Every finding on record at Brewster Convalescent Center

Based on closed record review, review of emergency medical services (EMS) run sheet, policy review, and interview, the facility failed to thoroughly assess and provide ongoing monitoring for Resident #64 following a significant change in condition. This affected one (Resident #64) of three residents reviewed for change of condition and hospitalization. The facility census was 57. Findings include: Closed medical record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including pulmonary embolism, neuromuscular dysfunction of bladder, calculus in bladder, cervical spinal cord injury at C-5 level, quadriplegia, chronic pain, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/23/26, revealed Resident #64 had intact cognition and required staff assistance with activities of daily living. Review of Resident #64's care plan, initiated on 03/17/26, revealed the resident had a urinary catheter in place due to chronic neurogenic bladder from a spinal cord injury with interventions including to change catheter per physician orders, flush catheter per physician orders, monitor/document for pain/discomfort due to catheter, and to monitor/record/report to physician signs and symptoms of urinary tract infection (UTI): burning, pain, blood tinged urine, cloudiness, no output, increased pulse, increased temperature, urinary frequency, and change in behavior. Review of a physician order, dated 03/17/26, revealed the order for catheter care every shift per facility protocol and to irrigate catheter with 10 milliliters (ml) as needed (prn). Review of a physician order, dated 03/31/26, revealed the order to flush the urinary catheter with 60-100 ml of sterile water or sterile normal saline at bedtime every other day for catheter maintenance. Review of a physician order, dated 04/25/26, revealed the order to change the catheter and drainage bag every two weeks and prn for buildup. Review of a nursing progress note, dated 07/17/26/24 at 2:20 P.M, (authored by Registered Nurse #81) revealed Resident #64 complained of pain in his neck, chest area and arms, and abdomen. This nurse gave Norco (narcotic pain medication) prn this morning and told the resident he can have ibuprofen or have both ibuprofen and Norco when it is able to be given again. The resident's bowel sounds are present in four quadrants. Abdomen is non-distended. No signs or symptoms of injury or skin issues The resident had a large bowel movement last night after his scheduled mini-enema. Resident's catheter was flushed last night and is draining well with clear, light yellow urine. Physician #400 was notified of pain and stated the resident can go to the hospital, or he can take both medications when time is due. The resident stated he doesn't want to go to the hospital and will wait until his pain medications can be given again. Review of the Medication Administration Record (MAR) dated July 2026 revealed Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain was administered on 07/17/26 at 2:36 P.M. with pain level noted to be an 8 on a 1-10 pain scale (a rating of one indicates minimal pain and 10 indicated the most severe pain the resident had ever experienced). The nurse documented the medication was effective (but no assessment or rating of the resident's pain level post pain medication administered. Further review of the medical record revealed no documentation or evidence of ongoing monitoring of the resident by RN #81 on 07/17/26. Review of a nursing progress note, dated 07/18/26 at 12:25 A.M., revealed Resident #64 complained of pain in his neck and abdomen. This nurse noted sediment in the catheter along with blood and mucous. Blood pressure was 165/109 millimeters (mm) of Mercury (Hg) (normal BP 120/60 mmHg), heart rate 65 beats per minute (bpm) , temperature 98.8 degrees Fahrenheit. The catheter was unable to be flushed due to sediment, and the resident requested the catheter to be removed. Physician #400 was notified and an order was given to transfer the resident to the hospital. Review of the EMS Run Sheet, dated 07/17/26, revealed EMS was dispatched on 07/17/26 at 11:42 P.M. for a male resident having issues with his catheter. The nurse stated she tried to change the catheter and had issues re-inserting it, that it felt like a blockage in the urethra. The resident did have some abdominal distention and complained of pain in his abdomen from the pressure. The resident stated he did have chest pain that had started three weeks ago. The resident was transported to the hospital and arrived on 07/18/26 at 12:18 A.M. Review of a nursing progress note, dated 07/19/26 at 12:11 A.M., revealed the resident was admitted to the hospital with admitting diagnoses of UTI and hypokalemia (low potassium level). He is receiving intravenous antibiotics and fluid boluses for low blood pressure. There are no discharge plans at this time. Interview on 08/12/26 at 12:49 P.M. with RN #81 revealed she was Resident #64's nurse on 07/17/26 when he initially complained of pain in his neck, chest area, arms, and abdomen. RN #81 confirmed that she did not obtain vital signs following the resident's complaint of pain nor during her shift. She stated that she administered the resident's scheduled pain medication Norco and prn Ibuprofen which were effective for the resident's pain; however, she did not re-assess or monitor the resident throughout the remainder of her shift. Interview on 08/13/26 at 9:18 A.M. with Family Member #408 revealed the resident would often call her and tell her that he felt ignored by some staff and would have to wait for the night shift nurses to come on shift for anything to be done for him. Family Member #408 stated on the evening prior to his hospitalization, he called her and asked her to please call the facility and ask them to come and check his catheter. Family Member #408 stated she called the facility and spoke with one of the nurses (unsure of which nurse) and asked that the resident's catheter be checked. Interview on 08/13/26 at 10:18 A.M. with Physician #400 stated that had the nurse reported Resident #64's complaint of pain in his neck, chest area, arms, and abdomen he would have advised her to call EMS and transfer the resident to the ED for evaluation. Physician #400 stated that he would never say to the nurse that the resident could choose to take pain medication or go to the hospital as documented. Interview on 08/13/26 at 12:50 P.M. interview with the Director of Nursing (DON) confirmed there was no evidence of vital signs obtained or a thorough assessment of Resident #64 on 07/17/26 following his initial complaint of pain in his neck, chest area, arms, and abdomen. Interview on 08/13/26 at 3:09 P.M. via phone with Licensed Practical Nurse (LPN) #83 stated when she started her shift on 07/17/26, Resident #64 was complaining of abdominal pain, and she could see that his abdomen was full and distended. She stated she would have expected the previous nurse to have tried to flush the urinary catheter due to the excessive amount of sediment and blood in the catheter. She attempted to re-insert the urinary catheter but was unable to do so. Review of the facility's policy, titled Urinary Catheter Insertion, Maintenance, and Removal, undated, revealed the facility will ensure safe clinical practice for insertion, ongoing care, and removal of urinary catheters. Our goal is to ensure that safe clinical practices are implemented in the risks of infection associated with insertion and ongoing care of urinary catheters are adequately managed and reduced. Inform the physician of any problems encountered. This deficiency represents non-compliance investigated under Complaint Number 3108432.

Based on observation, interviews, and record review, the facility failed to maintain a comfortable air temperature in the resident living environment. This affected two residents (Resident #32, Resident #28) and had the potential to affect all 10 residents on the 500 unit. The facility was census was 57.Findings include: 1. Record review of Resident #32 revealed an admission date of 03/17/26 with diagnoses of quadriplegia, anxiety disorder, major depressive disorder. Resident #32 was cognitively intact and was dependent with ADLs.Interview with Resident #32 on 06/01/26 at 8:14 A.M. revealed he was always cold and the room was always cold until the afternoon and then cold again at night. Observation of Resident #32 revealed he had four blankets on and was wearing a winter skull cap.2. Record review of Resident #28 revealed an admission date on 03/17/26 with diagnoses of emphysema, anxiety disorder, trigeminal neuralgia, and hypertension. Resident #28 was cognitively intact.Observation of Resident #28 on 06/01/26 at 8:16 A.M. revealed the resident had three blankets and a fuzzy robe on. Resident #28 stated they were cold and staff covered the registers due to cold air blowing out.3. Observation and interview with Licensed Practical Nurse (LPN) #202 at 8:12 A.M. on 06/01/26 revealed the temperatures of the thermostat were reading 70 degrees and 68 degrees. LPN #202 stated when they work nights it gets cold and residents complain, LPN #202 stated they tell management regarding the temperatures.Interview and observation with Administrator on 06/01/26 at 8:35 A.M. confirmed the thermostat #3 on the 500 hall read 68 degrees.Interview and observation with Maintenance Director #203 on 06/01/26 at 8:45 A.M. confirmed the thermostat #3 was reading 68 degrees. Maintenance Director #203 stated staff messes with the thermostats and there was a meeting last month with the Director of Nursing telling staff not to touch the thermostats. Maintenance Director #203 digitally laser temped the following rooms:Resident #24's room read 68 degrees, Resident #26's room read 67 degrees, Resident #28's room read 67 degrees, Resident #32's room read 68 degrees, Resident #15's room read 68 degrees, Resident #25's room read 69 degrees, Resident #31 and Resident #50's room read 70 degrees, Resident #2 and Resident #51's room read 71 degrees.Record review of Daily Thermostat Log for thermostat #3 on 500 hall for May 2026 revealed a temperature of 69 degrees on 05/07/26 at 2:00 A.M, and on 05/15/26 revealed a temperature of 70 degrees.This deficiency represents non-compliance investigated under Complaint Number 3007447.

Based on record review and interview, the facility failed to ensure Residents #24 and #42's medical records have the appropriate documentation of the education provided regarding the risks and benefits of the influenza and pneumococcal vaccines. This affected two (Residents #24 and #42) of five residents reviewed for immunizations. Findings include: 1. Review of Resident #24's Consent/Declination of Pneumococcal, Influenza, and COVID-19 Vaccines form dated 11/14/23 revealed the resident did not wish to receive the pneumococcal vaccine, the influenza vaccine or the COVID-19 vaccine and/or booster. Review of Resident #24's medical record revealed the resident refused the pneumovax and the influenza immunization. The medical record did not reveal evidence the resident was educated on the risks and benefits of the pneumovax and influenza immunizations. Interview on 12/27/24 at 9:09 A.M. with Registered Nurse (RN) #538 confirmed Resident #42's medical record did not have evidence the education was provided regarding the risks and benefits of the influenza and pneumococcal vaccines. 2. Review of Resident #42's Consent/Declination of Pneumococcal, Influenza, and COVID-19 Vaccines form dated 10/05/21 revealed the resident did not wish to receive the pneumococcal vaccine the influenza vaccine or the COVID-19 vaccine and/or booster. Review of Resident #42's medical record revealed the resident refused the influenza and pneumovax vaccine. The medical record did not reveal evidence the resident was educated on the risks and benefits of the influenza and pneumovax vaccines. Interview on 12/27/24 at 9:09 A.M. with Registered Nurse (RN) #538 confirmed Resident #42's medical record did not have evidence the education was provided regarding the risks and benefits of the influenza and pneumococcal vaccines. Review of the Resident Influenza Immunization policy dated 11/05/18 revealed before offering the influenza immunization, each resident, or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunization. The resident's medical record includes documentation that indicates, at a minimum, that the resident or resident's legal representative was provided education regarding the benefits and potential side effects of the influenza immunization. Review of the Pneumococcal of Residents Vaccine policy reviewed 01/01/17 revealed to provide the resident or responsible party with literature on the Pneumococcal vaccine (from the Centers for Disease Control or CDC).

