Every finding on record at Brookhaven Nursing & Rehabilitation Center

Based on medical record review, staff interview, and review of facility, the facility failed to ensure a resident's narcotic medication administration was accurately documented. This affected one (#4) of three residents reviewed for medication administration. The facility census was 87. Findings include: Review of Resident #4's closed medical record revealed an admission date of 06/27/26. Diagnoses listed include fibromyalgia, chronic kidney disease, and joint replacement. Resident #4 was discharged from the facility on 07/01/26. Review of physician orders revealed an order dated 06/27/26 for oxycodone hydrochloride (narcotic pain medication) five milligram (mg) tablet. Give one tablet by mouth every four hours as needed for moderate pain. An order dated 06/27/26 was for oxycodone hydrochloride five mg tablet. Give two tablets by mouth every four hours as needed for severe pain. Review of the scheduled drug log for Resident #4's oxycodone hydrochloride five mg tablets revealed two tablets were documented as being removed on 06/29/26 at 6:20 A.M., 06/29/26 at 4:30 P.M., and 06/30/26 at 1:30 A.M. Review of the medication administration record (MAR) revealed no administrations of two oxycodone hydrochloride five mg tablets being administered on 06/29/26 at 6:20 A.M., 06/29/26 at 4:30 P.M., and 06/30/26 at 1:30 A.M. Further review revealed one five mg tablet of oxycodone hydrochloride was documented as being administered on 06/29/26 at 6:21 A.M. and 06/30/26 at 3:14 A.M. Further review of the scheduled drug log for Resident #4's oxycodone hydrochloride five mg tablets revealed no documentation of one tablet being removed on 06/29/26 at 6:21 A.M. and 06/30/26 at 3:14 A.M. Interview with the Director of Nursing (DON) and Administrator on 07/14/26 at 12;03 P.M. confirmed the discrepancies between Resident #4's scheduled drug log and MAR for oxycodone hydrochloride five mg tablets. Review of the facility's policy titled Medication Administration - General Guidelines dated 10/08/25 revealed the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off duty without first recording the administration of any medications.This deficiency represents non-compliance investigated under Complaint Number 3069233.

Based on medical record review, staff, resident and family interviews and policy review, the facility failed to ensure care conferences were scheduled and conducted quarterly. This affected four (#36, #37, #61 and #85) out of four residents reviewed for care plans. The facility census was 84. Findings include: 1. Medical record review for Resident #36 revealed an admission on [DATE] with diagnosis including but not limited to cerebral atherosclerosis, stage four kidney disease, hypertension. Review of the annual Minimum Data Set for Resident #36 dated 12/29/25 revealed an impaired cognition. Resident #36 was independent for eating, supervision for toileting, transfers and bed mobility. Resident #36 was coded with application of ointments and medication other than to feet. Review of the MDS assessment schedule for Resident #36 revealed quarterly assessments were completed on 10/24/24, 01/21/25, 03/10/25, 05/19/25, 08/13/25, 11/11/25 and an annual on 12/29/25. Review of the plan of care for Resident #36 dated 08/23/24 and revised on 08/30/24 revealed resident at risk for skin breakdown or have a known area of skin breakdown. Interventions include administering treatments/medications as ordered, offloading devices as needed, monitor, document and report to the provider changes in my skin. Review of the electronic health record's interdisciplinary team meeting for Resident #36 revealed one care conference was documented dated 01/17/24. There were no other care conference documented. 2. Medical record review for Resident #37 revealed an admission on [DATE] with diagnoses including but not limited to atrial fibrillation, congestive obstructive pulmonary disease, and chronic pain. Review of the annual MDS assessment dated [DATE] for Resident #37 revealed an intact cognition. Resident #37 was coded as independent for eating and supervision for bed mobility, transfers and toileting. Resident was coded as receiving pain medication during the assessment period. Review of the MDS assessment schedule for Resident #36 revealed an admission assessment was completed on 03/25/25 and 01/30/26 and quarterly assessments were completed on 06/19/25, 08/29/25, 09/23/25, 11/06/25. Review of the plan of care for Resident #37 revealed resident is at nutritional risk due to congestive obstructive pulmonary disease, chronic pain and congestive heart failure. Interventions included monitor for signs and symptoms of dehydration, monitor laboratory results, monitor for decline in eating and assist as needed. Review of the electronic health record's interdisciplinary team meeting for Resident #36 revealed one care conference was documented dated 01/16/2026. Interview on 03/04/26 at 4:00 P.M. with Resident #37 and family verified they have not attended a care conference quarterly. 3. Medical record review for Resident #61 revealed an admission on [DATE] with diagnoses including but not limited to Alzheimer's disease, dementia, and psychotic disturbance. Review of the quarterly MDS for Resident #61 dated 01/27/26 revealed severely impaired cognition. Resident #61 was coded as independent for eating and dependent on staff for toileting, transfers and bed mobility. Review of the MDS assessment schedule for Resident #61 revealed quarterly assessments were completed on 12/17/24, 03/18/25, 09/11/25, 10/30/25, 01/27/26. An annual assessment was completed on 06/12/25. Review of the plan of care for Resident #61 revealed resident at risk for adverse effects/complications due to psychotropic medication due to major depressive disorder with psychotic symptoms. Interventions include monitor behaviors and record q shift, monitor resident for side effects of medication use, notify physician of any adverse side effects and use non-pharmacological interventions and document effectiveness Review of the electronic health record's interdisciplinary team meeting for Resident #61 revealed four care conferences dated 11/08/24, 12/04/24, 03/31/25 and 02/19/26 Additionally, the assessments were noted to all to be in error status. Review of the 02/19/26 assessment revealed the assessment to be incomplete with only the restorative nursing and the nursing section signed. Interview on 03/05/25 at 8:59 A.M. with Resident #61's family verified they have not had care conferences quarterly. 4. Medical record review for Resident #85 revealed an admission on [DATE] with diagnoses including but not limited to acute and chronic heart failure and vascular dementia with behaviors. Review of the quarterly MDS assessment dated [DATE] for Resident #85 revealed an impaired cognition. Resident #85 required set up for eating and moderated assist from staff members for toileting, bed mobility and transfers. Review of the MDS assessment schedule for Resident #85 revealed quarterly assessments were completed on 09/06/24, 11/29/24, 02/19/25, 08/25/25, 11/19/25 and 02/18/26. An annual assessment was completed on 05/12/25. Review of the electronic health record's interdisciplinary team meeting for Resident #85 revealed two care conferences dated 12/04/24 and 02/19/26. Additionally, the assessments were noted to all to be in error status or in progress. Review of the 02/19/26 assessment revealed the assessment to be incomplete with only the restorative nursing and the nursing section signed. Interview on 03/05/25 at 12:30 P.M. with Corporate Registered Nurse (RN) #126 verified the assessments for care conferences were in error, meaning the conference was not complete and/or lacked information and signatures. Additionally, RN #126 verified care conferences for Resident #36, #37, #61 and #85 were not conducted quarterly and should have been. Review of the facility policy titled Resident Assessment dated 11/2003 and revised on 05/2025 revealed the facility failed to implement the policy as written. Number five of the policy states that residents will have the opportunity to discuss their goals for care including their preferences for advance care planning. Number six under the policy that the care plan will include an interdisciplinary team and include the participation of the resident and or resident family. This deficiency represents non compliance investigated under Complaint Number 1321916 (OH00167273).

