Every finding on record at Brookview Healthcare Center

Based on observation, medical record review, staff interview, and review of facility policies, the facility failed to ensure infection control measures were properly utilized during wound care. This affected one (#61) of one residents reviewed for wound care. The facility census was 69.Findings include:Review of the medical record for Resident #61 revealed she was admitted on [DATE] with diagnoses including unspecified open wound to the right ankle, muscle weakness, difficulty walking, malnutrition, psychoactive substance abuse, Charcot's joint of the right ankle, and osteomyelitis.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was cognitively intact and did not display any behaviors at the time of the assessment. She required supervision to partial assistance with activities of daily living. She required surgical wound care with dressings to her foot.Review of physician orders for Resident #61 revealed an order dated 05/16/26 for enhanced barrier precautions to be used every shift due to her wound. Additionally, there was an order dated 07/01/26 to provide wound care to her right ankle every three days and as needed. The wound care instructions were to cleanse the site with soap and water, pat dry, apply antibiotic ointment, apply silver dressing, and secure with an abdominal pad and fishnet dressing.Observation on 07/01/26 at 1:30 P.M. with Licensed Practical Nurse (LPN) #101 revealed the nurse performed wound care to Resident #61's right ankle. During the wound care observation, LPN #101 did not wear a gown and did not perform hand hygiene between glove changes throughout the procedure. She changed her gloves after removing the old dressing, after cleansing the wound, and after applying the abdominal pad and fishnet dressing. Interview on 07/01/26 at 1:45 P.M. with LPN #101 confirmed she did not wear a gown while performing Resident #61's wound treatment and did not perform hand hygiene between glove changes.Review of facility policy titled, Enhanced Barrier Precautions, dated 07/13/22, revealed gowns and gloves were to be worn during high-contact resident care activities, including wound care.Review of an undated facility policy titled, Wound Care, revealed hand hygiene would be performed before beginning wound care, between glove changes, and at the completion of wound care.

Based on medical record review, facility investigation information, staff interview and review of facility policy, the facility failed to ensure timely medical follow up for residents following a fall with injury. This affected one Resident (#10) of three residents reviewed for falls. The facility also failed to complete a wound dressing change per the physician's orders. This affected one (#79) of five residents reviewed for wound dressing changes. The facility census was 74. Findings include:1. Review of Resident #10's medical record revealed an admission date of 12/09/25. Diagnoses included ovarian cancer, abdominal lining cancer, general anxiety disorder, type II diabetes, major depressive disorder, adult failure to thrive, dementia, difficulty walking, unsteady on her feet, dysphagia, disorientation, and osteoarthritis.Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #10 was cognitively intact. Resident #10 required supervision only with toilet use, bathing, dressing, bed mobility and transfer. Resident #10 had hallucinations and displayed verbal behavioral symptoms, other behavioral symptoms not directed toward others, rejection of care and wandering behaviors four to six days during the review period. Review of Resident #10's care plan revised 02/16/26 revealed supports and interventions for risk for alteration in nutrition, alteration in skin integrity: left wrist skin tear, hematoma to head with bruising and fractured nose from fall, self-care deficit, required the special care unit, allergy to Meloxicam and Trazodone and risk for falls. Review of Resident #10's Fall Investigation documentation from her fall on 02/12/26 revealed Resident #10 had an unwitnessed fall in her room at approximately 4:45 A.M. Certified Nursing Assistant (CNA) #325 entered Resident #10's room for a check and change and noted Resident #10's bathroom light had been turned off. CNA #325 had reported to have left the light on to be able to make observations of Resident #10. In the process of making her way in the dark to turn on the bathroom light back on CNA #325 tripped over Resident #10's wheelchair and fell to the floor. Upon rising CNA #325 came in contact with Resident #10 who was also lying on the floor. CNA #325 turned the light on and