Based on observation, record review and interview, the facility failed to ensure appropriate hand washing or hand sanitization was completed prior to completing Residents #1 and #33's non-pressure wound care. This affected two (Residents #1 and #33) of two residents reviewed for general skin conditions. Findings include: 1. Review of Resident #1's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease without dyskinesia, Alzheimer's disease and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 exhibited severe cognitive impairment. Review of Resident #1's Weekly Wound Report form dated 12/17/24 revealed the resident had left buttock moisture associated skin damage (MASD)/shearing acquired 12/14/24. Review of Resident #1's physician orders revealed an order dated 12/17/24 to cleanse the open area on the left buttock with normal saline, pat dry, apply collagen moistened with normal saline to the wound bed and apply a dry dressing in the morning for wound care and as needed. Observation on 12/26/24 at 11:29 A.M. with Licensed Practical Nurse (LPN) #545 of Resident #1's left buttock wound care revealed the nurse sanitized her hands and put on gloves. Then the nurse removed the soiled dressing on the resident's left buttock, cleansed the wound with normal saline, applied the collagen and normal saline to the left buttock and placed a dry dressing on the left buttock wound. LPN #545 did not change her gloves during the treatment change. Interview on 12/26/24 at 12:47 P.M. with LPN #545 verified she did not change her gloves, wash her hands and putting on new gloves prior to completing the resident's wound care after she removed the soiled dressing. 2. Review of Resident #33's medical record revealed the resident was readmitted on [DATE] with diagnoses including anxiety disorder, dementia and essential hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 exhibited severe cognitive impairment. Review of the Weekly Wound Report dated 12/17/24 revealed Resident #33 acquired left buttock moisture associated skin damage (MASD)/shearing on the left buttock which measured 1.5 centimeters (cm) length by 1.2 cm width by 0.1 cm depth; right buttock MASD/shearing which measured 0.5 cm length by 0.5 cm width by less than 0.1 cm depth; and right buttock MASD/shearing which measured 0.5 cm length by 0.5 cm width by less than 0.1 cm depth. Observation on 12/26/24 at 12:40 P.M. with Licensed Practical Nurse (LPN) #545 of Resident #33's left buttock dressing revealed the resident was rolled into the common bathroom on the unit. The resident was assisted in a standing position, the nurse put on gloves and cleansed the resident's left and right buttocks with normal saline, applied the collagen and normal saline on the left and right buttocks and applied a dry dressing. LPN #545 did not wash her hands prior to putting on gloves. Interview on 12/26/24 at 12:47 P.M. with LPN #545 confirmed she did not wash or sanitize her hands prior to completing Resident #33's left buttock dressing. She stated she was nervous and that was why she forgot to disinfect her hands prior to completing the dressing. Review of the Wound Cleansing policy dated 05/01/16 indicated the procedure indicated to adhere to Standard Universal Infection Control Guidelines/Precautions, review physician orders, explain procedure to the resident, establish a clean field with all the supplies and equipment, remove tape by pushing skin from tape, remove soiled dressing, discard dressing and change gloves, decontaminate hands and don new gloves, clean a linear wound from top to bottom working outward, dress wound with appropriate dressings following the manufacturer's guidelines for use, and discard soiled supplies in the appropriate containers.

Based on record review, staff interview, review of facility policy, and observation, the facility failed to update the physician on a change of condition for Resident #38. This affected one (Resident #38) of one resident reviewed for changes in conditions. The facility census was 55. Findings include: Review of the medical record for Resident #38 revealed an admitted [DATE] with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease and emphysema (a condition of the lungs that causes shortness of breath). Review of the care plan dated 04/03/23 for Resident #38 revealed she was at risk for altered respiratory status and difficulty breathing related to anxiety, chronic obstructive pulmonary disease, congestive heart failure and chronic respiratory failure. Interventions included to monitor for signs and symptoms of respiratory distress and report to the physician increased respirations, decreased pulse oximetry, restlessness, lethargy and confusion. Review of the physician's order for Resident #38 revealed an order for oxygen at two liters via nasal cannula continuously dated 07/15/24. Review of the treatment administration record for December 2024 for Resident #38 revealed nursing staff had been administering oxygen at two liters continuously and documenting her oxygen saturation at morning and bedtime. Review of the nursing progress notes for Resident #38 from 12/24/24 through 12/27/24, revealed on 12/24/24 at 4:56 A.M. Resident #38 appeared slightly lethargic when the nurse woke her for her morning medications. Resident #38 stated she was tired and oxygen saturation was checked which revealed it was 90-92 percent (%) on two liters nasal cannula. The nursing progress note dated 12/24/24 at 5:21 A.M. revealed oxygen had been increased to four liters nasal cannula. There was no indication the physician was updated related to increased need for oxygen. Observation with Registered Nurse (RN) #551 on 12/26/24 at 3:27 P.M. revealed Resident #38's oxygen concentrator was set to four liters. She verified Resident's #38's physician's orders were for two liters of oxygen continuously. RN #551 verified there was no written or verbal order for four liters of oxygen. Interview on 12/26/24 at 3:53 P.M. with the Director of Nursing (DON) verified the physician was not updated on Resident #38's change of condition of lethargy, decreased oxygen saturation and need for increased oxygen. Review of the facility policy titled, Use of Oxygen, dated 05/01/16, revealed oxygen therapy must be prescribed by the resident's physician. The physician was responsible for identifying the type of therapy and the rate of oxygen based on oxygen saturation and respiratory assessment.

Based on record review and interview, the facility failed to ensure interventions were implemented and monitored for Resident #33's trending weight loss. This finding affected one (Resident #33) of two residents reviewed for nutrition. Findings include: Review of Resident #33's medical record revealed the resident was readmitted on [DATE] with diagnoses including anxiety disorder, dementia in other diseases classified elsewhere and essential hypertension. Review of Resident #33's initial weight dated 07/29/24 revealed the resident weighed 187.2 pounds. Resident #33's weights revealed the resident weighed 196.6 pounds on 08/20/24, 183.9 pounds on 11/07/24 and 179.2 pounds on 12/04/24. Review of Resident #33's physician orders revealed an order dated 08/16/24 revealed a reduced carbohydrate diet, no added sodium with a regular texture, regular/thin consistency. There were no physician orders for nutritional supplements including the boost brought in by the resident's family members. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 exhibited severe cognitive impairment. Review of the quarterly Medical Nutrition Therapy form dated 11/05/24 revealed Resident #33 was on a reduced carbohydrate controlled diet with no added sodium, regular texture with thin liquids. The form indicated the resident received metformin as ordered and the oral intakes were greater than fifty-one percent at most per meals. The residents feeds himself after setup assistance. The weight was 183.9 pounds and has had a 3.3 pound weight loss since his initial admission weight of 187.2 pounds. No edema was noted. Review of Resident #33's nurse aide tracking from 11/28/24 to 12/26/24 revealed documentation the resident was offered the boost for weight loss on 11/29/24, 12/07/24, 12/08/24, 12/21/24, 12/22/24, and 12/25/24. The resident refused the boost supplement on 12/16/24, 12/18/24, 12/20/24 and 12/25/24. All other dates were blank or documented as not applicable. Review of Resident #33's medical record did not reveal evidence the resident's physician was notified of the resident's trending weight loss. Interview on 12/27/24 at 8:39 A.M. with Registered Dietitian (RD) #600 stated Resident #33's family brought in boost nutritional supplement from home for the resident's decreasing weight loss. RD #600 stated the resident's family supplied the boost and the facility offered and monitored the resident's boost intake. RD #600 confirmed Resident #33's medical record did not have specific orders for the implementation of the boost supplement for weight loss to determine how often or how much the resident should receive the boost supplement. Interview on 12/27/24 at 9:02 A.M. with the Director of Nursing (DON) confirmed Resident #33's medical record did not have evidence the resident's boost was offered for a specific duration and stated the facility offered the boost when the resident requested the boost supplement. The DON confirmed the medical record did not have specific orders for the resident's boost as an intervention for the resident's trending weight loss. An additional interview on 12/27/24 at 2:58 P.M. with RD #600 revealed it was her understanding if Resident #33 consumed less than 50% of the meal offered, staff would grab a magic shake or boost and nurses would administer. She stated that was the facility policy and she confirmed the boost supplement was not a documented intervention for the resident's trending weight loss including physician notification and specific orders to implement the boost supplement. Review of the Significant Weight Loss policy dated 01/01/17 revealed the facility has the goal of medical nutrition therapy (MNT) to stabilize the weight, identify underlying causes or factors contributing to the significant unplanned weight loss, and intervene as appropriate to resolve the problem.

Based on interview, medical record review, and facility policy review, the facility failed to ensure pre-treatment and post-treatment monitoring was completed for a dialysis resident. This affected one (Resident #24) of two residents reviewed for dialysis. The facility census was 55. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE] and diagnoses including type two diabetes mellitus, diabetic chronic kidney disease, diabetic polyneuropathy, dependence on renal dialysis, acquired absence of left leg below knee, and stage four chronic kidney disease. Review of physician's order dated 09/26/24 revealed Resident #24 received dialysis treatments on Tuesdays, Thursdays, and Saturdays. Resident #24 has right sided tunneled internal jugular catheter dialysis site. The medical record revealed no evidence of monitoring of Resident #24's condition prior to or following dialysis treatments. Interview on 12/27/24 at 11:07 A.M. with Licensed Practical Nurse (LPN) #542 revealed Resident #24's blood pressure and weight were obtained at dialysis. Interview on 12/27/24 at 12:02 P.M. with Director of Nursing (DON) confirmed they do not assess Resident #24 prior to or returning from dialysis treatments. DON indicated pre and post weights were obtained as well as their blood pressure. Review of the facility policy titled Managing and Monitoring Residents Receiving Outpatient Hemodialysis dated 06/01/22 revealed residents' vitals, dialysis site, and fluid retention would be assessed prior to departing for dialysis treatment. Upon return, residents' vitals, dialysis site, and symptoms of complications would be assessed. Residents would also be weighed following dialysis treatment to compare to pre-dialysis weight.

Based on record review, review of policy, observation and interview, the facility did not ensure infection control practices were maintained during a wound treatment for Resident #9. This affected one resident (#9) of three residents reviewed for hospice. The facility census was 47. Findings include: Record review was conducted for Resident #9 who was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, type two diabetes mellitus, moderate protein calorie malnutrition, dysphagia following a stroke and peripheral vascular disease. Resident #9 was admitted to hospice on 04/01/23 for a terminal diagnosis of dysphagia. Review of the Minimum Data Set 3.0 assessment, dated 07/10/23, revealed Resident #9 required extensive assistance by one staff for eating, dressing, toileting and hygiene and extensive assistance of two staff for transfers and bed mobility. Review of the plan of care, revised 08/28/23, revealed Resident #9 had potential for pressure ulcer development due to incontinence, impaired mobility, and protein calorie malnutrition. Interventions included administering medications and treatments as ordered and following facility policies for the prevention and treatment of skin breakdown. Review of a physician order dated 09/25/23 revealed Resident #9 had a wound on her coccyx and the treatment was to apply calmoseptine ointment to the wound and pad and protect the wound in the morning on Tuesday, Thursday and Saturday. Observation made on 10/03/23 at 11:15 A.M. of wound care provided to Resident #9 by the Wound Care Nurse Registered Nurse (RN) #801 revealed infection control practices were not followed. During the observation, Hospice Aide (HA) #804 was in the room and continued to perform a complete bed bath on Resident #9 while wound care was being provided by RN #801. HA #804 took the dirty wash rag used to wash the residents back and buttocks area and set it on top the clean four-by-four gauze pads RN #801 had set out with the wound supplies. RN #801 grabbed the dirty wash rag with her gloved hands to move it and with the same gloves grabbed the gauze pads that touched the dirty wash rag and proceeded to cleanse Resident #9's wound to her coccyx with the gauze pads. Interview was conducted on 10/03/23 at 12:48 P.M. with RN #801 who verified she saw the dirty wash rag touch the four-by-four gauzes, and she should not of used those gauzes to cleanse the wound. Review of the facility policy titled Nursing Skin Policies and Procedures, dated 05/01/16, revealed when changing dressings if the wound required a sterile technique, then a sterile field with all needed supplies would be established and standard universal infection control techniques/precautions would be applied. This deficiency was an incidental finding during the investigation of Complaint Number OH00146906.