Based on medical record review, observations and staff interviews, the facility failed to ensure foot care was routinely provided for a diabetic resident. This affected one (#85) of three residents reviewed for foot care. The facility census was 84. Findings included: Medical record review for Resident #85 revealed an admission on [DATE] with diagnoses including but not limited to acute and chronic heart failure, type two diabetes and vascular dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed an impaired cognition. Resident #85 was not coded with behaviors or rejection of care. Resident #85 required set up assistance for eating and moderate assistance for toileting bed mobility and transfers. Review of the plan of care for Resident #85 dated 06/21/24 revealed resident had diabetes mellitus and was insulin dependent. Interventions include blood glucose monitoring as ordered, diet as ordered, administer medication as ordered, check all of body for breaks in skin and treat promptly as ordered by physician. Review of the physicians' orders for Resident #85 for the month of March 2026 was silent for any orders related to nail care. Review of the facility podiatry services consent dated 01/22/25 revealed Resident #85 did not authorize podiatry services to be completed. Review of the weekly nursing skin and body review dated 02/28/26 Resident #85 was assessed from head to toes with no new skin areas noted. Review of the facility podiatry services authorization form dated 03/05/26 revealed Resident #85's durable power of attorney consented for podiatry services to be completed. Observation on 03/04/26 at 3:10 P.M. of Resident #85 attempted to propel herself in a wheelchair in the dining room and bumped into her foot and stating that her foot hurt. Observation on 03/05/26 at 2:00 P.M. of Resident #85's left foot revealed overgrown nails on the third and fourth digit. The nails extended past the end of the toe and curled towards the toe beside them leaving reddened indentions where the nails were touching the opposite toe. Additionally, the great toe was observed to have white colored tissue at the end of the toe, between the great toes and the second digit and along the side of second digit. During the observation staff present questioned Resident #85 and she complained of pain to the area. Interview on 03/05/26 at 4:00 P.M. with Licensed Practical Nurse (LPN) #130 stated an appointment was made for an emergency visit for Resident #85 by the podiatry services. Interview on 03/05/26 at 4:38 P.M. with Administrator verified the facility was unable to locate any documentation that nail care had been provided for Resident #85. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observation, staff interview and policy review, the facility failed to ensure staff followed enhanced barrier precautions as required. This affected one (#34) out of three resident reviewed for infection control. The facility census was 84. Findings include: Medical record review for Resident #34 revealed an admission on [DATE] with diagnoses including but not limited to osteomyelitis of sacral vertebra (spine), peripheral vascular disease and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 revealed an intact cognition. Resident #34 required set up assistance from staff for eating and was dependent on staff for toileting, transfers and bed mobility. Resident #34 was coded for urinary catheter use. Resident #34 was coded as receiving applications of ointment and medications to areas other than the feet during the assessment period. Review of the plan of care for Resident #34 dated 11/18/24 revealed resident at risk for infection related to wounds. Interventions include bag and transport used linen according to facility protocol, preventing skin exposure or contamination, enhanced barrier precautions, and medications and treatments as ordered. Review of the current physicians' orders for Resident #34 revealed an order to cleanse chest wound with saline, apply hydrocolloid paste to wound bed, place alginate over wound the cover with gauze dressing daily dated 11/21/25, an order to cleanse left calf wound with normal saline, apply hydrocolloid paste to wound bed, top with xeroform (non-adhering dressing), secure with abdominal dressing (ABD) pad, and wrap with kerlix dressing daily and as needed dated 02/17/26, cleanse right calf wound with normal saline, apply hydrocolloid paste to wound bed, top with xeroform, secure with ABD pad, and wrap with kerlix dressing daily and as needed dated 02/17/26, cleanse right heel wound with normal saline, apply alginate (debridement dressing) to wound bed and cover with gauze island dressing daily and as needed dated 09/29/25. Observation on 03/03/26 at 4:17 P.M. of door signage from the Center of Disease Control (CDC) on wall beside Resident #34's room revealed one sheet of paper with two stop signs in each corner. Large black lettering in between the stop signs revealed enhanced barrier precautions. Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high contact resident care activities including dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting and device care (central line, urinary catheter, feeding tube, tracheostomy, and wound care to any wound requiring a dressing. Observation on 03/03/26 at 4:17 P.M. of Certified Nurse Assistant (CNA) #107 enter room for Resident #34 without putting on a gown before providing urinary catheter care. CNA #107 explained task to resident, completed hand hygiene and donning gloves. CNA #107 gathered a plastic basin with warm soapy water and placed it on the bedside table without a barrier between the two surfaces. CNA #107 completed urinary catheter care without concerns but laid a cloth towel on the floor and when completed with catheter care tossed the dirty washcloth onto the towel on the floor. CNA #107 emptied the basin with soapy water, completed hand hygiene and donned new gloves. CNA #107 collected a urinal to empty the urinary drainage bag. CNA #107 removed the drainage tubing from the storage sleeve, opened the clamp and drained the contents into a urinal. CNA #107 then reinserted the tip of the drainage tubing back into the storage sleeve on the urinary catheter bag without cleaning the end of the tubing with alcohol. CNA #107 emptied the urinal and storing the urinary in the bathroom. CNA #107 then proceeded to pick up the towel and dirty washcloths from the floor and put them in a plastic bag. CNA #107 then removed a bath blanket from Resident #34's bed that had stains on it from a draining wound dressing and place it into the same bag. The bed clothing came in contact with the CNA #107's uniform. Interview on 03/03/26 at 4:35 P.M. with CNA #107 stated the enhanced barrier sign was not for Resident #34 as there was not a three-drawer chest beside the door with supplies in it for usage. CNA #34 verified there were two red laundry barrels with lids on them and supplied with red bags that were from a previous resident in the other side of the room. CNA #107 verified that he did not use a gown when providing care for Resident #34's catheter linen came in contact with his uniform when he was handling the blanket from the bed. Interview on 03/03/26 at 4:40 P.M. with Registered Nurse (RN) #111 confirmed Resident #34 was on enhanced barrier precautions for wounds and urinary catheter. RN #111 stated the staff should be using gowns when providing catheter care. Observation on 03/03/26 at 4:45 P.M. with RN #111 of the back of Resident #34's door revealed a bag hanging with washable gowns for staff to use for care. Review of the facility policy titled Enhanced Barrier Precautions dated 08/2022 stated staff providing care for residents on enhanced barrier precautions will wear an impervious gown when high contact resident care activities are being performed. High contact areas include bathing, showering, providing hygiene, changing linens, changing attends or assisting with toileting and device care (urinary catheter and wound care). This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observation, staff interviews and policy review, the facility failed to ensure medications were not left at bedside and unsupervised. This affected two (#36 and #37) out of three residents reviewed for medication storage. The facility census was 84. Findings include: 1. Medical record review for Resident #36 revealed an admission on [DATE] with diagnosis including but not limited to cerebral atherosclerosis, stage four kidney disease, hypertension. Review of the annual Minimum Data Set (MDS) for Resident #36 dated 12/29/25 revealed an impaired cognition. Resident #36 was independent for eating, supervision for toileting, transfers and bed mobility. Resident #36 was coded with application of ointments and medication other than to feet. Review of the plan of care for Resident #36 dated 08/23/24 and revised on 08/30/24 revealed resident at risk for skin breakdown or have a known area of skin breakdown. Interventions include administering treatments/medications as ordered, offloading devices as needed, monitor, document and report to the provider changes in my skin. Review of the physician orders for Resident #36 revealed an order for Triamcinolone Acetonide external cream 0.1 % (Topical steroid) apply to affected area lower legs topically two times a day for stasis dermatitis dated 09/13/25. Observation on 03/05/26 at 11:15 A.M. of Resident #36 room revealed a large tub of ointment and two bottles of roll on bio freeze with pharmacy labels on them. Interview on 03/05/26 at 11:21 A.M. with Corporate Registered Nurse (RN) #126 verified the observations and removed the medications from the room. Corporate RN #126 verified the medication should not be in the room unsupervised. 