Every finding on record at Briarfield at Ashley Circle

Based on observation, record review and interview, the facility failed to ensure transmission-based precautions (TBP) were clearly identified for Resident #82 and failed to maintain appropriate infection surveillance. This affected one resident (#82) of three reviewed for infection control. The facility identified Resident #82 as the only resident on TBP. This had the potential to affect all 65 residents in the facility. Findings include: Review of the medical record for Resident #82 revealed an admission date of 09/15/25. Diagnoses included osteomyelitis (an infection of the bone that can cause inflammation, pain, and damage), diabetes, cellulitis, and spinal stenosis. Review of the medical record revealed the Minimum Data Set (MDS) assessment and care plan were not yet due to be completed. Review of the physician's orders for September 2025 revealed an order for contact precautions, which began on 09/16/25. Observation on 09/22/25 at 9:32 A.M. revealed a bag containing personal protective equipment (PPE) hanging on the outside of Resident #82's door. Interview on 09/22/25 at 10:03 A.M. with Registered Nurse (RN) #541 revealed Resident #82 had open wounds which required the use of enhanced barrier precautions (EBP) during treatment. She confirmed the facility did not identify when TBP were in place for a resident by placing any signage on the door. The facility expected staff to review the residents' orders. She had no knowledge of Resident #82 being on contact precautions. Review of the facilities infection control logs revealed no documented evidence of an infection surveillance system. Interview 09/24/25 at 9:55 A.M. with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #600 revealed the facility did not have a surveillance system in place to track infections. Interview on 09/24/25 at 10:57 A.M. with the DON and LPN #600 confirmed that any resident on TBP should have signage on their door indicating what type of precautions they were on. They were aware Resident #82 was on contact precautions and should have had signage indicating such. Review of the facility policy titled Infection Prevention and Control Program, dated 06/01/27, revealed the facility would develop surveillance and control measures to protect residents and personnel from healthcare associated infections and perform surveillance to monitor and investigate the cause of infection and manner of spread in order to prevent infections in the facility. Review of the facility policy titled Isolation Precautions, dated 01/01/21, revealed the facility would notify residents, family and staff of the need for TBP, explain the relevant procedures and obtain appropriate signage for TBP and post them outside the residents' door frame.

Based on record review, interview and facility policy review, the facility failed to ensure there was consistent communication between the facility and the dialysis center regarding Resident #4's hemodialysis treatments. This affected one resident (#4) of three residents reviewed for dialysis. This had the potential to affect residents (#4, #21 and #41) identified by the facility who received dialysis. The facility census was 65. Findings include:Review of the medical record for Resident #4 revealed in admission date of 02/16/12. Diagnoses included end stage renal disease, schizophrenia, hypertension, depression, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact. She required setup help for eating, oral and personal hygiene, dressing, toileting, and showering. Review of the physician's orders for September 2025 revealed an order for hemodialysis on Mondays, Wednesdays and Fridays. Resident #4's thrill and bruit was expected to be checked every shift. Review of the care plan dated 09/05/25 revealed Resident #4's health status was compromised due to hemodialysis. Interventions included encouraging compliance with the recommended diet, consulting with the dialysis dietitian as needed, monitoring mental status after each dialysis treatment, monitoring for signs and symptoms of infection and monitoring labs and weights. The care plan also revealed Resident #4 demonstrated disregard for others by refusing to return her dialysis communication sheets to the facility after each dialysis session. Interventions included discussing the behavior with the resident, drawing on her strengths, and making limitations clear. Review of the dialysis communications sheets for August 2025 revealed pre and post dialysis assessments for Resident #4 were completed on 08/01/25, 08/04/25, 08/13/25, 08/18/25 and 08/25/25. Interview on 09/24/25 at 11:28 A.M. with the Director of Nursing (DON) confirmed the facility had a very difficult time obtaining communication sheets for Resident #4 from the dialysis center. She confirmed while Resident #4 was capable of returning the forms herself, she was not expected to do so, and the facility did attempt to follow up with the dialysis center on forms that had not yet been returned. She further explained she talked with both Resident #4 as well as the dialysis center on multiple occasions and explained the importance of the communication forms and making sure these forms were returned upon the residents' returned to the facility from dialysis but had not yet been successful in implementing a system to ensure effective communication and exchange of information. She confirmed she had no other evidence pre and post dialysis assessments had been completed. Review of the undated facility policy titled Pre Dialysis Patient Care revealed the facility would ensure ingoing assessment of the residents' condition and monitor for complications before and after dialysis treatments. Review of the facility policy titled Post Dialysis Care Policy dated June 2021 revealed a post dialysis assessment would be completed when a resident returned to the facility from dialysis and include monitoring the access site, assessing for pain, altered mental status and elevated temperature and assessing the bruit and thrill.

