was monitoring for pain and/or any potential for increased pain. Resident #120 did not receive any increase in pain medication. She had Tylenol 650 milligrams (mg) every six hours as needed, Oxycodone (narcotic) five mg every four hours as needed. The hospital sent her back with an order for [REDACTED]. Days later, Resident #120 went back out to the hospital (unrelated to the fracture). The facility heard Resident #120 quit receiving Dialysis services, went on Hospice and expired in the hospital. On [DATE] at 10:15 A.M., STNA #13 was interviewed over the telephone. STNA #13 revealed she was helping the other STNA. She said they were transferring Resident #120 from the toilet to the wheelchair. Resident #120 was almost on the wheelchair and her legs were getting weak so they lowered her to the fall. STNA #13 said she had a gown on but did not remember if she had a gait belt around her waist. She remembered trying to lift her under her arm to sit her in the chair and the Resident said her legs were giving out so she started to slide out and they grabbed under her arms to be lowered to the floor. The resident did not complain of pain. STNA #13 went for the nurse as the resident was sitting on the floor. She said they gently lowered her onto the floor. On [DATE] at 10:54 A.M. STNA #14 was interviewed over the telephone. STNA #14 said her and another STNA transferred Resident #120 from the wheelchair to the shower chair without a gait belt. Resident #120 received her shower and was placed in the wheelchair. STNA #14 transferred the resident from the wheelchair to the commode without a gait belt. When transferring Resident #120 from the commode back to the wheelchair, the residents legs gave out, they stopped the transfer and lowered her back to the commode. STNA #14 said she left the resident on the commode with STNA #13 and went to get a gait belt which they applied. When they were transferring the resident from the commode to the wheelchair, she began to slide and they did not use the gait belt to assist as it was too far down on the Resident. They grabbed under the residents' arms and lowered her to the floor. STNA #14 said this was the first time she had transferred the resident. She verified she did not check the Kardex prior to transferring the resident. STNA #14 said she asked a nurse who told her the resident required the assistance of two staff with transfers. On [DATE] at 12:03 P.M. Licensed Practical Nurse (LPN) #25 was interviewed. LPN #25 said a STNA came out of the shower room and told him they had to lower the resident to the ground. Resident #120 was having weakness in her lower extremities. When he entered the shower room, the resident was sitting up, he assessed the resident for injuries and obtained her vitals. There was no pain other than her usual aches. The resident said she was lowered to the ground and denied any pain. The resident indicated the only thing she hurt was her pride. LPN #25 said he asked the resident if she was sure she was lowered to the ground and she said yes. LPN #25 could not remember if the resident had a gait belt on. On [DATE] at 12:18 P.M., RN #34 was interviewed. RN #34 said Resident #120 could transfer with the assist of two staff or assist of two staff with a Hoyer. She verified the residents' skilled nursing assessment dated [DATE] at 10:15 A.M. documented the resident was dependent for transfers and was to be transferred per a mechanical lift. On [DATE] at 3:39 P.M., RN #35 was interviewed via telephone. RN #35 verified she had documented on [DATE], Resident #120 required the mechanical lift for transfers. She said on her shift, the resident used the mechanical lift when she was weighed. On [DATE] at 4:00 P.M. the DON was interviewed. During the interview, it was shared the skilled nursing progress note dated [DATE] at 10:15 A,M. documented the resident was dependent for transfers and a mechanical lift was indicated. This certification deficiency substantiated Complaint Number OH 590.

Based on observation, record review, and staff and family interview, the facility failed to prevent the development of two pressure ulcers for one resident. This resulted in harm when the resident developed two unstageable pressure ulcers under her knee immobilizer, which deteriorated with continued use. This affected one (Resident #132) of three reviewed with pressure ulcers. The facility identified 22 residents with pressure ulcers. Facility census was 116. Findings include: Review of the clinical record for Resident #132, admitted [DATE], revealed [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE] revealed the resident was moderately cognitively impaired. The MDS also revealed the resident had a pressure ulcer assessed as unstageable due to the presence of slough and eschar. Review of the nursing note dated 09/06/13 at 12:30 A.M. revealed that Resident #132 was to wear a knee immobilizer to the right knee at all times, which may be removed for hygiene purposes every shift. A physician order [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review revealed this order was signed by nursing staff every day, each 12 hour shift, as being on at all times. Review of the weekly skin assessment from 09/10/13 showed no areas of pressure. The next weekly skin assessment was not until 09/16/13, after the area of pressure developed. Review of the nursing note dated 09/14/13 at 5:58 P.M. revealed the nurse discovered a new pressure area to the back of the right lower leg, and the note specifically stated "this brace has made a pressure area to the leg". A request for a possible brace change was made at that time per the note. A review of the facility skin grids tracking the right lower leg