2. Medical record review for Resident #37 revealed an admission on [DATE] with diagnoses including but not limited to atrial fibrillation, congestive obstructive pulmonary disease, and chronic pain. Review of the annual MDS assessment dated [DATE] for Resident #37 revealed an intact cognition. Resident #37 was coded as independent for eating and supervision for bed mobility, transfers and toileting. Resident was coded as receiving pain medication during the assessment period. Review of the plan of care for Resident #37 revealed resident at risk for pain. Interventions include administer medication as ordered, pain assessment as needed and provide non-pharmacological interventions. Review of the physicians' orders for Resident #37 revealed an order dated 02/27/26 for Potassium Chloride extended release oral tablet 20 milliequivalent (meq) give one tablet by mouth one time a day for supplement and an order dated 05/22/25 for hydrocodone-acetaminophen oral tablet 7.5-325 milligram (mg) give 1 tablet by mouth every 6 hours for pain Observation on 03/04/26 at 12:40 P.M. of Resident #37 revealed resident sitting in her room in her wheelchair looking a mobile phone without staff present. Observation on her bedside table revealed a medication cup with two oval white pills and her lunch tray. Interview on 03/04/26 at 12:40 P.M. with Resident #37 stated the pills were left in her room for her to talk with her lunch. Resident #37 stated the medication included a pain pill and a potassium pill. Observation and interview on 03/04/26 at 12:51 P.M. of Corporate RN #126 removed the unsecured medication from the room. RN #126 verified the medication should not be in the room unsupervised and included hydrocodone-acetaminophen oral tablet 7.5-325 milligram (narcotic) pain medication. Review of the narcotic count sheet for resident #37 revealed the hydrocodone-acetaminophen oral tablet 7.5-325 milligram tablet had not been signed out by the nurse at the time of the observation. Interview on 03/04/26 at 12:55 P.M. with Corporate RN #126 verified that the facility staff did not sign out the hydrocodone-acetaminophen oral tablet 7.5-325 milligram on the controlled count sheet and should have. Review of the facility policy titled Medication Storage in the Facility dated March 1996 revealed under number two states only licensed nurses and those lawfully authorized to administer medication are allowed access to medication. Medications are locked or attended by persons with authorized access. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure appropriate urinary catheter care was provided. This affected one (#34) of three residents reviewed for catheter care. The facility census was 84. Findings include: Medical record review for Resident #34 revealed an admission on [DATE] with diagnoses including but not limited to neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 revealed an intact cognition. Resident #34 required set up assistance from staff for eating and dependent on staff for toileting, transfers and bed mobility. Resident #34 was coded for urinary catheter use. Review of the plan of care for Resident #34 revealed resident had a indwelling catheter due to bladder neuromuscular dysfunction. Interventions include catheter care every shift, changing catheter bag as needed and changing catheter per physicians' orders. Observation on 03/03/26 at 4:17 P.M. of Certified Nurse Assistant (CNA) #107 revealed urinary catheter care was provided and on completion of that task CNA #107 gathered a urinal to empty the drainage bag. CNA #107 informed the resident of the task, completed hand hygiene and applied gloves. CNA #107 removed the drainage tubing from the storage sleeve, opened the clamp and drained the contents of the urinary drainage bag into a urinal. CNA #107 then reinserted the tip of the drainage tubing back into the storage sleeve on the urinary catheter bag and emptied the urinal into the commode. The observations revealed CNA #107 did not use an alcohol pad to clean the end of the urinary drainage tubing before reinserting the tubing back into the storage sleeve on the urinary drainage bag. Interview on 03/03/26 at 4:25 P.M. with CNA #107 stated he did not use an alcohol pad to clean the end of the drainage tubing before reinserting the tubing back into the storage sleeve on the urinary drainage bag. Interview on 03/03/26 at 4:30 P.M. with Registered Nurse (RN) #111 verified the CNA should be using an alcohol pad to clean the end of the tubing prior to re-inserting the tubing back into the storage sleeve after emptying the drainage system. Review of the facility skill check list titled Catheter Care and Measuring Urinary Output dated 2009 revealed staff closes drainage outlet and wipes with alcohol pad then reinserted into catheter bag without contaminating it. This deficienc is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observations, staff interview and policy review, the facility failed to ensure activities were provided and documented in the medical record for evening hours. This affected three (#61, #43, #85) of three residents reviewed for activities. The facility census was 84. Findings include 1. Review of the medical record for Resident #61 revealed an admission on [DATE] with diagnoses including but not limited to Alzheimer's' disease, dementia and psychotic disturbances. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #61 dated 01/27/26 revealed an impaired cognition. Resident #61 was independent for eating. Resident #61 was dependent on staff for toileting, bed mobility and transfers. Review of the plan of care for Resident #61 dated 06/28/24 without revision revealed resident's interest included reading magazines, looking at picture books, being outdoors caring for flowers and televisions game shows. Interventions included activities that do not involve overly demanding cognitive tasks, assist and escort to activities, provide activity calendar, provide materials for individual activities and notify resident of any changes to the calendar. Review of the electronic health record for Resident #61 activity participation dated 02/05/26 to 03/05/26 was silent for any activities after 4:30 P.M. 2. Medical record review for Resident #43 revealed an admission date of 10/13/21 with diagnoses including but not limited to frontal lobe and executive function deficit following a stroke. Review of the quarterly MDS assessment dated [DATE] for Resident #43 revealed an impaired cognition. Resident #43 required staff assistance for meal set up and moderate assistance for toileting and transfers of one staff member. Resident #43 was limited assistance for bed mobility. Review of the plan of care for Resident #43 revealed resident was interested in reading, country music, cooking socializing with family and friends being outside in nice weather, holiday crafting and watching television. Interventions include allowing resident to help select movies, encourage participation in groups and establish and record prior levels of activity involvement and interest by talkie with the resident and the family. Review of the electronic health record for Resident #43 activity participation dated 02/05/26 to 03/05/26 was silent for any activities after 4:30 P.M. 3. Medical record review for Resident #85 revealed an admission on [DATE] with diagnoses including but not limited to acute and chronic heart failure, type two diabetes and vascular dementia. Review of the quarterly MDS assessment dated [DATE] revealed an impaired cognition. Resident #85 was not coded with behaviors or rejection of care. Resident #85 required set up assistance for eating and moderate assistance for toileting bed mobility and transfers. Review of the quarterly activity progress note dated 02/19/26 for Resident #85 revealed the resident participates in group programs daily. Resident #85 needs verbal invites and transported to activity. Resident #85 has impaired cognition, memory loss, and hallucination. Review of the electronic health record for Resident #85 activity participation dated 02/05/05 was silent for any activities after 4:30 P.M. Review of the facility March activity calendar revealed nail care was scheduled for 03/04/26 at 2:00 P.M. and snacks and hydration at 3:00 P.M. in the memory care unit. Observation on 03/04/26 at 2:35 P.M. of the memory care unit revealed no organized activity being conducted. Observation on 03/04/26 at 3:11 P.M. of the Activity Staff #151 enter the memory care and ask a resident if she would like to have her nails trimmed and painted. Interview on 03/05/26 at 10:30 A.M. with Activity Staff #152 verified the activity scheduled on the calendar was currently being organized. Activity Staff #152 stated the activity staff present in the facility usually included two staff members and they only worked until 4:30 P.M. every day, including Saturday and Sunday. Activity Staff #152 stated the facility had movies available in a drawer on the unit and snacks from the kitchen were in the unit pantry. Interview on 03/06/26 at 11:07 A.M. with Activity Staff #151 verified the schedule for activities in the memory unit were not followed on 03/04/26. Activity Staff #151 stated the snack and hydration activity was not carried out as scheduled. Activity Staff #151 stated she had to leave by 4:30 P.M. and did not have time to complete the activity. Interview on 03/06/26 at 11:38 A.M. with Activity Director #160 verified the activity participation documentation was silent for any documentation after 4:30 P.M. Activity Director #160 verified the activity calendar had an activity titled sensory boxes on the March 2026 scheduled 23 times and scheduled at 6:30 P.M. and movie and snack activity was scheduled 9 times in the month of March 2026 at 6:30 P.M. No other types of activity were scheduled in the month of March 2026 for residents residing in the memory care area. Activity Director #160 stated the floor staff working in the memory care unit are assigned to complete the activity and document the participation. Activity Director #160 verified she did not monitoring the charting to ensure staff were documenting resident participation. Review of the facility policy titled Activities Policy dated 05/2003 and revised on 2017 revealed under letter f, the records are maintained by the activity coordinator to include the individual participation documentation. This deficiency represents non compliance investigated under Complaint Number 1321916 (OH00167273).

