Every finding on record at Briar Hill Health Campus

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure chemicals were secured on the secured memory care unit. This had the potential to affect 11 residents (#2, #19, #46, #47, #48, #49, #50, #51, #52, #53, and #56) who the facility identified to be cognitively impaired, independently mobile and resided on the secured memory care unit. The facility census was 49.Findings include:Observations in the secured memory care on 07/13/26 at 3:14 P.M. revealed a small kitchenette that contained a working sink and unlocked cupboard underneath the sink. The cupboard under the sink contained four bottles of chemicals: one spray bottle of 3M disinfectant cleaner RCT concentrate. The 3M bottle contained a clear liquid with approximately 450 milliliters (ml) in the spray bottle. The spray bottle was the original spray bottle with safety warning intact that stated safety warning-keep out of reach of children. There was one spray bottle of ready-to-use (RTU) sanitizer. The RTU spray bottle contained a light beige colored liquid and the spray bottle was approximately less than a quarter of the bottle full. The spray bottle was the original spray bottle with a safety warning label intact that stated safety warning keep out of reach of children, and a precautionary statement hazard to humans and domestic animals. There was one spray bottle of food service sanitizer. The spray bottle was the original bottle with a safety warning to keep out of reach of children. There was one container of purple top Sani-cloth disinfectant wipes that were approximately one quarter full of wipes. The Sani-cloth container was the original container with a safety label intact that stated safety warning keep out of reach of children and required personal protection warning of when using this product wear disposable gloves. Concurrent interviews with several unknown staff stated no chemicals were supposed to be under the cupboard and they were to be locked in the a nearby closet.Interview on 07/13/26 at 3:22 P.M. with the Director of Health Services (DHS) verified the four bottles of unsecured chemicals in the cupboard underneath the sink on the secured memory care unit.The facility identified Residents #2, #19, #46, #47, #48, #49, #50, #51, #52, #53, and #56 were cognitively impaired, independently mobile, and resided on the secure unit.Review of the facility policy titled Storage Procedures reviewed 01/2025 revealed storage of cleaning supplies are stored in a janitors' closet or other areas away from food or stored off of the floor.This deficiency represents non-compliance investigated under Complaint Number 3067287.

Based on medical record review and staff interview, the facility failed to ensure resident assessments were completed timely. This affected one (#41) of two residents review for discharged resident assessments. The census was 43. Findings include: Review of the closed medical record review revealed Resident #41 was admitted on [DATE] and discharged home on 01/26/24. Diagnoses included fracture of unspecified part of neck of left femur, hypertensive chronic kidney disease, chronic kidney disease stage 4, essential (primary) hypertension, non-Hodgkin lymphoma, and unspecified osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 01/09/24, revealed the resident had an admission assessment completed. No further MDS assessments were entered. Interview on 06/18/24 at 4:37 P.M., with Licensed Practical Nurse (LPN) #559 and Corporate Registered Nurse (RN) #591 verified Resident #41 did not have a discharge MDS assessment completed.