Based on observation, medical record review, orthopedic consult review, therapy note review, and interview, the facility failed to manage Resident #31's pain adequately and within a timely manner. This affected one resident (#31) of one resident reviewed for pain management. The facility census was 51. Actual harm occurred on 04/16/23 to Resident #31, who had sustained a fall with fractured left humeral head and sacrum, when staff failed to adequately address the resident's pain resulting in Resident #31 having a decline in her activities of daily living. The facility also failed to administer pain medications timely when staff were notified Resident #31 was crying out in pain during therapy sessions and was declining to participate in therapy services. Findings included: Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including hypertension, major depressive disorder, osteoarthritis, anxiety disorder, overactive bladder, irritable bowel syndrome, and dementia. Review of a minimum data set (MDS) assessment completed on 04/06/23 revealed Resident #31 had a brief interview for mental status (BIMS) score of six (6) indicating moderately impaired cognition, required an extensive assist of one person for bed mobility, transfers, walking in the room and corridor, and toilet use and required the use of a walker. The MDS also indicated Resident #31 was frequently incontinent of bladder and had not been trialed on a toileting program. Review of MDS completed on 05/18/23 revealed Resident #31 required extensive assist of two staff for bed mobility and transfers and required extensive assist of one staff for toileting. Review of Resident #31's plan of care from 01/20/23 revealed interventions for pain included to monitor and report resident complaints of pain to the nurse and to notify physician if pain interventions are unsuccessful. Review of physician orders revealed Resident #31 had an order that started on 12/22/22 for Tramadol 50 milligram (mg) tablet to give 0.5 tablet every 8 hours as needed for pain, and an order that started on 12/22/22 for ibuprofen tablet 200 mg to give two tablets every 8 hours as needed for pain. The resident's current physician orders for pain management included the following: Tylenol, 650 mg, every eight (8) hours, as needed (started 05/06/23); Ibuprofen, 400 mg, every eight (8) hours, as needed (started 06/10/23). Review of nursing notes dated 04/16/23 revealed the front hall nurse witnessed Resident #31 on 04/16/23 at 5:08 P.M. walking into the bathroom when she fell on her bottom and hit her left elbow on the shower chair. Resident #31 was assessed with no injuries noted, was changed due to an episode of incontinence, and given ibuprofen for elbow pain. The facility documentation did not include a description of the pain to include rate or pain level. Review of a nursing note on 04/17/23 at 8:14 A.M. revealed Resident #31 was complaining of left arm and shoulder pain and presented with bruising on inner left upper arm and shoulder blade. Resident #31 was sent to the hospital where she was diagnosed with a fracture of the left humeral head, widening of subacromial space, and soft tissue swelling. Review of hospital discharge orders dated 04/17/23 revealed orders for Tramadol 50 mg give 0.5 tablet every 8 hours as needed for pain and ibuprofen tablet give 200mg, two tablets every 8 hours as needed for pain, remained unchanged. Review of a nursing note on 04/17/23 at 5:27 P.M. revealed Resident #31's family was concerned with the pain medication that was ordered, and requested staff to ask if the Medical Director could review the resident's orders for a stronger pain medication for the humeral fracture. The Medical Director declined to order more medication unless Resident #31 had additional complaints of pain. There was no documentation that Resident #31 was assessed for pain at this time. Review of a nursing note dated 04/19/23 at 9:26 P.M. revealed Resident #31 was complaining of pain to her left arm and tailbone, which was tender to touch. Nursing note stated Resident #31 said her tailbone was aching and painful. Further assessment was not completed due to Resident #31 being in pain and not able to reposition without causing additional discomfort. Resident #31's daughter had requested for day shift nursing staff to be notified of pain and to possibly get an X-ray. Review of a pain assessment completed on 04/19/23 revealed Resident #31 stated she had pain in the last five days frequently and it had made it hard for her to sleep at night as well as limited her day-to-day activities. Resident #31 rated her pain at an eight out of ten. Interventions listed on assessment included as needed (PRN) pain medication and ice. Review of an orthopedic consult dated 04/19/23 revealed Resident #31's orthopedic physician increased the order for Tramadol to 50 mg every 6 hours, scheduled, and to discontinue ibuprofen. Review of Resident #31's medication administration record (MAR) for April 2023 revealed multiple orders for Tramadol including: Tramadol 50 mg, 0.5 tablet, every eight hours PRN ordered on 12/22/22 and discontinued on 04/19/23. Tramadol 50 mg, four times a day ordered on 04/19/23 and discontinued on 04/20/23 which was administered four times. Tramadol 50 mg, every six hours for pain, ordered on 04/20/23 and discontinued on 04/21/23 which was administered twice. Tramadol 50 mg, four times a day for 14 days, ordered on 04/21/23 and discontinued on 04/21/23 which was administered twice. Ibuprofen 200 mg, two tablets every eight hours PRN, ordered on 12/22/22 and discontinued on 04/19/23. Tramadol 50 mg, every eight hours PRN, for 14 days ordered on 04/21/23. Tramadol, 50 mg, was discontinued on 06/09/23. There were no nursing notes regarding why the orthopedic physician orders for pain management on 04/19/23 were not followed. Review of physician orders revealed: An order dated 04/19/23 for a donut cushion to sit on to help alleviate tailbone pain. An order dated 04/24/23 for physical therapy (PT) to evaluate and treat the resident. An order dated 04/27/23 for occupational therapy (OT) to evaluate and treat the resident. Review of a nursing note on 04/29/23 revealed Resident #31 continued with complaints of pain to lower back and left arm. Further pain descriptors were not provided. Review of PT note from 05/04/23 at 3:21 P.M. revealed Resident #31 had complaints of left shoulder pain during treatment. Review of the May 2023 MAR revealed on 05/04/23 pain medication, Tramadol 50 mg, was given at 7:37 A.M. but was not given again after complaints of pain in therapy. Review of OT note from 05/05/23 at 12:16 P.M. revealed Resident #31 would wince with pain during range of motion (ROM). Review of MAR for 05/05/23 revealed pain medication was administered at 7:28 A.M. but was not given after complaints of pain in therapy. Review of PT note from 05/08/23 at 3:54 P.M. revealed Resident #31 complained of pain in her left arm. Review of MAR for 05/08/23 revealed Tylenol was administered at 5:30 P.M. and Tramadol was administered at 10:35 P.M. Both medications were administered after therapy. There was no evidence the resident was administered pain medication prior to her therapy. Review of PT note on 05/13/23 at 11:18 A.M. revealed Resident #31 had pain in her left shoulder. Review of 05/13/23 MAR revealed pain medication was not administered until 4:41 P.M. Review of OT on 05/16/23 at 1:00 P.M. revealed Resident #31 had complained of pain and nursing was made aware. Review of the 05/16/23 MAR revealed Resident #31 received Tramadol at 4:21 A.M. and at 3:32 P.M. Medication was ordered for administration every eight hours and could have been administered at 12:00 P.M. prior to her therapy. Review of PT note from 05/17/23 at 3:48 P.M. revealed Resident #31 had pain and excessive swelling in LUE. There was no documented evidence the resident's complaints of pain and swelling were reported to the nursing staff. Review of 05/17/23 MAR revealed Resident #31 received Tramadol 25 mg at 7:40 P.M. There was no evidence the resident was medicated for pain prior to her therapy appointment and was not provided pain medication until four hours after her she complained of pain during therapy. Review of PT note from 05/19/23 revealed at 11:07 A.M. Resident #31 had pain in her LUE. Review of OT note for 05/19/23 revealed Resident #31 yelled out and screamed with any movement to shoulder, 40-45 degrees of flexion was completed, and resident was visibly in pain even with pain medication prior to treatment. Occupational Therapy continued even with Resident #31 screaming out in pain. Review of the 05/19/23 MAR revealed Resident #31 had received 50 mg of Tramadol at 8:05 A.M. and Tylenol at 2:01 P.M. Review of OT note from 05/25/23 at 1:29 P.M. revealed Resident #31 had complained of pain to LUE with behaviors of screaming at therapist. Review of 05/25/23 MAR revealed Resident #31 received Tramadol 50 mg at 8 A.M., 2 P.M., and 8 P.M. Review of OT note from 05/30/23 at 7:47 A.M. revealed Resident #31 screamed out and moaned that ROM was painful with eight out of ten pain scale after medication was administered. Review of 05/30/23 MAR revealed Resident #31 received Tramadol 50 mg at 8 A.M., 2 P.M., and 8 P.M. The resident did not receive pain medication prior to ROM being performed. Interview on 08/23/23 at 8:37 A.M. with Physical Therapy Assistant (PTA) #501 revealed when Resident #31 received therapy, she had a seven out of ten pain at rest, and eight out of ten pain with movement. PTA #501 stated Resident #31 would yell out in pain during therapy at the slightest touch, but PTA #501 felt it was behavioral more than actual pain. Interview and observation on 08/24/23 at 9:00 A.M. with Resident #31 revealed she was unable to recall the incident (the fall on 04/16/23). Resident #31 was holding her upper left arm and complaining of pain stating, it hurts, hurts, hurts, at the time of the interview. Interview and observation on 08/24/23 at 9:03 A.M. with State tested Nursing Assistant (STNA) #37 revealed Resident #31 does still complain of pain often in her LUE. STNA #37 explained Resident #31's ROM in left arm has decreased and Resident #31 no longer walks around the facility like she did before but uses the wheelchair to get around. Wheelchair was in room at this time and observed to be without the donut cushion. When asked about the donut cushion missing from Resident #31's wheelchair, STNA #37 stated resident did not like the donut cushion because it hurt her. There was no documentation of Resident #31 refusing the donut cushion. During interview STNA #37 was helping Resident #31 go to the bathroom and resident complained of pain. Interview on 08/24/23 at 10:44 A.M. with RN #780 revealed Resident #31 does still complain of pain and guards her left arm. When asked if pain medication had been administered on this date (08/24/23), RN #780 stated no one had reported the resident complained of pain. Review of a policy titled General Pain Management revealed the nurse should assess a resident's pain and evaluate the effectiveness of the interventions, reassess pain, and document findings in the medical record. It stated dosage conversations should be held with the interdisciplinary team. This deficiency represents non-compliance investigated under Complaint Number OH00136232.