Based on medical record review, staff and Nurse Practitioner (NP) interviews, and facility policy review, the facility failed to monitor and document residents' bowel movements. Additionally, the facility failed to implement their bowel protocol when a resident did not have a bowel movement. This affected one (#93) of three resident reviewed for bowel protocol procedure. The facility census was 84. Findings include: Medical record review for Resident #93 revealed and admission on [DATE] and a discharge date to the hospital on [DATE] with diagnoses including but not limited to type one diabetes, epilepsy, history of myocardial infarction, and neurocognitive disorder with Lewy body (progressive cognitive decline) dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed an impaired cognition. Resident #93 was coded with rejection of care one to three days during the assessment period. Resident #93 required supervision for eating, moderate assistance for bed mobility. Resident #93 is dependent for toileting and transfers. Review of the plan of care for Resident #93 revealed the resident had increased nutrition and hydration needs related to Lewy body disorder, dementia with disturbances, type one diabetes, constipation, kidney disease stage three and sepsis. Interventions include monitoring for signs and symptoms of dehydration, monitor laboratory results, monitor weights as needed, monitor for decline in eating ability, monitor and report to physician refusals to eat or signs and symptoms of difficulty swallowing. Review of the physicians' orders for Resident #93 revealed a consistent carbohydrate diet, mechanical soft texture with regular consistency dated 01/06/2026, an order for Dulcolax rectal suppository 10 milligram (mg), insert one suppository rectally every 12 hours as needed for constipation dated 12/09/25 and order for Boost glucose control nutritional supplement two times a day initiated on 12/15/25. Review of the discontinued physician orders for Resident #93 revealed an order for MiraLax oral powder 17 grams (gm) per scoop (laxative) give 1 scoop by mouth every 24 hours as needed for constipation initiated on 12/09/25 and discontinued on 01/26/26 and an order for Colace (stool softener) oral capsule 100 milligrams (mg) give one capsule by mouth every twelve hours as needed for constipation initiated on 12/09/25 and discontinued on 01/26/26, an order for Senna oral tablet 8.6 mg one tablet every 12 hours as needed for constipation initiated on 12.09/25 and discontinued on 01/26/26. Review of the Medication administration record for the month of February 2026 was silent for any medication administration for treatment of constipation. Review of the facility Certified Nursing Assistant (CNA) documentation for bowel movement monitoring dated 02/03/26 to 02/11/26 was silent for any documentation of bowel movements. Review of the progress notes for Resident #93 dated 02/03/26 to 02/11/26 was silent for any documentation of bowel movements. Review of NP #125 visit note dated 02/04/26 for Resident #93 revealed the reason for the visit was a follow up related to rash on truck. Resident #93 was nonverbal but denied any acute concerns. Resident #93 continues to intermittently refuse her accu check and insulin. Physical exam revealed no acute distress with abdomen charted as soft with positive bowel sounds in all four quadrants and without masses. Interview on 03/04/25 at 3:00 P.M. with Registered Nurse (RN) #111 verified the electronic health record was silent for any documentation for Resident #93 bowel movements after 02/03/26. RN #111 stated staff should be charting everyday if they have a bowel movement or not. RN #111 stated the electronic health record should have triggered an alert for staff to conduct an assessment and provided a laxative if needed. RN #111 verified the physician was not notified of the lack of bowel movements. Interview on 03/04/26 at 4:10 P.M. with Administrator verified the facility staff did not implement the bowel movement protocol when Resident #93 did not have a bowel movement. Additionally, the Administrator verified bowel movements were not charted in the electronic health record on a daily basis for Resident #93, and after three consecutive days the facility failed to administer any as needed laxatives. Interview on 03/05/25 at 2:11 P.M. with NP #125 stated she was not notified that Resident #93 was not having bowel movements. Review of the facility policy titled Bowel Movement Protocol dated 04/2025 revealed the facility failed to implement the policy as written. The policy states bowel movements are documented every shift in point of care, bowel movements are monitored daily and as needed, if a resident does not have a bowel movement for three consecutive days, consider an ass needed or notification to the physician. This deficiency represents non compliance investigated under Complaint Number 2790056.