Based on record review, interview and facility policy review, the facility failed to ensure non-pharmacological interventions for pain were attempted prior to the administration of opioid pain medication. This affected one resident (#4) of five residents reviewed for unnecessary medications. The facility census was 65. Findings include:Review of the medical record for Resident #4 revealed in admission date of 02/16/12. Diagnoses included end stage renal disease, schizophrenia, hypertension, depression, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact. She required setup help for eating, oral and personal hygiene, dressing, toileting, and showering. Review of the physician's orders for September 2025 revealed an order for Percocet (an opioid pain medication) every eight hours as needed (prn) for pain which began on 08/15/25. Review of the Medication Administration Record (MAR) for August 2025 revealed Resident #4 was given Percocet once on 08/18/25 for a pain level of four on a zero to ten scale with ten being the worst, once on 08/20/25 for a pain level of six, once on 08/21/25 for a pain level of seven, once on 08/22/25 for a pain level of five, once on 08/25/25 for a pain level of five, once on 08/26/25 for a pain level of five, once on 08/27/25 for a pain level of four, and once on 08/30/25 for a pain level of five. There was no documented evidence that nonpharmacological interventions were attempted prior to administering the opioid pain medication. Review of the MAR for September 2025 revealed Resident #4 was given Percocet once on 09/03/25 for a pain level of four, once on 09/03/25 for a pain level of four, once on 09/04/25 for a pain level of four, once on 09/05/25 for a pain level of five, once on 09/06/25 for a pain level of seven, once on 09/09/25 for a pain level of five, once on 09/10/25 for a pain level of eight, once on 09/11/25 for a pain level of five, once on 09/12/25 for a pain level of five, once on 09/16/25 for a pain level of four, once on 09/19/25 for a pain level of eight, once on 09/20/25 for a pain level of five, once on 09/23/25 for a pain level of seven, once on 09/23/25 for a pain level of five, and once on 09/24/25 for a pain level of six. There was no documented evidence that nonpharmacological interventions were attempted prior to administering the opioid pain medication. Observation on 09/23/25 at 1:29 P.M. with Resident #4 revealed she was sitting in a wheelchair in her room, watching television. Interview at the time of the observation revealed no concerns regarding pain management. Observation on 09/24/29 at 6:56 A.M. revealed Resident #4 was sleeping in bed with no overt signs of pain evident. Observation on 09/25/25 at 8:42 A.M. revealed Resident #4 was sitting on the side of her bed eating breakfast. She was in good spirits and reported no concerns regarding pain at the time. Interview on 09/24/2025 at 1:30 P.M. with Licensed Practical Nurse (LPN) #510 revealed residents often just asked for their pain medication and were not offered nonpharmacological interventions. She revealed there were times she would offer an alternative to medication, but she could provide no evidence that those efforts had ever been documented. Review of the undated facility policy titled Pain Management revealed the facility would maintain optimal comfort and a pain free existence including assessing for pain, implementing interventions, monitoring after administration of medication and documenting all efforts in the residents' medical record.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of personnel files, review of Board of Executives of Long-Term Services and Support (BELTSS) documentation, and staff interview the facility failed to ensure the Administrator had a valid license. This had the potential to affect all 61 residents residing in the facility. Findings included: Review of the Administrator's personnel file revealed no evidence the Administrator had a valid license from 01/01/23 to 11/22/23. Review of facility documentation revealed on 11/22/23 at 12:26 P.M., BELTSS Employee #100 called and reported the Administrator had not had a valid Long Term Healthcare Administrator license since 01/01/23. On 12/09/23 at 11:40 A.M., surveyor interview with the Administrator confirmed BELTSS arrived to the facility on [DATE] and reported she did not have a valid Long-Term Nursing Home Administration license. Per the Administrator, mid- December 2022 she had submitted her continuing education (CE) and $300.00 payment and one of her CE's was rejected because she entered it incorrectly. The Administrator reported she had corrected the CE, however there was a late fee of $50.00 she was not aware of. When she looked in the BELTSS system it showed she had a zero balance. She was not aware of the $50 late fee and after so long the agency will keep adding late fees if not paid. The representative from BELTSS informed her she owed $100.00 and her license had not been valid since 01/01/23 and she needed to find coverage for the building. She immediately went online and paid the fines and BELTSS called her and told her that her license was then valid. Per the Administrator, all this happened on 11/22/23 within hours and they facility did not have to find an Administrator to cover the building. The Administrator reported she had no evidence to provide she had a zero balance or a valid license from 01/01/23 to 11/22/23. This deficiency represents non-compliance investigated under Complaint Number OH00148587. The deficient practice was corrected on 06/30/23 when the facility implemented the following corrective action: On 06/30/23 the Administrator paid her late fees and subsequently her license was active on this day.

Based on observation, record review, and interview the facility failed to treat residents with dignity and respect by not providing privacy for urinary catheter drainage bags. This affected two residents (#51 and #54) of twelve residents with urinary catheters. The facility census was 66. Findings include: Review of the medical record for Resident #51 revealed an initial admitted [DATE]. Diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder, and paraplegia. Review of physician orders effective July 2023 revealed Resident #51 required urinary catheter care twice daily and as needed. Review of the medical record for Resident #54 revealed an initial admitted [DATE]. Diagnoses included cerebral infarction with hemiplegia, and obstructive and reflux uropathy. Review of physician orders effective July 2023 revealed Resident #54 required urinary catheter care every shift. Observation on 07/21/23 at 9:50 A.M. revealed both Residents #51 and #54 lying in their beds with uncovered urinary catheter drainage bags hanging on the bed frames facing the doorway which were visible from the hallway outside of the rooms. Interview at the time of the observation with State tested Nursing Assistants (STNAs) #326 and #343 verified Residents #51 and #54 did not have their urinary catheter bags covered with privacy bags or were not hanging on the opposite side of the beds out of public view. This deficiency represents non-compliance investigated under Complaint Number OH00144200.

Based on medical record review, policy review and staff interview, the facility failed to ensure indwelling urinary catheter care was ordered by the physician and completed as indicated. This affected one (Resident #43) of one residents reviewed for indwelling urinary catheter use. The facility census was 59. Findings include: Review of Resident #43's medical record revealed an admitted [DATE] with diagnosis that included obstructive and reflux uropathy, cerebrovascular accident and epilepsy. Review of the medical record including physician's orders identified the use of an indwelling urinary catheter (foley catheter) due to obstruction. Further review of the physician's orders revealed no evidence of orders for foley catheter care or cleaning. Review of the Treatment Administration Record (TAR) and State tested Nurse Aide (STNA) Activities of Daily Living (ADL) Tasks found no evidence of foley catheter care documented as provided. Review of Resident #43's plan of care revealed an care plan in place related to the foley catheter with interventions indicating catheter care to be provided per facility policy and/or physician order. Review of the facility policy titled Indwelling Foley Catheters Changes and Care with a revision date of 04/16/21 indicated to clean urinary meatus with soap and water and dry every shift. Interview with STNA #355 on 02/28/23 at 10:01 A.M. revealed catheter care is completed at least once per shift, but STNAs do not document in the medical record as being completed. Interview with the Director of Nursing on 02/28/23 at 3:05 P.M. verified there was no physician's order for catheter care and no evidence of documentation of catheter care provided for Resident #43.

Based on record review, resident interview, staff interview, and facility policy review the facility failed to ensure Resident #16 received showers routinely per resident preference. This affected one (Resident #16) of three residents reviewed for showers. The facility census was 67. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had no cognitive impairment. Resident #16 required total dependence for transfers, extensive assistance of two staff for bed mobility and toilet use, and extensive assistance of one staff for personal hygiene and bathing. Review of the facility shower schedule revealed Resident #16 was scheduled for bed baths three times per week on Monday, Wednesday, and Friday. Review of the October and November 2022 shower records for Resident #16 revealed a tub bath was provided on 10/26/22 and bed baths were provided on 10/27/22, 10/31/22, 11/01/22, and 11/06/22. There was no other documented evidence of showers or bathing for Resident #16. On 11/22/22 at 9:07 A.M., interview with Resident #16 stated she did not receive showers or bed baths when she wanted. She stated facility staff would give her a bed bath occasionally. On 11/22/22 at 2:52 P.M., interview with the Director of Nursing (DON) verified there was no additional documented evidence to show Resident #16 received showers and bathing as scheduled. Review of the facility policy titled Showers, dated 09/10/18, revealed residents would be scheduled to receive at least two showers per week. This deficiency substantiates Complaint Number OH 267.