Based on medical record review and interview, the facility failed to thoroughly assess and provide timely medical treatment to a resident with multiple fractures. This affected one resident (#31) of four residents reviewed for accidents. Actual harm occurred on 04/16/23 when Resident #31 fell , hitting her elbow on the shower chair and landing on her buttocks. At the time of the fall, Resident #31 complained of elbow pain and tailbone pain, however only the elbow pain was assessed, and physician notified resulting in the resident receiving an Xray of the shoulder and being diagnosed with a fractured humeral head on 04/17/23. The failure of the facility to appropriately assess and document the resident's sacral pain at the time of the fall resulted in a delay in the diagnosis and treatment of the resident's fractured sacrum until 04/20/23. Harm continued 04/29/23 when facility staff failed to notify the resident's physician of swelling and pitting edema in Resident #31's left arm until 05/06/23 when the resident's physician was notified of the change in condition (swelling and pitting edema) and the resident received diagnostic testing and was diagnosed with a superficial venous thrombosis (SVT). Actual harm continued 05/06/23 when the resident's physician ordered the resident to receive a blood thinning medication in the treatment of the SVT and the treatment was not initiated until two days later on 05/08/23. Findings included: Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including hypertension, major depressive disorder, osteoarthritis, anxiety disorder, overactive bladder, irritable bowel syndrome, and dementia. Review of a minimum data set (MDS) assessment completed on 04/06/23 revealed Resident #31 had a brief interview for mental status (BIMS) score of six (6) indicating moderately impaired cognition, required an extensive assist of one person for bed mobility, transfers, walking in the room and corridor, and toilet use and required the use of a walker. The MDS also indicated Resident #31 was frequently incontinent of bladder and had not been trialed on a toileting program. Review of nursing notes dated 04/16/23 through 04/20/23 revealed the front hall nurse, Licensed Practical Nurse (LPN) #21, witnessed Resident #31 on 04/16/23 at 5:08 P.M. walking into the bathroom when she fell on her bottom and hit her left elbow on the shower chair. Resident #31 was assessed with no injuries noted, was changed due to an episode of incontinence, and given ibuprofen for elbow pain with no rating or description of pain noted. There was no documentation regarding the resident's complaints of tailbone/sacrum pain. The morning of 04/17/23 at 8:14 A.M. Resident #31 was complaining of left arm and shoulder pain and presented with bruising on inner left upper arm and shoulder blade. The Medical Director was contacted and gave a verbal order to send to the emergency department for evaluation. At the hospital, Resident #31 was diagnosed with a fracture of the left humeral head, widening of subacromial space, and soft tissue swelling. Resident #31 returned to the facility with new orders to follow up with an orthopedic physician. On 04/19/23 at 9:26 P.M. a nursing note by LPN #21 stated Resident #31 was complaining of pain to her tailbone, which was tender to touch and aching. Resident's daughter had requested for day shift nursing staff to be notified of pain and to possibly get an X-ray. The order for an X-ray was not received until 04/20/23 at 2:13 P.M. and results were received at 6:40 P.M. stating Resident #31 had a fracture in her distal sacrum. Review of a nursing note from Registered Nurse (RN) #11 on 04/29/23 at 2:52 P.M. revealed Resident #31's left hand was swollen and hanging from the arm sling. The nurse readjusted the sling but did not notify the physician of the swelling. There were no further relevant nursing notes until a note on 05/05/23 at 2:09 P.M. from LPN #105 revealed Resident #31's daughter was made aware of a new order from the Medical Director for a doppler (ultra-sound) to the left upper extremity due to redness and edema. An additional nursing note on 05/05/23 at 3:13 P.M. revealed Resident #31 presented with +2 pitting edema with redness to her left hand. Review of a nursing note from RN #11 on Saturday, 05/06/23 at 11:51 A.M. revealed an ultrasound had been completed and preliminary results were positive for a deep vein thrombosis. The nurse did notify the on-call physician who stated no new orders were needed until Monday (05/08/23). Resident #31's daughter was notified and requested the Medical Director be contacted to address the thrombus, but the facility staff declined stating the on-call physician had already addressed her concerns. Resident #31's daughter continued to request the Medical Director to be contacted regarding the thrombus. On 05/06/23 at 4:17 P.M. the final results for the ultrasound showed an SVT to the left basilic vein. On 05/06/23 at 6:13 P.M. the Medical Director ordered the blood thinning medication, Eliquis 2.5 milligrams (mg) twice a day for SVT. Review of the medication administration record (MAR) from May 2023 revealed the code of 9 for the administration of Eliquis 2.5 mg on the evening on 05/06/23, both doses on 05/07/23, and the morning dose of 05/08/23. Review of the MAR code keys revealed 9 indicates to review nursing notes. Review of MAR nursing note from LPN #105 on 05/06/23 at 6:13 P.M. revealed the order for Eliquis was received at that time and requested from the pharmacy. The MAR nursing notes on 05/07/23 from LPN #80 at 2:06 P.M. and from LPN #19 at 9:24 P.M. revealed Eliquis continued to be unavailable and was on order from the pharmacy. A MAR nursing note from RN #11 on 05/08/23 at 7:03 A.M. revealed Eliquis was not available from the pharmacy yet. The Medical Director was not notified regarding late administration of Eliquis. Interview on 08/23/23 at 11:33 A.M. with LPN #105 revealed on 05/05/23 she was helping with meals in the dining room when she noticed Resident #31 had pitting edema to her left hand and it was red. LPN #105 stated she spoke with RN #11 who normally works that unit and RN #11 stated Resident #31's hand had been like that for a while. LPN #105 stated she then contacted the Medical Director to get a doppler ordered and she scheduled the doppler test once the order was received. Interview on 08/23/23 at 11:49 A.M. with RN #11 revealed after Resident #31 had broken her shoulder, her hand began to swell as well, so the doctor was contacted and an order for a doppler was received. RN #11 stated she did not recall contacting the physician on 04/29/23 when she had first noticed the swelling because she thought it was related to Resident #31 leaning to her right side and the gravity was shifting the swelling to the left hand. Interview on 08/23/23 at 12:53 P.M. with LPN #510 revealed on 04/16/23 Resident #31 got up and walked out of her room to the front hall bathroom and fell . LPN #510 stated Resident #31 had complained of pain to her tailbone, and she thought she administered Tylenol at the time of the fall. LPN #510 verified she did not assess the resident's complaints of tailbone pain, failed to document the resident's tailbone pain, and failed to notify the physician of the tailbone pain. Interview on 08/24/23 at 9:18 A.M. with Director of Nursing (DON) revealed Eliquis was ordered on 05/06/23 which was a Saturday which would cause the medication to be delayed in arriving for administration. Interview on 08/24/23 at 2:12 P.M. with RN #222 revealed the pharmacy is on-call during the weekends so if she doesn't hear back after the first request for medication, she follows up. RN #222 stated the pharmacy works really quick, and that if she ordered a medication, that is not a controlled substance, on the weekend at about 8:00 A.M. it would typically arrive the same day between 11:00 A.M. and 2:00 P.M. The surveyor requested a facility policy for change in condition and notifying physician of change in condition, but none were received. This deficiency represents non-compliance investigated under Complaint Number OH00136232.

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program in the kitchen area. This had the potential to affect all residents receiving meals from the facility kitchen. The facility identified one Resident (#38) as not receiving meals from kitchen for Nothing by Mouth (NPO) status. The facility census was 51. Findings include: Observations on 08/21/23 from 9:06 A.M. to 9:23 A.M. revealed significant fly and gnat activity in kitchen preparation areas. Observations revealed door through dry storage room in kitchen leading directly outside to dumpster area. There were noted kitchen cleanliness concerns in the kitchen preparation areas. Observations on 08/23/23 from 10:51 A.M. to 11:08 A.M. revealed continued significant fly and gnat activity in kitchen preparation areas. Interview on 08/23/23 at 11:08 A.M. with Dietary Director #900 confirmed fly and gnat activity. Dietary Director #900 indicated maintenance was responsible for pest control. Dietary Director #900 indicated staff try to mitigate activity by killing flies and gnats. Interview on 08/23/23 at 3:08 P.M. with Maintenance Director #450 revealed the facility used a pest control service on a monthly basis. Maintenance Director #450 indicated there was a high concentration of flies in general due to weather. Maintenance Director #450 indicated it was recommended by pest control service that the dumpster outside of the dietary department be closed. Maintenance Director #450 indicated he had a meeting scheduled for next week with trash company to discuss moving the dumpster further from the building. Maintenance Director #450 stated he had planned to educate the dietary staff on using the further of the two dumpsters for food items and the closer of the two for boxes and non-perishable items. Maintenance Director #450 also stated he planned to tell dietary to keep the kitchen door closed to the outside. Interview on 08/24/23 at 12:13 P.M. with Pest Control Representative (PCR) #702 revealed he inspects and treats the facility monthly. PCR #702 stated it was recommended the dumpster lids be closed last month. PCR #702 stated the facility had not requested additional services. Review of Orkin Service Information reports dated 05/26/23, 06/05/23, and 07/28/23 revealed no treatments for gnats or flies. Review of Orkin Service Information report dated 06/30/23 revealed kitchen was treated for flies. There was no evidence of additional services requested to address flies or gnats.

Based on observation, interview, and record review, the facility failed to ensure clean and sanitary kitchen area and ensure appropriate glove use by kitchen staff. This had the potential to affect all residents receiving meals from the facility kitchen. The facility identified one resident (#38) as not receiving meals from kitchen for Nothing by Mouth (NPO) status. The facility census was 51. Findings include: Observations on 08/21/23 from 9:06 A.M. to 9:23 A.M. revealed under dry storage room storage racks was darkened, sticky flooring and there was various food debris and plasticwares. The main food preparation area contained food preparation tables, racks for storing cookware, and equipment including steamtable, deep fryer, oven with range and flat grill top. There was a microwave on a storage rack. Inside the microwave was splattered with red food substance. Under preparation tables revealed darkened flooring with grease build up with significant food debris. Observation of deep fryer revealed significant dark brown grease build up on splash guards and yellow colored build up on basket hanger. There was splatter of grease/ food debris down front of deep fryer. Observation of oven with range revealed splattering of grease/food debris down front of oven range. Observation of flat top grill revealed significant dark brown grease build up and food debris. There was splatter of grease/food debris down front and sides of flat top grill. Observation of kitchen hood revealed significant grease build up with dust sticking to grease on the fire suppression system within kitchen hood and grates. Findings were confirmed with Dietary Director #900 at time of observation. Observation on 08/23/23 from 10:51 A.M. to 11:08 A.M. of Cook #520 preparing pureed lunch items revealed Cook #520 wearing disposable gloves. Dietary Director #900 was present during time of puree preparations. Cook #520 was observed to use gloved hand to scoop vegetable blend into food processor. Cook #520 did not dispose gloves after scooping vegetables. Cook #520 continued to prepare purees while wearing same disposable gloves. Cook #520 continued on to prepare pureed veal patties while wearing same gloves. Cook #520 grabbed tongs from a drawer on prep table while wearing same disposable gloves. Cook #520 was noted to pull down surgical mask to taste test vegetable blend puree and veal puree while wearing same disposable gloves. Cook #520 continued on to puree garlic bread. Cook #520 grabbed garlic bread out of oven with same gloved hands and did not use utensil. Observation also revealed tray of garlic bread on metal storage rack placed on top of clean cookware. The tray of garlic bread was uncovered. Interview on 08/23/23 at 11:08 A.M. with Cook #520 and Dietary Director #900 confirmed findings of inappropriate glove usage and uncovered garlic bread left on the shelf. Review of facility policy General Sanitation of Kitchen dated 2017 revealed staff would maintain the sanitation of the kitchen through a written comprehensive cleaning schedule. Review of Weekly Cleaning Schedule undated revealed cleaning schedules for kitchen hood and filters, stove and oven, tables including bottom, floors including corner, fryer, and cook room. Review of kitchen education on personal hygiene and hand washing dated 03/28/23 revealed glove are used to protect food and not keep hands of employee clean, gloves should be changed between each activity, and gloves were not a substitute for washing hands. The education revealed when handling food use tongs or other appropriate utensils. The education was completed by Cook #520 on 07/14/23.