Based on medical record review and staff interview, the facility failed to ensure an accurate resident assessment was completed for an anticoagulant medication. This affected one (#21) of thirteen residents reviewed for accurate resident assessments. The facility census was 43. Findings include: Review of the medical record revealed Resident #21 was admitted on [DATE]. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified dementia, type two diabetes mellitus without complications, major depressive disorder, anxiety disorder, and essential hypertension. Review of the Minimum Data Set (MDS) assessment, dated 05/06/24, revealed the resident was rarely understood. According to the MDS assessment one of the high-risk medications the resident was taking included anticoagulant medications. Review of physician orders dated April and May 2024 (including discontinued orders) and current orders for June 2024, revealed no anticoagulant medications had been prescribed. Interview on 06/18/24 at 4:39 P.M., with Licensed Practical Nurse (LPN) #559 and Corporate Registered Nurse (RN) #591 verified Resident #21 was not prescribed an anticoagulant medication and was documented inaccurately.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, staff interview, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), in-service record review, plan of correction review, and facility audit reviews, the facility failed to conduct adequate skin assessments and failed to implement interventions to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers as recommended by the physician. This resulted in Actual Harm when Resident #01 was discovered with multiple in-house acquired tissue injuries to the left buttock, right foot/ankle and right heel. This affected one (#01) of three residents reviewed for skin integrity. The census was 53. Findings include: Review of Resident #01's closed medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #01 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital discharge transfer form dated 06/01/22 for Resident #01 revealed a discharge from the hospital with a pressure sore to the right anterior foot that was covered by a splint. On 06/01/22 at 1:03 P.M., nurse's notes document Resident #01 arrived at facility via stretcher. Resident #01 had a tibial/fibula fracture to the right lower extremity (RLE) and is non-weight bearing. Resident #01 has a splint on her RLE. Resident #01's skin is free of any impairments. Resident #01 denied any concerns at the time. On 06/02/22, Resident #01 was assessed at risk for skin breakdown. On 06/02/22, a nursing plan of care was developed to address the resident's risk for skin breakdown. Interventions included a pressure relieving device to the chair and turning/repositioning. On 06/03/22, the orthopedic physician indicated the splint was not to be removed. On 06/11/22, a head-to-toe assessment was completed, and no new skin issues noted. Review of an orthopedic physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurse's note dated 06/16/22 at 7:24 A.M., documented Resident #01 with a pressure area to the right coccyx measuring 2 centimeters (cm) long by (x) 1.3 cm wide x 0.1 cm deep. On 06/17/22, the pressure ulcer plan of care was implemented with the following interventions: ROHO(R) cushion (pressure relieving cushion) to the chair; observe for and report signs of pain related to pressure ulcer; pressure reducing mattress; administer analgesics per physician order; treatment per physician order; obtain dietary consult; assess and record condition of the skin surrounding the pressure ulcer; weekly skin assessment, measurement, and observation of the pressure ulcer and record. Review of the treatment administration records (TAR) lacked documentation indicating the ROHO(R) cushion was applied to the chair. Further review of the record lacked documentation indicating assessment of skin integrity under the removable cast was attempted. Review of the progress notes dated 06/17/22, indicated a blister was discovered to the right foot under the removable cast. The area measured 4.5 cm x 0.2 cm. Interventions included: monitor, keep clean, dry, and intact. On 06/22/22, documentation indicated the blister as reabsorbed. No further documentation recorded skin assessments under the removable cast. Review of the skin observation detail dated 06/30/22 at 3:13 A.M., Resident #01 was noted to have a wound to the left buttock measuring 4 cm x 4 cm x less than 0.2 cm. The area was described as denuded from shearing and moisture. Wound bed was noted as red with little bleeding. Resident complained of discomfort when cleansing area. A sacral dressing was applied and to be change every 3 days and as needed (PRN). On 06/30/22 at 4:26 P.M., the physician reviewed the resident's skin breakdown and ordered the application of Allevyn foam dressing every 3 days and as needed (PRN). Also, offloading, and frequent turns/checks with a ROHO(R) cushion for the chair. Review of treatment administration records from 07/01/22 to the resident's discharge from the facility on 08/26/22 noted the ROHO(R) cushion to be recorded in place twice daily. No evidence interventions were implemented to the resident's bed including offloading and frequent turns/checks. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No interventions were documented to be implemented to address the dependent resident's pressure relief when in bed or additional interventions to promote skin integrity. Review of the orthopedic physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note recorded no open wounds proximally and a 2.0 cm x 3 cm decubitus ulcer with necrotic skin to the posterior heel. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound descriptions noted the right heel with eschar measuring 2.5 cm x 1.5 cm with pink peri wound. Additional order included: apply [MEDICATION(S)] and rewrap with abdominal dressing (ABD) applied under splint area. Apply treatment daily. Review of the nursing plan of care, dated 07/08/22, revealed a care plan was implemented to address the resident demonstrating non-compliance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included assess for need for guardian or other legal oversight as needed, monitor residents' ability to give informed consent and fluctuations in decision making, educate resident regarding physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, no attempts to implement physical or mechanical interventions to promote the resident's skin integrity were documented. Review of the progress note dated 07/31/22 at 1:28 A.M., revealed a State tested Nurse Aide notified nursing about a wound on Resident #01. Registered Nurse (RN) #202 reassessed and found a pressure wound to the right lateral ankle. Wound measured 3 cm x 1.5 cm. Wound was necrotic with eschar. No drainage or odor noted. Painful to touch. No mechanical intervention is noted in the medical record to prevent further skin breakdown. Review of the wound center documentation date of service 08/23/22 at 2:30 P.M., description of the wounds included a non-pressure chronic ulcer to the right calf with fat layer exposed; pressure ulcer to the right heel, unstageable; pressure ulcer to the left buttock and right ankle stage 3. No wound measurements were included in the wound center evaluation. Review of the wound detail reports dated 08/24/22, noted the following wounds: left buttock measured 2.5 cm x 1.8 cm x 0.2 cm with a moderate amount of serosanguineous drainage and staged as unstageable; the right calf measured 2.8 cm x 1.1 cm x 0.2 cm with moderate serosanguineous drainage and classified as a venous ulcer; the right ankle wound was classified as a venous ulcer measuring 2 cm x 1.3 cm x 0.3 cm with moderate serosanguineous drainage; and the right heel was classified as unstageable due to slough and/or eschar and necrotic tissue, with a moderate amount of serosanguineous drainage measuring 2.4 cm x 1.3 cm x 0.1 cm. Review of progress notes dated 08/24/22 at 2:07 P.M., indicated the left gluteal area noted to have deteriorated to unstageable pressure area. Resident #01 is non-compliant with laying down and turning side to side. Area now 2.5 cm x 1.8 cm x 0.2 cm with irregular shape and defined wound edges. Wound bed 25% granulation tissue and 75% adherent slough with moderate serosanguineous drainage. No additional interventions were listed in the medical record. Further review of the medical record revealed only four incidents of resident refusing care. Review of the progress note dated 06/03/22 at 1:59 P.M., per nursing assistant the resident refused to be checked and changed throughout the shift. On 06/19/22 at 11:29 A.M., resident often complained of pain this A.M., some relief from medication and re-positioning. Refuses to sit in recliner to try other interventions/propping of leg. On 08/24/22 at 2:03 A.M., nursing assistant attempted to assist the resident to bed again and resident is refusing at this time. At 3:55 A.M., staff once again attempted to lay resident down and resident once again refused nursing to lay down. Review of Physical Therapy (PT) discharge summary dated 06/02/22 through 08/25/22 revealed PT was discontinued on 08/25/22 with destination home and highest practical level achieved. The discharge location was home with support from others. Functional skills assessment noted Resident #01 bed mobility as roll right to left as substantial/maximal assistance, sit to lying as dependent, lying to sitting on side of bed as dependent. The resident's transfer sit to stand as dependent, chair to bed as dependent, toilet transfer and car transfer were dependent. Patient progress was documented as low level of mobility at evaluation and continues to require extensive assistance. However, due to progressive Multiple [CONDITION(S)], the patient's mobility will remain low. Therapist submitted for patient to have custom wheelchair at home, family education on need for two assist of person for bed mobility and Hoyer lift at home for transfers. Interview on 10/11/22 at 1:00 P.M., with wound nurse Registered Nurse (RN) #201, during review of wound documentation verified care planned interventions and physician ordered treatments were not implemented. RN #201 verified the assessments and wound documentation was very difficult to follow the resident's progress. Furthermore RN #201 was unable to provide documentation indicating Resident #01 was consistently repositioned and interventions were implemented. Review of the NPIAP guidelines dated 2014 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [CONDITION(S)], and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for [CONDITION(S)] (redness of the skin) was the first component of every skin inspection. Skin redness and tissue [CONDITION(S)] resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Inspect the skin under and around medical devices at least twice daily for the signs of pressure-related injury on the surrounding tissue. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of 08/11/22: Beginning on 08/04/22 to 08/11/22, all residents were re-assessed for risk of skin impairment development, by the nursing staff. Beginning on 08/04/12 to 08/11/22, all residents were audited to ensure physician ordered and care planned interventions for skin integrity were in place. On 08/11/22, all nurses and nursing assistants were in-serviced on how to access and look at the resident's profile for care plan interventions; square magnets on door frame for moderate or high risk for skin breakdown; new admission assessments; change in condition events - when opening a Braden scale to be completed to identify and changes related to change in condition, conducted by DON and or designee. On 09/12/22, the routine Quality Assurance Plan for Improvement (QAPI) plan was reviewed related to decreasing the inhouse development of wounds to ensure all updated Braden scales were completed on all residents, education to nursing staff, magnets on doors for at risk residents, and specialized interventions in place for applicable residents. Review of September and October 2022 audits for wound management revealed audits were completed to ensure skin impairment interventions and treatments were in place and being completed. Review of two additional resident records (#02 and #03) revealed no concern with wound management and preventative skin interventions in place. This deficiency substantiates Complaint Number OH 181.

