Every finding on record at Bridgeport Healthcare Center

Based upon observation and interview, the facility failed to maintain a safe, clean homelike environment for residents. This was found to be true in three (3) rooms of eight (8) observed. Room identifiers: #202, #204, #206. Facility census: 59. Findings included: During the initial walk through of the resident rooms on 04/06/26 at 1:00 PM, the surveyor observed air conditioner/heater filters were dirty with a one-quarter inch dust on them in room [ROOM NUMBER], #204, and #206. The surveyor went to the nursing station closest to the resident rooms and asked Licensed Practical Nurse (LPN) #36 to accompany her to the resident rooms for observation of air filters. LPN #36 verified the filters were covered with a dust layer at 1:30 PM on 04/06/26.

Based upon record review and staff interview, the facility failed to coordinate the diagnoses on the Minimum Data Set (MDS) and the Pre-admission Screening and Record Review (PASARR). This was found to be true for two (2) of four (4) residents reviewed during the long term care survey process. Resident identifiers: #7, and #19. Facility census: 59.Findings included: a) Resident #7Resident #7 was admitted to the facility on [DATE]. Upon admission, the resident had a diagnosis of major depressive disorder, vascular dementia, both dated 08/04/25 For these illnesses, the resident was prescribed -Zoloft Oral Tablet 50 MG (Sertraline HCl)The resident's PASARR was most recently completed on 01/29/24 by the facility.Question 40 of the PASARR asked about the resident's major mental illness or suspected mental illness. The facility responded None/NA to this question. b) Resident #19 This resident was initially admitted to the facility on [DATE]. Upon admission to the facility, the resident had diagnoses which included: -Epilepsy, -Anxiety, -Major Depressive Disorder, During the resident's stay on 05/30/25, the resident was diagnosed with Bipolar Disorder. The resident's PASARR was most recently completed on 04/24/25 at another nursing home.Under Question 30, Current Diagnosis, none are marked. Under question 47 The individual has a primary diagnosis of: N/A is marked. This PASARR did not reflect any mental illnesses. The most recent MDS was completed on 03/25/26. It was marked yes for diagnoses of seizure disorder or epilepsy; anxiety disorder; and bipolar disorder. It was marked no for depression. These discrepancies were reviewed with the Nursing Home Administrator on 04/08/2026 at 12:43 PM.

Based on record review, observation and staff interview the facility failed to have an accident free environment for Resident #39 in regards to fall interventions. This was true for one of five residents. Resident identifier: #39. Facility Census: 59.Findings included: a) Resident #39 Medical record review revealed Resident #39 had a care plan developed for falls. The care plan called non-skid socks and non-skid strips to left strips to the left side of the bed. Observations revealed fall interventions for Resident #39 were not in place as stated in care plan, non-skid socks when in bed were not in place, non-skid strips to the left side of bed were not in place. This was verified by Licensed Practical Nurse (LPN) #38 at 10:27 AM on 04/07/26.

Based on record review, and staff interview the facility failed to ensure Resident #14 was free from unnecessary medications. This was true for one (1) of five (5) residents who were reviewed for unnecessary medications. Resident identifier: #14. Facility Census: 59. a) Resident #14 On 04/09/26 at 9:42 AM a medical record review for Resident #14 found a current Physician order for Pantoprazole 40 milligrams two (2) times a day. Continued record review revealed a pharmacist recommendation made on 07/18/25. The pharmacist had noted that the resident had received a proton pump inhibitor, Pantoprazole 40 MG, two times a day and recommended to change to once daily before food. A review of this recommendation revealed the response from the physician who prescribed the medication was blank. It had no signature. A Medication Administration Record (MAR) Reviewed found Resident #14 received Pantoprazole scheduled two times a day without a change in the 07/18/25 order, through 04/07/26. On 04/09/26 at 9:30 AM during an Interview with the Director of Nursing (DON) she stated the Pantoprazole order should have been reviewed by the Physician prescriber. She continued to say that the pharmacist recommendation was missed on 07/18/25. She provided a copy with the change made and the physician signature 04/07/26.

Based on record review and staff interview, the facility failed to submit a Five-Day Follow-Up Investigation report to the required agencies following an Initial Reporting of Allegations. This failed practice had the potential to affect a limited number of residents. Facility census: 54. Findings included: a) On 05/13/25, a Facility Reported Incident (FRI) dated 09/24/24 was reviewed. Fax confirmation sheets were not found for the Five-Day Follow-Up Investigation. On 05/13/25 at 12:24 PM, the Administrator confirmed they did not have the fax confirmation sheets. The Administrator asked the state surveyor to contact the Office of Health Facility Licensure and Certification (OHFLAC) to obtain the Five-Day Follow-Up. The state surveyor replied OHFLAC did not have the follow-up investigation on file. The Administrator stated, I'll go look for it. The Administrator stated she was going to contact the fax company to see if they can trace the job number. No additional information was provided.