Based on observation, medical record review, policy review and interview the facility failed to ensure appropriate infection control interventions were implemented to prevent the potential spread of COVID 19. This had the potential to affect all 69 residents currently residing in the facility. Findings include: 1. On 01/24/22 between 11:17 A.M. and 11:27 A.M., Activity Assistant (AA) #100 was observed in the main dining room providing fluids to residents. AA #100 was observed using the palm of her hand and cupping the outside of her surgical mask to pull it away from her face while she was holding a cup of fluids to deliver to an unidentified resident. Without performing hand hygiene, AA #100 then provided clothing protectors to Residents #25 and #45. AA #100 again pulled her surgical mask away from her face then ran her fingers through Resident #49's hair before performing hand hygiene. AA #100 then pulled the mask away from her face again, handled the television remote, handled the outside of her mask, then touched a table and chair. A resident was sitting at the table that was touched. On 01/24/22 at 11:23 A.M., the behavior of touching and pulling on the mask without hand hygiene performed was addressed with AA #100 and she stated okay. At 11:27 A.M., after reaching for her mask again, AA #100 stated she now realized she was pulling at her mask because when she spoke it started coming down on her face. On 01/25/22 at 10:00 A.M. the Director of Nursing (DON) was interviewed and verified the handling of the mask in the dining room in which the outside of the mask was touched and/or pulled away from the face was inappropriate. 2. Review of Resident #85's medical record revealed an original admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 01/18/22 at 8:21 A.M. indicated Resident #85 was sent to the hospital for evaluation after being found to be lethargic with a temperature of 100.8 degrees. Oxygen saturation levels ranged between 70% and 85% until a non-rebreather was applied and it rose to 92%. A COVID test at the hospital on 01/18/22 revealed [CONDITION(S)]-CoV-2 was detected. A nursing note dated 01/25/22 at 3:40 A.M. indicated Resident #85 arrived at the facility with a mask in place. On 01/25/22 at 9:38 A.M. a sign was observed posted outside Resident #85's room which indicated he was on isolation for 14 days. A cart of personal protective equipment (PPE) was observed in the hall outside the door. State tested Nursing Assistant (STNA) #105 was observed entering the room without a gown, gloves, or eye protection. STNA #105 had an N95 mask on when entering the room but it was not changed upon exiting. STNA #105 proceeded to Resident #35's room to assist with transferring the resident to bed. On 01/25/22 at 9:40 A.M., Licensed Practical Nurse (LPN) #110 responded to Resident #85's alarm sounding. Gloves, a mask and goggles were worn into the room. LPN #110 stood next to Resident #85 to reposition and check the alarm. LPN #110 went to the doorway of the room to ask for help. STNA #105 once again entered Resident #85's room (after just leaving Resident #35's room) without applying gowns, gloves or eye protection. Upon exiting the room, STNA #105 did not remove the N95 mask. Another unidentified nursing assistant went to the doorway at 9:45 A.M. and handed LPN #110 an isolation gown. On 01/25/22 at 9:52 A.M., STNA #105 verified she only wore eyeglasses and not goggles or a face shield when in Resident #85's room and verified she had been in Resident #85's room without applying a gown, stating she had just arrived and did not realize Resident #85 was on isolation. STNA #105 claimed after exiting Resident #85's room the second time she walked down the hall to change her N95 mask. STNA #105 and another unidentified aide prepared to enter Resident #85's room. On 01/25/22 at 9:55 A.M., LPN #110 verified she had not disinfected her goggles upon leaving Resident #85's room. LPN #85 had a surgical mask on and stated she had worn two masks while in Resident #85's room then removed one prior to exiting. LPN #85 stated she had not applied a gown prior to entering the room because she was concerned for Resident #85's safety due to his alarm sounding. On 01/25/22 at 10:00 A.M., the DON confirmed Resident #85 was in isolation due to testing positive for COVID 19. Staff should have worn eye protection (goggles or face shields), gowns, gloves and N95 masks into the room. Eye protection should be disinfected/sanitized when staff left the room. The N95 masks worn into Resident #85's room should not have been worn into any other residents' rooms. At 11:25 A.M., the DON stated when she learned Resident #85 tested positive for COVID she did contact tracing and learned he never left his room so he only had contact with staff. Once somebody tested positive the facility policy was to keep the resident in isolation for ten days so Resident #85 remained in isolation. The DON stated the unit where Resident #85 resided had two unvaccinated residents. The facility identified Residents #8, #21, #52, and #66 as being unvaccinated. This deficiency substantiates Complaint Number OH 547 and OH 026.

Based on medical record review, policy review and interview the facility failed to ensure responsible parties were notified when a resident experienced changes in condition. This affected one (Resident #1) of four residents reviewed for notification of change. Findings include: Review of Resident #1's open medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 01/02/22 at 6:17 P.M. indicated Resident #1 was not acting like herself that afternoon. Resident #1 looked at staff but needed much coaxing to answer questions. Vital signs recorded included: temperature 98.4 degrees, pulse 82, respirations 18, blood pressure 114/66, and oxygen saturation was 98% on room air. The nurse documented Resident #1's lungs were clear to auscultation. Resident #1's appetite was poor that day and fluid intake was poor. A nursing note dated 01/02/22 at 9:38 P.M. indicated Resident #1 was not answering questions appropriately but consumed her medications. The nurse documented vital signs were stable and Resident #1 would continue to be monitored. A nursing note dated 01/03/22 at 6:30 A.M. indicated Resident #1 was sleepy but responsive. A nursing note dated 01/03/22 at 7:41 P.M. indicated Resident #1 remained lethargic with vital signs within normal range. Much coaxing was needed to get Resident #1 to consume medication. The previous nurse ordered a chest x-ray and Resident #1 would continue to be monitored. A nursing note dated 01/04/22 at 5:02 P.M. indicated Resident #1 was lethargic and did not seem herself. Vital signs were out of range and Resident #1 had raspy breathing and diaphoresis (excretion of fluid by the sweat glands of the skin). A chest x-ray revealed a left lower lobe infiltrate (generic term for any blockage to an air space in a lung caused by the build-up of a substance that is foreign to the lung). an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During shift report she advised the oncoming nurse that Resident #1 should be sent to the hospital due to vital signs fluctuating and not feeling well. The transport company was called around 7:30 P.M. to take Resident #1 to the local hospital and Resident #1 was picked up around 7:50 P.M. A nursing note dated 01/04/22 at 7:45 P.M. indicated Resident #1 was very lethargic and not responding to verbal stimuli. Vital sign recordings included: temperature 97.3 degrees, pulse 33, respirations 24, blood pressure 88/42, and oxygen saturation 65% with oxygen at 2 liters/minute (LPM). Oxygen was increased to 5 LPM and oxygen saturation raised to 72%. Resident #1 was diaphoretic. The nurse practitioner ordered Resident #1 be sent to the hospital and transport was called. A message was left with Resident #1's daughter and sister. The daughter returned the call and was updated. Resident #1 returned to the facility 01/18/22 and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation was located indicating Resident #1's family was notified of the decline in condition which began 01/02/22 until Resident #1 was being sent to the hospital. Review of the facility's Notification of Change in Condition policy (not dated) indicated all symptoms and unusual signs would be communicated to the physician, resident and family promptly. The charge nurse was responsible for making the notifications when the change in condition was noted prior to the end of the assigned shift. All attempts at notification were to be documented in the nursing notes. On 01/25/22 at 8:49 A.M. interview revealed Resident #1's daughter stated when Resident #1 was sent to the hospital 01/04/22 she received at call at 8:06 A.M. Resident #1's blood pressure was low at 7:45 A.M., she was unresponsive, not eating or drinking and refused her medication. The next thing she heard was when a hospital doctor called her to see if Resident #1 could be placed on a ventilator. Resident #1's daughter stated she was informed Resident #1 had lung infiltrate, [CONDITION(S)], and could not swallow and was admitted to the medical ICU with a staph infection/[CONDITION(S)]. On 01/26/22 at 12:51 P.M. interview with the Director of Nursing (DON) revealed prior to Resident #1's hospitalization both her daughter and sister were listed as primary emergency contacts. The nurses could notify either one with changes in Resident #1's condition. The DON indicated she was made aware the family had not been notified when Resident #1's condition began declining and identified a new nurse had been working and needed to be educated. On 1/26/22 at 3:43 P.M. interview revealed Resident #1's sister (the other primary contact) stated she was not notified of a change in Resident #1's condition until the day she was hospitalized and questioned if she had known if she could have intervened before Resident #1's condition deteriorated to the point it did. This deficiency substantiates Complaint Number OH 010 and OH 547.