Based on observation, staff interview, and review of a facility policy, the facility failed to properly store foods and maintain the kitchen in a sanitary manner. This affected all 49 residents in the facility who the facility identified as receiving food from the kitchen. Findings include: Observation of the facility kitchen on 12/19/21 at 9:45 A.M. revealed pre-sliced deli meats stored in a plastic bin on the bottom shelf of the walk in refrigerator. Inside the plastic bin revealed opened bags of bologna, corned beef, pepperoni, ham, and turkey which were placed inside plastic zip sealed bags inside the plastic bin. The bag of ham had a slimy liquid covering the bag. Further inspection revealed a slimy liquid covered all the bags of meat inside the plastic bin and a bag of sliced bologna was noted to not be fully sealed and leaking the slimy liquid. Observation of a food label sticker placed on the bag of bologna revealed a used by date of 11/28/21. A second bag of bologna inside the plastic bin had a food label sticker with a used by date of 12/13/21. Interview on 12/19/21 at 9:49 A.M. with Director of Food Services (DFS) #531 stated the used by dates should be seven days from when the food item was opened. DFS #531 verified the bologna was outside the used by dates. DFS #531 also confirmed the slimy liquid all over each bag of pre-sliced meat and threw the meat away. Additional observation of the walk in refrigerator on 12/19/21 at 9:52 A.M., after hand washing was completed, revealed a green metal rack which had salad dressings stored on the top shelf. Closer inspection of the metal grates and the underside of the shelf revealed a grayish-white fuzzy growth along the length of the metal shelf and between the grates directing under the bottles of salad dressing. Located under the top metal shelf were open boxes of fresh fruits and vegetables. Observation of the walk in freezer on 12/19/21 at 9:56 A.M. revealed a bag of opened French fries which were not properly sealed and exposed to the elements in the freezer, five breaded chicken tenders that were laying loose inside a plastic bin with other sealed meats, and a breaded meat patty that was also laying loose inside a separate plastic bin which contained other meats in the sealed packages. Interview on 12/19/21 at 10:02 A.M. with DFS #531 stated she was not sure when the last time the walk in refrigerator was deep cleaned but estimated it was around a month ago. DFS #531 verified the grayish-white fuzzy growth on the length of the top shelf and stated it was most likely mold growth from spilled food items. DFS #531 then observed the open bag of French fries and the two plastic bins in the freezer that contained the loose breaded meat tenders and patty and confirmed they should have been secured and stored in containers of some kind and not left open to air. Review of a facility policy titled Food Labeling and Dating Policy, dated 03/18/19, revealed any food product removed from its original container, has a broken seal, or has been processed in any way must have a label. The food label must have the item name, the date and time the food was labeled, the use by date, initials of the person labeling the item, and securely cover the food item.

Based on observation, medical record review, staff and resident interview, and review of facility policies, the facility failed to assess a resident to determine their appropriateness for self-administering medications. This affected one (#42) of five residents reviewed for unnecessary medications. The facility identified no current residents assessed as able to self-administer their medications. The census was 49. Findings include: Review of Resident #42's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed Minimum Data Set (MDS) assessment, dated 12/02/21, revealed Resident #42 had intact cognition. Review of Resident #42's comprehensive care plan, last reviewed on 10/18/21, revealed no care plan for Resident #42 to self-administer medications. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no directions in the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's medical record revealed no documented evidence of Resident #42 being assessed by the interdisciplinary team to determine if she was clinically able to self-administer her [MEDICATION(S)] eye drops. Observation on 12/19/21 at 11:08 A.M. revealed Resident #42 sitting in her room at the side of the bed. Further observation revealed two boxes of [MEDICATION(S)] eye drops on her over the bed table with one box opened and the other box sealed. Interview with Resident #42 at this time stated she was having dry eyes and the physician recently ordered the eye drops to treat her condition. Resident #42 verified she was administering the eye drops by herself. Subsequent observations on 12/19/21 at 4:38 P.M., on 12/20/21 at 8:38 A.M., at 10:28 A.M., and at 12:21 P.M. revealed Resident #42 remained with both boxes of [MEDICATION(S)] eye drops on her over the bed table in her room. Interview on 12/20/21 at 10:29 A.M. with Resident #42 stated she had been administering the [MEDICATION(S)] eye drops four times each day with doses given in the morning, before noon, in the afternoon, and at bedtime. Resident #42 stated she told the nurses when she gave herself the eye drops but did not document the medication being administered any where. Resident #42 stated no one talked to her about how often she should administer it, where she should store the medication, or any side effects of taking the medication. Interview on 12/20/21 at 1:13 P.M. with Licensed Practical Nurse (LPN) #536 verified Resident #42 was self-administering her [MEDICATION(S)] eye drops but was not aware exactly how often Resident #42 was administering the eye drops. LPN #536 stated she knew Resident #42 was administering the eye drops at least twice daily because the nurses administered different eye drops to Resident #42 twice each day and Resident #42 would indicate she gave herself the [MEDICATION(S)] eye drops at that time. LPN #536 was not aware if Resident #42 was ever assessed to determine if she was able to self-administer medications. Observation on 12/20/21 at 1:30 P.M. of Resident #42's bedroom, with LPN #536, revealed both boxes of [MEDICATION(S)] eye drops remained on her over the bed table. One box was opened and the other remained sealed. LPN #536 verified the [MEDICATION(S)] eye drops on Resident #42's over the bed table were the eye drops she was self-administering. Interview on 12/20/21 at 1:37 P.M. with Director of Nursing (DON) stated the facility had an assessment they completed with any resident who was self-administering medications but she was not aware of any resident in the nursing home who were currently self-administering medications. DON stated the resident would need to be assessed on how to read and follow medication instructions and if they were physically and mentally able to administer the medication. DON verified Resident #42 was not assessed for self-administration of her [MEDICATION(S)] eye drops. Review of a facility policy titled Medication Administration General Guidelines, revised November 2018, revealed residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Review of a facility policy titled Guidelines for Self-Administration of Medications, dated 05/22/18, revealed residents requesting to self-medicate or has self-medication as part of their plan of care shall be assessed using the facility's self administration of medication assessment within the electronic health record. The resident and/or family/responsible party will be informed of the results of the assessment and whether the resident has been determined to safely self-administer medications. The medication will be kept in a locked drawer in the resident's room. The resident may be supplied with a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A self-administration care plan will be initiated and updated as indicated.