Based on record review and staff interview, the facility failed to provide information, and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manner. This failed practice affected more than a limited number of residents who currently resided in the facility. Resident identifiers: #3, #6, #7, #29, #33, #36, #37, #45, and #46. Facility census: 60 Findings included: a) RSV immunization During an interview, on 10/02/24 at approximately 11:18 AM, the Infection Preventionist (IP) #36 stated the facility had contended with an outbreak of RSV in January 2024. During a follow up interview with IP #36 on 10/03/24 at approximately 10:55 AM, she confirmed that to her knowledge, the residents had not been provided with educational information about the risks and benefits of receiving the Respiratory Syncytial Virus (RSV) vaccination. She further confirmed that the facility had not offered the RSV vaccine during the Fall immunization period of 2023. Record review for Residents #3, #6, #7, #29, #33, #36, #37, #45, and #46, on 10/03/24 at approximately 11:12 AM, revealed that the facility had failed to offer education on the RSV vaccine, failed to offer the RSV vaccine, and failed to notify the residents of locations where they could obtain a vaccine, if they so desired. The Centers for Disease Control and Prevention (CDC) has provided guidance that states: Respiratory syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older adults are more likely to develop severe RSV and need hospitalization . Vaccines are available to protect older adults from severe RSV. Monoclonal antibody products are available to protect infants and young children from severe RSV. The CDC recommends RSV vaccines to protect adults ages 60 and older from severe RSV, using shared clinical decision-making. According to the CDC the RSV vaccine was made available in early August of 2023. b) Resident #3 Record review revealed that Resident #3 tested positive for RSV on 02/07/2024. A nursing note on 02/7/2024 at 9:30 PM by LPN #96 stated: Resident positive for RSV. Resident has bilateral chest congestion and diminished lung sounds. O2 sat 92% room air. Is receiving Doxycycline Hyclate 100mg po BID for cough/congestion and Duo nebulizer treatments as per order. Is on droplet precautions. contact droplet precautions. Wearing oxygen @2.5L/min via nasal cannula for breathing comfort. A note by RN #55 on 02/8/2024 at 1:40 PM which stated: [AGE] year-old female, positive for RSV and is in isolation. contact droplet precautions. Contact / Droplet Precautions due to positive RSV test every day and night shift for RSV for 10 Days. A note on 02/9/2024 at 5:24 AM by LPN #96 stated: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for Shortness of breath for 3 Days PRN Administration was: Effective Follow-up Pain Scale was: 5 Resident appears to look more comfortable now and not as distressed, anxious and labored breathing A note on 02/9/2024 at 7:00 AM by LPN #24 stated: No injuries noted with witnessed fall Resident was not transferred to the hospital Physician was not notified Family/Responsible party was not notified No C/O PAIN A note on 02/12/2024 at 10:26 AM by LPN #24 which stated: NP #95 notified via telephone at 08:00 of residents fall on 02/9/2024. Resident was lowered to the floor related to weakness due to currently having RSV. Resident is now a 2 assist for transfers. c) Resident #6 Record review revealed that Resident #6 tested positive for RSV on 01/15/24. A nursing note on 01/16/2024 at 11:00 AM by Licensed Practical Nurse (LPN) #59 which stated: Lung sounds diminished with faint expiratory wheezes. Does have a non-productive cough and reports a runny nose. Receives Guaifenesin 400mg po BID daily for cough and congestion. Change in Condition tested positive for RSV, had a cxr and it's negative for pneumonia. A note by Nurse Practitioner (NP) #95 on 01/19/2024 at 02:14 PM stated: Resident #6 is [AGE] year-old female who resides at Bridgeport Healthcare Center. She is seen as a follow up for a call for shortness of breath and hypoxia. She was started on oxygen overnight at 2 LNC. She tested positive for RSV on 1/15. Staff report she has had increased confusion overnight. CBC and BMP are ordered today. A nursing note on 01/18/2024 at 4:49 AM by LPN #13 stated: Resident c/o dyspnea, spo2 was at 82% on room air, this nurse called after hours and [physician] gave verbal orders for o2 @ 2l per n/c PRN and duo nebs q 4hrs PRN, resident's o2 went up to 94 with 2l O2 n/c, resident is currently resting in bed comfortably A nursing note on 01/18/2024 at 11:45 AM by Registered Nurse (RN) #61 which stated: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 3 ml inhale orally every 4 hours as needed for SOB or Wheezing via nebulizer Resident wheezing at this time and needing redirected with continuous O2. Another nursing note by RN #61 on 01/18/2024 at 11:45 AM stated: Furosemide Solution 10 MG/ML Inject 4 ml intramuscularly one time only for fluid retention until 01/18/2024 17:59 2 injection sites R and L deltoids A further nursing note on 10/18/2024 at 11:54 AM by RN #61 which stated: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 4 hours as needed for SOB or Wheezing via nebulizer PRN Administration was: Effective Resident's wheezing reduced at this time and resident does not appear short of breath. Complaint with O2 therapy. Wet sounding cough. A note on 01/18/2024 at 6:47 PM by RN #61 which stated: Resident's Medical Power of Attorney (MPOA) notified of resident's worsening shortness of breath, new PRN ipratropium, O2 via 2L via NC and one time dose of 40 mg Lasix. MPOA made aware of elevated blood pressure that lowered following medications readministered per NP orders this am after previous pills found by this LN spit out by resident in bites of food on resident's bedside table. A nursing note on 01/19/2024 at 12:13 PM by LPN #96 which stated: Resident continues Medrol dose pack and O2 as prescribed for RSV. No s/s of adverse reaction. Resident resting in bed quietly with oxygen 2 L via NC and denies any distress at this time. A note by NP #95 on 02/15/2024 at 10:43 PM which stated: Resident #6 is [AGE] year-old female who resides at Bridgeport Healthcare Center. She is being seen today for the management of chronic conditions. She has a history of RSV on 1/15. She continues to have a loose cough at times, but her lung sounds are clear. d) Resident #7 Record review revealed that Resident #7 tested positive for RSV on 2/13/2024. A note by NP #95 on 02/13/2024 at 10:34 PM which stated: RSV (acute bronchiolitis due to respiratory syncytial virus) tested positive on 2/13. Start Medrol dose pack and Mucinex. A nursing note on 02/13/2024 at 12:30 PM by LPN #27 which stated: Resident has nasal drainage, cough and congestion. States she is just tired and wants to take a nap. Resident eating lunch at this time with no other complaints. On 02/13/2024 at 7:04 PM by RN #42 Resident is RSV +, orders for isolation x 10 days. Message left for MPOA to call facility to be updated on new orders and results. Awaiting return call. A nursing note on 02/14/2024 at 4:30 AM by LPN #69 which stated: Resident remains alert with confusion, and in pleasant mood. Sat up in wheelchair this shift before being assisted with HS care and transferring to bed. Has not exhibited cough this shift. Vital signs remain stable. Currently resting in bed with eyes closed and respirations at ease. Call bell within reach. A note on 02/20/2024 at 7:03 PM by NP #95 which stated: Resident #7 is a [AGE] year-old female member who resides at Bridgeport Healthcare Center. She is a DNR and lacks medical decision-making capacity. She tested positive for RSV on 2/13 and has continued to decline since that time. Staff report she has had poor oral intake. She is seen and examined lying in bed. She has crusting to both of her eyes. She reports she is having difficulty taking a deep breath. Her lung sounds are diminished. She continues to have a loose cough. Another note by NP #95 on 02/21/2024 at 9:40 which stated: Resident #7 is a [AGE] year-old female member who resides at Bridgeport Healthcare Center. She is a DNR and lacks medical decision-making capacity. She tested positive for RSV on 2/13 and has continued to decline since that time. Had a portable chest x-ray yesterday which was positive for pneumonia. She was given clysis of normal saline yesterday x 1 L, although due to her dementia and confusion she continued to remove the needles from her abdomen requiring the discontinuation of the fluids with only 500 cc infused. Today she is seen and examined lying in her room. She reports she is not feeling well. She has a cough. Will start Rocephin 1 g daily for 5 days and doxycycline 100 mg p.o. twice daily for 7 days. e) Resident #29 Record review revealed that Resident #29 tested positive for RSV on 01/15/24. A nursing note on 01/15/2024 at 12:06 PM by RN #61 stated: Resident had complaints of nasal drainage, sore throat, headache, and general malaise this am. Rapid Covid and flu tests done by this LN, with negative results. NP [NAME] made aware and new orders for 4 plex testing today and guaifenesin 400 mg BID x 5 days. Resident's MPOA called and notified of change and new orders. A note by LPN #27 on 01/16/2024 at 12:06 PM which stated: 4 plex results came back positive for RSV. (name) in facility at time and made aware. Resident quarantined to room for 10 days. new order for solumedrol 40mg X1 and Medrol dose pack. MPOA aware of new orders. Droplet isolation precautions maintained. A note on 01/19/2024 at 1:49 AM by NP #95 which stated: Resident #29 is an (age/gender) who is being seen today for follow up. She tested positive for RSV on 1/15. She denies any shortness of breath. She reports she still has a cough, but is feeling better overall. Her lungs are clear. LPN #69 entered a note on 01/20/2024 at 3:15 AM which stated: Resident remains alert and oriented x3, and in pleasant mood. Remains in isolation for RSV. Denies shortness of breath and cough; does report clear nasal drainage. Vital signs remain stable to resident's baseline. Received HS medications without difficulty. Currently resting in bed with eyes closed and respirations at ease. Call bell within reach. f) Resident #33 Record review revealed that Resident #33 tested positive for RSV on 02/07/24. A nursing note on 02/7/2024 at 2:52 PM by RN #55 stated: Contact / Droplet Precautions due to testing positive for RSV. every day and night shift for RSV for 10 Days. Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 1 vial inhale orally BID for 5 days. Guaifenesin ER Tablet Extended Release 12 Hour 600 MG, give 1 tablet by mouth every 12 hours. oxygen @2L/min via nasal cannula for breathing comfort, O2 sat 94%. She reports pain with deep breathing to her right side. Gabapentin Capsule 100MG Capsule. Give 1 capsule by mouth two times a day for Nerve Pain A note by NP #95 on 02/13/2024 at 9:19 PM stated: Resident #33 is a [AGE] year-old female who is being seen today for an RSV follow up. She tested positive on 2/7. She reports pain with deep breathing to her right side. She continues to have a cough. Will order chest Xray and DuoNeb for 5 days. A nursing note on 02/13/24 at 10:04 AM by LPN #59 stated: Potential COVID-19 symptom of 'Cough-dry or productive' has been identified in the COVID-19 Symptoms Evaluation UDA. Resident is RSV +, continue to maintain contact droplet precautions. Lung sounds diminished with expiratory wheezes. Reports a productive cough of white colored sputum and clear nasal drainage. Wearing oxygen @2L/min via nasal cannula for breathing comfort, O2 sat 94%. g) Resident #36 Record review revealed that Resident #33 tested positive for RSV on 02/07/24. A nursing note on 02/7/2024 at 9:00 AM by LPN #59 which stated: Positive for RSV Contact / Droplet Precautions due to RSV positive. every day and night shift for RSV for 10 Days. Continues to receive guaifenesin 400mg BID for cough, prednisone 30mg po and nebulizer treatments as per order. Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 1 vial inhale orally three times a day for URI Resident refused this medication. NP in facility and is aware of this refusal. h) Resident #37 Record review revealed that Resident #33 tested positive for RSV on 02/07/24. A nursing note by RN #61 on 01/23/2024 at 8:39 AM stated: Resident assessed this morning to be short of breath with labored breathing, using accessory muscles. Resident's vitals taken with respirations at 23 breaths/min ad O2 81% on 2L O2. Diaphoretic, bounding radial pulses bilaterally, not responding to verbal or physical stimuli. NP [NAME] made aware of situation and new orders for 1 gram Rocephin now and 50 mls/hr. of 0.9% normal saline for 1 Liter. MPOA called and made aware of situation and orders at this time A nursing note on 01/23/2024 at 9:25 AM by LPN #27 stated: Clysis and Rocephin administered and resident continues to decline at this time blood pressure 63/32, oxygen 84 on 4L via nasal cannula. MPOA made aware of resident's condition and would like resident sent out. Resident continues to not respond to verbal commands. NP #95 made aware and gave orders to send resident out. A nursing note by LPN # 69 on 01/25/2024 at 4:19 AM stated: Resident returned to facility at 6:25 PM via [NAME] County EMS with two attendants. Remains alert with confusion, and in pleasant mood. States she is happy to be back and did not enjoy her time at the hospital. Resident denies pain and discomfort. Respirations are even and unlabored. Receiving supplemental oxygen via nasal cannula at 2LPM. Lung sounds diminished bilaterally with crackles heard in lower lobes. Abdomen is soft, not distended, and not tender. Bowel sounds active x4 quadrants. Resident was incontinent of small bowel movement upon arrival. 16 fr 10mL foley cath draining medium yellow urine to bedside bag. Peri and cath care provided by staff. Bruising from insulin administration observed to resident's RLQ and LLQ. 4cm x 4cm unstageable pressure injury observed to left buttock, red and blue in appearance. Resident reoriented to room. Food and fluids supplied. Resident currently resting in bed with eyes closed and respirations at ease. Call bell within reach. i) Resident #45 Record review revealed that Resident #45 tested positive for RSV on 02/07/24. A note on 02/8/2024 at 1:40 PM by RN #55 stated: positive for RSV and is in isolation. contact droplet precautions. Contact / Droplet Precautions due to positive RSV test. every day and night shift for RSV for 10 Days. j) Resident #46 Record review revealed that Resident #46 tested positive for RSV on 02/16/24. A note on 02/16/2024 at 6:00 AM by LPN #24 stated: Resident has a nonproductive cough, lung sounds diminished throughout lobes, currently resting in chair in room, denies pain or discomfort, tested positive for RSV. A nursing note by LPN #69 on 02/16/2024 at 10:00 PB stated: Resident has rested in bed this shift. Remains alert and oriented x3, and in pleasant mood. Has denied pain and discomfort thus far this shift. Continues to have nonproductive cough. Denies shortness of breath. Vital signs remain stable to resident's baseline. Received HS medications without difficulty. Currently resting in bed with eyes closed and respirations at ease. Call bell within reach. A nursing note on0 2/18/2024 at 10:55 AM by LPN #27 stated: Resident continues on ceftriaxone Sodium Injection Solution Reconstituted 1 GM and Azithromycin 250mg for cough and congestion. Has had no adverse reactions and is tolerating medications well. Resident sitting up in wheelchair at bedside at this time with call bell in reach.