Based on interview, record review, and review of PBJ (Payroll Based Journal) data report the facility failed to ensure accuracy of PBJ information. This had the potential to affect all 51 residents residing in the facility. Findings include: Review of the facility PBJ Staffing Data Report dated 01/01/23 through 03/31/23 revealed submitted weekend staffing data was excessively low. Review of the facility nursing schedules from 01/03/23 through 02/28/23 did not reveal documentation when nurses assigned to the Nursing Home area of the facility were also required to cover the Assisted Living area on night shift. Further review did not reveal nurses signed out from the Nursing Home when they needed to go to the Assisted Living area, and did not sign back in when they returned. Interview on 08/21/23 at 11:30 A.M. of Registered Nurse (RN) #445 revealed she worked in the Nursing Home part of the facility, but sometimes when she worked night shift from 6:00 P.M. through 6:00 A.M. she was required to cover the Nursing Home and the Assisted Living (AL) because the AL did not have a nurse who worked night shift. RN #445 stated she could not remember the dates she covered the Assisted Living as part of her assignment. RN #445 indicated she had not been required to cover the Assisted Living for at least a couple months now. RN #445 stated she did not know what changed or why she was not required to cover the AL now. RN #445 stated she did not know if the AL staffing was better now, and if that was the reason she was not required to cover the AL now. RN #445 stated when she did cover the AL it was pretty much every other night that she worked. RN #445 indicated she could not think of any negative effect residents in the Nursing Home experienced when she covered the AL. RN #445 revealed night shift was the only time the nurses were required to take the keys for the AL and cover the AL if a nurse was needed. RN #445 stated two nurses usually worked night shift in the Nursing Home, and depending on the needs of the residents in the AL she would usually be gone about a half hour, but had been gone for two hours due to a resident fall. Interview on 08/21/23 at 3:59 P.M. of the Director of Nursing (DON) confirmed nurse's from the Nursing Home covered the Assisted Living during some night shifts. The DON stated nurses from the Nursing Home had not been required to cover the AL for a few months now. The DON indicated it only happened for a few months because the AL did not have enough staff, but now they had enough staff. The DON stated she could not provide information for which nights the nurses covered the Assisted Living and the time they spent in the AL meeting the residents needs. The DON stated the nursing schedule did not reflect the days the nurses were required to cover the AL. The DON stated the nurses did not sign in and out when they went to the AL and there was no way to tell how long they were in the AL. The DON stated the nurse who took the AL keys for the medication cart completed a narcotic count with the nurse who was leaving the AL, then came back to the Nursing Home. Interview on 08/22/23 at 5:46 A.M. of RN #445 revealed she did not document how long she was gone when she left the Nursing Home and went to the AL to meet a resident's needs. RN #445 stated on the nights she was required to cover the AL, she would go to the AL when she arrived for work, complete a narcotic count with the nurse who was leaving, then return to the Nursing Home. RN #445 stated when the AL attendants called her because a resident needed her for a reason like medication administration or a fall she did not document when she left the Nursing Home or when she returned. Interview on 08/24/23 at 1:10 P.M. of the DON revealed she was not the Director of Nursing during the months when the Nursing Home nurses covered the Assisted Living. The DON stated she could not answer any questions related to the accuracy of the PBJ data since she was not in the DON role at that time. The DON stated the facility did not have a shared staffing policy because the AL and the NH were all one entity. This deficiency represents non-compliance investigated under Complaint Number OH00140656 and OH00137403

Based on observation, interview, record review, and review of facility policy the facility failed to identify a pattern of urinary tract infections (UTIs) did not occur for ten residents (#13, #18, #23, #34, #38, #41, #50, #156, #158 and #256) residing in the same nursing unit, the facility failed to ensure appropriate use of personal protective equipment (PPE) for resident (#308) on droplet precautions, and failed to ensure documentation of education for hand hygiene, gloves and cleansing of perineal area. This affected ten residents (#13, #18, #23, #34, #38, #41, #50, #156, #158 and #256) of 16 residents reviewed for UTIs, one (#308) out of four residents reviewed for transmission based precautions. The facility census was 51. Findings include: 1.Review of the infection control log dated July 2023 revealed ten residents (that resided on the same nursing unit and required staff assistance with personal/incontinence care) had UTIs in July 2023; however the log did not provide the contact organism for all of them. a. Resident #13 developed a UTI on 07/05/23. The resident was identified as incontinent by Registered Nurse (RN) #500 on 08/24/23 at 3:30 P.M. b. Resident #18 developed a UTI on 07/20/23. The resident was identified as incontinent by RN #500 on 08/24/23 at 3:30 P. M c. Resident #23 developed a UTI on 07/12/23. The resident was identified as incontinent by RN #500 on 08/24/23 at 3:30 P.M. d. Resident #34 developed a UTI on 07/12/23. The resident was identified as occasionally incontinent by RN #500 on 08/24/23 at 3:30 P.M. e. Resident #38 developed a UTI on 07/20/23. The resident was identified as incontinent by RN #500 on 08/24/23 at 3:30 P.M. f. Resident #41 developed a UTI on 07/08/23. The resident was identified as occasionally incontinent by RN #500 on 08/24/23 at 3:30 P.M. g. Resident #50 developed a UTI on 07/13/23. The resident was identified as occasionally incontinent by RN #500 on 08/24/23 at 3:30 P.M. h. Resident #156 developed a UTI on 07/06/23. The resident was identified as incontinent by RN #500 on 08/24/23. i. Resident #158 developed a UTI on 06/12/23. The resident was identified as incontinent by RN #500 on 08/24/23. j. Resident #256 developed a UTI on 07/12/23. The resident was identified as occasionally incontinent by RN #500 on 08/24/23 at 3:30 P.M. 2. Observation and interview on 08/24/23 at 12:01 P.M. revealed a gown hanging on outside of door of Resident #308 (under isolation precautions). The gown was for staff reuse. This was verified verified by Licensed Practical Nurse (LPN) #19 at the time of the observation. Interview on 08/24/23 at 2:23 P.M. with RN #500 revealed gowns should not be hung outside an isolation room for reuse. She stated they are disposable for a reason. RN #500 verified the trend for UTIs in July 2023 in the same nursing unit for residents (#13, #18, #23, #34, #38, #41, #50, #156, #158 and #256) who were incontinent and required staff assistance with perineal/incontinence care. RN #500 stated she completed audits for handwashing in July 2023 but only did verbal training on perineal care in July 2023. The last documented evidence of training for perineal care was in April 2023. Review of the Hand Hygiene Contact Precautions Monitoring Tool, dated July 2023, revealed instances of hand hygiene not being completed upon entry or exit from resident room and gloves were not always worn as expected. Review of the facility policy titled Infection Control Policies and Procedures, dated 01/01/17 revealed the facility should provide on-going employee education counseling based on results of investigation in a timely manner. Education should include proper use of personal protective equipment and sterile technique.

Based on observation, interview, record review, review of facility policy, and manufacturer's recommendations the facility failed to ensure open bottles of insulin for Resident's #17, #47, and #256 were dated. This had the potential to affect nine resident's (Resident's #3, #15, #17, #18, #24, #43, #48, #156, #256) requiring insulin who resided in the facility. The facility census was 51. Findings include: 1. Review of Resident #256's medical record revealed an admitted [DATE] and diagnoses included type two diabetes mellitus without complications. Review of Resident #256's physician orders dated 08/09/23 revealed Lantus (insulin glargine) subcutaneous solution 100 units per milliliter (ml), inject 10 units subcutaneously at bedtime for type two diabetes mellitus. Further review revealed Humalog (insulin lispro) injection solution 100 units per ml, inject per sliding scale: if blood sugar was 151 to 200 administer 4 units, for blood sugar 201 to 250 administer 6 units, for blood sugar 251 to 300 administer 8 units, for blood sugar 301 to 350 administer 10 units, and for a blood sugar of 351 to 400 administer 12 units subcutaneously before meals and at bedtime for blood glucose. 2. Review of Resident #47's medical record revealed an admitted [DATE] and diagnoses included type two diabetes mellitus with diabetic neuropathy. Review of Resident #47's physician orders dated 05/30/23 revealed Humalog (insulin lispro) injection solution 100 units per ml, inject per sliding scale if blood sugar was 151 to 200 administer 4 units, for blood sugar 201 to 250 administer 6 units, for blood sugar 251 to 300 administer 8 units, for blood sugar 301 to 350 administer 10 units, for blood sugar 351 to 400 administer 12 units, call physician if blood sugar greater than 400, subcutaneously four times a day for blood sugar control. 3. Review of Resident #17's medical record revealed an admitted [DATE] and diagnoses included type two diabetes mellitus with diabetic neuropathy. Review of Resident #17's physician orders dated 08/10/23 revealed Toujeo SoloStar (insulin glargine) subcutaneous solution Pen-Injector 300 units per ml, inject 8 units subcutaneously at bedtime for type two diabetes mellitus. Observation on 08/22/23 at 9:01 A.M. of a facility medication cart with Registered Nurse (RN) #780 revealed: a. Resident #256 had an opened, undated bottle of insulin lispro (Humalog) in the medication cart. Further observation revealed the box the insulin lispro was stored in was labeled with Resident #256's name and dated 07/05/23. RN #780 confirmed Resident #256's bottle of insulin lispro was opened and undated. RN #780 indicated insulin was only good for a month after it was opened and first used. RN #780 stated Resident #256 was currently receiving insulin lispro. Further observation of the medication cart with RN #780 revealed Resident #256 had an opened, undated bottle of Lantus insulin (insulin glargine) stored in a box labeled with Resident #256's name and dated 06/25/23. RN #780 confirmed the box was dated 06/25/23, the bottle of Lantus insulin was opened and not dated, the box was dated almost two months ago and insulin was only good for 30 days once it was opened. RN #780 stated Resident #256 was currently receiving Lantus insulin. b. Resident #47 had an opened, undated bottle of insulin lispro 100 units per ml in the medication cart. Resident #47's insulin was stored in a box labeled with her name and a date of 06/27/23 written on the box. RN #780 confirmed Resident #47's insulin lispro was opened, undated, and stored in a box with the date 06/27/23 written on it. RN #780 confirmed insulin was only good for a month once it was opened. RN #780 indicated Resident #47 was currently receiving insulin lispro. c. Resident #17 had an opened Toujeo SoloStar (insulin glargine) subcutaneous solution Pen-Injector 300 units per ml, and the date on the pen was 05/06/23. RN #780 confirmed the pen was dated 05/06/23 which was three and a half months ago. RN #780 confirmed Resident #17 was currently receiving Toujeo SoloStar (insulin glargine) Pen-Injector 300 units per ml. Interview on 08/22/23 at 9:30 A.M. of the Director of Nursing (DON) confirmed insulin bottles were opened and undated for Resident #256 and #47. The DON confirmed Resident #17's Toujeo SoloStar Pen-Injector was dated 05/06/23. The DON confirmed the insulin bottles should have been dated when they were opened, and insulin glargine and lispro were only good for a month once they were opened. Review of the manufacturer's instructions for Insulin Lispro Injection 100 units per ml included do not use Insulin Lispro Injection past the expiration date printed on the label or 28 days after you first use it. Review of the manufacturer's instructions for Lantus Insulin (insulin glargine injection) 100 units per ml included do not use Lantus after the expiration date stamped on the label or 28 days after you first use it. Review of the manufacturer's instructions for Toujeo SoloStar Pen-Injector 300 units per ml included to only use your pen for up to 56 days after its's first use. Review of the facility policy titled General Guidelines-Medication Administration dated 05/01/16 included remember to date and initial the vial (bottle) and the box of multi-dose medications the first time you use a medication. Once opened and dated, the medication can be used for 30 days.