Based on observation, record review, and interview, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 91 residents who received meals in the facility. The facility identified Resident #13, #39 and #74 as receiving no food and drink from the kitchen. The facility census was 94. Findings include: Observation on 11/18/24 at 8:58 A.M. and 11/20/24 at 11:19 A.M. revealed a tacky substance on the hoses and a dark substance on the nozzles that connect to juice boxes. Interview on 11/20/24 at 11:19 A.M. with Dietary Director #172 confirmed a tacky substance on the hoses and the presence of a dark substance on the nozzles that connect to the juice boxes. Interview on 11/20/24 at 11:19 A.M. with Corporate Dietician #135 confirmed a tacky substance on the hoses and the presence of a dark substance on the nozzles that connect to the juice boxes. Record review of document titled, Monthly Kitchen Deep Clean, not dated, revealed Dietary and Maintenance will work in combination on a pre-scheduled evening to clean equipment.

Based on medical record review, observation, and staff interview, the facility failed to timely address concerns with a resident's feeding tube. This affected one (#39) of two residents reviewed for feeding tubes. The census was 94. Findings include: Review of Resident #39's medical record revealed an admitted [DATE]. Diagnoses listed included abnormal weight loss, Parkinson's disease, bipolar disorder, dementia, and dysphagia. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severe cognitive impairment, had a feeding tube, and was receiving Hospice services. Review of nursing notes revealed on 11/02/24 at 9:08 P.M. Resident #39's feeding tube was clogged. After unclogging the feeding tube it was noticed that the feeding tube was dark almost black in color and had a foul odor. Feeding tube was flushed repeatedly and a new dressing place. A note was left for physician in the physician communication book. On 11/08/24 at 5:56 A.M., Resident #39's feeding tube was black and had a foul odor even after flushing. Feeding tube was not clogged and working properly. A note would be left for physician in the physician communication book. On 11/09/24 at 1:28 A.M., Resident #39's feeding tube was black and had a foul odor even after flushing. Attempted to be flushed again with no change in appearance. A note would be left for physician again. On 11/13/24 at 4:59 A.M., Resident #39's feeding tube was black and had a foul odor. A note would be left for physician and reported to oncoming nurse. Feeding tube was flushed and feed given as ordered. On 11/13/24 at 5:01 A.M., the Hospice on call physician was notified about Resident #39's feeding tube. Further review of Resident #39's medical record revealed no documentation of feeding tube concerns being addressed by physician, Nurse Practitioner (NP), or Hospice staff. Observation of Resident #39's feeding tube on 11/20/24 at 11:49 A.M. revealed it was black in color. Interview with Licensed Practical Nurse (LPN) #185 on 11/20/24 at 11:54 A.M. revealed Resident #39's feeding tube was black in color when he was admitted . Interview with the Director of Nursing (DON) on 11/21/24 at 9:42 A.M. confirmed concerns with Resident #39's feeding tube were not addressed by the facility physician, NP, or Hospice staff.

Based on observation, staff interviews, and policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for two residents. This affected two (Residents #75 and #138) of four reviewed for infection control. The facility census was 94. Findings include: 1. Review of the Medical Record for Resident #75 revealed an admitted [DATE] with diagnoses of Parkinsonism, dementia, and neuromuscular dysfunction of the bladder. Review of Resident #75's medical record revealed no documentation for EBP. Observation on 11/18/24 at 3:30 P.M. of Resident #75 revealed the resident had a suprapubic catheter. Observation revealed there were no gowns or gloves available, and there was no sign to advise staff resident was in EBP. Observation on 11/21/24 at 3:00 P.M. revealed Resident #75 with suprapubic catheter to abdomen, with no EBP in place. 2. Review of the Medical Record for Resident #138 revealed an admitted [DATE] with diagnoses of acute kidney failure, end stage renal disease, and dependence on renal dialysis. Review of Resident #138's medical record revealed no documentation for EBP. Observation on 11/19/24 at 8:44 A.M. of Resident #138 revealed the resident had a dialysis catheter located on the right upper chest. Observation revealed there were no gowns or gloves available, and there was no sign to advise staff resident was in EBP. Interview on 11/19/24 2:41 P.M. with Licensed Practical Nurse (LPN) Unit Manager/Infection Preventionist (IP) #212 confirmed all residents with foleys, ostomies, wounds, picc lines, and dialysis catheters should all be in EBP at a minimum. Observation on 11/21/24 at 2:58 P.M. revealed Resident #138 with dialysis catheter to right upper chest area, with no EBP in place. Interview on 11/21/24 at 3:03 P.M. with LPN/IP #212 confirmed Resident #138 had a dialysis catheter to right upper chest area, with no EBP in place. Interview also confirmed Resident #75 with suprapubic catheter to abdomen, with no EBP in place. Interview also conformed Resident #75 and Resident #138 should have been in EBP. Review of the EBP list provided to the survey team on 11/18/24, undated, revealed Resident #75 and Resident #138 were not listed on the list. Interview on 11/21/24 at 3:30 P.M. with the Director of Nursing (DON) confirmed Resident #75 and #138 was not listed on the Enhanced Barrier Precautions list provided to the survey team on 11/18/24 and confirmed Residents #75 and #138 were not care planned for EBP. Review of the Enhanced Barrier Precautions policy dated 08/2022, revealed EBP may be considered for indwelling medical devices (central line, urinary catheter, feeding tube, tracheostomy /ventilator). Gloves and gowns would be utilized for residents on EBP.

Based on record review, staff interview, and policy review, the facility failed to administer medications per physician orders. This affected one (Resident #57) of four residents reviewed for medication administration. The facility census was 94. Findings include: Review of the medical record for Resident #57 revealed an admitted [DATE] with diagnoses of malignant neoplasm of right kidney, anemia in chronic kidney disease, and unspecified atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, was independent with eating, required set-up assistance with oral hygiene, required supervision with wheelchair mobility, required partial assistance with bed mobility, and required substantial assistance with toileting hygiene, bathing, and dressing. Review of the Medication Administration Record (MAR) for Resident #57 for November 2024 revealed Potassium Chloride ER Capsule Extended Release (Potassium Chloride) 20 mEq was ordered, but the facility had Potassium Chloride ER Oral Tablet Extended Release (Potassium Chloride) 20 mEq in stock for the resident. Review of the physician orders revealed an order dated 09/09/24 to crush medications with applesauce or pudding two times a day for preventative and an order dated 10/08/24 for Potassium Chloride ER Oral Capsule Extended Release (Potassium Chloride) give 20 mEq by mouth one time a day. Observation on 11/19/24 at 8:35 A.M. with Licensed Practical Nurse (LPN) #188 confirmed during medication administration, Potassium Extended Release 20 mg 1 tab was held due to medication is not crushable. Interview on 11/19/24 at 8:35 A.M. with Licensed Practical Nurse (LPN) #188 confirmed the resident has an order to crush medications due to a swallow evaluation result. Interview on 11/19/24 at 10:02 A.M. with Licensed Practical Nurse (LPN) #188 confirmed the resident has had her medications crushed the whole month of November per the MAR and that the Potassium Chloride ER Oral Tablet Extended Release (Potassium Chloride) 20 mEq has been administered every day in November 2024, except this morning due to needing a crushable form of the medication. Interview on 11/19/24 at 10:58 A.M. with LPN #188 and Director of Nursing (DON) confirmed there was a Fax Form for Non-Emergency Communications dated 10/05/24 and signed by the Nurse Practitioner (NP) on 10/07/24 approving Potassium Chloride ER Oral Capsule Extended Release (Potassium Chloride) 20 mEq crushable, and that the order was processed but not initiated. Review of the Medication Administration - General Guidelines policy, dated 01/17/24 revealed medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube fed. Long-acting or enteric-coated dosage forms should generally not be crushed, and an alternative should be sought.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a resident's emergency contact was notified of a fall and a change in condition. This affected one (Resident #3) of three reviewed for notification of changes. The facility census was 91. Findings include: Review of Resident #3's closed medical record revealed an admitted [DATE]. Diagnoses included muscle weakness, vascular dementia, heart failure, and pleural effusion. Resident #3 was transferred to a local hospital on 04/07/24 and did not return to the facility. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10. Review of the progress notes dated 04/06/24 at 3:46 P.M. revealed Resident #3 was found by an State tested Nursing Assistant (STNA) sitting upright on the floor next to his bed with his wheelchair next to him. The wheelchair was locked and Resident #3 was wearing gripper socks. Resident #3 stated he was standing to transfer from his wheelchair to his bed and his feet slipped out from under him causing him to slide to the floor landing on his bottom. Resident #3 denied any head injury. Resident #3's physician and son were notified. Resident #3's son was not listed as an emergency contact. Review of the neurological checks conducted post-fall revealed Resident #3's level of consciousness (LOC) had declined from one (alert wakefulness: responds quickly and appropriately) on 04/07/24 at 3:15 A.M. to a two (drowsy/lethargic: responds to stimuli appropriately, but with delay and slowness) on 04/07/24 at 7:15 A.M. Resident #3's LOC was documented as two on 04/07/24 at 11:15 A.M. and 3:15 P.M. The progress notes dated 04/07/24 at 1:28 P.M. revealed Resident #3 was increasing lethargic and drowsy. Resident #3's blood pressure was trending low. There was no documentation of Resident #3's emergency contact being notified of the decline in LOC until 04/07/24 at 7:50 P.M. when Resident #3's emergency contact came to the facility and had concerns about Resident #3's hallucinations and twitching. Resident #3 was sent the the emergency room (ER) for evaluation. Interview on 05/08/24 at 11:20 A.M. with the Director of Nursing (DON) and Register Nurse (RN) #75 revealed when Resident #3 fell on [DATE], Licensed Practical Nurse (LPN) #50 was the nurse assigned to his care. A family member came to visit Resident #3 on 04/06/24 after his fall and LPN #50 at first believed this family member was the Resident #3's emergency contact. When discussing Resident #3's fall with this family member, she discovered he was not the emergency contact. LPN #50 thought she heard this family member talking to the listed emergency contact on the telephone. LPN #50 did not call Resident #3's listed emergency contact about the fall on 04/06/24. Telephone interview with LPN #50 on 05/08/24 at 1:36 P.M. revealed she was the nurse caring for Resident #3 when he fell on [DATE]. A family member came to visit Resident #3 right after the fall on 04/06/24. LPN #50 talked with this family member about fall interventions and thought the family member had spoken with Resident #3's emergency contact about Resident #3's fall. LPN #50 confirmed the family member she had spoken with on 04/06/24 was not Resident #3's listed emergency contact. LPN #50 stated that Resident #3 was lethargic the next day (04/07/24) and had called Resident #3's physician. LPN #50 did not call Resident #3's emergency contact about Resident #3's decline in LOC on 04/07/24. Review of the facility's policy titled Notification of Changes Policy, revised 11/02/16, revealed the facility will inform the resident, the attending physician and the resident's representative or interested family member of changes which affect the resident. The facility must inform the resident immediately, the attending physician and the resident's representative or interested family member when there is: An accident involving the resident, which may or may not result in injury. A significant change in the resident's physical, mental or psychosocial status. A need to alter treatment significantly. A decision to transfer or discharge the resident from the facility. This deficiency represents non-compliance investigated under Complaint Number OH00153323.