Based on observation and staff interviews, the facility failed to have clean sanitized, steam table, freezer, refrigerators and dish room. This had the potential to affect all residents that get their nutrition from the kitchen. Facility census. 60. Findings included: a) Kitchen tour Initial tour on 09/30/24 at 11:30 AM found: 1. Floor in walk in freezer had debris and dirt 2. Floors in the walk-in refrigerator had debris and dirt 3. The reach in refrigerator had debris and food spillage in the inside and spillage on the outside. 4. The Floor in the dish room had multiple missing floor tiles with brown and black substances in area making it an issue to have a clean floor and area around the dish machine. 5. A black substance on the walls around the dish machine. During an interview with the Dietary Manager during the initial tour all the issues above were verified. The Dietary Manager said the issues would be fixed. She stated the corporate representative provided her with a cleaning schedule form that had not been implemented at this time. DM also stated the dish room floor had been in that condition since she has taken over as DM three (3) months earlier. During a second tour in the kitchen on 10/03/24 at 11:55 AM an observation of the steam table found old food debris in the well. During an interview with the Dietary Manager and corporate dietary manager it was verified that the steam table needed to be cleaned and sanitized. During an interview, on 10/03/24 12:12 PM, with the kitchen manager and corporate dietary manager verified the disrepair in the dish room, had previously been in put in the maintenance program to be fixed but has never been completed. During an interview, on 10/03/24, the Executive Director revealed that the Maintenance Director obtained a quote for the dish room floor on August 21, 2024, but nothing else was completed and no further documentation was provided.

Based on staff interview and observation the facility failed to post, in a form and manner accessible and understandable to residents a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services, the Office of the State Long-Term Care Ombudsman program, and the Medicaid Fraud Control Unit. This deficient practice had the potential to affect a limited number of residents in the facility. Resident #16. Resident census: 60. Findings included: a) Required Postings Observation on 10/02/24 at 9:00 AM found the required postings were placed high on the wall. During an interview with Resident #16, on 10/02/24 at 10:45 AM, the resident was asked to read the required postings from her wheelchair. Resident #16 responded by saying, That's way too high!!! I can't see that from here. During an interview, on 10/02/24 at approximately 11:00 AM, the Administrator acknowledged that the required posting was too high for residents in a wheelchair to be able to read.

Based on record review and staff interview, the facility failed to provide evidence that the required Notification of Medicare Non-Coverage (NOMNC) was issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: 22. Facility census: 60. Findings included: a) Resident #22 On 10/01/24 at 2:08 PM, a review was completed regarding the beneficiary protection notification liability notice(s) given for Resident #22 who was discharged to home following her last covered day of Medicare Part A services. Resident #22's last covered day of Part A Services was on 04/05/24. The facility failed to produce evidence that the required Notification of Medicare Non-Coverage (NOMNC) was issued. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. On 10/01/24 at 2:30 PM, the Director of Rehab stated that Resident #22 had met her goals in therapy and was ready to be discharged home since she was performing at her baseline. During an interview, on 10/01/24 at 3:15 PM, the Business Office Manager acknowledged the facility was unable to provide evidence that the appropriate notice was issued to Resident #22 prior to her last covered day of Medicare Part A skilled services and subsequent discharge to home.

Based on observation and staff interview, the facility failed to honor a resident's right to a safe, clean, comfortable, and homelike environment. The facility failed to ensure the bathroom door and a wall in a resident room were in good repair. Room identifier: 205. Facility Census: 60. Findings included: a) room [ROOM NUMBER] On 09/30/24 at 3:40 PM, it was observed that the lower section of the bathroom door in room [ROOM NUMBER] had many multiple scrapes and scratches on it. In addition, the wall to the right of the sink in room [ROOM NUMBER] had what appeared to have been four (4) nail holes that had been plastered over leaving uneven, rough splotches on the wall in the shape of a bow tie approximately two (2) feet wide. During an interview, on 10/01/24 at 3:40 PM, the Director of Maintenance acknowledged the patched wall was visible from the hallway and did not honor the residents' right to a homelike environment. When asked, the Director of maintenance reported the wall had been patched approximately four (4) or five (5) months ago when an old towel rack had been taken down. He also stated the room was on the list to be painted. Additionally, he reported that the facility had identified the need to place a new order for the bathroom door to be replaced.

Based on medical record review and staff interview, the facility failed to ensure a written Notice of Transfer / Discharge was provided to the long-term care Ombudsman for one (1) of two (2) residents reviewed for hospitalization s during the long-term care survey process. This had the potential to affect all residents being transferred or discharged . Resident identifier: 57. Facility census: 60. Findings included: a) Resident #57 A medical record review was completed on 10/01/24 at 12:43 PM. The record review revealed Resident #57 was transferred to the hospital on 05/10/24. The record reflected the resident/resident's representative was provided with a written Notice of Transfer indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred, and a statement of the resident's appeal rights. There was nothing in the electronic medical record to indicate the long-term care Ombudsman had been notified. During an interview on 10/01/24 at 2:55 PM, the Administrator reported the facility could produce no evidence that the long-term care Ombudsman was notified of the transfer.

Based on record review and staff interview, the facility failed to coordinate with the appropriate, State-designated authority, to ensure individuals with a mental disorder, intellectual disability or a related condition received care and services in the most integrated setting appropriate to their needs. This was true for one (1) of three (3) residents reviewed during the survey process. Resident identifier: #12. Facility Census: 60. Findings included: a) Resident #12 Record review on 10/01/24 at approximately 2:30 PM revealed that the resident was admitted to the facility on [DATE] with no diagnosis of a Level II mental illness. Record review indicated Resident #12 was diagnosed with Major Depressive Disorder on 7/31/24, and the PASARR was not revised to reflect this diagnosis. During an interview with the Admissions Director (AD) #14, and the Executive Director (ED) #79 on 10/01/24 at approximately 3:30 PM, they reviewed Resident #12's records and confirmed that the PASARR had not been revised to reflect the new diagnosis of Major Depressive Disorder.

Based on observation, record review, and interview, the facility failed to provide proper care and treatment, including assistive devices, to prevent a decline, maintain, or improve the resident's communication abilities, or other functional communication system. This was a random opportunity for discovery. Resident Identifier: #44. Facility Census: 60. Findings included: a) Resident #44 During the initial brief screening process on 09/30/24 at approximately 1:16 PM, Resident #44 gestured that he was unable to converse with this surveyor because he did not have his hearing aid. Upon being asked where his hearing aid was, the resident managed to imply that his hearing aid was broken. Resident motioned that he was unsure when he had lost the use of his hearing aid. Further investigation, and an interview with Licensed Practical Nurse (LPN) #24 on 10/01/24 at approximately 3:08 PM, revealed that resident's broken hearing aid had been turned into the nursing staff on 09/03/24. LPN #24 then produced a blue sticky tab dated 09/02 with a hearing aid taped to it. A review of Facility's grievance policy on 10/01/24 revealed the following statement: Grievances will be resolved in a reasonable time frame, generally within 5 business days, consistent with the type of grievance. A review of Resident #44's care plan on 10/01/24 at approximately 3:00 PM, found no information regarding the use of a hearing aid. During an interview with the facility's Executive Director (ED) #79 on 10/01/24 at approximately 3:11 PM, related to Resident #44's hearing aid, and any orders or appointments related to his hearing, the ED #79 produced the following documents, and stated that they were all the documentation she had on resident's appointments and hearing aid. a) A nursing note dated 08/02/24 at 11:17 AM by LPN #27 which stated: Resident left at this time to go to appointment with (hospital name) Audiology. Transported by facility van. b) Another nursing note, also dated 08/02/24 at 1:16 PM, by LPN #27 which stated: Resident returned from appointment at this time, no new orders follow up appointment on June 2, 2025, at 12:30. c) A handwritten note that stated: [Resident #44] 9/30/24 - Eye Center @ the (hospital name) 2/11/25 @ 8 AM - May see Audiology 8a -2p to get hearing aid checked Walk in Clinic Further record review confirmed the eye center appointment in a nursing note dated 9/30/2024 at 12:16 PM which stated: Residents eye center appointment at the (clinic name) Clinic rescheduled to 2/11/25 at 8 am facility to transport. Message left for MPOA to call facility to be updated on new orders. The results of this investigation reveal that the facility had made no effort to schedule appointments, or provide services, to prevent a decline, maintain, or improve the resident's communication abilities, or other functional communication system.