found Resident #10 lying on the floor parallel to the bed with blood on her face and two pools of blood on the floor. CNA #325 notified the nurse and assisted Resident #10 back to bed. Licensed Practical Nurse (LPN) #390 cleaned Resident #10's facial wounds and completed assessments. Resident #10 reported facial pain and at 4:51 A.M. it was documented Resident #10 was provided Tylenol 650 milligrams (mg). The effectiveness of the Tylenol was documented as unknown. The on-call physician was contacted on 02/12/26 at approximately 6:45 A.M. and the facility received an order to send Resident #10 to the emergency room for evaluation and treatment. At approximately 7:00 A.M. Emergency Medical Services (EMS) was called and transported Resident #10 to the hospital emergency room for evaluation and treatment. Resident #10 arrived at the emergency room at 7:23 A.M. Review of Resident #10's Emergency Medical Services (EMS) run report dated 02/12/26 revealed the 911 call was received on 02/12/26 at 6:57 A.M. and the EMS was dispatched. The EMS arrived on the scene at 7:00 A.M. and arrived at Resident #10 at 7:01 A.M. The EMS departed the scene at 7:21 A.M. and arrived at the emergency room at 7:23 A.M. The call was closed at 7:39 A.M. It was noted nursing home staff had reported Resident #10 had fallen approximately two hours prior to the 911 call. Resident #10 was noted to have had a large hematoma on her forehead, bruising under both eyes, and a laceration to her upper lip rendering her teeth visible. It was noted Resident #10 had an allergy to Meloxicam and Trazodone. The injuries were consistent with the reported fall. Resident #10 reported a final pain score of nine on a scale of one to ten upon arrival at the destination. Review of Licensed Practical Nurse (LPN) #390's Coaching Program information revealed on 02/13/26 LPN #390 was educated on where the physician numbers were located. It was noted it was LPN #390 first time working in the building (agency) and he was unable to find where the physician contact information was located. A floor nurse had instructed him to fax the physician with the fall information which delayed the physician of being notified of Resident #10's fall. Interview on 02/24/26 at 2:24 P.M. with CNA #325 verified she was the staff who had discovered Resident #10 on 02/12/26 after she had fallen. CNA #325 reported she had last seen Resident #10 sleeping in bed around 4:30 A.M. and had last taken her to the toilet around 4:00 A.M. CNA #325 reported she had left Resident #10's bathroom light on so she could see Resident #10 without disturbing her with the overhead light. When CNA #325 had walked past Resident #10's room after caring for another resident, approximately 4:45 A.M. she noticed Resident #10's bathroom light was off, and the room was pitch black. CNA #325 reported she felt her way along the wall trying to get to the bathroom to turn on the light and ended up tripping over Resident #10's wheelchair and falling to the floor. While getting herself up CNA #325 reported she felt Resident #10 on the floor next to her. CNA #325 reported she got herself up and turned the light on. When she could see, she found Resident #10 lying on the floor next to her bed with blood on her face and blood on the floor. CNA #325 reported she immediately went to the agency nurse (LPN #390) and got his help. LPN #390 had her help get Resident #10 into her bed and after she was assessed and cleaned up he had her get Resident #10 dressed and out into the common area in the recliner. CNA #325 reported she gave shift change report and left the facility around 6:30 A.M. and at the time Resident #10 was still seated in the recliner in the common area. CNA #325 verified Resident #10's fall with significant injury happened around 4:45 A.M. and around 6:30 A.M. Resident #10 had not been transferred to the hospital. Interview on 02/24/26 at 4:12 P.M. with the Director of Nursing (DON) verified there was approximately two hour delay from when Resident #10 fell and when she was transferred to the hospital. The DON reported the LPN #390 had been educated on the proper timelines and procedures for contacting emergency services following a fall. Review of the facility policy titled, Accident/Incident Procedure, revised 04/28/25 revealed the charge nurse would notify the physician and obtain orders when an incident occurred. 