Based on interview and record review, the facility failed to monitor a dialysis fistula site for a resident receiving dialysis. This affected one resident (#48) of one reviewed for dialysis treatments. The facility identified one resident as receiving dialysis treatments. The facility census was 51. Findings include: Review of the medical record for Resident #48 revealed an admitted [DATE] and diagnoses included end stage renal disease, dependence on renal dialysis, diabetes mellitus, heart failure, and lymphedema. Review of the physician order dated 01/18/23 revealed Resident #48 received dialysis treatments on Monday, Wednesday, and Friday. Review of progress note dated 06/26/23 revealed Resident #48 had dialysis fistula (hemodialysis access connection made by joining a vein onto an artery) replaced. Review of care plan dated 07/10/23 revealed Resident #48 had tunneled hemodialysis catheter (hemodialysis access by placement of catheter under skin and into major vein) to right internal jugular and fistula to left arm. Care plan indicated to monitor for signs and symptoms of infection to dialysis access sites. Review of the Treatment Administration Record (TAR) for July 2023 and August 2023 revealed no evidence of monitoring dialysis access site for infection and patency. Review of Dialysis and Nursing Home Handoff Communication Tools for July 2023 and August 2023 revealed access site monitoring on 08/21/23, 08/14/23, 08/11/23, 08/07/23, 08/04/23, 08/02/23, 07/31/23, 07/29/23, and 07/28/23. There was no additional evidence of monitoring access site. Interview on 08/23/23 at 2:29 P.M. with Registered Nurse (RN) #222 revealed there was no order for monitoring dialysis access site. RN #222 indicated she only documents on the TAR when Resident #48 goes to dialysis and checks vitals and weight prior to treatment. Interview on 08/24/23 at 10:07 A.M. with Director of Nursing (DON) confirmed there was no order for monitoring dialysis access site for infection or patency. This deficiency represents non-compliance investigated under Complaint Number OH00136232. Review of facility policy Hemodialysis Therapy dated 01/01/17 revealed dialysis shunt patency will be monitored daily by palpation of thrill and auscultation of bruit. The policy indicated staff will monitor resident for signs of infection (fever, chills, warmth around site) and report to physician and dialysis center of any findings.

Based on observation, interview, record review, the facility failed to ensure a resident was assisted to the bathroom timely. This affected one resident (#15) of three residents reviewed for activities of daily living (ADL) assistance. The facility census was 51. Findings include: Review of Resident #15's medical record revealed an admitted [DATE] and diagnoses included type two diabetes mellitus with diabetic neuropathy, morbid obesity, and schizoaffective disorder, depressive type. Review of Resident #15's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 was cognitively intact. Resident #15 required extensive assistance of two staff members for toilet use. Resident #15 was occasionally incontinent of urine and frequently incontinent of bowel. Review of Resident #15's care plan revised 07/10/23 included Resident #15 had an ADL (Activity of Daily Living) self care deficit including incontinence. Resident #15 would maintain functional abilities through next review. Interventions included to toilet in advance of need; toileting with extensive assistance of one staff member. Observation on 08/24/23 at 7:45 A.M. of Resident #15 revealed State tested Nursing Assistant's (STNA)'s #46 and #703 were changing Resident #15's shirt, pants and sheets because they were saturated with urine. STNA #46 stated Resident #15 had an accident because STNA #46 could not get to her call light fast enough. STNA #46 stated she was helping another resident and by the time she got to Resident #15 she was incontinent and it saturated her clothes and bedding. STNA #46 indicated this happened sometimes because there were only three aides for 51 nursing home residents and a lot ot the residents required extensive care to meet their needs. Interview on 08/24/23 at 8:32 A.M. of Resident #15 revealed she put her call light on because she had to go to the bathroom, but the aide did not answer her call light fast enough and she had an accident. Resident #15 stated her incontinence brief, bed and shirt needed to be changed because they were wet with urine. Resident #15 stated often she would put her call light on and the aides could not answer it fast enough and she would have an accident. Resident #15 did not remember how long her call light was on before she had an accident. This deficiency represents non-compliance investigated under Complaint Number OH00136232.

Based on interview and record review, the facility failed to develop care plans for a resident with pressure ulcers and included a resident's code status. This affected two residents (#17, #27) of 20 residents reviewed for care planning. The facility census was 51. Findings include: 1. Review of the medical record for Resident #17 revealed an admitted [DATE] and diagnoses included chronic kidney disease, osteoarthritis, diabetes mellitus, and diabetic neuropathy. Review of physician's orders dated 08/15/23 revealed Resident #17 had sacral wound and left hip wound. Review of Weekly Wound Report dated 08/15/23 revealed Resident #17 readmitted from hospital on 06/27/23 with Stage 3 pressure ulcer on sacrum and a suspected deep tissue injury on left hip. Review of the current care plan for 08/24/23 revealed no evidence of care planning for actual pressure injuries. Interview on 08/24/23 at 9:25 A.M. with Minimum Data Set (MDS) Coordinator #73 verified there was no care plan for actual pressure injuries for Resident #17. MDS Coordinator #73 indicated she would expect to see a care plan for a specific wound and would be reviewed/revised by the wound nurse. Interview on 08/24/23 at 10:09 A.M. with the Director of Nursing (DON) verified there was no care plan for actual pressure injuries for Resident #17. Review of the facility policy Skin-Wound Care Treatment dated 01/30/16 revealed a plan of care was to be initiated no later than eight hours after admission regarding altered skin integrity. 47985 2. Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including asthma, gastro-esophageal reflux disease, hypertension, dementia, osteoporosis, and fracture of unspecified part of next of right femur. Review of a MDS completed on 06/28/23 revealed Resident #27 had a BIMS score of 3 indicating severely impaired cognition, required extensive assistance of two for bed mobility, transfer, and toilet use, and required a limited assist of one staff for eating. Review of Resident #27's orders revealed an order in place for a do not resuscitate comfort care (DNRCC) in place. Review of Resident #27's care plan did not indicate her code status. Interview on 08/23/23 at 1:43 P.M. with LPN #105 confirmed Resident #27's care plan did not indicate a code status, but orders revealed a code status of DNRCC.

Based on record review, facility policy review and interview the facility failed to ensure Resident #54's Do Not Resuscitate (DNR) advance directives/order was honored. This affected one resident (#54) of three reviewed for DNR advanced directives. The facility census was 50. Finding include: Review of Resident #54's closed medical records revealed an admission date of [DATE] with diagnoses including high blood pressure and chronic kidney disease. Record review revealed the resident passed away on [DATE]. Review of the resident's advance directives revealed the resident had a signed Do Not Resuscitate Comfort Care (DNR-CC) form, dated [DATE]. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition and required extensive assistance with with bed mobility, transfers, toileting and personal hygiene. Review of care plan dated [DATE] revealed Resident #54 had advance directives for a Do Not Resuscitate Comfort Care (DNR-CC). Review of physician's orders dated [DATE] revealed Resident #54 was a DNR-CC. Review of a progress note dated [DATE] authored by Licensed Practical Nurse (LPN) #200 revealed Resident #54 was observed to be unresponsive with no pulse. The progress note revealed Cardiopulmonary Resuscitation (CPR) was initiated and emergency services had been called. The progress note revealed CPR had lasted for 20 minutes until the physician had declared a time of death and Resident #54 had expired at 6:17 P.M. Interview on [DATE] at 12:15 P.M. with the Director of Nursing (DON) confirmed the resident's physician orders, care plan and signed DNR-CC paperwork were contained in Resident #54's medical record. The DON confirmed CPR had been performed on Resident #54 and should not have been due to Resident #54's DNR-CC status. Interview on [DATE] at 12:31 P.M. with LPN #200 revealed she was the assigned nurse for Resident #54 on [DATE]. LPN #200 stated Resident #54's roommate had put the call light on and had told her Resident #54 had not been responding to her. LPN #200 stated she had observed Resident #54 to have been unresponsive and was barely breathing. LPN #200 stated she had checked her report sheet that had indicated Resident #54 was a full code (all life saving measures to be done) as well as another nurse who had checked the computer system which also indicated Resident #54 was a full code. LPN #200 stated she had immediately began CPR until the paramedics arrived. LPN #200 stated she had been informed a few days after the incident Resident #54 was a DNR-CC and stated she was not sure why the computer and report sheet had indicated a full code status. Review of facility undated policy titled DNR Protocol revealed no resuscitative measures should be done to save or sustain life.

Based on record review, facility policy review and interview the facility failed to ensure Resident #54's Do Not Resuscitate (DNR) advance directives/order was honored. This affected one resident (#54) of three reviewed for DNR advanced directives. The facility census was 50. Finding include: Review of Resident #54's closed medical records revealed an admitted [DATE] with diagnoses including high blood pressure and chronic kidney disease. Record review revealed the resident passed away on [DATE]. Review of the resident's advance directives revealed the resident had a signed Do Not Resuscitate Comfort Care (DNR-CC) form, dated [DATE]. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition and required extensive assistance with with bed mobility, transfers, toileting and personal hygiene. Review of care plan dated [DATE] revealed Resident #54 had advance directives for a Do Not Resuscitate Comfort Care (DNR-CC). Review of physician's orders dated [DATE] revealed Resident #54 was a DNR-CC. Review of a progress note dated [DATE] authored by Licensed Practical Nurse (LPN) #200 revealed Resident #54 was observed to be unresponsive with no pulse. The progress note revealed Cardiopulmonary Resuscitation (CPR) was initiated and emergency services had been called. The progress note revealed CPR had lasted for 20 minutes until the physician had declared a time of death and Resident #54 had expired at 6:17 P.M. Interview on [DATE] at 12:15 P.M. with the Director of Nursing (DON) confirmed the resident's physician orders, care plan and signed DNR-CC paperwork were contained in Resident #54's medical record. The DON confirmed CPR had been performed on Resident #54 and should not have been due to Resident #54's DNR-CC status. Interview on [DATE] at 12:31 P.M. with LPN #200 revealed she was the assigned nurse for Resident #54 on [DATE]. LPN #200 stated Resident #54's roommate had put the call light on and had told her Resident #54 had not been responding to her. LPN #200 stated she had observed Resident #54 to have been unresponsive and was barely breathing. LPN #200 stated she had checked her report sheet that had indicated Resident #54 was a full code (all life saving measures to be done) as well as another nurse who had checked the computer system which also indicated Resident #54 was a full code. LPN #200 stated she had immediately began CPR until the paramedics arrived. LPN #200 stated she had been informed a few days after the incident Resident #54 was a DNR-CC and stated she was not sure why the computer and report sheet had indicated a full code status. Review of facility undated policy titled DNR Protocol revealed no resuscitative measures should be done to save or sustain life.