Based on resident interview, observation, staff interview, and review of facility policy, the facility failed to maintain a clean and sanitary environment. This affected two (#32 and #44) of 24 residents reviewed for environment. The facility census was 49. Findings include: Review of the medical record for Resident #32 revealed ad admitted [DATE]. Diagnoses included COVID-19, cerebral infarction (stroke), type II diabetes, [CONDITION(S)] ([CONDITION(S)]), and major depressive disorder. Additional review of the quarterly Minimum Data Set (MDS) assessment, dated 11/26/21, revealed Resident #32 was cognitively intact, required supervision with toilet use, and was always continent of bowel and bladder. Review of the medical record for Resident #44 revealed an admitted [DATE]. Diagnoses included wedge compression fracture of the second and fourth lumbar vertebra, heart disease, end stage renal disease, type II diabetes, difficulty walking, lack of coordination, and muscle weakness. Additional review of the quarterly MDS assessment, dated 11/27/21, revealed Resident #44 was severely cognitively impaired, required extensive assistance with toilet use, was occasionally incontinent of bladder, and always continent of bowel. Interview on 12/19/21 at 10:58 A.M. of Resident #32 revealed her bathroom had not been cleaned yet today. Resident #32 stated she was able to use the bathroom without assistance, but the toilet was always dirty and had something smeared all over it. Resident #32 stated she shared the bathroom with Resident #44. Observation of Resident #32's bathroom at the time of the interview revealed a small garbage can sitting to the left of the toilet. The garbage can was full. There was an unknown reddish-brown substance smeared on the back of the toilet seat and a quarter sized black spot dried on interior of the toilet bowl. Observations on 12/19/21 from 1:30 P.M. through 4:30 P.M. revealed the garbage in Resident #32's bathroom had been emptied, but the toilet had not been cleaned. Observation on 12/20/21 at 9:50 A.M. of Resident #32's bathroom revealed the toilet continued to have a reddish-brown substance smeared on the back of the toilet seat and the quarter sized dried black substance on the interior of the toilet remained. Interview at the time of the observation on 12/20/21 at 9:50 A.M. with Environmental Services Associate (ESA) #568 revealed resident rooms were to be cleaned daily, including the bathroom. ESA #568 stated staff did not have checklists and just knew what needed to be done based on daily assignment area. ESA #568 verified there was an unknown substance on Resident #32's toilet. ESA #568 stated staff were aware the toilet was frequently dirty and she tried to check Resident #32's bathroom each day before she left at the end of her shift. ESA #568 verified both Resident #32 and Resident #44 utilized that bathroom. Interview on 12/21/21 at 6:56 A.M. with Licensed Practical Nurse (LPN) #564 revealed Resident #32 was independent with toilet use, but Resident #44 required staff assistance with using the restroom. Review of facility policy titled Room Cleaning - Health Center Rooms, revised 06/23/20, revealed resident rooms were cleaned daily, including cleaning and disinfecting bathrooms.

Based on observation, medical record review, and staff interview, the facility failed to monitor for [CONDITION(S)] and ensure non-pharmaceutical interventions were implemented to minimize the occurrence of lower extremity [CONDITION(S)] for one (#36) of 24 residents reviewed for timely care and treatment. The facility census was 49. Findings include: Review of the medical record for Resident #36 revealed an admission to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most current Minimum Data Set (MDS) assessment, dated 11/25/21, identified the resident with moderately impaired cognition, requires staff supervision for the completion of activities of daily living, utilizes a wheel chair for mobility, frequently incontinent of bladder, continent of bowel, and receives a diuretic medication daily. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/13/21 the physician ordered the diuretic [MEDICATION(S)] 20 mg three times daily. Review of plan of care implemented 03/18/20 addressed the resident's administration of a diuretic medication. On 11/27/21 the plan of care was reviewed and revised with interventions including: observe cardiovascular system and fluid status to determine effectiveness of diuretic therapy (e.g., [CONDITION(S)], jugular vein distention, mental confusion, shortness of breath, abnormal breath sounds, abnormal heart sounds), administer medications in accordance with physician orders, observe and report effectiveness as needed. There were no interventions to prevent/decrease [CONDITION(S)] other than the diuretic use. Review of the nursing progress notes did not revealed Resident #36 was being assessed for the presence of [CONDITION(S)], or was experiencing any [CONDITION(S)]. Observation on 12/19/21 at 10:17 A.M. revealed Resident #36 in his room seated in a wheelchair with his feet to the floor. Interview at this time, Resident #36 asked What are they doing about the swelling in my feet and legs? He then lifted his pant legs exposing the bilateral lower extremities. The resident's sport socks were constricting both ankles with approximately 3+ [CONDITION(S)] to the bilateral lower extremities. including the lower legs/calves. Interview on 12/20/21 at 10:55 A.M., Licensed Practical Nurse (LPN) #570 revealed no knowledge Resident #36 had bilateral lower extremity [CONDITION(S)]. Observation with LPN #570 at the time of the interview noted LPN #570 to assess Resident #36 with 3+ [CONDITION(S)] to both lower extremities extending up from both feet to the lower legs. LPN#570 confirmed there was no information contained in the medical record documenting Resident #36 was being assessed for any [CONDITION(S)] and verified no interventions were in place to prevent or decrease any [CONDITION(S)]. Interview on 12/20/21 at 11:09 A.M. the Director of Nursing verified Resident #36 had no additional interventions in place to address bilateral lower extremity [CONDITION(S)] other than diuretic medications.