2. Review of Resident #79's medical record revealed an admission date of 02/11/26. Diagnoses included cellulitis of the left lower limb, severe protein-calorie malnutrition, hyperlipidemia, acute kidney failure, hypocalcemia, essential hypertension, and dysphagia.Review of Resident #79's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. Furthermore, Resident #79 required partial/moderate assistance for personal hygiene.Review of Resident #79's care plan dated 02/15/26 revealed Resident #79 had an alteration in skin related to scattered scabbing covering the whole surface area of both legs with interventions that included to administer treatments as ordered and to assess, record, and monitor wound healing. Review of Resident #79's physician orders revealed an order with a start date of 02/19/26 that read to cleanse skin tear to right knee with normal saline, pat dry, cover with non-adherent dressing, wrap daily and as needed until healed.Review of the progress note completed by Licensed Practical Nurse (LPN) #362 on 02/19/26 at 8:49 P.M. revealed Resident #79 had fallen in his room. Upon assessment, Resident #79 had two skin tears on his right knee that measured 4.4 x 4.5 centimeters (cm) and 2 x 2.5 cm. The physician was updated and new orders were given to cleanse the skin tears to the right knee with normal saline, pat dry, cover with non-adherent dressing, wrap daily and as needed until healed. Observation on 02/23/26 at 9:34 A.M. of wound care for Resident #79 with Wound Nurse Practitioner (WNP) #388 revealed the dressing on Resident #79's right knee was dated 02/21/26 and initialed. Concurrent interview with WNP #388 verified the dressing was dated 02/21/26 and initialed.Interview on 02/23/26 at 9:35 A.M. with Resident #79 verified the dressing change was not completed the day before.Review of Resident #79's Treatment Administration Record (TAR) for the month of February revealed the staff initials on the dressing dated 02/21/26 matched the TAR documentation for 02/21/26.Review of the facility policy titled Pressure Injury Treatment, with a last reviewed date of 04/28/25 revealed orders for treatment are obtained from or approved by the physician or nurse practitioner and orders are to be followed as written.This deficiency represents non-compliance investigated under Complaint Numbers 2629125 and 1266301.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure all medications ordered by the physician were administered to a resident. This affected one (#70) of eight residents review for medication administration. The facility census was 74.Findings include:Review of Resident #70's medical record revealed an admission date of 04/08/16. Diagnoses included Alzheimer's disease, diabetes mellitus due to underlying condition with diabetic polyneuropathy, psychotic disorder with delusions, hypertension, severe protein calorie malnutrition, and muscle weakness.Review of Resident #70's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 03.Review of Resident #70's care plan dated 02/17/26 revealed Resident #70 was at risk for alteration in mood related to her diagnoses of anxiety, dementia, and depression with interventions that included to administer medications as ordered and to monitor for feelings of sadness.Review of Resident #70's physician orders revealed orders for the following medications:- Preservision AREDS 2 milligram (mg) oral capsule with instructions to give one tablet by mouth one time a day for macular degeneration.- Protonix Oral Tablet delayed release 40 mg with instructions to give one tablet one time a day for gastroesophageal reflux disease. - Refresh Tears Ophthalmic solution with instructions to instill one drop in both eyes four times a day for dry eyes.Observation on 02/23/26 at 9:05 A.M. with Licensed Practical Nurse (LPN) #362 revealed LPN #362 to be preparing medications for Resident #70. Concurrent interview with LPN #362 verified she would not be administering the Preservision AREDS, Protonix, or refresh eye drops due to the medications being unavailable. LPN #362 stated she would re-order the medications and call the physician to inform them of the missed medications.Review of Resident #70's Medication Administration Record (MAR) for the month of February revealed the Preservision AREDS, Protonix, and refresh eye drops were not administered on 02/23/26 due not being available for administration. Review of the medication error rate revealed there were 28 opportunities for medication administration and three errors due to omission of medications resulting in a medication error rate of 10.7%.Review of the facility policy titled Administering Medications, with a last reviewed date of 04/28/25 revealed medications must be administered in accordance with the orders, including any required time frames.This deficiency represents non-compliance investigated under Complaint Numbers 2629125 and 1266301.