Based on observation, record review and interview, the facility failed to ensure Resident #19's pressure ulcer documentation was complete and accurate. This finding affected one of three resident records reviewed for wounds. Findings include: Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited a memory problem. Review of Resident #19's Weekly Wound Flow Sheet dated 01/22/21 indicated the resident had a coccyx pressure wound measuring 1.0 cm (centimeters) in length, 1.2 cm width and 0.1 cm depth and charted as a stage two (shallow open ulcer with a red/pink wound bed without slough, which is devitalized tissue). Review of Resident #19's Weekly Wound Flow Sheet dated 02/01/21 indicated the resident has a coccyx pressure wound measuring 1.0 cm in length, 1.2 cm width and 0.1 cm depth and was charted as a stage two. Review of Resident #19's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to cleanse the sacrum with normal saline, apply Santyl and calcium alginate (absorptive dressing), cover with Allevyn dressing (removes fluid) daily and as needed. Review of Resident #19's Weekly Wound Flow Sheet dated 02/22/21 indicated the resident had a coccyx pressure wound measuring 3.1 cm in length, 2.9 cm width, 0.4 cm depth and was charted as a stage two. Review of Resident #19's Weekly Wound Flow Sheet form dated 03/15/21 indicated the resident had a coccyx pressure wound measuring 3.3 cm in length, 3.2 cm width, 1.5 cm depth and was charted as a stage two. Observation on 03/22/21 at 7:02 A.M. with Licensed Practical Nurse (LPN) #1002 of Resident #19's coccyx wound care revealed the wound was open and appeared to have a medium sized cavity with slough and eschar noted. Slough (yellowish/tannish/greenish tissue) and eschar (firmer, leathery black tissue) is tissue which is dead or devitalized. No drainage was identified and no odors were identified. Interview on 03/22/21 at 7:34 A.M. with LPN #1002 confirmed she inaccurately documented Resident #19's coccyx pressure wound as a stage two because the previous wound nurse told her not to change the staging of the wound. LPN #1002 confirmed the resident's coccyx pressure wound was unstageable due to the eschar in the wound, which prevented accurate staging. Review of the undated facility Pressure Ulcer Prevention and Management policy indicated weekly assessments of the resident's condition and response to the treatment would be completed.

Based on record review and interview, the facility failed to ensure Resident #30's lower extremity wound treatments were completed as ordered by the physician. This finding affected one of three residents reviewed for wounds. Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #30's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order directed staff to cleanse both lower extremities with normal saline, apply [MEDICATION(S)], cover with an [MEDICATION(S)] (non stick dressing) and wrap daily and as needed. Review of the Medication Administration Records (MARS) from 02/01/21 to 03/22/21 revealed the treatments to Resident #30's lower extremities were not completed on 02/02/21, 02/03/21, 02/08/21, 02/12/21, 02/20/21, 02/26/21, 03/01/21, 03/04/21, 03/05/21, 03/13/21, 03/15/21 and 03/16/21. Interview on 03/22/21 at 10:40 A.M. with Licensed Practical Nurse #1002 confirmed Resident #30's medical record did not have evidence the wound treatment to the lower extremities was completed on 12 days between 02/01/21 and 03/22/21. This deficiency substantiates Complaint Number OH 613.

Based on observation and interview, the facility failed to ensure Resident #7's wheelchair was maintained. This affected one resident (Resident #7) of 35 residents reviewed for wheelchair maintenance residing in the facility. The facility census was 85. Findings include: Review of medical record for Resident #7 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severe cognitive impairment. Observation on 02/05/20 at 1:32 P.M. revealed the front part of the right armrest on Resident #7's wheelchair was missing a four inch piece of plastic, bare metal was visualized with a screw sticking up in the middle of it. The metal area was rough to the touch. Interview on 02/05/20 at 1:44 P.M. with the Director of Nursing (DON) confirmed wheelchair was missing part of the right armrest cover. Observation on 02/06/20 at 9:31 [NAME]M. revealed Resident #7's right armrest was covered with a white material and wrapped with tape. Interview on 02/06/20 at 9:32 [NAME]M. with the DON indicated the part for Resident #7's wheelchair was ordered, and the wheelchair would be fixed as soon as the part arrived to the facility. Interview on 02/06/20 at 3:40 P.M. with Licensed Practical Nurse (LPN) #805 verified the wheelchair was missing part of the right armrest on 02/01/20. LPN #805 called Resident #7's wife and was told the wheelchair had been missing part of the right armrest for at least two weeks.