Based on observation, medical record review, resident interview, and staff interview, the facility failed to follow up with a physician for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 49. Findings include: Review of the record for Resident #24 revealed an admission to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 11/15/21, Resident #24 was alert, able to make needs known, dependent on staff for the completion of activities of daily living, and at risk for skin breakdown with no concerns listed. Review of a physician clinical note dated 12/01/21 documented Resident #24 with multiple toenails with fungal infection. The clinical note lacked documentation implementing a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 12/19/21 at 9:59 A.M., Resident #24 stated her physician discovered toe nail fungus to both great toes and no treatment has been implemented. The resident further stated Having fungus on my body is disgusting. Resident #24 stated she wanted the condition resolved. Observation on 12/20/21 at 7:46 A.M. Resident #24 was noted in bed with State tested Nurse Aide (STNA) #575 providing morning hygiene. Resident #24's feet were exposed with her bilateral great toenails noted to have the presence of a yellow substance. Interview with STNA #575 at the time of the observation verified the presence of the yellow substance. Interview on 12/20/21 at 8:05 A.M., STNA #508 revealed Resident #24's toe condition was reported to a nurse. Interview on 12/20/21 at 10:45 A.M., Licensed Practical Nurse (LPN) #570 revealed she was unaware Resident #24 was discovered with toenail fungus and confirmed no treatment had been initiated. Interview on 12/20/21 at 1:58 P.M., the Director of Nursing (DON) confirmed Resident #24 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON verified nursing did not follow-up to obtain a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on medical record review, observation, staff interview, and review of Safety Data Sheet, the facility failed to ensure hazardous chemicals on the 100-Hall of the facility were secured. This had the potential to affect one resident (#251) residing on the 100-Hall, and identified by the facility as being cognitively impaired and independently mobile. The facility census was 49. Findings include: Review of the medical record revealed Resident #251 was admitted on [DATE]. Diagnoses included COVID-19, altered mental status, dementia with behavioral disturbance, and [CONDITION(S)] disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 12/13/21, revealed Resident #251 was severely cognitively impaired. Observation on 12/19/21 at 10:11 A.M. of the soiled linen room located next to the shower room on the 100-Hall revealed the door was not locked. Inside the soiled linen room was a cabinet hanging on the wall. A sign posted on the cabinet stated not to leave the key in the lock. Further observation revealed the cabinet was not locked and a key was hanging on the side of the cabinet. Inside the unlocked cabinet were bottles of disinfectant cleaner approximately half-full , one bottle of deodorizer approximately three-quarter full , and three full eight ounce bottles of personal cleanser. Interview on 12/19/21 at 10:38 A.M. with Life Enrichment Director (LED) #549 verified both the door to the soiled linen closet and the cabinet inside of the closet were unlocked. LED #549 locked the cabinet, verified it was supposed to be locked and she would remind the staff of this. Observations on 12/20/21 from 8:10 A.M. through 9:50 A.M. of the soiled linen closet on the 100-Hall revealed the door to the soiled linen closet and the cabinet holding the chemicals in the closet was unlocked. Interview on 12/20/21 at 9:50 A.M. with Environmental Services Associate (ESA) #568 revealed the door to the soiled linen closet did not have a lock. ESA #568 verified the cabinet inside of the soiled linen closet was unlocked and held chemicals that were accessible to residents. Interview on 12/20/21 at 9:55 A.M. with Licensed Practical Nurse (LPN) #536 revealed Resident #251 was a new admission to the facility from the assisted living. LPN #536 stated Resident #256 moved to the facility due to increased confusion and forgetfulness. Review of the Safety Data Sheet, issue date 01/11/18, for the disinfectant cleaner revealed the disinfectant was harmful if swallowed and caused severe skin [CONDITION(S)] and eye damage. Additional review revealed the disinfectant should be kept in locked storage. Review of the Safety Data Sheet, Revision E, for the personal cleanser revealed the cleanser was harmful if swallowed, caused serious eye irritation and damage. Review of the Safety Data Sheet, undated, for the deodorizer, revealed the deodorizer caused serious eye damage or eye irritation. The facility identified Resident #251 to be the only resident on the 100-Hall who was independently mobile and had cognitive impairment.

Based on review of the lunch menu, observations, and staff interview, the facility failed to ensure meals were served at an appetizing and appropriate temperature. This had the potential to affect fifteen (#1, #2, #5, #6, #7, #8, #10, #11, #14, #16, #17, #25, #29, #32, #34) residents who received meal trays in their rooms. The facility census was 49. Findings include: Review of the lunch menu for 10/27/21, revealed the main entrée included roasted turkey, au gratin potatoes, zucchini red pepper medley and banana cream pie. Observation on 10/27/21 at 12:50 P.M., of the meal test tray, revealed the turkey and the au gratin potatoes tempted at 88 degrees Fahrenheit (F). The cooked zucchini was not able to provide an accurate temperature. The turkey, au gratin potatoes and zucchini were barely warm to the touch. Interview on 10/27/21 at 12:51 P.M. with Cook #300, verified the hot foods were not tempting at a preferred temperature. This deficiency substantiates Complaint Number OH 787.

Based on medical record review, observation, staff interview, and facility policy guidelines for COVID-19, the facility failed to ensure interventions to contain and prevent the spread of COVID-19 infections were consistently implemented. This had the potential to affect all 46 residents residing in the facility. Finding include: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's physician orders [REDACTED]. The order indicated isolation was to be open ended without a date for discontinuation. The resident attended outside [MEDICAL TREATMENT] treatments every Monday, Wednesday and Friday. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's physician orders [REDACTED]. The order was to be discontinued on 07/10/20. A second physician order [REDACTED]. The order was to be discontinued on 07/11/20. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/29/20 the physician ordered Contact/Droplet infection control isolation, and for the resident to stay in the room with no roommate. All therapy, meals, activities and services were to be provided in the room. The order was set to be discontinued on 07/13/20. On 07/08/20 at 6:15 A.M. observation with the Administrator revealed Resident #4 and Resident #5 were in isolation sharing a semi-private room. The two residents also shared a bathroom with Resident #6. The Administrator stated the facility policy indicated Resident #4 would remain in isolation continuously due to exposure for potential COVID-19 at the outside [MEDICAL TREATMENT] center. Residents #5 and #6 were in isolation due to being new admissions to the facility and policy requiring new admissions was to quarantine for 14 days following admission. Observation and interview at 6:37 A.M. on 07/08/20 with State tested Nurse Aide (STNA) #22 revealed she had just assisted Resident #6 in the bathroom. STNA #22 confirmed no cleansing of the restroom was completed between Resident #4, #5, or #6, and all three residents used the bathroom. Review of the facility COVID-19 policy titled, Resident Essential and Medically Necessary Appointment, dated 06/18/20 revealed residents that routinely leave the facility for medically necessary appointments such as [MEDICAL TREATMENT] are to be placed on Contact/Droplet precautions and returned to their private room. Interview on 07/08/20 at 6:30 A.M. with the Administrator and Director of Nursing (DON) verified according to facility policy Resident #4 could potentially cross-contaminate Resident #5 and Resident #6 requiring extended time in isolation or exposure to COVID-19. 2. Observation on 07/08/20 at 7:10 A.M. revealed the Director of Food Services (DFS) #1 was at the time clock room located in the central core of the facility. DFS #1 then proceeded toward the front entry door/lobby of the facility where COVID-19 employee screening was set up. The DFS had been walking among two residents seated in the lobby and various staff. DFS #1 was then screened by the Administrator, and proceeded to his office. On 07/08/20 at 7:15 A.M. interview with DFS #1 revealed he entered the designated entry door in the front lobby and no staff was available to screen him so he proceeded to the time clock and signed in for work. Then he went back to the screening location to be screened. Review of the facility COVID-19 policy, revised 07/06/20 revealed, Employees are to be screened and a temperature is to be obtained by the screener upon entry to the facility. A temperature equal to or greater than 100.0 degrees Fahrenheit (F) is an automatic denial of entry. An employee is advised to see a doctor for testing and treatment.