Based on observation, record review, staff interview, review of manufacturer instructions, and review of facility policy, the facility failed to ensure resident were not administered medications they were identified as having allergies to. This affected one (#10) of three residents reviewed for medication allergies. Additionally, the facility failed to remove medication patches prior to administering/applying another medication patch. This affected one (#78) of eight residents observed for medication administration. The facility census was 74. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 12/09/25. Diagnoses included ovarian cancer, abdominal lining cancer, general anxiety disorder, type II diabetes, major depressive disorder, adult failure to thrive, dementia, difficulty walking, unsteady on her feet, dysphagia, disorientation, and osteoarthritis. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #10 was cognitively intact. Resident #10 required supervision only with toilet use, bathing, dressing, bed mobility and transfer. Resident #10 had hallucinations and displayed verbal behavioral symptoms, other behavioral symptoms not directed toward others, rejection of care and wandering behaviors four to six days during the review period. Review of Resident #10's care plan revised 02/16/26 revealed supports and interventions for risk for alteration in nutrition, alteration in skin integrity, risk for falls, self-care deficit, required the special care unit, and allergy to Meloxicam and Trazodone. Review of Resident #10's history and physical provided to the facility prior to Resident #10's admission facility admission dated 11/14/25 revealed Resident #10 had an allergy to Trazodone. The medication was noted to increase depression and aggression and cause abdominal pains. Additionally, Resident #10 was allergic to Meloxicam which would cause her nausea. Review of Resident #10's pharmacy recommendations found a recommendation dated 01/08/26. The pharmacist noted Resident #10 was currently taking Hydroxyzine for treatment of insomnia and anxiety. It was recommended this medication not be used for geriatric patients due to side effects. Please consider switching to low-dose Zolpidem 5 milligrams (mg) or Trazodone 12.5-25 mg as an alternative. The physician reviewed the recommendation, agreed, and changed the order to Trazodone 50 mg daily. The order was started 01/21/26. Review of Resident #10's progress notes revealed a note dated 01/28/26 at 3:30 P.M. documented by Registered Nurse (RN) #346 reporting Resident #10 had an allergy to Trazodone. The physician was notified and made aware of alternatives. At 4:30 P.M. it was noted Resident #10's physician ordered Melatonin 5 milligrams every night and Trazodone was discontinued. Review of Resident #10's physician orders revealed an order dated 01/21/26 and discontinued 01/28/26 for Trazodone 50 milligrams (mg) give one tablet by mouth at bedtime for insomnia and anxiety. Review of Resident #10's corresponding Medication Administration Record (MAR) revealed Resident #10 received the medication (Trazodone), one of the medications she was allergic to, on five occasions, 01/21/26, 01/23/26, 01/24/26, 01/26/26 and 01/27/26. Interview on 02/23/26 at 2:16 P.M. with the Director of Nursing (DON) verified Resident #10 had previously had an order for and was administered Trazodone. 2. Review of Resident #78's medical record revealed an admission date of 04/01/24. Diagnoses included type two diabetes mellitus, ataxia, hyperlipidemia, facial weakness following unspecified cerebrovascular disease, anxiety, dysphagia, and cognitive communication deficit. Review of Resident #78's quarterly MDS assessment dated [DATE] revealed Resident #78 had intact cognition with a BIMS score of 13. Furthermore, Resident #78 was dependent for all mobility and hygiene needs. Review of Resident #78's care plan dated 02/24/26 revealed Resident #78 had impaired cognition as evidence by deficits in memory, judgement, and decision making with interventions that included to administer medications as ordered and to review medications and record possible causes of cognitive deficits. Review of Resident #78's physician orders revealed an order for Rivastigmine Transdermal Patch 24 hour 4.6 mg/24 hour with instructions to apply one patch transdermally one time a day for dementia. Change the patch daily and place the patch in different areas of the body; remove old patch before applying a new one. Observation of incontinence care and a bed bath on 02/24/26 at 10:36 A.M. revealed Resident #78 had two Rivastigmine patches on his left shoulder/chest area. Interview on 02/24/26 at 10:58 A.M. with Licensed Practical Nurse (LPN) #362 verified Resident #78 had two Rivastigmine patches on at the same time. One patch was dated 02/24/26 and the other patch was dated 02/23/26. LPN #362 stated she had taken off a patch this morning when she applied the Rivastigmine patch and so Resident #78 must have had three patches on at the same time. Review of the manufacturer's instructions for the Rivastigmine patches revealed the previous days patch must be removed prior to applying a new patch. Review of the facility policy titled, Administering Medication, revised 04/28/25 revealed if a dosage was believed to be inappropriate or excessive for a resident, or a medication had been identified as having potential adverse consequences for the resident or was suspected of being associated with adverse consequences the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concern. The policy also stated medications must be administered in accordance with the orders, including any required time frames. This deficiency represents non-compliance investigated under Complaint Numbers 2629125 and 1266301.