Based on observation, record review, and interview, the facility failed to ensure the resident received the proper treatment and assistive devices to maintain his hearing abilities. This was a random opportunity for discovery. Resident identifier: #44. Facility Census: 60. Findings include: a) Resident #44 During the initial brief screening process on 09/30/24 at approximately 1:16 PM, Resident #44 gestured that he was unable to converse with this surveyor because he did not have his hearing aid. Upon being asked where his hearing aid was, the resident managed to imply that his hearing aid was broken. The resident motioned that he was unsure when he had lost the use of his hearing aid. An interview with Licensed Practical Nurse (LPN) #24 on 10/01/24 at approximately 3:08 PM, revealed that the resident's broken hearing aid had been turned into the nursing staff on 09/03/24. LPN #24 then produced a blue sticky tab dated 09/02/24 with a hearing aid taped to it. A review of Facility's grievance policy on 10/01/24 revealed the following statement: Grievances will be resolved in a reasonable time frame, generally within 5 business days, consistent with the type of grievance. Further record review revealed no notes, or interventions, regarding resident's hearing aid. During an interview with the facility's Executive Director (ED) #79 on 10/01/24 at approximately 3:11 PM, related to Resident #44's hearing aid, and any orders or appointments related to his hearing, ED #79 produced the following documents, and stated that they were all the documentation she had on resident's appointments and hearing aid. a) A nursing note dated 08/02/24 at 11:17 AM by LPN #27 which stated: Resident left at this time to go to appointment with VA Audiology. Transported by facility van. b) Another nursing note also dated 08/02/24 at 1:16 PM by LPN #27 which stated: Resident returned from appointment at this time, no new orders follow up appointment on June 2, 2025, at 12:30. c) A handwritten note that stated: [Resident #44] 9/30/24 - Eye Center @ the VA 2/11/25 @ 8 AM - May see Audiology 8a -2p to get hearing aid checked Walk in Clinic Further record review confirmed the eye center appointment in a nursing note dated 9/30/24 at 12:16 PM which stated: Residents eye center appointment at the VA Clinic rescheduled to 2/11/25 at 8 am facility to transport. Message left for MPOA to call facility to be updated on new orders. A review of the progress notes after the interview with ED #79 revealed the following notes: A note dated 10/1/2024 at 3:29 PM by RN #42, which stated: Spoke to Audiology clinic regarding residents broken hearing aid. We can drop off hearing aids between 8am and 2 pm M-F to be fixed. And another note on 10/02/24 at 10:43 AM which stated: Resident's hearing aid sent with facility van driver at this time to VA Audiology to be dropped off for repair.

Based on observation, interview and record review the facility failed to deliver respiratory care services consistent with professional standards of practice. The physician's order for oxygen was not followed. This practice affected one (1) of three (3) residents reviewed for respiratory care during the Long-Term Care Survey Process (LTCSP). Resident identifier: #2. Facility Census: 60. Finding included: a) Resident #2 A review of American Association for Respiratory Care Clinical Practice Guideline -Oxygen Therapy in the Home or Alternate Site Health Care Facility -2007 Revision & Update P1063-1067- Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia. Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. An observation of Resident #2, on 10/01/24 at 9:41 AM, revealed the resident was receiving oxygen at four and a half (4.5) Liters Per Minute (LPM) via nasal cannula (an oxygen delivery device) from an oxygen concentrator. A second observation of Resident #2, on 10/02/24 at 3:40 PM, revealed the resident was receiving oxygen at four and a half (4.5) LPM via nasal cannula from an oxygen concentrator. A review of the Resident's physician order on 10/03/24 at 9:45 AM, revealed the order Oxygen via nasal cannula two (2) LPM, continuous. Every day and night shift for shortness of breath, with an order date of 02/21/24. An interview with Licensed Practical Nurse (LPN) #59 on 10/03/24 at 10:09 AM, verified Resident #2 was receiving oxygen at about five (5) LPM. She verified the resident was ordered oxygen at two (2) LPM via nasal cannula continuous. The LPN verified the oxygen level was wrong and corrected the flow liter at that time.

Based on record review, observation and staff interview the facility failed to ensure Resident #9 who required dialysis received such services, consistent with professional standards of practice, by documenting/taking a Blood Pressure (BP) on residents left arm. This was found true for 1 of 1 resident reviewed for dialysis during the long-term care survey process. Facility census: 60. Resident identifier: 9. Findings included: a) Resident #9 1) A record review on 10/03/24 at approximately 8:40 AM found physicians' orders: -- Observe permcath to right upper chest every shift for s/s of infection and or bleeding every day and night shift. Order date active 5/7/2024. --No blood draws or blood pressure to left arm every day and night shift. Order date active 5/7/2024. --Check fistula to left arm for +thrill and +bruit every shift every day and night shift. Order date active 05/07/24. A review of Resident #9s care plan revealed an intervention: - AV Fistula in the left arm. stating not to take BP in left arm. A review of the Treatment Administration Record (TAR) found documentation from nursing checking Resident #9's AV Fistula in the left arm. The TAR stated not to take BP in left arm starting 05/07/24 being checked off as completed with no issues noted from check. 10/03/24 09:05 AM found nurses documenting BP being taken in the left arm. Record review of weights/Vital summary revealed between 05/07/24 through 10/03/24, documentation that Resident #9 had a BP taken in the left arm on 74 different occasions. An observation on 10/03/24 at approximately 9:30 AM revealed Resident #9 had no signage in the room, bringing awareness to identify AV Fistula in the left arm. stating not to take BP in left arm. On 10/03/24 at 9:52 AM a call was placed to Resident #9's dialysis center revealed the order for no BP in left arm did not come from the dialysis center or Neurologist. There was no reason not to take B/P in left arm from them. The representative from the dialysis center stated that Resident #9's fistula was not functioning and would never be used for a dialysis port. On 10/03/24 at 9:20 AM, The Director of nursing (DON) stated, The orders and care plan should have been followed to not take a B/P in the left arm and the nursing staff should not have been documenting the AV Fistula was working.