Based on observation, record review, resident interview, staff interview, and family interview, the facility failed to preserve the dignity of one resident by having her use a bedside commode instead of providing her assistance to use the toilet in the bathroom which would provide privacy. This affected one (Resident #7) of one resident reviewed for resident rights. The census was 45. Findings include: Review of the medical record revealed Resident #7 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care for Resident #7 revealed the resident was at risk for falling related to a history of falls and decline in her Activity of Daily Living (ADL)'s. Her goal was to remain free from falls with major injury. Her interventions included the resident required two staff assistance with transfers and to encourage the commode during bedtime care. Review of the Individual Plan Report for Resident #7 for ADL's from Matrix Care which was what the aides used to assist residents, revealed she used a walker and required one to two assistance with ADL's. Fall interventions included to use the commode for toileting for safety. Review of progress notes for Resident #7 dated 03/31/18 at 11:52 A.M. which was an interdisciplinary team note revealed the resident tends to show signs of weakness with ambulating to the restroom. When resident was returning to the bed, the resident lost balance and was lowered to the floor. Intervention was to have the resident use the commode due to increased weakness and balance concerns. Interview with spouse of Resident #7 of 07/08/19 at 9:26 A.M., revealed she was not able to use the toilet in her room because there was a male resident in the adjoining room who uses it so she had to use a bed side commode. Observation of toileting on 07/09/19 at 11:59 P.M., with Certified Resident Care Associate (CRCA) (#400, #401) in the room of Resident #7 for toileting before lunch was completed. They used a two-assistance transfer with a gait belt to the commode. Resident #7 was in her wheelchair in her room, the bedside commode was by the curtain which was pulled. Resident pulled up using the walker and moved her feet slightly to aide with the transfer. Interview with CRCA #400 on 07/10/19 at 11:17 A.M. revealed Resident #7 had not walked to the bathroom for about a year and she was pivoted to the bedside commode unless she was having a shower then they take her to the shower room toilet but never use the toilet in her room. Interview with CRCA# 401 on 07/09/19 at 12:10 P.M., verified they do not take her into the bathroom because they use the commode with her all the time. She stated the resident can't use the regular toilet due to it being used by the male resident in the adjoining room. Observation on 07/09/19 at 1:30 P.M., of Resident #7 in therapy room revealed she was on the bike machine using her arms and legs. Interview with Director of Therapy #500 on 07/09/29 at 1:30 P.M., revealed Resident #7 does work with the therapist and uses the toilet in the therapy room. Interview with Resident #7 on 07/11/19 at 10:30 A.M. revealed she does not like using the bedside commode due to it seems very public and she expressed she was a private person. She would rather go into a toilet with a door for privacy. She likes her room and does not want to move but just wants to use the bathroom for toileting.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to provide a resident with a special shoe accommodation. This affected one Resident (#37) of three residents reviewed for accommodations. The facility census was 45. Findings include: Review of Resident #37's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED].#37 to be fitted for diabetic shoes. Review of the progress notes dated 12/12/18 at 11:18 A.M., revealed notification had been made to a shoe company initiating the process of retrieving diabetic specialty shoes for Resident #37. Review of Resident #37's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be dependent on staff for mobility and transfers. Interview and observation on 07/08/19 at 10:08 A.M., with Resident #37 revealed the resident reported she was waiting on specially ordered shoes that were to be of a wider width to accommodate her bunions. The resident stated the shoes were ordered approximately four months ago but had not received the shoes as to date. Observation at this time revealed the resident did not have diabetic specialty shoes in place and was wearing house slippers. Resident #37 did confirm the availability of tennis shoes but stated they were tight fitting across her toes. Interview on 07/09/19 at 10:43 A.M., with Social Services Staff (SSS) #100 confirmed Resident #37 had informed staff that she had been measured for diabetic specialty shoes. SSS #100 revealed the resident had been seen by the podiatrist at the facility but was not aware of any shoes being ordered. Interview on 07/09/19 at 2:40 P.M., with Registered Nurse (RN) #200 confirmed awareness of Resident #37 being fitted for specialty shoes but was unaware of the date in which this occurred. Review of the progress notes dated 07/09/19 at 2:57 P.M., revealed SSS #100 notified the family and resident regarding the cost for private payment of the specialty shoes. Interview on 07/09/19 at 3:15 P.M., with SSS #100 confirmed Resident #37 had been fitted for specialty diabetic shoes in (MONTH) (YEAR) and that she had forgotten about it. SSS #100 revealed calling the shoe company on 07/09/19 to inquire about the specialty shoes and was advised Resident #37's insurance required prior authorization and had denied the claim for the shoes. Interview on 07/10/19 at 2:30 P.M. with SSS #100 revealed a fax had been sent to the medical director of the facility at a number that was not the facility's fax number on 12/30/18 regarding the shoe company not being in Resident #37's insurance provider network.