Based on resident interview, medical record review, hospital record review, staff interview, and policy review, the facility failed to ensure residents received timely treatment for constipation. This resulted in actual harm after Resident #14 had no bowel movement (BM) for seven days in the facility and was admitted to the hospital the following day with abdominal pain and was found to be impacted with stool. This affected one (#14) resident reviewed for bowel movements. The facility census was 72. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses of constipation, anxiety, and generalized abdominal pain. Review of the comprehensive admission assessment completed 12/14/24 revealed Resident #14 had intact cognition and was occasionally incontinent of bowel. Constipation was not present at the time of the assessment. Resident #14's care plan, reviewed on 03/26/25, revealed a care area initiated 01/17/25 indicating Resident #14 was at risk for alteration in elimination constipation. The goal was for Resident #14 to have a bowel movement every 1-3 days. Interventions included assessing for abdominal distention and noting type, color, and amount of stool. Review of the current care plan, revised 03/27/25, revealed Resident #14 was at risk for constipation. The goal indicated Resident #14 would have a normal, soft formed, bowel movement through the review date. Interventions included following the facility bowel protocol for bowel management. Review of Resident #14's physician orders active on 01/29/25 revealed an order initiated 12/31/24 for sennosides-docusate sodium oral tablet 8.6-50 milligrams (mg) once daily for constipation. Additionally, Resident #14 had a physician order dated 01/14/25 for Dulcolax rectal suppository 10 mg (bisacodyl), insert one suppository rectally every 24 hours as needed for constipation. Additionally, Resident #14 had a physician order initiated 01/14/25 for Milk of Magnesia Oral Suspension, give 30 milliliters (ml) by mouth as needed for constipation. Finally, Resident #14 had a physician order initiated 12/08/24 for polyethylene glycol powder, give 17 grams by mouth every 24 hours as needed for constipation. Review of Resident #14's physician order initiated 02/05/25 and discontinued on 02/06/25 revealed an order for Enema Rectal Enema (Sodium Phosphates), insert one unit rectally one time only for constipation. Review of Resident #14's BMs in January 2025 and February 2025 revealed no BMs were documented from 01/29/25 through 02/04/25 (seven days). A small BM was documented in the evening of 02/05/25. Review of the Medication Administration Record (MAR) for January 2025 revealed Resident #14 received sennosides-docusate sodium once daily as ordered. No as-needed medications for constipation were administered between 01/29/25 and 01/31/25. Review of the MAR for February 2025 revealed Resident #14 received sennosides-docusate sodium once daily as ordered. Further review revealed Resident #14 received a rectal enema on 02/05/25 at 4:31 P.M. Additionally, Resident #14 received an as-needed dose of Milk of Magnesia on 02/06/25 at 12:24 A.M. Review of a nursing progress note dated 02/06/25 at 8:43 A.M. revealed Resident #14 continued to cry out in pain and requested to go to the emergency room (ER) as Resident #14 stated she had not had a BM in 12 days. Further review revealed the night shift nurse stated Resident #14 was given an enema with no results. The physician was contacted and staff were awaiting a response. Review of the hospital emergency room document, dated 02/06/25 at 11:00 A.M., revealed Resident #14 presented with severe abdominal pain and was dry-heaving. A manual disimpaction was completed with a significant amount of stool removed. Review of the hospital document, General History and Physical, dated 02/07/25 at 11:53 A.M., revealed Resident #14 had abdominal pain and was found to be impacted with stool. Resident #14 was disimpacted and was having bowel movements. Interview on 03/24/25 at 10:07 A.M. with Resident #14, who was lying in her recliner, revealed she was hospitalized after having no BM for 12 days in the facility. Interview on 03/25/25 at 3:46 P.M. with the Director of Nursing (DON) confirmed Resident #14's medical record indicated she had no stool beginning on 01/29/25 through 02/04/25 (seven days). Interview on 03/25/25 at 4:59 P.M. with the DON confirmed no as-needed interventions for constipation were provided to Resident #14 until 02/05/25, after Resident #14 had gone seven days without a BM. Review of the undated policy, Bowel Elimination Policy and Procedure, revealed if a resident has been without a BM for 48 hours the facility would provide 120 ml of prune juice or bran mixture. Further, if the resident has been without a noted BM for 72 hours (24 hours after prune juice or prune mixture has been given) the nurse will consider administering an osmotic laxative such as Milk of Magnesia per physician order. Additionally, if the resident has been without a BM 8 hours after Milk of Magnesia, the nurse will obtain an order, or follow established PRN (as needed) order for a stimulant laxative such as Dulcolax suppository and administer. (This should be effective within 15-60 minutes). Finally, if the resident has been without a bowel movement 8 hours after the suppository was given, the nurse will administer a phosphate enema as ordered by the physician (or as ordered by primary care provider if not previously ordered). Should no results occur at this time, resident assessment and interventions will be reported to the primary care provider for further measures to be taken until bowel elimination has occurred and the resident has no acute symptoms of constipation.

Based on observation, resident and staff interview, record review, and policy review, the facility failed to ensure residents received interventions to offset significant weight loss. This affected two (#31 and #60) of three residents reviewed for significant weight loss. The facility census was 72. Findings include: 1. Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses of dehydration and moderate protein-calorie malnutrition. Review of the initial comprehensive Minimum Data Set (MDS) assessment, dated 03/03/25, revealed Resident #31 had intact cognition and required set-up or clean-up assistance for eating. Further review of the medical record revealed Resident #31 was hospitalized overnight for altered mental status from 03/10/25 through 03/11/25. Review of the weight history for Resident #31 revealed he weighed 157.7 pounds on 03/10/25, and weighed 138.2 pounds on 03/11/25, upon return from the hospital. Review of the hospital discharge records, dated 03/11/25, revealed no hospital weight and revealed no indication any procedures were performed (such as fluid removal) that could have caused notable weight loss. Review of a current physician order dated 03/11/25 revealed Resident #31 received a sugar-free healthshake with meals for supplement. Review of a nutrition progress note dated 03/19/25 revealed Resident #31 had a significant weight loss of 13.5% since 03/01/25. Further review revealed the current nutrition intervention was a sugar-free house shake with meals. The recommendation was to add liquid protein 30 milliliters once daily. Interview and observation on 03/25/25 at 11:50 A.M. revealed Resident #31 lying in bed with his meal tray on his overbed table. Resident #31 had consumed some of his meal but was more interested in receiving personal care than finishing his meal. Resident #31 stated he was aware he had lost weight. No nutrition supplement was observed on the meal tray or overbed table. Observation on 03/26/25 at 5:34 P.M. revealed the dinner trays were delivered to Resident #31's hall on a cart. Interview on 03/26/25 at 05:40 P.M. with Unit Manager (UM) #314 and concurrent observation of Resident #31's meal tray, still on the cart, revealed no nutrition supplement was on the tray. Additionally, concurrent review of Resident #31's electronic medical record (EMR) with UM #314 confirmed the sugar-free healthshake was to be provided with meals. Observation on 03/27/25 at 8:46 A.M. revealed Certified Nursing Assistant (CNA) #312 talking with Resident #31 in his room. Resident #31's breakfast tray remained on his overbed table and Resident #31 had consumed all of his meal. CNA #312 confirmed there was no evidence Resident #31 received a sugar-free healthshake with his meal. Interview on 03/27/25 at approximately 8:50 A.M. with Dietary Manager #333 revealed she coordinated care for residents with the Registered Dietitian (RD). DM #333 stated the facility usually provided nutrition supplements between meals rather than on meal trays. Upon request from the Surveyor, DM #333 provided a sugar-free healthshake to the Surveyor. Interview on 03/27/25 at approximately 9:00 A.M. with Resident #31 revealed he recognized the sugar-free healthshake in the Surveyor's hand. Resident #31 stated the supplements were full of vitamins, he liked them, and he wanted to drink them. The Surveyor returned the sugar-free healthshake to staff to provide to Resident #31 as ordered. 