Based on observation, record review and staff interview, the facility failed to ensure the resident environment, over which it had control, was as free of accident hazards as possible, by having a dysfunctional magnetic lock on the French doors to the outside of the facility through the activities office, exposing residents to hazards that could potentially cause serious injury or death. Resident Identifier: #58. Facility Census: 57. The State agency determined this failure placed the residents in an immediate jeopardy (IJ) situation due to the potential of serious injury and/or death as a result of a documented elopement. The State agency notified the Nursing Home Administrator of the immediate jeopardy at 12:50 PM on 07/02/24. The facility submitted a plan of correction (POC) at 2:42 PM. At 3:42 PM on 07/02/24, the POC was accepted by the State agency. The State agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 10:35 AM on 07/03/24. Findings Include: On 07/01/24 at approximately 1:00 PM, a record review was completed for Resident #58. The review found the resident had eloped on 03/29/24 at 11:50 AM. At this time, Emergency Medical Service (EMS) #93 was picking up another resident for transport. EMS #93 noticed Resident #58 and redirected her into the facility and took her to the Director of Nursing (DON). The resident was unable to explain how she got out of the facility. The resident was admitted to the facility on [DATE] for long-term care due to the family being unable to provide care due to the dementia diagnosis. The resident was administered a Brief Interview for Mental Status (BIMS) on 03/21/24. The score of the BIMS was found to be 03 (three) which indicates severe cognition deficits. On 07/01/24 at approximately 1:15 PM, an interview was held with the Administrator regarding Resident 58's elopement on 03/29/24. The Administrator stated, it was a system failure with the door .we have placed signs .we have a bid on a new door system and possibly putting a fence around the gazebo area. The Administrator also stated, the door is going through the activities office leading to the gazebo outside. The Administrator stated, access was only obtained with a key card and only certain staff obtained the key card. The door leading into the activities office from the residents' hallway has a keypad. However, the door was left open the date the resident eloped. This gave the resident access to the French doors which were not locked; and, did not have a wander guard alarm. On 07/01/24 at 2:15 PM, the facility provided a list of seven (7) residents who currently are wearing a wander guard bracelet and are considered to be wanderers. The following residents were listed: --Resident #10 --Resident #16 --Resident #29 --Resident #31 --Resident #34 --Resident #37 --Resident #45 On 07/01/24 at approximately 2:30 PM, an interview was held with the Maintenance Director (MD) #4. The MD #4 acknowledged there was a system failure with the magnetic lock on the French doors leading outside to the gazebo from the activities office. The MD #4, also, stated, if the door is not completely closed and the magnets touching, the system will consider the doors locked when they are not locked and the alarm will not sound .if the magnets are 1/8 of an inch apart, the system thinks the doors are locked but they are not. At this time, the MD #4 showed this surveyor what the magnetic lock looks like when touching and when the magnetic lock is 1/8 inch apart. The French door could be opened, and the door alarm will not sound. When the magnetic lock functioned properly, the alarm would alert staff to someone exiting the facility. The alarm sound is noted to be extremely loud and sounds like a fire alarm when it is activated. The MD #4, also, stated, there is no wander guard lock at this door. On 07/01/24 at 3:10 PM, after Surveyor intervention, the MD #4 stated, I will use the dead bolt to keep the doors locked .it will only be accessed with a key. The plan of correction included: Resident #58, who eloped out of the French doors located in the activities ' office on March 29, 2024, was returned to the center without incident and was re-assessed by the licensed nurse with no injuries identified immediately upon discovery. An updated wandering observation tool, pain observation tool and fall risk observation tool were completed by the licensed nurse. Family was notified. Provider was notified. A full-scale elopement drill was completed with headcount with no additional concerns identified. The event was reported to OHFLAC. Signage was placed on the doors to ensure the staff made sure door was fully secure. Three additional elopement drills were completed with staff education (one per shift) to validate staff response. Immediately upon discovery of the magnetic lock not functioning properly on the French doors located in the activities ' office, the Director of Maintenance/designee started all-staff education to include: Door is to be closed all the way so magnetic lock engaged. The door dead bolt is to be locked when no one is present in activities. Door is not to be used as an exit/egress by staff. Activities office door is to remain closed at all times unless there is a staff member in the activities room. A deadbolt lock was installed on the door 7-1-24. At 12:00 p.m. on 7-2-24 an activities aide/designated staff member was placed at the French doors in the activities room to monitor the doors with instruction that no one was to use the courtyard door to enter or exit the building as un-intended egress. At 12:30p on 7-2-24 a keyed deadbolt was added to the Activities ' French doors by the center maintenance director, verified by the Mobile ED to be securely closed to prevent residents from exiting the facility without supervision. At 1:00 p.m. a supplemental door open (a.k.a. Screamer) alarm was placed on the French doors, and verified to be functioning correctly by the center maintenance director. The activities aide/designated staff member is assigned to monitor the activities French doors until a self-closure device is installed on the door and to ensure the door appropriately closes and the maglock engages, with verification to be working appropriately by maintenance director. The supplemental door open alarm (a.k.a. screamer) will remain in place until it is established that the magnetic lock on the French doors is correctly functioning with a self-closure device by the center maintenance director. If the magnetic lock cannot be repaired to manufacturer specifications it will be replaced and the supplemental door open alarm will remain in place until that time. An audit of all facility exiting doors was conducted at 1:30 by the center maintenance director to ensure all doors were securely latched, opening alarms were functioning properly and that self-closure devices are properly functioning with no additional findings of concern. An elopement drill was conducted at 1:40p on 7/2/24 by the center maintenance director and no additional concerns were noted. All staff present in the building are immediately being re-educated to not use the activities French doors to enter and exit the building and that the door will only be used for center specific activities when activities/designated staff are present for the duration of the activity with a door monitor assigned. All-staff not present will be educated upon return to work. Daily for 3 weeks, then 3 times a week for 2 weeks, maintenance will perform an audit to ensure all exit door self-closers and their magnetic locking components are working correctly and that the door is secured. The center maintenance director will immediately report findings of concern to the center administrator. Results of audits will be reported in the monthly Quality Assurance and Process Improvement meeting by the Center Maintenance Director for follow-up and in servicing needs to ensure compliance.

Based on observation and staff interview, the facility failed to prepare meal trays in a safe and sanitary manner. Staff wore jewelry on the tray line. This practice has the potential to affect more than a limited number of residents. Facility census 59. Findings included: a) On 11/14/23 at 12:00 PM observations in the kitchen noted the Dietician with no gloves, a stone ring on each hand and a [NAME] bracelet on the left wrist, repeatedly taking temperatures of food without donning gloves. On 11/14/23 at 1:37 PM, Culinary Director (CD) #23 reported staff are permitted to wear a plain wedding band during meal tray service but nothing else. The above observation was reviewed with the CD #23, he agreed the dietician was stirring and checking food temperatures with her jewelry on and no gloves. At 1:45 PM on 11/14/23, the Registered Dietician (RD) #124 approached the survey team and was found to be wearing a white silicone wedding band and no other jewelry. RD #124 acknowledged she was wearing a bracelet and two stone rings during temperature checks of the lunch tray line on 11/14/23.

Based on record review and staff interview, the facility failed to maintain pharmacy related information, pertaining to the monthly medication regimen review, for each resident, that was readily accessible. This deficient practice was found true for five (5) of five (5) residents reviewed for the care area of unnecessary medications and for one (1) of one (1) residents reviewed for the care area of anticoagulants. Resident identifiers: Residents #28, #52, #17, # 33, #10, and #31. Census: 59. Findings included: a) Resident #28 A record review on 11/14/23, for Resident #28, showed no evidence of a monthly medication review, by the pharmacist, for the months of 08/23, 09/23 and 10/23. An interview, with the Director of Nursing (DON), on 11/14/23 at 10:45 AM, revealed there was no information noted in the medical record or in any facility documentation, showing a medication regimen review for the dates of 08/23, 09/23 and 10/23. An interview, with Registered Nurse (RN) #122, on 11/14/23 at 11:59 AM, revealed the pharmacist was contacted and was requested to send the results of the monthly medication regimen reviews for 08/23, 09/23 and 10/23, because the results of the reviews were not located in the building. An additional interview, with RN #122, on 11/14/23 at 3:00 PM, confirmed the facility was not aware of the results of the 08/23, 09/23 and 10/23 medication regimen reviews, prior to obtaining a copy of the results on 11/14/23, after surveyor interaction. b) Resident (R) #17 On 11/14/23 a review of the medical record revealed no evidence of monthly medication regimen reviews (MRR) by the pharmacist. At 10:45 AM on 11/14/23, The Director of Nursing (DON) confirmed the MRRs were not in the electronic medical record. The DON presented a notebook with reviews for May, June and July 2023. On 11/14/23 at 11:59 AM, the consultant Registered Nurse (RN) #122, reported the pharmacist was contacted to send MRR results for the residents. Later on 11/14/23 colored copies of MRR reviews were presented from the pharmacist for April, August, September, and October 2023. c) R#31 Review of the medical record on 11/14/23, revealed one (1) pharmacy medication regimen review (MRR) in the past six (6) months. The review dated 09/05/23 was completed on readmission and noted no concerns. At 10:45 AM on 11/14/23, The Director of Nursing (DON) confirmed the MRRs were not in the electronic medical record. The DON presented a notebook with MRRs for April, May, June, July, and November 2023. The form dated 09/05/23 was an admission reconciliation of R#31's medications. On 11/14/23 at 11:59 AM, the consultant Registered Nurse (RN) #122, reported the pharmacist was contacted to send MRR results for the residents. Later on 11/14/23 colored copies of MRR reviews were presented from the pharmacist for September, and October 2023. No MRR for August 2023 was received. d) Resident #52 A review of the medial record on 11/14/23 revealed there were no monthly medication regimen reviews (MRR) by the pharmacist for the months of July, August, September, and October 2023. On 11/14/23 at 10:45 AM, the Director of Nursing (DON) confirmed the MMRs were not in the electronic medical record. e) Resident #10 A review of the medial record on 11/14/23 revealed there were no monthly medication regimen reviews (MRR) by the pharmacist for the months of August, September, and October, 2023 On 11/14/23 at 10:45 AM, the Director of Nursing (DON) confirmed the MMRs were not in the electronic medical record. f) Resident #33 On 11/14/23 at 10:00 AM, a record review was completed for Resident #33. The review showed no evidence of the monthly medication reviews, by the pharmacist, for 08/23, 09/23 and 10/23. An interview, with the Director of Nursing (DON), on 11/14/23 at 10:45 AM, revealed there was no information noted in the medical record or in any facility documentation showing a medication regimen review for the dates of 08/23, 09/23 and 10/23. On 11/14/23 at 11:59 AM, an interview with the Corporate Nurse #122, revealed the pharmacist was contacted to send the results of the monthly medication regimen reviews for 08/23, 09/23 and 10/23, because the results of the reviews were not located in the building. An additional interview, with Corporate Nurse #122, on 11/14/23 at 3:00 PM, confirmed the facility was not aware of the results of the 08/23, 09/23 and 10/23 medication regimen reviews, prior to obtaining the results on 11/14/23, after surveyor interaction. 31498 31518 45173

Based on observations, medical record review, and staff interviews, the facility failed to ensure the Pharmaceutical services of provision, monitoring and/or the use of medication-related devices were completed on a consistent basis. This deficient practice was found during a random opportunity for discovery. Facility census: 59. Findings included: a) Emergency Kit Pharmaceutical Services refers to: The provision, monitoring and/or the use of medication-related devices per the definition by the Centers for Medicare and Medicaid Services (CMS). On 11/14/23 at 12:45 PM during an inspection of the medication room, the locked emergency kit had a note that an item in the box expired on 09/01/23. Licensed Practical Nurse (LPN) #48 acknowledged that the note indicated something had expired. LPN #48 took the box to the Director of Nursing (DON) and the Corporate Nurse. The box tie was then cut off and contents observed. Four (4) 1 cc (centimeters) syringes were identified to have expired on 06/30/23. LPN #48 removed the syringes at that time. The DON and Corporate Nurse acknowledged that the emergency kit had not been updated and the 1 cc syringes were expired. The pharmacy policy was provided on 11/14/23 at 1:00 PM, the pharmacy policy stated that the On-Site unit is not exchanged regularly, a pharmacy representative will perform an on-site inspection and remove expired drugs on a consistent basis. The Corporate Nurse on 11/14/23 at 2:22 PM, provided an email from the pharmacy of the medication storage review completed per policy on 09/06/23. The Emergency Kit was not listed on this medication storage review list as being completed at that time.