Based on medical record review and staff interview, the facility failed to ensure a resident with a serious mental health disorder was referred for a Preadmission Screening and Resident Review (PASARR) level two upon a significant change in status. This affected one (Resident #43) of two residents reviewed for PASARR concerns. The facility census was 45. Findings include: Review of Resident #43's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's most recent PASARR dated 10/12/16 revealed the resident had no indications of a serious mental illness or a developmental disability and a level two screen had not been completed. Review of the resident's most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was not currently considered by the state level two PASARR process to have a serious mental illness and/or intellectual disability or a related condition. Continued review of Resident #43's medical record revealed the resident was admitted for psychiatric hospitalization s on 09/29/17, 03/07/18, and 04/13/18. Interview with Social Services Director (SSD) #236 on 06/05/18 at 2:20 P.M. verified Resident #43 should have received a PASARR level two screen due to a significant change in status of three psychiatric hospitalization s.

Based on observation, medical record review and staff interview, the facility failed to ensure a contracture prevention device was being used as ordered for a dependant resident. This affected one (Resident #30) of one reviewed for Mobility/Range of Motion. The facility identified two residents with contractures. The facility census was 45. Findings include: Medical record review of Resident #30 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review for Resident #30 revealed the physicians order dated 01/05/17 , Ensure that padded handroll or a wash cloth is in right hand every shift. Three times a day. Review of the Treatment Administration Record (TAR) for Resident #30 revealed the daily treatment to wash the right hand with soap and water, provide range of motion and place a new wash cloth or padded hand roll in that hand after cleansing. Review of the TAR for previous 30 days (to include dates of observations) revealed no documentation of resident behavior issues or noncompliance with treatment. Review of the nursing progress notes for previous 30 days (to include dates of observations) revealed no documentation of resident behavior issues or noncompliance in regards to use of the hand roll. Review of the most current annual Minimum Data Set (MDS) assessment, dated 04/20/18, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The annual assessment indicated Resident #30 had limited range of motion (ROM) to the upper extremity. Additional review of the residents comprehensive history and [DIAGNOSES REDACTED]. Observations of Resident #30 were conducted on 06/04/18 at 9:33 A.M., 10:07 A.M., 12:32 P.M., and 3:18 P.M. Observations of Resident #30 were also conducted on 06/05/18 at 8:23 A.M. and 1:35 P.M. Additional random observations were made periodically on 06/04/18, 06/05/18 and throughout the survey dates of 06/06/18 and 06/07/18. The resident was most frequently observed resting in bed watching television. On one occasion, Resident #30 was up in the wheelchair, watching others in the hallway. Resident #30 was alert, demonstrated some [MEDICAL CONDITION], and was able to follow directions. A right hand contracture was noted. On several occasions the resident was asked to open the right hand. Resident #30 was able to independently move the fingers minimally and slightly open the right hand unaided. At no time was the resident observed to have a soft splint or rolled wash cloth in place to the right hand. At no time was a displaced wash cloth noted in or around the bed linens during observations. Observation and interview with Registered Nurse (RN ) #232 on 06/05/18 at 1:49 P.M. verified Resident #30 was to have a soft hand roll or wash cloth in place to the right hand. RN #232 observed and verified the assistive device was not in place as ordered. No displaced hand roll was found in the bed/linens. The facility had no policy regarding the use of hand rolls for contracture prevention.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure a resident received a mechanically altered diet as ordered. This affected one (Resident #40) of two residents reviewed for nutrition. The facility identified eight residents on mechanically altered diets. The facility census was 45. Findings include: Review of Resident #40's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required supervision with setup for eating. The resident had obvious or likely cavity or broken natural teeth. Review of the resident's dietary order dated 05/02/18 revealed the resident was ordered a regular diet, staff to cut up foods. Review of the resident's nutrition progress note dated 06/06/18 revealed the resident's weight was trending down, but was not significant. The resident was to receive a regular diet, encourage to use maroon cups, and staff to cut up foods. The resident was missing some teeth, but denied chewing or swallowing issues on current diet. Observation of the resident on 06/06/18 at 5:47 P.M. revealed the resident in her room eating dinner. She was served mashed potatoes, mixed beans, and a piece of turkey. The turkey was not cut up and the resident was not eating it. Interview and observation with the Director of Nursing (DON) on 06/06/18 at 5:50 P.M. verified the resident's meat entrée was not cut up by staff per her dietary order. Review of a facility policy titled Resident Dining and Nutrition Preferences dated 11/22/17 revealed the individual resident's food plan was to meet his or her nutritional needs.

Based on observation, medical record review, staff interview and policy review, the facility failed to ensure appropriate pharmacy monitoring and justification for use of an antibiotic on a resident. This affected one (Resident #42) of five residents reviewed for unnecessary medications. The facility census was 45. Findings include: Medical record review for Resident #42 revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] to 04/12/18 for pneumonia, and returned to the facility. Medical record review revealed the physicians order dated 04/26/18 for [MEDICATION NAME] (antibiotic) 100 milligrams (mg) daily [MEDICATION NAME] (preventative) use for urinary tract infections (UTI's). The order gave no ending date for use of the antibiotic. The order end date was indicated as, Open ended. Medical record review revealed the pharmacy did monthly medication reviews as required. The pharmacy made periodic recommendations to the physician regarding [MEDICAL CONDITION] and other medications. However, the pharmacy failed to recognize/question/make recommendations to the physician regarding the continued use of an antibiotic with no stop date indicated. Observation and interview with Resident #42 was conducted on 06/06/18 at 11:22 A.M. The resident was resting in bed watching television. Interview revealed Resident #42 to be alert, oriented, somewhat forgetful and pleasant. The resident was aware of being on a blood thinning medication, water pill and a medication for mood. Resident #42 laughed and stated, My daughter takes care of deciding what medications I am on. Staff interview with Licensed Practical Nurse (LPN) #238 on 06/06/18 at 6:00 P.M. revealed Resident #42's Medication Administration Record [REDACTED]. daily. During interview, LPN #238 verified the medication was ordered as preventative against UTI's and no stop date was indicated. Staff interview with the Infection Control Nurse (LPN #237) on 06/07/18 at 10:17 A.M. revealed Resident #42 did not have an active urinary tract infection. LPN #237 verified the resident was on [MEDICATION NAME] (an antibiotic) as [MEDICATION NAME] use for UTI's. During the interview, LPN #237 reported the daughter of Resident #42 suggested the medication and the physician ordered it. LPN #237 verified use of the antibiotic on Resident #42 did not meet McGreer's criteria for antibiotic use (standard adopted for use by the facilities antibiotic stewardship program). In addition, the Infection Control Nurse (LPN #237) reported they (the facility) did not track/monitor residents on [MEDICATION NAME] antibiotics. Review of the facility policy titled, Antibiotic Stewardship, dated as effective 11/10/17 revealed the procedure to include: #6. Pharmacy provider will assist in review of all antibiotic usage for appropriateness.