Based on medical record review, observations, and staff interview, the facility failed to accommodate residents needs by ensuring call lights were within reach of residents. This affected two (#16 and #17) of three reviewed for call lights. The census was 80. Findings include: 1. Review of Resident #17's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #17 was assessed as being severely cognitively impaired, requiring extensive assistance with activities of daily living (ADL's), and as receiving Hospice services in an admission Minimum Data Set (MDS) assessment dated [DATE]. Observation of Resident #17 on 02/15/22 at 10:11 A.M. revealed her call light was not in reach. Resident #17 was lying in bed with eyes closed. Two call light cords were observed hanging on the wall to the right side at the foot of the resident's bed. One of the the call lights was a soft touch and the other was a push button. 2. Review of Resident #16's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #16 was assessed as being severely cognitively impaired, requiring extensive assistance with activities of ADL's, and as receiving Hospice services in a quarterly MDS assessment dated [DATE]. Observation of Resident #16 on 02/15/22 at 10:14 A.M. revealed her call light was not in reach. Resident #16 was in a geriatric (Geri) chair to the left side of her bed. Further observations revealed Resident #16's call light cord was attached to the left side of her bed out of her reach. Interview with Registered Nurse (RN) #190 on 02/15/22 at 10:25 A.M. revealed both Resident #16 and Resident #17 were capable of using their call lights. Observation and interview with State tested Nursing Assistant (STNA) #120 on 02/15/22 at 10:25 A.M. confirmed Resident #16's and Resident #17's call lights were not within reach. This deficiency substantiates Complaint Number OH 837.

Based on observation, record review and interview, the facility failed to store and serve food in accordance with professional standards for food safety. This had the potential to affect 78 residents who received meals in the facility. The facility census was 78. Findings include: Observation of the kitchen on 08/30/21 at 08:28 A.M. revealed a tray of chocolate pudding and vanilla pudding dated 08/23/21. Seven gallons of drinks marked tea, prune juice, and lemonade were not dated. The next cooler contained eight glasses of poured dinks. The drinks were not labeled or dated. Review of the facility food temperature log revealed on 08/02/21, 08/19/21, and 08/20/21 the facility did not record any food temperatures for the meals served on that day. On 08/03/21, 08/04/21, 08/05/21, 08/08/21, 08/09/21, 08/10/21, 08/11/21, 08/12/21, and 08/13/21, the facility did not record any food temperatures of the evening meal. During interview on 08/30/21 at the time of the observations, Registered Dietitian (RD) #500 during the initial tour of the kitchen confirmed the pudding were labeled and dated 08/23/21 and the drinks were not dated. RD #500 also verified the food temperate logs were incomplete. During observation on 09/01/01 at 11:20 A.M. of kitchen of food prep and tray line, Dietary Manger (DM) #355 check the temperature of a piece of cooked chicken without cleaning the thermometer. DM #355 used the same food thermometer to check the temperature of a cooked hamburger without sanitizing the food thermometer. DM #355 donned plastic gloves and attempted to separate raw frozen beef patties. Without removing the gloves, DM #355 opened a drawer and pulled out a utensil to separate the frozen raw beef patties. DM #355 went back to the raw beef patties and attempt to separate without washing her hands or changing her gloves. During interview on 09/01/21 at 11:20 A.M., DM #355 stated she did not sanitize the thermometer in between food items and did not change her gloves while working with the raw beef patties. She stated thought it was okay not to remove her gloves, because cooking the hamburger would kill the germs. She said she would go back later and clean the drawer she touched with the gloves on. During observation on 09/01/21 at 12:00 P.M. the top of the trash can was soiled with splashes of dried stains and food debris. There was a dried grease like substance on the bottom of a food prep table with stacked clean dishes. The top of the food tray line shelf contained bottles of spices that was dirty with food particles and droppings. Review of the facility cleaning log notebook revealed a cleaning schedule for each day of the week. The kitchen was last documented as cleaned on 08/12/21. This was verified by RD #500. During interview 09/01/21 at 12:00 P.M. RD #500 verified the above findings and verified the kitchen was last documented as being clean on 08/12/21. During interview on 09/02/21 at 1:31 P.M., RD #500 stated she was unable to provide a policy regarding labeling and discarding food or the kitchen cleaning schedule.