Based on observation, resident interview, staff interview, and medical record review, the facility failed maintain the highest practicable well being for one (1) of six (6) sample residents. The facility failed to adequately treat Resident #21's vocalization of pain during wound treatments and incontinence care. Facility census: 59. Findings include: a) Resident #21 During an observation of wound care and incontinence care, on 07/12/16 at 3:05 p.m., Licensed Practical Nurse (LPN) positioned Resident #21 for wound care. The resident was lying on his back with his left leg dangling over the side of the bed. When the nurse lifted the resident's leg, the resident cried out in pain and the LPN apologized. The nurse continued with the treatment. The resident continued to voice complaints of pain and LPN #51 informed the resident she was trying to hurry and would medicate him when finished. Upon completion of the left foot wound, LPN #51 proceeded with a dressing change of Resident #21's suprapubic catheter. The resident complained of pain during the dressing change and the nurse responded, I know (Resident's name), I know. LPN #51 asked Resident #21 about pain and the resident raised his thumb in the air. The nurse said that meant yes, the resident was experiencing pain. LPN #51 continued with wound care, and performed the wound treatment for [REDACTED].#21 continued to complain of pain, and the nurse again informed him she would medicate him upon completion of wound care. The nurse explained she needed to put cream/ointment on the buttocks and then would obtain pain medication. Resident #21 had a bowel movement, and the nurse aides performed incontinence care. The buttocks and perineal area were excoriated and bright red in color. Upon completion of incontinence care, the nurse applied the ointment, then proceeded to put away the supplies and dispose of garbage. After completion, at 3:30 p.m., the nurse told the resident she was going to check and see what medication she could provide for his pain. During an interview with the assistant director of nursing (ADON) on 07/18/16 at about 10:00 a.m., the nurse related staff should have offered pain relief when voiced by the resident. The ADON related the expectation was for the nurse to stop the treatment if the resident complained of pain, treat the pain, then continue with the treatment. Review of the medical record indicated LPN #51 administered Tylenol 650 milligrams (mg) at 3:38 p.m. on 07/12/16, after completion of the wound treatments and incontinence care.

Based on medical record review, staff interview, and review of the facility's policy, the facility failed to ensure a resident received the necessary care and treatment to promote healing of existing pressure ulcers and to prevent new pressure ulcers from developing. Resident #33 was admitted to the facility with an unstageable pressure ulcer. The area subsequently opened. The resident also developed additional pressure sores after admission. One (1) of three (3) residents reviewed for the care area of pressure ulcers was affected. Resident identifier: #33. Facility census: 59. Findings include: a) Resident #33 Review of Resident #33's clinical record, on 11/18/13 at 2:00 p.m., revealed the resident was admitted to the facility on [DATE] with a suspected deep tissue injury that was present on admission. The area was noted to be on the bottom of his left foot. A review of the admission Minimum Data Set (MDS), dated as complete on 08/09/12, revealed the resident required extensive assistance with bed mobility, and total assistance with transfers. The resident was always incontinent of bowel and frequently incontinent of bladder functions. Section M (Skin Condition) of the MDS indicated the resident had been assessed to be at risk of developing pressure sores. The thirty (30) day Minimum Data Set (MDS), with an assessment reference date of 08/30/13 was reviewed. It revealed the resident continued to require extensive assistance with bed mobility, total assistance for transfers and was frequently incontinent of bowel and bladder functions. Review of Section M (Skin Condition) indicated the resident had developed an unstageable pressure ulcer due to the presence of slough/eschar. The wound was no longer identified as having been present upon admission. According to the assessment, the dimensions of an unhealed Stage 3 or 4 area or eschar was measured as 2.0 centimeters (cm) long by 1.5 cm wide by 0.1 cm deep. Review of the wound sheets, dated 09/12/13, identified the resident had a Stage 2 area behind his left ear measuring 0.2 cm x 0.2cm. He also had a suspected deep tissue injury on the left great toe measuring 0.5 cm x 0.8 cm which was covered with dry blackish colored eschar. In addition, he had an unstageable area on the right buttock measuring 2 cm x 0.9 cm, with 50% of the wound covered with yellow slough. The depth could not be determined. An interview, on 11/19/12 at 3:45 p.m. with Employee #25, the MDS coordinator, revealed the facility determined pressure ulcer risk by completing a Braden Scale on admission, then weekly for four (4) weeks, and then quarterly. Review of Resident #33's clinical record revealed evidence a Braden Scale was completed at the time of admission and then weekly. It revealed he was at risk for the development of pressure sores due to his extensive need for assistance with bed mobility and incontinence. The facility's standing orders/wound guidelines/facility policy were reviewed. This revealed orders should have been written and initiated for an alternating pressure air mattress and an air or gel filled seat cushion to the wheelchair/regular chair when up to alleviate pressure on bony prominences. No orders could be located for a mattress or cushion for the chair. Review of the resident's comprehensive care plan, dated 08/13/13 and revised on 09/05/13, revealed the plan of care for "Skin Integrity Assessment: Prevention and Treatment". The care plan did not address the use of pressure reducing/positioning devices in his bed or chair. The resident had worsening of an existing pressure area and developed additional pressure sores after admission. As of the time of exit, no further evidence was provided by the facility to indicate the resident had a pressure reducing mattress or cushion to his chair. .