Based on interview, observation and record review, the facility failed to ensure Resident #50's pacemaker check was completed accurately and sent to the physician's office and did not ensure nurse aides did not disconnect tube feeding for Resident #53. This affected one resident (Resident #50) of one resident reviewed for pacemaker checks and one resident (Resident #53) of four residents (Resident #6, Resident #28, Resident #39 and Resident #53) reviewed for tube feedings. The facility census was 85. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had moderate cognitive impairment. Review of the physician's orders [REDACTED]. Make sure the resident is in her room near the machine and it is turned on, then press the heart button and follow the prompts; to start 12/18/19. Observation on 02/03/20 at 1:22 P.M. revealed a white box with the words Boston Scientific Latitude sitting on Resident #50's bedside stand with a heart shaped button in the middle of it with a blinking green light. Interview on 02/03/20 at 1:22 P.M. with Resident #50 indicated I have been waiting for parts for my heart monitor for a couple weeks. Interview on 02/05/20 at 8:05 [NAME]M. with the Director of Nursing (DON) revealed the information from Resident #50's pacemaker did not get sent to the physician's office on 12/18/19 as ordered by the physician. The facility did not find out the information was not sent to the physician's office until Insurance Representative (IR) #807 called the physician's office on 01/23/20 and was told the information did not get transmitted. Interview on 02/05/20 at 8:15 [NAME]M. with Licensed Practical Nurse (LPN) #806 revealed on 12/18/19 she took Resident #50 to her room and had her sit in front of the machine and pushed the button on the heart monitor. An orange light started flashing from the monitor and did not change to a different color. The lights stopped flashing and nothing else happened. LPN #806 did not know if the information had been sent but thought the physician's office would call if they did not receive it. Interview on 02/05/20 at 8:37 [NAME]M. with IR #807 revealed he contacted Resident #50's daughter via telephone on 01/23/20 and was told the physician's office had contacted her because the pacemaker information had not been received from the facility on 12/18/19. Resident #50's daughter did not call the facility about the missing information. IR #807 then called the physician's office and was told they did not receive the pacemaker information from Resident #50. IR #807 contacted the manufacturer of the pacemaker home monitor and was informed that a cellular adapter was needed to send the data. The cellular adapter was ordered and mailed to the facility on [DATE] and had not been received yet. Interview on 02/05/20 at 9:01 [NAME]M. with the DON revealed the facility did not have an in-service on the operation of Resident #50's home heart monitor. Interview on 02/05/19 at 12:50 P.M. with the DON revealed Resident #50 had an appointment with her cardiologist on 05/08/19 and was given the heart home monitor at that time. At an appointment on 09/18/19, Resident #50 was told that the heart home monitor would be used for the next data check. Interview on 02/07/20 at 2:08 P.M. with Manufacturer Representative (MR) #810 revealed the cellular adapter was received and signed for by the facility on 01/27/20 at 10:48 [NAME]M. Review of information provided by the facility titled Latitude Communicator, dated 03/2015, revealed connection method using cellular data network required an adapter kit which was available separately. Further review revealed the Communicator can perform a patient initiated Interrogation by pressing the heart button located in the middle of the Communicator. The Interrogation was complete and had been sent to Latitude when all the waves were lit green. 2. Review of the medical record for Resident #53 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment revealed a Brief Interview for Mental Status (BIMS) was unable to be conducted because resident was rarely/never understood. Review of Resident #53's physician's orders [REDACTED]. Observation on 02/03/20 at 1:50 P.M. revealed Resident #53 lying in bed with his side rails up and tube feeding running continuously at 62 ml per hour via peg tube. Interview on 02/03/20 at 1:58 P.M. with Resident #53's mother revealed two days ago when the State tested Nursing Assistants (STNAs) were putting Resident #53 back to bed from his chair, the back of his gown and pants were saturated with tube feeding. She stated this had happened eight times recently when the STNAs disconnected the tube feeding from the peg tube when they moved Resident #53 from bed to chair and chair to bed. The STNAs stop the tube feeding, disconnect the tube feeding from the peg tube, place a plastic cap on the end of it and hang the tubing on the tube feeding pump. When they are finished moving Resident #53, they take the tubing with the plastic end on it, connect it to the peg tube without removing the plastic cap and turn the pump back on. The tube feeding begins to run, but cannot flow into the peg tube because of the plastic cap. Instead the tube feeding backs up and flows onto the resident and saturates his clothing. Resident #53's mother stated that she told the staff this was happening and they got mad at me and will not talk to me. Interview on 02/06/20 at 11:15 [NAME]M. with STNA #804 revealed STNA #804 will re-connect Resident #53's tube feeding if she cannot find a nurse, and turn it back on. When I turn the tube feeding on I make sure the tube feeding bag is full and the rate is 62 ml per hour. STNA #804 further stated she makes sure the lighted circle is on and working that shows the pump is infusing the tube feeding. Review of facility policy titled Job title: State tested Nursing Assistant, undated, revealed no instruction for administration of tube feeding to the residents. Review of facility policy titled IIB12: Enteral Tube Medication Administration, revised 01/2018, revealed no documentation that STNA's are able to administer tube feedings to residents.

Based on record review and interview, the facility failed to ensure Resident #33's medical record accurately coded the medications administered to the resident. This finding affected one (Resident #33) of one resident reviewed for [MEDICAL TREATMENT]. Findings include: Review of Resident #33's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #33's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited intact cognition. Review of Resident #33's physician orders [REDACTED]. for renal capsule one mg give by mouth one time a day for vitamin supplement, an order dated 04/14/17 for vitamin D give 4000 units by mouth one time a day for a vitamin supplement, and an order dated 10/01/19 for Eliquis five mg give one tablet by mouth two times a day for [MEDICAL CONDITION]. Review of Resident #33's medication administration records (MAR) from 01/01/20 to 02/05/20 revealed the aspirin, fish oil, [MEDICATION NAME], renal capsule, vitamin D and Eliquis were documented on the MAR dated 01/10/20, 01/13/20, 01/15/20, 01/22/20, 02/03/20 and 02/05/20 as away from home with medications (Code #1). Interview on 02/04/20 at 1:50 P.M. with Corporate Registered Nurse (RN) #803 confirmed the nursing staff inaccurately signed medications were given to the resident to be administered when she was away from the facility. Corporate Registered RN #803 stated the facility investigation verified the staff actually administered the resident's medications but coded it inaccurately in the resident's record.