Based on medical record review, observation, and staff interview, the facility failed to provide adaptive equipment as ordered. This affected one (Resident #12) of two residents reviewed for use of adaptive equipment. The facility census was 78. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE]. Diagnoses included [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)] following unspecified [CONDITION(S)] disease affecting left non-dominant side. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required extensive assistance of one staff for eating. Review of the care plan dated 03/10/21 revealed the resident required a divided plate to aid in self-feeding. Review of the nutrition services progress note dated 03/10/21 revealed the resident was able to feed herself at times and a divided plate would be provided with meals. Review of the nutrition services progress note dated 08/26/21 revealed a divided plate was provided to aid in self-feeding. During observation on 08/30/21 at 12:03 P.M., Resident #12 was seated in a wheelchair by herself at a table in the dining room. The resident was attempting to scoop mashed potatoes from a regular, non-divided plate with a spoon. The mashed potatoes were pushed off the left side of the plate as the resident attempted to place the food onto the spoon. The resident then picked up the mashed potatoes from the table with her fingers and placed them in her mouth. Review of Resident #12's meal ticket on 08/30/21 at 12:06 P.M. stated she needed a divided plate. During interview on 08/30/21 at 12:12 P.M., State tested Nursing Assistant (STNA) #322 verified Resident #12 did not have a divided plate and was pushing her food off the plate as she was attempting to scoop the food. STNA #322 stated dietary staff are supposed to provide adaptive equipment when preparing the meal tray. During observation on 08/31/21 at 12:21 P.M., Resident #12 was laying in her bed attempting to eat a pureed sandwich. The food was not served on a divided plate. Resident #12 picked up the pureed food from the plate with her fingers. During interview on 08/31/21 at 12:29 P.M., Registered Nurse (RN) #358 verified the resident did not have a divided plate.

Based on review of infection control logs, staff interview and policy review, the facility failed to have an adequate antibiotic stewardship program in place to ensure proper antibiotic usage as required. This had the potential to affect all 96 residents residing in the facility. Facility census was 96. Findings include: Review of infection control logs/surveillance information for (MONTH) 2019 revealed multiple missing areas of documentation which included; a lack of all organism being tracked to ensure adequate trending to identified and prevent the spread of infections. Further review of the antibiotic use was not completed to ensure it appropriately use for the identified infection to meet the requirements for antibiotic stewardship program on a consistent basis. Review of infection control logs/surveillance information for (MONTH) 2019 revealed no organism were identified tracked and trended to identified and prevent the spread of infections. There was documentation of percentages of antibiotic used and percentages of infections. There was a color coded map of infection but no documentation again of organism to ensure tracking and trending was accurate. Further review of the antibiotic use was not completed to ensure it appropriately use for the identified infection to meet the requirements for antibiotic stewardship program on a consistent basis. Review of infection control log/surveillance for (MONTH) 2019 lacked any documented information related to infections, organisms or antibiotic use. On 11/20/19 at 4:27 P.M. an interview Infection Preventionist #200 with revealed he acquired the infection control position in (MONTH) 2019. He then verified (MONTH) 2019 infection control logs/surveillance were incomplete to ensure proper tracking and trending of infections. He then verified he does not have the log started for (MONTH) 2019 to ensure proper tracking and trending of infections. Infection Control Preventionist #200 verified the Antibiotic Stewardship Program to monitor the use for the antibiotic is not being followed up on when ordered per the physician to ensure it is prescribed for the proper organism or type of infection on a consistent basis following McGeer's criteria for (MONTH) 2019 and (MONTH) 2019. He also revealed he was just starting to review antibiotic use, and track and trend infections for (MONTH) 2019 but had no documentation to provide. The facility confirmed this had the potential to affect all 96 residents residing in the facility. Review of policy and procedure for antibiotic stewardship dated 10/17/19 documented the review of antibiotics is a vital aspect of the infection prevention and control program. Further review revealed surveillance of antibiotic use is ongoing to include trends, outcome and patterns will be conducted. The facility will review the use of antibiotics for the appropriateness.

Based on review of the infection control logs, staff interview and policy review, the facility failed to have an adequate infection control surveillance program in place to ensure proper monitoring as required. This had the potential to affect all 96 residents residing in the facility. Facility census was 96. Findings include: Review of infection control logs/surveillance information for (MONTH) 2019 revealed multiple missing areas of documentation which included; a lack of all organism being tracked to ensure adequate trending to identified and prevent the spread of infections. Further review of the antibiotic use was not completed to ensure it appropriately use for the identified infection to meet the requirements for antibiotic stewardship program on a consistent basis. Review of infection control logs/surveillance information for (MONTH) 2019 revealed no organism were identified tracked and trended to identified and prevent the spread of infections. There was documentation of percentages of antibiotic used and percentages of infections. There was a color coded map of infection but no documentation of organism to ensure tracking and trending was accurate. Further review of the antibiotic use was not completed to ensure it appropriately use for the identified infection to meet the requirements for antibiotic stewardship program on a consistent basis. Review of infection control log/surveillance for (MONTH) 2019 lacked any documented information related to infections, organisms or antibiotic use. On 11/20/19 at 4:27 P.M. and interview with Infection Preventionist #200 revealed he acquired the infection control position in (MONTH) 2019. He then verified the (MONTH) 2019 infection control logs/surveillance were incomplete to ensure proper tracking and trending of infections. He then verified he does not have the log started for (MONTH) 2019 to ensure proper tracking and trending of infections. Infection Preventionist #200 verified the Antibiotic Stewardship Program to monitor the use for the antibiotic is not being followed up on when ordered per the physician to ensure it is prescribed for the proper organism or type of infection on a consistent basis following McGeer's criteria for (MONTH) 2019 and (MONTH) 2019. He also revealed he was just starting to review antibiotic use, and track and trend infections for (MONTH) 2019 but had no documentation to provide. The facility confirmed this had the potential to affect all 96 residents residing in the facility. Review of policy and procedure for infection control overview revised 11/02/16 documented the primary purpose for of the infection control plan was to establish guidelines to follow in preventing, identifying, reporting, investigating, and controlling the spread of contagious, infection or communicable diseases.

Based on medical record review and staff interview, the facility failed to ensure a resident's advance directives matched in the electronic and hard copy medical record. This affected one (#47) of two residents reviewed for advance directives. The census was 96. Findings include: Review of Resident #47's medical record revealed an admitted d of 11/14/17. [DIAGNOSES REDACTED]. Review of Resident #47's electronic medical record revealed an order for [REDACTED]. Review of Resident #47's hard chart medical record revealed a page located under the advance directives tab that contained Resident #47's name and statement of full code status. Interview with the Director of Nursing (DON) on 11/20/19 at 8:00 [NAME]M. confirmed Resident #47's electronic and hard chart medical directives did not match. The DON confirmed this would cause confusion during an emergency situation.

Based on medical record review and staff interview; the facility failed to complete a level one preadmission screening and resident review (PASRR) prior to the 30th day following admission to the facility from the hospital. This affected one (#75) of one resident reviewed for preadmission screening and resident review. The census was 96. Finding include: Review of the medical record for Resident #75 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the medical record for Resident #75 revealed a document titled, Hospital Exemption from Preadmission Screening Notification dated 10/19/19. Review of the document revealed the nursing facility accepted the admission of Resident #75 only after receipt and review of this notification form for 100 percent accuracy and completion. Further review of the document revealed the nursing facility accepted responsibility for requesting a resident review prior to the 30th day following admission from the hospital. Interview on 11/19/19 at 1:16 P.M. with social service director (SSD) #250 revealed the SSD was not aware of Resident #75's need for a level one prescreening. SSD #250 verified the level one PASRR was not completed prior to the 30th day following Resident #75's admission to the facility from the hospital.