pressure ulcer, which developed in-facility on 09/14/13, revealed that on 09/14/13, the wound was assessed as a deep tissue injury, which is a purple or maroon localized area of discolored intact skin or a blister due to damage of underlying soft tissue from pressure and may be preceded by tissue that is mushy, boggy, warmer or cooler compared with adjacent tissue. It was measured at 4 centimeters (cm) by 2 cm with no open area. The skin grid from 09/16/13 revealed the area was a Stage II, blister intact and irregular in shape, brown black in color, soft to touch, measuring 4.5 cm by 1 cm with no depth, noting a decline in condition. On 09/23/13, the area to the right lower leg was noted to be unstageable, which means eschar (black dead tissue) was covering the wound. The wound was described as an absorbed blister, slightly open on the edges, brown in color and irregular in shape, measuring 6.5 cm by 1.5 cm and depth was undeterminable, noted as a decline in wound condition. On 10/03/13, the wound measured 5.5 cm by 2 cm and was described as yellow slough tissue, 25% eschar, oval in shape, which was a decline in condition. On 10/07/13, the wound measured 7 cm by 1.5 cm and was described as 100% eschar and irregular in shape, which was a decline in condition. On 10/16/13, the area measured 5 cm by 2 cm, same description as the prior assessment. On 10/21/13, the area measured 4.5 cm by 2 cm, same description. The most recent assessment on 10/28/13 revealed the area measured 3 cm by 2.5 cm as 75% necrotic tissue, irregular in shape. A review of the facility skin grids tracking the right knee pressure ulcer, which developed in-facility on 09/16/13, revealed that on discovery, the wound was assessed as a Stage II area, which means partial thickness loss of dermis, presenting in a shallow open ulcer with a pink wound bed or slough or may present as an intact or ruptured blister. This area measured 3 cm by 3 cm and was described as a fluid-filled intact blister. On 09/23/13, the wound measured 2 cm by 2 cm and was described as a brown, absorbed blister, irregular in shape. On 10/03/13, the area measured 2 cm by 2 cm, same description, and assessed as unchanged. On 10/07/13, the area measured 1.5 cm by 2 cm, same description. On 10/16/13, the area measured 2 cm by 2 cm, described as a brown scabbed area/absorbed blister, irregular in shape, and assessed as unstageable at that point, which was a decline in condition. A review of the Nurse Practitioner (NP) wound assessment from 09/16/13 revealed the wound was assessed as 75 to 100% necrotic tissue and as deteriorating. The wounds were noted to be deteriorating on 09/23/13 and 10/07/13. On 10/16/13 and 10/21/13, the NP assessed the right lower leg wound as painful black eschar with noted periwound redness, which was unchanged from the prior assessment. Review of the care plan related to risk of skin impairment, original date 07/22/13, revealed the intervention to use the knee brace for transfers only, was addeded on 09/25/13. The care plan revealed no other interventions to prevent deterioration of the pressure areas to the right lower leg and right knee. Review of the nutrition laboratory test for Resident #132 from 10/24/13 revealed low protein and [MEDICATION NAME] levels, indicating a high risk for skin breakdown. Review of the progress note from the physician, dated 11/04/13, revealed a notation that the resident was assessed and "she is somewhat stiff from being in the immobilizer". On 11/06/13 at 1:51 P.M., an observation of the pressure ulcer dressing change for Resident #132 was made. During the dressing change, the resident cried out in pain multiple times, grasped the hand of the assisting nurse for comfort, and made multiple facial expressions indicating pain was present when her right lower leg pressure ulcer was touched. When asked if she was in pain, Resident #132 indicated she was. On 11/06/13 at 1:49 P.M., a staff interview with Wound Nurse #1 revealed Resident #132's pressure areas were caused by the knee immobilizer. On 11/06/13 at 4:30 P.M., a staff interview with Wound Nurse #1 revealed after the area on Resident #132's right lower leg developed, the immobilizer was still ordered and worn. More pain was present after the wounds developed. Resident #132 was also up in a Geri-chair (a speciality recliner) as opposed to a wheel chair due to the immobilizer, and Wound Nurse #1 stated she reminded the staff to prop the leg and she could not verify staff was removing the brace to check the skin daily for areas of pressure. She revealed that the facility does not have a policy or procedure regarding pressure ulcer prevention or treatment and care. On 11/07/13 at 8:37 A.M., a staff interview with the Registered Dietician (RD) #2 revealed that Resident #132 was not currently on liquid protein supplement for wound healing and that when a resident shows a decline in a wound she usually adds a supplement. On 11/07/13 at 9:38 A.M., an interview with a member of Resident #132's family revealed that prior to the development of the pressure areas; she wore the immobilizer all the time. The family member revealed the aids often times did not have the brace applied correctly when he came in to visit. On 11/07/13 at 2:48 P.M., an interview with a member of Resident #132' s family revealed that the immobilizer caused the pressure areas. The family member related that after the pressure areas were found, the facility staff did provide the treatments and then reapplied the brace over the treatments and her clothing. This family member removed the brace from the facility when the physician said Resident #132 did not need it, and stated that the wounds began improving at that point.