2. Review of the medical record for Resident #60 revealed an admitted [DATE] with diagnoses of dementia and dysphagia (difficulty swallowing). Review of the quarterly MDS assessment dated [DATE] revealed Resident #60 had impaired cognition, was able to feed himself with set-up or clean-up assistance. Review of the weight history for Resident #60 revealed a weight of 162 pounds on 11/01/24, indicating a significant weight loss of 8.1% over 30 days from a weight of 176.2 pounds on 10/04/24. Resident #60's weights remained in the 160-pound range from 11/01/24 through 03/26/25. Review of a dietary progress note dated 11/04/24 revealed a reweigh was requested and pending. Review of a dietary progress note dated 12/02/24, written by RD #405, revealed Resident #60 had a significant weight loss of 9.2% over 90 days. Further review revealed the weight loss was stabilized and Resident #60's current body mass index (BMI) was 26.2 indicating Resident #60 was overweight. RD #405 did not recommend any new interventions for Resident #60 to offset the significant weight loss. Review of a dietary progress note dated 03/10/25, written by RD #405, revealed Resident #60's weight had stabilized in the 160-pound range, though he showed a significant weight loss of 12% over 180 days. RD #405 recommended double portions for added nutrition support. Review of the current physician order, dated 02/03/25 and revised 03/24/25, revealed Resident #60 received a gluten free, mechanical soft texture, nectar thickened liquids diet with food in separate bowls. All bowls to be suction cup bowls. Small red spoon on all meal trays. Resident intolerant of gluten and dairy products. Double portions. Interview on 03/25/25 at 11:24 A.M. with [NAME] #337 and DM #333 revealed they both were aware Resident #60 was recently changed to double portions. Observation on 03/25/25 at 11:26 A.M. during the noon meal service revealed Resident #60 independently consuming his meal. Resident #60 received cauliflower, sweet potatoes, and ground chicken, each in separate bowls. The cauliflower and sweet potatoes did not appear to be a double portion. Review of Resident #60's meal ticket indicated he should receive large portions. Observation on 03/26/25 at 11:01 A.M. revealed [NAME] #337 plating Resident #60's lunch meal. [NAME] #337 served one 4-ounce scoop of vegetable blend, one 4-ounce scoop of mashed potatoes, and one 4-ounce scoop of ground beef brisket. [NAME] #337 covered each bowl with a plastic lid. Concurrent interview with [NAME] #337 confirmed she provided a single scoop of each food item for Resident #60. [NAME] #337 then read Resident #60's meal ticket and determined Resident #60 should receive double portions. [NAME] #337 proceeded to remove the lids from each bowl and add a second scoop. Telephone interview on 03/26/25 at 4:30 P.M. with RD #405 confirmed Resident #60's weight on 11/01/24 revealed a significant weight loss. RD #405 confirmed no re-weight was obtained. RD #405 confirmed she should have written a progress note and assessed Resident #60 after the significant weight change on 11/01/24. RD #405 further confirmed she did not recommend any nutrition intervention to offset the significant weight loss in the progress note dated 12/02/24. Additionally, RD #405 confirmed she recommended double portions for Resident #60 on 03/10/25 and the double portions were not added to Resident #60's orders until 03/24/25. Review of the policy, Weight Management Program and Weight Gain/Loss Policy, revised 08/2024, revealed if there is a weight loss/gain of five percent or more from the previous month, the resident will be reweighed. Additionally, the Director of Nursing (DON) or designee will review the dashboard for high-risk weight change progress notes daily and address accordingly.