Based on record review and staff interview, the facility failed to provide goods and services to avoid physical harm, by failing to assess / monitor and obtain timely medical intervention for one (1) of seven (7) sampled residents, resulting in a delay in identification and treatment of [REDACTED]. Resident #14 developed a blister on his left great toe, which was identified in a podiatry consult dated 05/12/11, to which the podiatrist applied a topical antibiotic ([MEDICATION NAME]) and recommended follow-up with the attending physician. The facility did not obtain an order to continue the application of this topical antibiotic to the toe until 05/14/11, and there was no evidence the family was informed of the blister or the topical antibiotic ordered to treat this area. There was no evidence to reflect the nursing staff routinely assessed / monitored the status of this blister after the daily application of a topical antibiotic and a dressing were ordered on [DATE], as evidence by a lack of any nursing progress notes from 04/22/11 until 05/19/11. On 05/19/11, the resident's family member brought to a nurse's attention that his left great toe was red and painful to touch, the left foot was warm to touch, and red streaking was present up to the resident's ankle; however, receipt of the order for a topical antibiotic received on 05/14/11 and an acknowledgement of the family's concerns about the resident's left foot were not recorded in any nursing progress notes until a late entry was made on 07/08/11. On the evening of 05/19/11, the physician ordered a 10-day course of oral antibiotics (Keflex) to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose of Keflex was not administered until 6:00 a.m. on 05/20/11, and the 6:00 p.m. dose on 05/26/11 was skipped due "awaiting delivery from pharmacy". After the Keflex was started, there remained a lack of evidence to reflect that nursing staff was routinely assessing / monitoring the status of this area as well as the resident's response to the treatment, as evidenced by no description of resident's left great toe in any nursing notes until a late entry was recorded by a nurse on 05/22/11 (with only periodic descriptions recorded thereafter) and the absence of any wound assessment and progress review records describing the affected area. When the presence of yellow drainage was identified in a nursing note signed by the author on 05/22/11, there was no evidence to reflect the nursing staff notified the physician or the family of this new finding. The tip of the toe was noted to be "blackish / brownish" in color on 05/26/11, after which the physician discontinued the topical antibiotic to the toe (and ordered the application of skin prep) and discontinued the Keflex for the infection to the toe (and ordered [MEDICATION NAME] for a new upper respiratory infection). There was no evidence to reflect nursing staff notified the resident's family of the change in the status of the resident ' s great toe or of the discontinuation of both the oral and the topical antibiotics to treat the infection. After this discoloration to the tip of the toe was noted, there again remained a lack of evidence to reflect the nursing staff was routinely assessing / monitoring the status of this area, as the documentation began to focus on the resident's respiratory status. On 06/02/11, the physician diagnosed the resident as having gangrene to the left great toe. A subsequent arterial ultrasound revealed impaired circulation to the left lower extremity, and the family elected to place the resident on comfort measures only. On the afternoon of 06/13/11, a 7-day course of Keflex was ordered at the family's request to treat gangrene to the left great toe, which was to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose was not administered until 12:00 p.m. on 06/14/11, with the first three (3) doses having been skipped due to "awaiting delivery from pharmacy". The last dose was administered at 12:00 p.m. on 06/20/11, with no evidence to reflect the resident received all twenty-eight (28) doses of the 7-day course ordered by the physician, and no evidence to reflect the family or the physician was notified of these missed doses. Resident identifier: #14. Facility census: 59. Findings include: a) Resident #14 1. Medical record review revealed this [AGE] year old male was most recently re-admitted to the facility on [DATE]. According to his comprehensive annual minimum data set assessment (MDS) with an assessment reference date (ARD) of 12/16/10, he was alert, but his score of "3" on the Brief Interview for Mental Status indicated his cognitive skills were severely impaired. In Section G, the assessor noted he was totally dependent on staff for the performance of all activities of daily living (ADLs). In Section I, his active [DIAGNOSES REDACTED]. Other health conditions included pain almost constantly and shortness of breath when lying down. In Section M, the assessor noted he did not have any pressure sores during the assessment reference period, nor did he have any pressure sores during the prior assessment period, by he was at risk for developing pressure sores; the assessor also noted he had no venous or arterial ulcers present during that assessment reference period and no foot problems (including no infections of the foot). According to his abbreviated quarterly MDS with an ARD of 03/10/11, he remained dependent on staff for the performance of all ADLs. In Section I, the assessor did not indicate the presence of any new [DIAGNOSES REDACTED]. According to his abbreviated quarterly MDS with an ARD of 06/02/11, he remained dependent on staff for the performance of all ADLs. In Section I, his active [DIAGNOSES REDACTED]. In Section M, he was noted to have one (1) Stage 2 pressure ulcer (with the oldest Stage 2 ulcer having been identified on 05/20/11) and one (1) Stage 3 pressure ulcer (measuring 3.0 cm x 0.8 cm). The assessor also noted the presence of an infection of the foot (e.g., [MEDICAL CONDITION]). Subsequently, the facility completed and electronically submitted a comprehensive MDS for a significant change in status with an ARD of 07/06/11, in which the assessor noted he remained dependent on staff for the performance of all ADLs, his active [DIAGNOSES REDACTED]. -- 2. According to an article about gangrene found on Medline Plus, a service of the U.S. National Library of Medicine, National Institutes of Health: "Gangrene is the death of tissue in part of the body. "Gangrene happens when a body part loses its blood supply. This may happen from injury, an infection, or other causes. You have a higher risk for gangrene if you have: - A serious injury - Blood vessel disease (such as [MEDICAL CONDITION], also called hardening of the arteries, in your arms or legs) - Diabetes - Suppressed immune system (for example, [MEDICAL CONDITIONS]) - Surgery "Symptoms "The symptoms depend on the location and cause of the gangrene. If the skin is involved, or the gangrene is close to the skin, the symptoms may include: - Discoloration (blue or black if skin is affected; red or bronze if the affected area is beneath the skin) - Foul-smelling discharge - Loss of feeling in the area (which may happen after severe pain in the area) "Treatment "Gangrene requires urgent evaluation and treatment. In general, dead tissue should be removed to allow healing of the surrounding living tissue and prevent further infection. Depending on the area that has the gangrene, the person's overall condition, and the cause of the gangrene, treatment may include: - Amputating the body part that has gangrene - An emergency operation to find and remove dead tissue - An operation to improve blood supply to the area - Antibiotics - Repeated operations to remove dead tissue (debridement) - Treatment in the intensive care unit (for severely ill patients) "When to Contact a Medical Professional "Call your doctor immediately if: - A wound does not heal or there are frequent sores in an area - An area of your skin turns blue or black - There is foul-smelling discharge from any wound on your body - You have persistent, unexplained pain in an area - You have persistent, unexplained fever "Prevention "Gangrene may be prevented if it is treated before the tissue damage is irreversible. Wounds should be treated properly and watched carefully for signs of infection (such as spreading redness, swelling, or drainage) or failure to heal." (URL for this article is <http://www.nlm.nih.gov/medlineplus/ency/article/ 8.htm>) -- 3. Record review revealed a podiatry services progress note date 05/12/11, which noted the presence of a blister on the left great toe, to which the podiatrist applied [MEDICATION NAME]; the podiatrist also recorded the need for follow-up by the facility's physician. ([MEDICATION NAME] is a topical antibiotic.) A box located at the bottom of the form contained a checkmark next to the following statement (quoted as typed): "Based on review of history medical records and exam; this pt (patient) is at medical risk of significant complications and medical care is indicated." -- 4. A review of the resident's physician orders, treatment administration records (TARs), and medication administration records (MARs) found the following: - Order Date: 05/14/11 at 10:00 a.m. (quoted as typed) - "Cleanse lt (left) great toe with dial soap and rinse with NSS (normal sterile saline). Apply [MEDICATION NAME] ointment to toe and cover with a dry dressing." The order was discontinued at 1:50 p.m. on 05/27/11. Nurses' initials on the TAR indicated this treatment was completed daily from 05/14/11 through 05/26/11. Documentation on the physician order [REDACTED]. Reeval (re-evaluate). Area is unstageable." - - Order Date: 05/20/11 at 6:00 a.m. - Keflex Oral Suspension 250 mg / 5 ml ("Instructions: Great toe on left foot"); give 500 mg by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. The order was discontinued at 1:47 a.m. on 05/27/11. Nurses' initials on the MAR indicated [REDACTED]. Documentation indicated a dose was missed at 6:00 p.m. on 05/26/11 due to "awaiting delivery from pharmacy". According to the physician order [REDACTED]. - - Order Date: 05/27/11 at 3:00 a.m. - [MEDICATION NAME] Oral Tablet 400 mg, give 1 tab once daily at 8:00 a.m. for "UTI" (urinary tract infection). (Note: Elsewhere in the resident's record, documentation indicated this antibiotic was for a "URI" (upper respiratory infection).) The order was discontinued at 1:00 a.m. on 06/03/11. Nurses' initials on the MAR indicated [REDACTED]. - Order Date: 06/02/11 at 5:00 p.m. - "TO (telephone order) Arterial ultrasound to Left lower foot Stat, Call office in AM (morning) to get paper faxed." - Order Date: 06/04/11 - "... D/C Skin prep to tip of (lt) gt (great) toe. ..." - - Order Date: 06/13/11 at 4:00 p.m. - Keflex 250 mg / 5 ml ("Instructions: gangrene grt (great) lt (left) toe); give 10 cc (500 mg) by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. Nurses' initials on the MAR indicated [REDACTED]. Documentation on the MAR indicated scheduled doses found entries for 6:00 p.m. on 06/13/11 and 6:00 a.m. on 06/14/11 ("awaiting delivery from pharmacy"), but no reason was documented for the skipped dose due at 12:00 a.m. on 06/14/11. The order was discontinued at 4:00 p.m. on 06/20/11, although the resident did not receive all scheduled doses for this course of antibiotics. (Note: There was no evidence in the nursing progress notes for this time period to reflect that nursing staff notified the physician and/or the family that the resident did not receive all twenty-eight (28) doses of this 7-day course of antibiotics.) -- 5. Nursing Progress Notes Review of the nursing notes found no entries from 04/22/11 through 05/19/11, and no entries made on 05/19/11 addressed the status of the resident's left great toe. (Note: There was no contemporaneous entry to correspond with the receipt of an order for [REDACTED]. There was also no contemporaneous entry to correspond with the receipt of a verbal order from the physician for Keflex to treat "possible infection / [MEDICAL CONDITION]" of the left great toe on the evening of 05/19/11 and evidence to reflect nursing staff notified the resident's family of this new medication order or the reason for its use.) - An