Based on record review and interview, the facility failed to ensure residents and/or resident representatives received written notification for the reason for the discharge to the hospital in an easily understood language at the time of the discharge or within twenty-four hours as appropriate. This finding affected six (Residents #1, #25, #39, #82, #83 and #89) of six resident records reviewed for hospitalization . The facility census was 85. Findings include: 1. Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #25's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Review of Resident #25's progress note dated 12/02/19 at 11:59 P.M. indicated the resident was admitted to the hospital with [REDACTED]. Interview on 02/05/20 on 9:18 [NAME]M. with the Administrator confirmed the facility did not provide Resident #25 and/or the resident's representative written notification of the reason for the discharge at the time of the discharge to the hospital or within twenty-four hours as appropriate in an easily understood language. 2. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS 3.0 assessment dated [DATE] indicated the resident was cognitively intact. Review of Resident #1's progress note dated 01/13/20 at 5:37 P.M. indicated the nurse was called to the dining room due to the resident shaking and not feeling well. The resident had a small emesis and complained of cough and congestion. The resident sent to the emergency room and the guardian was notified. Interview on 02/05/20 at 9:18 [NAME]M. with the Administrator confirmed the facility did not provide Resident #1 or the resident's representative written notification of the reason of the discharge to the hospital at the time of the discharge or within twenty-four hours as appropriate in an easily understood language. 3. Review of Resident #82's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #25's MDS 3.0 assessment dated [DATE] indicated the resident's memory was impaired. Review of Resident #82's progress note dated 12/19/19 at 11:12 P.M. indicated the resident was admitted to the hospital with [REDACTED]. Interview on 02/05/20 on 9:18 [NAME]M. with the Administrator confirmed the facility did not provide Resident #82 and/or the resident's representative written notification of the reason for the discharge at the time of the discharge to the hospital or within twenty-four hours as appropriate in an easily understood language. 4. Review of Resident #89's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #89's progress note dated 11/11/19 at 9:03 A .M. indicated resident was sent to the hospital due to labored breathing and generalized weakness and was admitted . Interview on 02/05/20 at 9:18 [NAME]M. with the Administrator confirmed the facility did not provide Resident #1 or the resident's representative written notification of the reason of the discharge to the hospital at the time of the discharge or within twenty-four hours as appropriate in an easily understood language. 5. Review of Resident #83's medical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #83's MDS 3.0 assessment dated [DATE] indicated the resident's memory was intact. Review of Resident #83's progress note dated 01/25/20 at 8:45 P.M. indicated the resident was admitted to the hospital with [REDACTED]. Interview on 02/05/20 on 9:18 [NAME]M. with the Administrator confirmed the facility did not provide Resident #83 and/or the resident's representative written notification of the reason for the discharge at the time of the discharge to the hospital or within twenty-four hours as appropriate in an easily understood language. 6. Review of Resident #39's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #39's MDS 3.0 assessment dated [DATE] indicated resident was cognitively intact. Review of Resident #39's progress notes dated 11/30/19 at 4:53 P.M. revealed the resident was admitted to the hospital with [REDACTED]. Interview on 02/05/20 at 9:18 [NAME]M. with the Administrator confirmed the facility did not provide Resident #39 and/or the resident's representative written notification of the reason for the discharge at the time of the discharge to the hospital or within twenty four hours in a easily understood language.

Based on observation, medical record review and interview, the facility failed to ensure restorative programs were provided in accordance with physician's orders [REDACTED].#19, #38, and #53). The facility identified 40 residents on restorative programs. The facility census was 76. Findings include: 1. On 01/13/19 at 10:45 A.M., Resident #38 was observed with a left hand contracture without any assistive devices. Resident #38 stated she did not receive range of motion services. Review of Resident #38's medical record revealed [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The weeks of 12/02/18 - 12/08/18 and 12/09/18 - 12/15/18 restorative programs were provided three times. The weeks of 12/16/18 - 12/22/18 and 12/23/18 - 12/29/18 restorative programs were provided twice. On 01/16/19 at 1:20 P.M., Licensed Practical Nurse (LPN) #100 verified Resident #38 did not receive restorative nursing programs as ordered. #2. Resident #19 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Each of the three programs was to be 15 to 30 minutes. Review of the Restorative Care Plan revealed a goal to maintain current strength with range of motion and brainstorming. The treatment plan included bilateral range of motion of the upper extremities for 15 to 30 minutes, bilateral range of motion of the lower extremities for 15 to 30 minutes and brainstorming for 15 to 30 minutes. The program was to be provided five to seven days each week. Review of a Restorative Care Flow Record dated 11/01/18 through 11/30/18 revealed each program was provided 13 of the minimum 20 days. The same flow record revealed Resident #19 refused the program one of the 20 minimum days. Review of a Restorative Care Flow Record dated 12/01/18 through 12/31/18 revealed each program was provided seven of the minimum 20 days. The same flow record revealed no evidence Resident #19 refused the program. On 01/16/19 at 1:20 P.M., LPN #100 verified Resident #38 did not receive restorative nursing programs as ordered. #3. Resident #53 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Restorative Care Plan revealed a goal to maintain strength, range of motion, and ambulation. The treatment plan included ambulating 400 to 600 feet with a rollator walker, and bilateral range of motion of the upper and lower extremities. The program was to be provided five to seven days each week for 15 to 30 minutes. Review of a Restorative Care Flow Record dated 10/01/18 through 10/31/18 revealed the program was provided 14 of the minimum 20 days. The same flow record revealed no evidence Resident #53 refused the program. Review of a Restorative Care Flow Record dated 11/01/18 through 11/30/18 revealed the program was provided 16 of the minimum 20 days. The same flow record revealed no evidence Resident #53 refused the program. Review of a Restorative Care Flow Record dated 12/01/18 through 12/31/18 revealed the program was provided six of the minimum 20 days. The same flow record revealed no evidence Resident #53 refused the program. On 01/16/19 at 1:20 P.M., LPN #100 verified Resident #38 did not receive restorative nursing programs as ordered.