Based on review of facility infection tracking logs, staff interview, and review of a facility policy, the facility failed to ensure resident's receiving [MEDICATION NAME] antibiotics were monitored as required for implementation of the Antibiotic Stewardship program. This affected one (Resident #42) of five residents reviewed for unnecessary medications. The facility identified three residents (#10, #35, and #42) on [MEDICATION NAME] antibiotics. The facility census was 45. Findings include: 1. Medical record review for Resident #42 revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] to 04/12/18 for pneumonia, and returned to the facility. Medical record review revealed the physicians order dated 04/26/18 for [MEDICATION NAME] (antibiotic) 100 milligrams (mg) daily [MEDICATION NAME] (preventative) use for urinary tract infections (UTI's). The order gave no ending date for use of the antibiotic. The order end date was indicated as, Open ended. Medical record review revealed the pharmacy did monthly medication reviews as required. The pharmacy made periodic recommendations to the physician regarding [MEDICAL CONDITION] and other medications. However, the pharmacy failed to recognize/question/make recommendations to the physician regarding the continued use of an antibiotic with no stop date indicated. Observation and interview with Resident #42 was conducted on 06/06/18 at 11:22 A.M. The resident was resting in bed watching television. Interview revealed Resident #42 to be alert, oriented, somewhat forgetful and pleasant. The resident was aware of being on a blood thinning medication, water pill and a medication for mood. Resident #42 laughed and stated, My daughter takes care of deciding what medications I am on. Staff interview with Licensed Practical Nurse (LPN) #238 on 06/06/18 at 6:00 P.M. revealed Resident #42's Medication Administration Record [REDACTED]. daily. During interview, LPN #238 verified the medication was ordered as preventative against UTI's and no stop date was indicated. Staff interview with the Infection Control Nurse (LPN #237) on 06/07/18 at 10:17 A.M. revealed Resident #42 did not have an active urinary tract infection. LPN #237 verified the resident was on [MEDICATION NAME] (an antibiotic) as [MEDICATION NAME] use for UTI's. During the interview, LPN #237 reported the daughter of Resident #42 suggested the medication and the physician ordered it. LPN #237 verified use of the antibiotic on Resident #42 did not meet McGeer's criteria for antibiotic use (standard adopted for use by the facilities antibiotic stewardship program). In addition, the Infection Control Nurse (LPN #237) reported they (the facility) did not track/monitor residents on [MEDICATION NAME] antibiotics. Review of the facility policy titled, Antibiotic Stewardship, dated as effective 11/10/17 revealed the procedure to include: #4. Report on number of antibiotic prescribed (e.g., days of therapy), per prescriber, and the number of residents treated each month. #5. Include a separate report for the number of residents on antibiotics that did not meet criteria (McGeer Criteria) for active infection. #6. Pharmacy provider will assist in review of all antibiotic usage for appropriateness. Further review of a facility policy titled Antibiotic Stewardship dated 11/10/17 revealed the purpose of the policy was to encompass a facility wide system to monitor the use of antibiotics. Procedures included reviewing infections and monitoring antibiotic usage patterns. A separate report for the number of residents on antibiotics that did not meet criteria for active infections was to be included. Education for prescribing practitioners and nursing staff on antibiotic use may be verbal, written or online.

Based on observations, review of the facility laundry log and task list and staff interview, the facility failed to ensure the laundry room was free from a heavy build up of lint and dust around the dryers, ceiling vents and fans. This had the potential to affect 42 of 42 residents who reside in the facility. Findings include: Observations on 04/13/17 at 9:37 A.M., during a tour of the laundry room, revealed a heavy build up dust and lint behind the facility's two commercial dryers. In addition, excessive dust and lint was observed behind a table positioned next to one of the two dryers, and along the wall where the dryers and table were positioned. Interview at the time of the tour on 04/13/17 with Environmental Health Associate #100, revealed the lint filters on the two commercial dryers were checked hourly each day. She stated the dryers were cleaned monthly by the Director of Plant Operations who cleans in and around the machines. Environmental Health Associate #100 confirmed the presence of the excessive amount of lint and dust behind the dryers, behind the table, along the wall, in the ceiling vent and ceiling fan, and in the floor fan. Further observations on 04/13/17 at 11:42 A.M., revealed a ceiling vent and ceiling fan located above the dryers, each contained an excessive amount of dust. In addition, a floor fan positioned near the washers and dryers, and facing the center of the laundry room, was observed to have a build-up of dust. Interview with Director of Plant Operations #300 and Director of Environmental Services #500 on 04/13/17 at 11:42 A.M., confirmed an excessive amount of dust and lint had been present prior to its removal after the initial observation. They also verified the ceiling vent and ceiling fan above the dryers, and the floor fan facing the center of the room, still contained excessive dust. Further interview with Director of Plant Operations #300 during this second observation, revealed he cleans in and around the two dryers once a month. He stated he takes the dryers apart and cleans and vacuums dirt and debris including excess lint. Director of Plant Operations #300 stated he most recently cleaned around the dryers and in the ceiling vent and ceiling fan during the second week of March 2017, but didn't include the exact date on the tracking log. Review of a log attached to one of the dryers titled, Dryer Inspection, was signed by Director of Plant Operations #300 for January, February and March 2017. Review of a log for April 2017 for Dryer Cleaning Times, revealed the form tracks removal of lint from the dryers on an hourly basis from 7:00 A.M. to 2:00 P.M. The instructions on the log indicated, If the dryer requires more detailed cleaning beyond routine lint removal, the DPO (Director of Plant Operations) shall be notified by staff. An X was to be used to document this notification, but review of the log revealed no such documentation. Review of a task list titled, Laundry End of Day Task List, dated April 2017, revealed the floor was to be swept and mopped. The log included initials for each day of the month to present. Interview on 04/13/17 at 3:18 P.M. with the Administrator, revealed the facility does not have a policy or procedure for cleaning the laundry room.