Based on medical record review, observations, interviews, review of a facility policy and review of information from National Pressure Ulcers Advisory Panel (NPUAP), the facility failed to implement pressure ulcer preventative measures and failed to identify a pressure ulcer at an early stage resulting in actual harm to Resident #282 who developed an avoidable Stage 3 pressure ulcer on the coccyx. Additionally, the facility failed to accurately assess and monitor Resident #52's pressure ulcer on the right heel. This affected two Residents (#282 and #52) of four residents reviewed for pressure ulcers. The facility identified seven residents who have pressure ulcers. The facility census was 119. Findings include: 1. Review of the medical record for Resident #282 revealed the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the physicians order dated 03/02/16 revealed the resident had an order for [REDACTED].#282's Braden Scale for Predicting Pressure Sore Risk dated 03/02/16 the resident was at moderate risk for pressure ulcer development related to being slightly limited with sensory perception, he is very moist, the resident is chairfast, very limited with mobility, nutrition is probably inadequate and there is a potential problem with friction/ shearing. Review of a document entitled, Skin Assessment Admission and Weekly Head to Toe dated 03/02/16, revealed there was no pressure ulcers noted on the resident's coccyx or other skin locations upon admission. Review of the admission minimum data set 3.0 (MDS) section M dated 03/08/16 revealed the resident was at risk for development of a pressure ulcer; however, the resident did not have any current pressure ulcers. Review of Resident #282's comprehensive care plan dated 03/11/16 revealed the resident had potential/ actual impairment to skin integrity related to fragile skin. Resident #282's care plan identified to notify the nurse immediately of any new areas of redness, blisters, bruises, discoloration noted during bath/ daily care; however, the care plan did not address the need for ongoing weekly skin assessment and/ or skin monitoring as ordered by the physician. Further review of the medical record revealed there was no weekly skin assessments conducted after Resident #282's admission until 03/15/16. Review of the document entitled Ulcer Tracking Tool dated 03/15/16, revealed the discovery of a stage three pressure ulcer to the coccyx of Resident #282 measuring 2.3 centimeters (cm) in length by 1.3 cm in width by 0.1 cm in depth with slough noted. Further review of the Ulcer Tracking Tool revealed a new order to cleanse the wound, apply hydrogel and a foam dressing; however, there was no frequency to the dressing change order. Additional review of a document titled, Order Summary Report dated 03/15/16 and 03/16/16 and review of the Treatment Administration Record (TAR) for March 2016, revealed no physician order for [REDACTED].>Observation on 03/16/16 at 8:50 A.M. revealed state tested nursing assistant (STNA) #195 was providing catheter care for Resident #282. During the observation a bordered foam dressing was intact to the residents coccyx. Observation of Resident #282's coccyx pressure ulcer on 03/17/16 at 10:21 A.M. with certified nurse practitioner (CNP) #510. The observation revealed the presence of a pressure ulcer on Resident #282's coccyx that measured 1.5 cm in length by 0.8 cm in width by 0.1 cm in depth with a 50% yellow colored film noted to the wound bed, CNP #510 stated the yellow colored film was slough. The coccyx peri wound was observed to be red in color. Resident #282 voiced complaints of pain during the dressing removal. During the observation CNP #510 stated Resident #282's coccyx wound was unstageable. Interview with STNA #195 on 03/16/16 at 1:31 P.M. revealed a head to toe assessments is completed by the STNA's daily. If a new skin area is found it is reported to the residents nurse. During the interview, STNA #195 stated the last day she worked with Resident #282 was on 03/11/16 and the resident did not have an open area on the coccyx; however, redness was noted to the area. STNA #195 stated a house barrier cream was to be applied to Resident #282's coccyx with every incontinent episode. Interview with LPN #5 on 03/16/16 at 1:42 P.M. revealed the last time he assessed the coccyx area of Resident #282, the coccyx was noted to be red and blanchable. LPN #5 stated he could not recall the exact date but he thought it was 03/04/16. LPN #5 revealed when a resident is admitted to the facility a body assessment is completed on admission and then every seven days. LPN #5 confirmed Resident #282 was scheduled for skin and Braden assessments every Saturday on third shift. LPN #5 confirmed no documented skin or Braden assessments were completed for Resident #282 on 03/05/15 or 03/12/16. Information from the NPUAP was reviewed. According to the NPUAP a stage 3 pressure ulcer is a full thickness loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, there may be undermining and tunneling, the depth of a Category/Stage III pressure ulcer varies by anatomical location. Additionally, the NPUAP identified an unstageable pressure ulcer as a full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed, until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. 2. Review of the medical record for Resident #52 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan initiated 08/05/15 revealed the resident was at risk for impaired skin integrity related to fragile skin with goal of keeping skin intact through next review date. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #52 as having a brief interview for mental status score of 15 making her cognitively intact for interview. Also at this time she was assessed at risk for pressure area with no current areas present during the look back period. She was also assessed as having preventative skin treatments in place. Review of the weekly skin assessment dated [DATE] documented a pressure area to the right heel measuring two centimeters (cm) by five centimeters with no depth or staging of the area. Review of the weekly skin assessments dated 02/29/16, 03/04/16 and 03/12/16 documented a pressure area to the right heel with no staging measurements or description of the area. Review of the nurses note dated 02/23/16 documented a pink blanchable area to the heel. In addition a new order was received to apply skin prep every shift and float heels while in bed. Review of the nurses note dated 02/24/16 documented a pressure area was noted to the right heel with no complaints of pain. On 03/15/16 at 3:50 P.M. interview with Resident #52 denied any pain to her right heel. She stated the nurses have been using a wipe on her right heel area. She also stated approximately three weeks ago the nurses stopped using ace wraps on her legs for the swelling and started using her a special pillow to keep her heels of the bed at night. On 03/15/16 at 4:30 P.M. interview with Registered Nurse (RN) Supervisor #78 verified he and another nurse round with the wound practitioner on a weekly basis. He verified he was unaware of Resident #52 having any current pressure ulcers. He stated the resident was not on his current list of residents with pressure areas. He reviewed Resident #52's medical record and verified nursing staff had documented a pressure area to the right heel without an appropriate assessment of the area. On 03/15/16 at 4:45 P.M. an observation was made of Resident # 52's pressure area on her right heel. At this time it was verified with RN Supervisor #30 Resident #52 had an unstageable pressure area to her right heel measuring 1 cm by 1 cm covered with hard eschar and right next to the area was a stage one nonblanchable reddened area measure 0.7 cm by 0.8 cm. On 03/16/16 at 10:00 A.M. an observation was made of Resident #52's pressure area to her right heel with Licensed Practical Nurse (LPN) #165 who reported the dry eschar came off this morning with the skin prep treatment. The are appeared dark pink and was non blanchable at this time. On 03/17/16 at 4:17 P.M. interview with LPN #33 verified she found an area on Resident #52's right heel approximately three weeks ago. She stated she couldn't remember what the area looked like but verified it was a pressure area. She also stated she notified the wound team to follow up with Resident #52's pressure area. She verified her follow up weekly assessments completed on 02/29/16 and 03/04/16 lacked documentation of measurements and description of the wound. Review of the pressure ulcer policy dated 2010 documented all residents will be assessed for pressure ulcer risk on admission, monitored weekly, quarterly and as needed. The policy also documented a resident with a pressure ulcer will receive interventions, monitoring to promote healing, prevent infection and prevent new ulcers from developing. In addition if a pressure ulcer is identified on admission or in house the wound will be monitored weekly including location, staging, size, drainage if present, any presence of pain and description of wound bed and surrounding tissue.