Based on observation, medical record review and staff interview, the facility failed to ensure there was sufficient nursing staff to provide restorative programs for two of three residents reviewed for range of motion and one additional resident (Residents #19, #38, and #53) . The facility identified 40 residents on restorative programs. The facility census was 76. Findings include: 1. On 01/13/19 at 10:45 A.M., Resident #38 was observed with a left hand contracture without any assistive devices. Resident #38 stated she did not receive range of motion services. Review of Resident #38's medical record revealed [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The weeks of 12/02/18 - 12/08/18 and 12/09/18 - 12/15/18 restorative programs were provided three times. The weeks of 12/16/18 - 12/22/18 and 12/23/18 - 12/29/18 restorative programs were provided twice. #2. Resident #19 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Each of the three programs was to be 15 to 30 minutes. Review of the Restorative Care Plan revealed a goal to maintain current strength with range of motion and brainstorming. The treatment plan included bilateral range of motion of the upper extremities for 15 to 30 minutes, bilateral range of motion of the lower extremities for 15 to 30 minutes and brainstorming for 15 to 30 minutes. The program was to be provided five to seven days each week. Review of a Restorative Care Flow Record dated 11/01/18 through 11/30/18 revealed each program was provided 13 of the minimum 20 days. The same flow record revealed Resident #19 refused the program one of the 20 minimum days. Review of a Restorative Care Flow Record dated 12/01/18 through 12/31/18 revealed each program was provided seven of the minimum 20 days. The same flow record revealed no evidence Resident #19 refused the program. On 01/16/19 at 1:20 P.M., LPN #100 verified Resident #38 did not receive restorative nursing programs as ordered. #3. Resident #53 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Restorative Care Plan revealed a goal to maintain strength, range of motion, and ambulation. The treatment plan included ambulating 400 to 600 feet with a rollator walker, and bilateral range of motion of the upper and lower extremities. The program was to be provided five to seven days each week for 15 to 30 minutes. Review of a Restorative Care Flow Record dated 10/01/18 through 10/31/18 revealed the program was provided 14 of the minimum 20 days. The same flow record revealed no evidence Resident #53 refused the program. Review of a Restorative Care Flow Record dated 11/01/18 through 11/30/18 revealed the program was provided 16 of the minimum 20 days. The same flow record revealed no evidence Resident #53 refused the program. Review of a Restorative Care Flow Record dated 12/01/18 through 12/31/18 revealed the program was provided six of the minimum 20 days. The same flow record revealed no evidence Resident #53 refused the program. On 01/16/19 at 1:20 P.M., LPN #100 verified Resident #38 did not receive restorative nursing programs as ordered. On 01/14/19 at 9:20 A.M., restorative State tested Nursing Assistant (STNA) #80 stated she was working the unit that day because of staffing needs. When pulled to the floor, she was not always able to provide restorative programs as ordered. On 01/16/19 at 1:20 P.M., Licensed Practical Nurse (LPN) #100 verified Resident #38 did not receive restorative nursing programs as ordered. LPN #100 stated two to three days each week both restorative aides were pulled to work the unit and provide care to residents at least part of their shift. There were a total of 40 residents on restorative programs. On 01/16/19 at 2:00 P.M., Registered Nurse (RN) #60 stated at the end of (MONTH) (YEAR) she began reviewing the restorative program for staffing issues and found there were 70 residents on restorative programs. There was no way two restorative aides could deliver all the restorative programs as ordered. The programs were re-evaluated to determine who truly needed the programs. On 01/16/19 at 2:06 P.M., restorative STNA #80 verified the reason restorative programs were not completed in accordance with plans at times was related to staffing On 01/16/19 at 2:14 P.M., restorative STNA #120 stated the amount of residents on restorative case load in (MONTH) (YEAR) was overwhelming. There were too many programs to be able to be delivered as written. In addition, she was pulled from delivering restorative programs to work an assigned unit frequently.

Based on observation, interview and record review, the facility failed to ensure fall prevention devices were in place for Resident #27. This affected one of five residents reviewed for accidents. The facility census was 76. Findings include: Resident #27 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a Brief Interview for Mental Status (BIMS), dated 10/24/18, revealed Resident #27 had severe cognitive impairment. Review of a Minimum Data Set (MDS) 3.0 assessment, dated 10/24/18, revealed Resident #27 was unable to walk and required a mechanical lift for transfers. Review of a Fall Risk assessment, dated 12/02/18, revealed Resident #27 was at a high risk for falls. Interventions to prevent falls included bed and chair alarms to alert staff of unassisted transfers. Review of fall investigations from 12/01/18 through 01/13/19 revealed Resident #27 had three falls. The falls occurred on 12/03/18, 12/27/18, and 01/02/19. Review of the fall investigation, dated 12/03/18, revealed Resident #27 was found sitting on his buttocks in the hallway at 6:46 P.M. The same investigation revealed no alarm was sounding. Resident #27 was observed on 01/14/19 at 3:14 P.M. Resident #27 was awake in his room, in a wheelchair next to his bed. A chair alarm was observed on the back of the wheelchair. However, the green light on the back of the alarm was not flashing. The flashing green light is an indicator the alarm was functional. An interview was completed with Licensed Practical Nurse (LPN) #40 at the time of the observation. LPN #40 verified the alarm was not flashing. LPN #40 checked the on/off switch and verified the alarm was not activated.

Based on medical record review and staff interview, the facility failed to administer medications in accordance with parameters set in physician's orders. This affected one (Resident #29) of five residents reviewed for medication use. The facility census was 76. Findings include: Review of Resident #29's medical record revealed [DIAGNOSES REDACTED]. Resident #29 had a physician's order for [MEDICATION NAME] (medication used to treat hypertension) 25 milligrams (mg) twice a day. The order included instructions to hold the [MEDICATION NAME] if the top number of the blood pressure was less than 100 or the heart rate was less than 60. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. On 01/15/19 at 10:05 A.M., Registered Nurse (RN) #60 verified the MAR indicated [REDACTED].