entry, with no date or time recorded but signed by a registered nurse (RN - Employee #11) on 05/20/11, stated (quoted as typed): "Wound assessment: ... He's also on abt (antibiotic therapy) d/t (due to) [MEDICAL CONDITION] to lt (left) grt (great) toe, no odor or drainage noted. Res (resident) did c/o (complain of) pain when area was tx'd (treated), but he's on scheduled [MEDICATION NAME]. ..." - An entry, with no date or time recorded but signed by a licensed practical nurse (LPN - Employee #56) on 05/21/11, stated (quoted as typed): "5/20/11 (Name of attending physician) to see resident this shift, no new orders. Progress note written." - An entry, with no date or time recorded but signed by Employee #56) on 05/21/11, stated (quoted as typed): "5/20/11 Resident alert and verbal w/ (with) intermittent confusion observed, able to make some needs known to staff. Resident started Keflex Oral Suspension 250 MG/ML 500MG PO (by mouth) TID (three-times-daily) related to great toe on left foot. No s/s (signs / symptoms) of adverse reaction to medication observed at this time. ..." (Note: There was no description of the affected area, and the frequency at which the antibiotic Keflex was to be given was four (4) times daily, not three (3) times daily as stated in this note.) - An entry, with no time recorded but signed by Employee #40 (an LPN) on 05/22/11, stated (quoted as typed): "05/21/11 Late entry Vital signs ... Resident remains on Keflex elixer 250mg/5cc 10cc po (by mouth) administered per md orders qid (four-times-daily). No s/s of adverse reaction noted. Keflex administered for left great toe infection. Resident left great toe red and warm with slight [MEDICAL CONDITION] noted. No c/o pain offered. Dsg (dressing) changed per md orders. Call bell within reach." (Note: This was the first description of the resident's left great toe to have been documented in the record since the podiatry consult dated 05/12/11.) - An entry, signed by Employee #40 on 05/22/11, stated (quoted as typed): "05/22/11 1642 (4:42 p.m.) Vital signs ... Resident continues on Keflex elixer 500mg po qid r/t (related to) left great toe infection. No s/s of adverse reaction noted. Left great toe is discolored red with yellow drainage observed. Toe is warm to touch. No c/o pain or discomfort noted. ..." (Note: There was no evidence that nursing staff notified the resident's family or physician of the yellow drainage from the left great toe, which was a new finding.) - Subsequent entries stated the following: - 05/22/11 at 2317 (11:17 p.m.) by Employee #61 (an RN) - "... continues to receive Keflex ..." (No description of the affected toe was provided.) - 05/23/11 at 0318 (3:18 a.m.) by Employee #61 - "... Resident continues to receive Keflex ..." (No description of the affected toe was provided.) - 05/23/11 at 1024 (10:24 a.m.) by Employee #40 - "... Resident continues on Keflex ... Left great toe is discolored red with small amount of yellow drainage noted ..." - 05/24/11 (no time recorded) by Employee #51 (an LPN) - "... He is currently on Keflex related to infected toe ..." (No description of the affected toe was provided.) - An entry, with no date or time recorded but signed by Employee #62 (an RN) on 05/24/11 - "... Resident taking Keflex for [MEDICAL CONDITION] in L foot and L great toe. ..." (No description of the affected foot or toe was provided.) - Further entries reiterated that Resident #14 was receiving Keflex for an infected left great toe, with no descriptions of the affected area provided. - The next entry that provided a description of the affected area, which had no date or time recorded but was signed by Employee #11 on 05/26/11, stated (quoted as typed): "... Res (resident) is on keflex d/t infection to lt grt toe, the tip of toe is blackish / brownish. It's measuring 2.5cmx2.5cm, no odor or drainage, periwound is a pinkish color. Res does yell out in pain when toe is dressed but was already med. (medicated) with a prn (as needed) [MEDICATION NAME]. Once tx (treatment) is finished, res no longer yells out. ..." (Note: There was no evidence the nursing staff notified the resident's family of this change in the color of the affected area.) - On 05/26/11, the physician discontinued the Keflex for the infected left great toe and ordered [MEDICATION NAME] to treat an upper respiratory infection. On 05/27/11, the topical antibiotic treatment to the toe was also discontinued, and the twice daily application of skin prep for fourteen (14) days was ordered. (Note: There were no entries in the nursing progress notes to reflect the resident's family was notified of the change in the status of the resident's great toe or that both the topical antibiotic ([MEDICATION NAME]) and the oral antibiotic (Keflex), which had been ordered to treat the infection toe, had been discontinued.) - After the [MEDICATION NAME] was started, nursing documentation began to focus on the resident's respiratory status, and documentation of the status of the resident's left great toe diminished in frequency with the following entries noted (all quoted as typed): - 05/28/11 at 11:52 a.m. by Employee #62 - "... Wound to left great toe, skin prep every day applied. ..." - 05/29/11 at 3:17 p.m. by Employee #11 - "... Res has [MEDICAL CONDITIONS], and the area to lt grt toe could be d/t (due to) that disorder. The area is measuring 0.8cmx2cm and is a dark purplish/brownish area. No odor or drainage noted. The tx of skin prep continues as ordered. ..." - 06/03/11 at 2:30 a.m. by Employee #30 (an LPN) - "... resident has new order for arterial ultrasound of left lower leg stat. ..." - 06/03/11 at 6:21 p.m. by Employee #11 - "Res is on abt d/t infection to lt grt toe, the area is black, no odor or drainage. The outer part of the wound is slightly reddened and a little warm to touch. The area is measuring 2.5cmx2.5cm. He c/ pain when area is touched. He went for ultrasound and per MD and mpoa (medical power of attorney representative) is aware res will be cmo (comfort measures only). ..." (Note: The resident was receiving [MEDICATION NAME] to treat an upper respiratory infection; contrary to what was stated in this note, the resident was not on any antibiotics at this time to treat the infection of his left great toe.) - 06/04/11 at 12:02 a.m. by Employee #51 - "... He, Finished his [MEDICATION NAME] for the URI. His right Great toe is black in color and no drainage at this time. ..." (Note: This entry identified his right (not his left) great toe as the site of the infection.) - 06/04/11 at 6:35 p.m. by Employee #11 - "Res is on [MEDICATION NAME] d/t an infiltrate ... The wound to his lt grt toe remains black and is warm to touch, no odor or drainage noted. It is slightly reddened around the outside of the nail bed. ..." (Note: This entry identified that he was still receiving [MEDICATION NAME] when the previous entry stated he had taken his last dose of this antibiotic.) - 06/05/11 at 8:23 a.m. by Employee #11 - "Weekly summary: late charting ... Per (name of attending physician) he has gangrene to the lt grt toe, and the family has decided that surgery is not an option for him d/t his overall condition. ..." - After the resident was placed on comfort measures only, the family requested another course of antibiotics to treat the infection to the left great toe. On 06/13/11 at 4:53 p.m., Employee #11 recorded the following entry (quoted as typed): "... Res is also to start keflex 250mg/ml 10cc po qid x 7 days per Dr. (name) at mpoa's request. This is d/t gangrene to lt grt toe at this time area remains black but is dry. No odor noted, area is warm to touch. ... " As noted above, documentation on the MAR for June 2011 indicated the first three (3) scheduled doses of Keflex were missed; "awaiting delivery from pharmacy" was noted as the reason for two (2) of these skipped doses. There were no entries in the nursing progress notes to reflect that staff notified either the family member (who had requested this course of antibiotics) or the physician that the resident did not receive all twenty-eight (28) scheduled of the Keflex. - Further review of the nursing notes found an entry, dated 07/08/11 at 5:11 p.m., stating (quoted as typed): "Late entry: On 05/14/11 evaluation of the left great toe revealed red area on tip of the toe, that was warm to touch. Also some dried blood was on the left great toe around the toenail. After reading the consult form from (name of podiatry service), Dr. (name of attending physician) was notified of the findings. [MEDICATION NAME] external topical ointment was ordered for 14 days. On 05/19/11 residents daughter approached the nurses station and asked for a nurse to evaluate the residents left foot. On assessment, the left great toe was very red, and painful to touch. Also, the left foot was warm and red streaked covering foot up to the ankle. At this time, the resident stated the foot was painful to touch, even with the blankets. Dr. (name) was notified of the reassessment on the residents foot. Keflex liquid 500mg 4 times a day for 10 days was ordered. First dose was given on 5/20/11." -- 6. physician progress notes [REDACTED]. Review of the physician's progress notes revealed an entry dated 04/14/11 which contained no mention of any problems with the resident's feet. The next consecutive entry, dated 05/20/11, also made no mention of any problems with the resident's feet. The next consecutive entry, dated 05/26/11, noted the resident was on Keflex for [MEDICAL CONDITION] of the left great toe and identified a plan to change the Keflex to [MEDICATION NAME] to treat an upper respiratory infection. The next consecutive entry, dated 06/02/11, noted the physician had been asked to re-evaluate the resident's left great toe. The tip of the toe was black. The physician noted, "... Gangrene (L) great toe - failed antibiotics. ..." -- 7. Review of the wound assessment and progress review forms on Resident #14's medical record found no such records were initiated to track the status of the blister, which was intact when identified by the podiatrist on the resident's left great toe on 05/12/11. -- 8. Care Plans Review of the resident's care plans found an episodic care plan, dated 05/20/11, stating (quoted as written): Problem: "Infection great left toe. Goal: "Will resolve during the next 14 days." Approaches: "(1) Antibiotic as ordered. (2) Treatment as ordered. (3) Monitor for improvement or decline of area. Notify MD as needed." This care plan has a "D/C (Discontinuation) Date" of 05/27/11. - There was no evidence that an episodic care plan was developed to address the resident's left great toe on 05/12/11, when the podiatrist identified and treated the blister, or on 05/14/11, when the attending physician ordered the daily application of a topical antibiotic and a dry dressing to the resident's left great toe. The facility also failed to review / revise the resident's care plan to address the need for on-going monitoring of the resident's left great toe and left foot between the date the 05/20/11 episodic care plan was discontinued on 05/27/11 and when the comprehensive care plan was updated on 06/14/11, to note the presence of gangrene and the initiation of comfort measures only. -- 9. In interviews with the administrator, the director of nursing, and the owner on the morning of 08/05/11, they were asked for any additional information to demonstrate the facility's nursing staff had been routinely assessing / monitoring the resident's left great toe from 05/12/11 until gangrene was diagnosed on [DATE], as well as any additional information to reflect the nursing staff had contemporaneously notified the resident's family of changes in the condition of his left foot and when changes were made with medication and treatment orders. The administrator provided evidence of an internal investigation that confirmed a lack of documentation to reflect changes in his left great toe / foot were being routinely assessed / monitored and that staff had failed to notify the family as changes occurred in his left great toe / foot, as well as when changes were made to medication and treatment orders related to the infection. No additional information to the contrary was provided prior to this surveyor's exit on the early afternoon of 08/05/11. .