Based on observation, review of the medical record, interviews with staff, and review of the facility policy the facility failed to prevent the development of a pressure ulcer for Resident #28. Actual harm occurred when Resident #28 developed an avoidable, in house acquired, stage three (full thickness wound with fat and tissue exposed) pressure ulcer to the left outer ankle. This affected one (Resident #28) of three residents reviewed for pressure ulcers. The facility census was 42. Findings include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed Resident #28 was discharged to the hospital on 11/22/20 and the order for the Left Ankle Foot Orthosis (AFO) brace was discontinued on 11/24/20. Resident #28 was readmitted to the facility on [DATE] without an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Braden scale dated 12/02/20 revealed Resident #28 was high risk for developing pressure ulcers. Review of the significant change in status Minimum Data set 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition, required extensive assistance for all activities of daily living (ADLS), and was at risk for pressure ulcers. The resident did not have any unhealed pressure ulcers and had a surgical wound. Review of the plan of care dated 01/21/21 revealed Resident #28 was at risk or had altered skin integrity due to being admitted with surgical wounds and being at risk for skin breakdown due to immobility, disease process and weakness. Interventions included to follow the facility skin protocol, immediately report any skin redness or breakdown to the nurse, inspect the skin with showers and baths and provide information to the nurse to review, notify the physician of any changes in the skin as needed, and perform treatments as ordered. Review of the January 2021 and February 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During review of the medical record there was no evidence found of skin checks or shower sheets with skin checks for Resident #28. Review of physician orders for January and February 2021 revealed Resident #28 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the wound/skin progress note dated 02/16/21 revealed Resident #28 had a stage three pressure ulcer on the left outer ankle due to him rubbing his foot repeatedly on the bed and from the plastic AFO brace. Review of the Weekly Wound Report dated 02/16/21 revealed Resident #28 was found to have a stage three pressure ulcer to his left outer ankle which measured 4.0 centimeters (cm) in length by 1.0 cm in width by less than 1.0 cm in depth. Review of the physician's orders dated 02/16/21 revealed Resident #28 had an order to hold the use of the AFO brace due to a pressure area on the left ankle. Interview on 07/21/21 1:20 P.M. the Director of Nursing (DON) indicated the State tested Nursing Assistants (STNA) did not document under tasks for skin observations. During a telephone interview on 07/21/21 at 1:40 P.M. Registered Nurse (RN) #51, who was the facility's wound nurse, indicated she was told by the wound company to stage Resident #28's wound at a stage three for proper treatment. She indicated his AFO brace was rubbing his ankle and caused a pressure ulcer. During interview on 07/21/21 at 2:00 P.M. the DON verified there was no documentation of skin observation prior to the facility finding the stage three pressure ulcer to the left outer ankle of Resident #28 and there were no shower sheets to indicate the staff had been performing skin assessments on Resident #28 per his plan of care. During interview on 07/21/21 at 4:10 P.M. STNA #74 indicated they were to check a resident's skin during their bath or shower. They would then fill out a shower sheet and give it to the nurse, the nurse would sign it and they would put it in the shower book. She stated Resident #28 did get up and get a shower every week before he went on hospice but now hospice does his shower. She indicated they put the resident's AFO brace on when he got up out of bed and took it off while he was in bed. Review of the medical record revealed Resident #28 did not go under hospice care until 02/28/21. During interview on 07/21/21 at 4:15 P.M. Licensed Practical Nurse ((LPN) #73 indicated the STNA would fill out the shower sheet, give the sheets to the nurses, the nurses would sign the shower sheet and the STNA would put the sheet into the shower book on the unit. She indicated she had been checking the skin under Resident #28's AFO brace, however, she had not documented anywhere in his chart she had done it. During interview on 07/22/21 at 8:37 A.M. LPN #62 indicated Resident #28 had been in and out of the hospital so many times the order for his AFO brace must have dropped off and was never picked back up. She verified Resident #28 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 07/22/21 at 8:45 A.M. Resident #28 indicated he was unable to move his left leg and didn't feel much, however, he had told the staff his ankle was bothering him and that was when they found the sore. He indicated the staff did take the brace off at night, but they did not take his socks off. Observation on 07/22/21 at 11:09 A.M. revealed LPN #63 provided wound care to the left outer ankle pressure wound of Resident #28 with no concerns. The wound was approximately 1.0 cm in width by 1.0 cm in length with an undetermined depth due to the nurse did not measure the wound. The wound bed and peri wound was pink with granulation. There was a small amount of yellow drainage on the old dressing. Review of the facility policy, Nursing-Skin, dated 05/01/16 revealed the policy was to identify resident at risk for the development of pressure ulcers and define early interventions. Early interventions refer to treatment prescribed for those residents determined to be a risk for developing pressure ulcers.

Based on record review, staff interview, and review of the policy for falls, the facility failed to provide adequate supervision and implement fall interventions as ordered by the physician to prevent falls for Resident #1, Resident #2, and Resident #3. Actual harm occurred when Resident #2, who was at high risk for falls, was left unattended in the bathroom and fell resulting in [MEDICAL CONDITION] requiring hospitalization . This affected three of three residents reviewed for falls. Findings include: 1. Record review for Resident #2 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the discharge Minimum Data Set (MDS) assessment, dated 02/13/18, revealed Resident #2 had impaired cognition and required extensive assistance from staff for bed mobility and transfers. Review of the care plan dated 07/04/15 revealed Resident #2 was at risk for falls due to being unaware of safety needs, decreased cognition, confusion, psychoactive drug use, and wandering behaviors. Interventions included staff to complete every 15 minute checks, increased supervision with resident to be in the common area when possible and for gripper socks to be worn. On 11/07/17, the intervention section was updated and indicated Resident #2 had a cognitive score of 2, (scores of zero to seven indicate severe cognitive impairment), and was not able to be educated on safety measures. On 12/16/17, the intervention section revealed Resident #2 was unable to be educated related to safety concerns due to cognitive status. Review of the fall risk assessment dated [DATE] revealed Resident #2 was at high risk for falls. Interventions included increased supervision. Resident #2 was to be kept in common areas and staff were to check on her every 15 minutes. A nurse's note dated 02/03/18 at 1:15 P.M. revealed Licensed Practical Nurse (LPN) #20 found Resident #2 on the floor in another resident's room. Resident #2 was grimacing and guarding her left lower leg and was observed with bruising on her left forehead area. At 1:40 P.M., 911 was called to transport Resident #2 to the hospital. The nurse's note dated 02/03/18 at 5:15 P.M. revealed the emergency room nurse notified the facility that Resident #2 would be returning to the facility with a fracture (broken bone) of her left wrist. Review of physician orders [REDACTED].#2 was ordered a lap buddy (a cushion that fits into the wheelchair frame and across the person's lap to attempt to deter them from standing unassisted) to her wheelchair. This intervention was added to the fall risk care plan on 02/05/18. A nurse's note dated 02/07/18 at 12:36 A.M. revealed a loud noise was heard. Resident #2 was found lying on her back on the floor with her head between the bed and dresser and her legs pointed toward the bathroom. Resident #2 stated she had to go to the bathroom. A bowel and bladder tracking form was started. Bowel and bladder tracking is used to identify habits and patterns to develop an individualized bowel and bladder program. Review of the facility fall investigation for the fall on 02/07/18 at 12:15 A.M. revealed neurological checks (an evaluation to monitor for changes in level of consciousness) were started, the bowel and bladder tracker was initiated, and 15 minute checks by staff were to be continued. The fall risk assessment dated [DATE] revealed Resident #2 continued to be at high risk for falls. Interventions included Resident #2 was to wear gripper socks, staff would continue 15 minute checks, staff would complete bowel and bladder tracking, and send a urine specimen to determine if Resident #2 had a urinary infection. A nurse's note dated 02/10/18 at 8:30 A.M. revealed Resident #2 had fallen in the common bathroom. The nurse assisted Resident #2 on the toilet and stepped out of the bathroom, leaving her unattended. The nurse heard Resident #2 calling for help and returned to the bathroom. Resident #2 was found lying on the floor on her right side, crying and touching her left groin area. An X-ray was completed at the facility on 02/10/18 at 10:21 A.M. and revealed Resident #2 had a slightly displaced overriding [MEDICAL CONDITION] femoral neck (a [MEDICAL CONDITION]). Resident #2 was transported to the hospital on [DATE] at 1:05 P.M. The nurse's note dated 02/10/18 at 9:56 P.M. revealed Resident #2 was admitted to the hospital for a left [MEDICAL CONDITION]. Resident #2 was discharged from the facility on 02/13/18 and had not returned. Interview on 03/08/18 at 1:28 P.M. with LPN #20 revealed a lap buddy was initiated as an intervention after Resident #2 fell on [DATE] and sustained a fractured wrist. RN #23 also verified a lap buddy was ordered for Resident #2 on 02/05/18. RN #23 reviewed and verified there was no documentation of a lap buddy being used for Resident #2 according to the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the facility investigation of Resident #2's fall on 02/10/18 at 8:30 A.M. revealed staff were educated on the need to remain with residents during toileting if the resident was at risk for falls. Resident #2 was left unattended on the toilet when she fell , fracturing her hip. 2. Review of the medical record for the Resident #1 revealed an admission date of [DATE] with readmission on 10/27/17. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE], revealed Resident #1 had severe cognitive impairment, required extensive assistance of two staff for bed mobility and transfers and required extensive assistance of one staff for walking in her room. Review of the plan of care dated 01/31/18 revealed Resident #1 was at risk for falls due to gait/balance problems, psychoactive drug use, being unaware of safety needs, and incontinence. Interventions included a lap buddy and 15 minute checks. Review of the physician order [REDACTED].#1 was ordered a lap buddy to her wheelchair. Review of nurse's note from 01/09/18 at 5:43 A.M. to 01/19/18 at 11:01 P.M. revealed Resident #1 continued to get out of bed and wheelchair by herself. Resident #1 was to be checked by staff every 30 minutes during the day and every 60 minutes at night, also called 30/60 checks. The nurse's note dated 01/20/18 at 8:40 P.M. revealed Resident #1 was observed lying on her left side on the floor in the dining room with her wheelchair behind her. Resident #1 was transported to the hospital at 9:15 P.M. Review of the facility investigation of the fall on 01/20/18 revealed Resident #1 was to be checked by staff every 15 minutes with increased supervision. The nurse's note dated 01/22/18 at 10:37 P.M. revealed staff were to continue to do 30/60 checks due to Resident #1 attempting to transfer from her wheelchair without assistance. Review of the fall risk assessment dated [DATE] revealed Resident #1 was at high risk for falls. Interventions included 15 minute checks and Resident #1 to be within eye sight of staff when up in wheelchair. Interview on 03/08/18 at 4:20 P.M. with RN #23 verified Resident #1 was ordered a lap buddy to her wheelchair on 12/26/17. RN #23 verified there was no documentation of the lap buddy being in place when Resident #1 fell on [DATE]. RN #23 also verified there was no documentation of the lap buddy being used as ordered by the physician according to the January, (MONTH) and (MONTH) (YEAR) MARs and TARs. 3. Review of the medical record for Resident #3 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed Resident #3 was alert and oriented and required extensive assistance of one staff for bed mobility and transfers. The current plan of care revealed Resident #3 was at risk for falls related to gait/balance problems, history of falls, decreased strength and mobility. Interventions included Resident #3 to have appropriate footwear when ambulating or moving about in his wheelchair. Dycem (a non-slip material) was to be on his wheelchair as of 01/30/18. A nurse's note dated 02/12/18 at 3:30 P.M. revealed Resident #3 was found lying on his stomach in the dining room. Resident #3 stated his wheelchair hit the strip between the carpet and vinyl and shifted him forward out of his wheelchair. There was no documentation that the dycem was in place as ordered. Interview on 03/08/18 at 4:08 P.M. with RN #23 verified dycem was ordered on [DATE] for Resident #3 and verified there was no documentation of the dycem being in place when Resident #3 fell on [DATE]. Review of facility policy titled, Policy #RC-17.0 Falls, dated 01/01/17, revealed a resident with an increased risk for falls or had fallen will be visually checked by direct care staff as often as possible, with a goal of every 30 minutes while they are up and every 60 minutes while in bed. Staff would offer toileting to residents every two hours. If toileting played a role in the fall, a bowel and bladder assessment would be completed. For residents at high fall risk and a history of falls at least one intervention was required immediately and then additional long term interventions as appropriate. Documentation of falls should include safety measures in effect at the time of the fall. This deficiency substantiates Complaint Number OH 440.