Based on observation, interview and record review, the facility failed to ensure adequate infection control practice during the insertion of a urinary catheter for Resident #34. This affected one of three residents reviewed for urinary catheters. The facility census was 76. Findings include: Resident #34 was admitted [DATE] with [DIAGNOSES REDACTED]. [MEDICATION NAME] is defined as inflammation of the urinary bladder. It is often caused by infection and is usually accompanied by painful urination. Resident #34 was observed in bed on 01/14/19 at 07:06 A.M. Resident #34 was heard crying out, Oh, it hurts. It hurts. Licensed Practical Nurse (LPN) #42 responded. Resident #34 complained of pain and burning at the urinary catheter insertion site. LPN #42 reassured Resident #34 she would get her something for the pain. Resident #34 responded, It doesn't help. An interview with Resident #34 was completed at 7:54 A.M. Resident #34 revealed the nurse put some medicine (cream) on down there. Resident #34 verified the medicated cream relieved some of the pain. Resident #34 also revealed she knew she should drink more water, but the water was cold and makes it burn worse. The same day 01/14/19 at 01:41 P.M., Resident #34 was observed shaking her side rail, and again complaining of the same pain. Staff responded. An interview was completed with LPN #42 at the time of the observation. LPN #42 revealed Resident #34 completed 10 days of antibiotic therapy on the previous evening of 01/13/19. The antibiotic was given to treat a urinary tract infection. The original order included changing the urinary catheter at the end of the antibiotic therapy. The catheter change was scheduled for the evening shift of the same day. However, since Resident #34 was uncomfortable LPN #42 planned to change the catheter the same afternoon. An observation of the urinary catheter change was completed on 01/14/18 at 2:30 P.M. LPN #40 and LPN #42 entered the resident's room. LPN #40 applied clean gloves and went to the resident's bedside. LPN #40 revealed she would be assisting LPN #42, as needed. LPN #40 did not wash or sanitize her hands before applying the gloves. LPN #42 washed her hands and applied clean gloves. LPN #42 removed and discarded Resident #34's urinary catheter. LPN #42 washed her hands and applied clean gloves. LPN #42 placed the packaged catheter supplies on the resident's bedside table. LPN #42 opened the catheter package revealing the sterile supplies. These included gloves, cotton balls, tweezers, a package of lubricant, a package of [MEDICATION NAME] liquid (a topical, antibiotic cleanser) and a urinary catheter. LPN #42 washed her hands and applied clean, but not sterile, gloves. LPN #42 picked-up and opened the packaged lubricant. LPN #42 squeezed the lubricant onto the sterile field and discarded the package. LPN #42 picked-up, opened, and poured the [MEDICATION NAME] over the cotton balls. LPN #42 discarded the package. LPN #42 picked-up the sterile tweezers to grasp the [MEDICATION NAME] soaked cotton balls. With the same gloves, LPN #42 opened the resident's outer labia with her thumb and index finger. LPN #42 cleansed the outer labia by swiping the cotton ball up and down several times. LPN #42 discarded the cotton ball. LPN #42 cleansed the inner labia by swiping the cotton ball up and down several times. LPN #42 discarded the cotton ball. LPN #42 grasped a clean cotton ball. Then, LPN #40 instructed LPN #42 to swipe the meatus (direct opening to the urinary tract) in one downward stroke, rather than the up/down motion. LPN #42 corrected the swipe motion as instructed. After cleansing Resident #34, LPN #42 removed and discarded the gloves. LPN #42 washed her hands and applied sterile gloves. LPN #42 lubricated the tip of the catheter, spread the labia and inserted the catheter. LPN #42 attempted to inflate the inner catheter balloon but met resistance. Wearing the same gloves, LPN #42 readjusted the exposed tubing several times and the resistance resolved. However, upon completion, LPN #42 did not remove her gloves and wash her hands. Wearing the same gloves, LPN #42 picked-up the bedside drainage bag, straightened the tubing and placed the bag into a privacy bag suspended from the bed. LPN #42 gathered and discarded the soiled supplies. LPN #42 removed and discarded the gloves and washed her hands. An interview was completed with LPN #40 and LPN #42 immediately following the observation. LPN #40 and LPN #42 verified the infection control concerns. Resident #34 was observed on 01/16/19 at 09:41 A.M. Resident #34 was in a wheelchair waiting transport to the urologist. The urine observed in the catheter tubing was orange due to a side effect of a medication. The same urine was blood tinged. Resident #34 returned from the urologist with the following physician orders: Irrigate the urinary catheter, as needed. Send Resident #34 to the hospital if the bleeding continues. The antibiotic medication was re-started and ordered to continue twice a day for 14 days. Review of the undated Catheter Insertion Procedure revealed: GENERAL INFECTION CONTROL GUIDELINES Wash your hands before and after all procedures. Step #4. Open sterile wrap to create a sterile field. Step #5. Put on sterile gloves. Step #8. Cleanse outer labia using one stroke downward and discarding the cotton ball. Clean the inner labia in the using a clean cotton ball. Step #11. Insert the catheter and place the open end into a sterile container.

Based on observation, interview and record review, the facility failed to ensure safety interventions were in place to prevent a fall for Resident #84, resulting in a fractured left hip. The facility failed to ensure a safety device was in place for Resident #44. This affected two of three residents reviewed for falls. The facility census at the time of the complaint survey was 82. Findings include: 1. Resident #84 was admitted [DATE] at 9:52 P.M. with [DIAGNOSES REDACTED]. Review of a Fall Risk assessment dated [DATE] revealed Resident #84 was at a risk for falls due to being a new admission to the facility, impaired cognition, requiring assistance with activities of daily living, bladder incontinence, a recent fall with a fracture and medications. Review of a plan of care to prevent falls revealed an intervention for "sitter to be at bedside for frequent monitoring". Review of the Night Shift Daily Assignment form dated 01/11/13 revealed State tested Nurse Aide (STNA) #5 was assigned as a sitter for Resident #84. Review of a nurse's note dated 01/12/13 revealed Resident #84 fell out of bed at 3:30 A.M. Resident #84 was "alert and said he did not know why he was trying to get out of bed without help". Resident #84 sustained a laceration to the left upper arm, a bruise on the left forehead and complained of left hip pain. Review of the nurses' notes from admission 01/11/13 at 9:52 P.M. through the fall on 01/12/13 at 3:30 A.M., revealed no evidence of a bedside sitter monitoring the Resident. Review of the same nurses' notes revealed the physician was notified of the fall and hip pain. An x-ray of the left hip was completed. Review of the x-ray result dated 01/12/13 revealed Resident #84 had a fractured left hip. Resident #84 was admitted to the hospital on [DATE] at 11:40 A.M. Review of a falls investigation report dated 01/12/13 revealed STNA #5 was "leaving Resident's room". STNA #5 had provided incontinence care and a clothing change for Resident #84. Review of a Statement For Resident Injury Of Unknown Origin dated 01/12/13 revealed STNA #5 wrote "Yes I just did care for him but had to go to other room to deal with the other resident, so I was at his doorway". Review of an additional Statement For Resident Injury Of Unknown Origin dated 01/12/13 revealed STNA #6 wrote "(Resident #84) would not stay in bed so aides kept checking on him". An interview was completed with the Director of Nursing (DON) on 04/15/13 at 6:00 P.M. The DON verified the use of a sitter was the intervention to prevent Resident #84 from falls. The DON verified STNA #5 was assigned as a sitter for Resident #84 on the night he fell . The DON verified the fall occurred when STNA #5 left the bedside. Review of the facility's undated Falls Protocol revealed 'On admission each Resident's fall risk is assessed based on nurse-to-nurse report, medical information sent with Resident, and by visual assessment. Fall assessment to be completed on admission, quarterly, after each fall, and prn (as needed). Based on this assessment, the necessary interventions applicable to the Resident are implemented, based on the least restrictive, first. Physician orders [REDACTED]. 2. Resident #44 was readmitted [DATE] with [DIAGNOSES REDACTED]. Review of a Fall Risk assessment dated [DATE] revealed Resident #44 was at a moderate risk for falls due to impaired cognition, impaired physical function, bowel incontinence, an acute medical condition, medications and a history of falls. Review of a current physician order [REDACTED]. Review of a plan of care to prevent falls revealed the use of a wheelchair alarm. An observation was completed on 04/15/13 at 5:30 P.M. Resident #44 was in his room, awake and sitting in a specialized wheelchair. A wheelchair alarm was not in place. An interview was completed with Licensed Practical Nurse (LPN) #7 at the time of the observation. LPN #7 verified Resident #44 did not have a wheelchair alarm in place. LPN #7 was not aware of a physician order [REDACTED]. This deficiency substantiates Complaint Number OH 772.