Based on observation, record review and interview the facility failed to ensure adequate interventions, including nutritional interventions were in place to prevent Resident #49 from developing an unstageable pressure ulcer to his right heel and failed to properly assess, treat and provide nutritional interventions for Resident #5's pressure ulcer to the buttocks. This affected two residents (Resident #49 and #5) of two residents reviewed related to pressure ulcers of three residents identified by the facility to have pressure ulcers. The facility census was 38. Findings include: 1. Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A skin risk assessment, dated 08/15/12 revealed the resident was at risk for skin breakdown. Review of the comprehensive Minimum Data Set 3.0 assessment with an assessment reference date of 08/22/12 revealed the resident was non-ambulatory and required extensive assistance from two staff for bed mobility. The assessment indicated the resident required total dependence from two staff for transferring. No pressure ulcers were identified on the assessment. A plan of care related to impaired skin integrity/potential for impaired skin integrity related to decreased activity, assistance for mobility and incontinence was initiated on 08/22/12. A goal developed was for the resident's skin to be intact with no redness, infection, rash or dryness. Interventions written on the plan of care included to turn and reposition every two hours, float heels in bed, refer to dietary as needed, monitor nutritional and hydration status and inspect skin on a daily basis. Review of the resident's treatment administration records from August 2012 revealed no written documentation the resident was being turned and repositioned every two hours or that the resident's heels were being floated in bed. Review of nurse's notes, dated 08/27/12 at 5:30 P.M. revealed the resident was found to have an unstageable pressure ulcer to his right heel. The note indicated the pressure ulcer was assessed to be six centimeters by six centimeters with no depth noted. The pressure ulcer was assessed to be purple in color. The note indicated the resident's bilateral heels were elevated off the bed at that time, however there was no written indication the resident's physician was notified of the development of the unstageable pressure ulcer or any type of treatment was considered or initiated. Record review revealed the resident's plan of care was not updated to reflect the development of the unstageable pressure ulcer. Review of weekly skin assessments revealed the pressure ulcer continued to be assessed as an unstageable pressure ulcer. Weekly skin assessments from 08/28/12 through 09/17/12 revealed to float the resident's heels. On 09/17/12 (21 days after the ulcer developed) a physician order [REDACTED]. The pressure ulcer was assessed to be black to purple in color and noted to be larger than when first identified on 08/27/12. Wound tracking grids revealed the resident was seen at an outside wound clinic on this date and treatment orders were obtained for Santyl (a [MEDICATION NAME] topical agent) and also for the resident to wear Prafo boots (a specialized boot to remove pressure from the heel area). On 10/05/12 the treatment order for the Santyl was discontinued and the pressure ulcer was left open to air with no treatment in place. Review of the most current pressure ulcer assessment, dated 10/22/12 revealed the ulcer continued to be unstageable measuring 4.5 centimeters by five centimeters with no depth noted. The ulcer was assessed to be 100% black necrotic tissue. A wound care center note, also dated 10/22/12 reflected the right heel wound and noted to continue the Santyl to the ulcer daily. However, there was no evidence this treatment was being done nor had it been done since 10/05/12. On 10/30/12 at 4:23 P.M., interview with licensed practical nurse (LPN) #7 revealed she was responsible for the facility wound care. The LPN indicated she had assumed responsibility for the program in September 2012, but verified she was the unit nurse who had found the unstageable pressure ulcer to Resident #49's right heel on 08/27/12. The LPN indicated she had written the nurse's note on this date, however failed to indicate the physician had been notified of the area. The LPN verified she documented to float the resident's heels at that time. Review of the resident's plan of care and physician orders, with LPN #7 at that time verified there was no written documentation to ensure the resident's heels were being floated between 08/15/12 and 08/27/12, the date an unstageable pressure ulcer was discovered to the resident's right heel. The LPN verified the resident's plan of care was not updated to reflect the development of the unstageable pressure also. The LPN also verified the protein supplement, [MEDICATION NAME] was not initiated until 09/17/12 and the Prafo boots were ordered by the wound care center on 10/01/12. During the interview, the LPN also verified current wound care center instructions, dated 10/22/12 included orders to apply Santyl to the right heel, however that treatment was not being provided. The LPN indicated she did not agree with the wound care center and thought it would be best to have no treatment to the area since it wasn't draining and intact. However, there was no documentation to support that on-going communication or coordination of care was in place to provide optimal and the most appropriate care to the resident and the treatment of [REDACTED]. On 10/31/12 at 2:40 P.M., the unstageable pressure ulcer to Resident #49's right heel was observed. The resident was sitting in a wheelchair with a Prafo boot in place to the right foot. LPN #7 was observed to remove the Prafo boot. The resident's right heel was open to air and the entire heel area was observed to be black in color. The edges of the ulcer were observed to have some white tissue present. No drainage or odor was noted. After observing the pressure ulcer, LPN #7 reapplied the Prafo boot. Interview with the resident at that time revealed he had discomfort to the area, but mostly if he put pressure on it. When asked about the development of the pressure ulcer, the resident indicated he was aware it was a "bed sore". 2. Resident #5 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Resident #5 was admitted from the hospital. The history and physical dated dated 08/06/12 indicated Resident #5 had come in with [MEDICAL CONDITION] and was found with an incarcerated umbilical hernia that required a subcolectomy. He was on mechanical ventilation via [MEDICAL CONDITION] and was in need of non-oral feedings. The physician talked with the resident and his wife and they understood the need for peg tube placement. Resident #5 was admitted to the nursing facility with a tube feeding and the physician ordered Nevasure Renal to be administered at 40 cubic centimeters (cc's) per hour. The admission nursing assessment dated [DATE] indicated Resident #5's right and left buttocks were reddened and open, but no measurements or other description/assessment was documented. The pressure ulcer tracking sheets revealed an assessment of the left buttocks on 08/28/12 and was described as a Stage 2, a partial thickness skin loss involving epidermis, dermis or both and is superficial and presents clinically as an abrasion, blister or shallow crater, and measured 4.9 cm by 4.9 cm by 0.1 cm deep. There were no assessments for the right buttocks pressure ulcers until eight days later on 09/05/12 and these were described as Stage II's. One measured 2.9 cm by 1 cm by 0.2 cm deep and one measured 5.5 cm by 1.5 cm by 0.2 cm deep. These documents were reviewed with the wound nurse, licensed practical nurse (LPN) #7 on 10/30/12 at 1:45 P.M. She indicted these assessments were completed by the previous wound nurse. Laboratory testing on 09/04/12 revealed a low [MEDICATION NAME] level at 2.9, with normals being 3.5-5.5 grams per deciliter (g/dl). The admission dietary assessment dated [DATE] indicated Resident #5 had pressure ulcers on his buttocks. Resident #5's post-[MEDICAL TREATMENT] weight was documented on this assessment as 193 pounds. He was ordered a tube feeding which provided 1700 calories and 76 grams of protein. The section which estimated Resident #5's needs indicated he needed 2200 calories and 82-98 grams of protein. The tube feeding provided to Resident #5 did not meet his caloric or protein needs to maintain his weight and assist in tissue healing of his pressure ulcers. The dietary note on 09/18/12 stated Resident #5 has pressure areas noted on his buttocks and the [MEDICAL TREATMENT] dietician started "IDPN" for additional protein. A second note on 09/18/12 indicated Resident #5 had a post-[MEDICAL TREATMENT] weight of 183.6, approximately a ten pound loss since admission and was 4.7 %. The dietician indicated the weight loss was desirable but protein was a concern due to skin breakdown and his low [MEDICATION NAME] level. The dietician documented Resident #5's estimated needs were 2100 calories and 84 to 101 grams of protein. There was no documentation as to what "IDPN" was or how much protein it added to Resident #5's intake. Registered dietician (RD) #8 was interviewed on 10/31/12 at 11:20 A.M. She reviewed the dietary assessment she completed and verified Resident #5's tube feeding did not meet his caloric or protein needs and that his [MEDICATION NAME] level was low. She indicated the [MEDICAL TREATMENT] dietician added the IDPN, which is a protein supplement, but she did not know how much protein this added. She indicated she attempted to contact the [MEDICAL TREATMENT] dietician but had not reached her. There was no documentation of any phone calls or communication with the [MEDICAL TREATMENT] dietician. The dietary note on 09/18/12 also indicated that Resident #5's weight loss was 4.7% in 22 days since his admission. She indicated this was a "desirable" weight loss but that protein ([MEDICATION NAME]) was a concern due to his skin breakdown. There was no document to support why weight loss would be desirable for a resident who was recently hospitalized , had a colectomy, had pressure ulcers, required a tube feeding for all nutrition and was extremely medically compromised. There were no recommendations to change or increase the tube feeding to met Resident #5's needs. Review of the physician orders [REDACTED]. The physician order [REDACTED]. The treatment orders were changed on 09/05/12 and were for honey gel and [MEDICATION NAME] dressing to be applied and change every three days and as needed. On 10/31/12 at 2:10 P.M., the wound nurse, LPN #7, reviewed and verified all the dietary information including that the tube feeding did not meet Resident #5's nutritional needs and he sustained a weight loss of approximately nine pounds since admission, that there was no evidence of treatment orders for the pressure ulcers until 08/31/12 and that the acute care plan for skin on admission listed only red areas not pressure ulcers. Resident #5 was sent to the hospital on [DATE] and was admitted with a [DIAGNOSES REDACTED].