Based on observation, medical record review, staff and resident interview, and policy review, the facility failed to ensure resident's dialysis access sites were monitored by the facility. Additionally, the facility failed to ensure pre and post dialysis evaluations were completed. This affected two residents (#21 and #24) of two reviewed for dialysis. This facility census was 72. Findings include: 1. Review of the medical record of Resident #21 revealed an admitted [DATE]. Diagnoses included end stage renal disease and dependence on renal dialysis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact, and diagnoses were listed. The assessment further indicated Resident #21 was on hemodialysis while a resident. Review of the physician orders revealed an order dated 02/24/25 to monitor the AV fistula for bruit and thrill every shift. A second order was placed on 03/25/25, after surveyor inquired, to monitor the left arm for bruit/thrill every shift. Review of the medical record revealed Resident #21 the following pre/and or post dialysis evaluations absent: 02/24/25 no post; 02/27/25 no post; 03/03/25 pre and post; 03/05/25 pre and post; 03/07/25 pre; 03/10/25 post; 03/12/25 post; 03/14/25; post; 03/17/25 post; 03/19/25 post; 03/21/25 post; and 03/21/25 pre and post. The evaluation consisted of assessing the access site for bruit, thrill, decreased circulation distal to the site, and skin color and turgor. This form was to be sent to the dialysis center with Resident #21. Interview on 03/24/25 at 8:36 A.M. with Resident #21 revealed the facility staff do not monitor his arteriovenous graft. He stated he removes the Band-Aid the day after dialysis himself. Interview on 3/25/25 at 11:22 A.M. with the Director of Nursing (DON) revealed Assistant DON #301 had placed an order on 02/24/25 to monitor the fistula every shift, for bruit and thrill, but had failed to schedule the times, henceforth, it had not appeared on the MAR or TAR. Interview on 03/25/25 at 3:18 P.M. with Registered Nurse #376 revealed the nurse will complete a pre-dialysis assessment in the electronic record, print it off and send it with the resident. The dialysis center will send it back with the weights and any notes. As far as she knows, the facility does not keep these. Interview on 03/25/25 at 3:31 P.M. with Regional Clinical Support Nurse (RSCN) #396 revealed the facility should be sending communication with the resident. A follow-up interview with RCSN #396 revealed the facility practice is to fill out the pre-dialysis assessment, print it out, and send that with the resident to the dialysis center. Interview on 03/26/25 at 1:00 P.M. with RCSN #396 provided verification of the lack of pre and/or post dialysis assessments. Review of the policy titled Dialysis Care revised 08/24, revealed the bruit and thrill of the fistula was to be assessed every shift for patency and recorded on the Medication Administration Record. The facility shall use a form to communicate with the dialysis center with each visit. The nurse will complete an assessment of the resident prior to leaving the facility and upon return from the dialysis center. 37451 2. Review of Resident #24's medical record revealed an admitted [DATE]. Diagnoses included end stage renal disease, type II diabetes, dysphagia, muscle weakness and dependence on renal dialysis. Review of Resident #24's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 15 indicating Resident #24 was cognitively intact. Resident #24 was independent with toilet use, bed mobility, and transfer. Resident #24 required moderate assistance with bathing. Resident #24 displayed no behaviors during the review period. Resident #24 was on dialysis at the time of the review. Review of Resident #24's care plan revised 03/24/25 revealed the resident received hemodialysis Monday, Wednesday, and Friday. Dialysis interventions included check for new orders upon return from dialysis, diet as ordered, maintain communication with dialysis staff and physician, monitor dialysis access site, left chest port for signs and symptoms of infection, and weights as ordered. Review of Resident #24's physician orders revealed an order dated 02/11/25 for a dialysis port left chest. There was no order found for the placement of Resident #24's fistula and no order for monitoring Resident #24's fistula for thrill and bruit for her new graph site which began on 03/20/25. Review of Resident #24's Medication Administration Record (MAR) and Treatment Administration Record (TAR) found neither record contained documentation or a location to document monitoring of Resident #24's new graph site, thrill or bruit. Interview on 03/24/25 at 2:39 P.M. with Resident #24 found she had just returned from dialysis. Resident #24 reported she had a port that was currently being used for her dialysis. Resident #24 reported she had previously had a fistula access on her right arm but it repeatedly was clogged so the port was added and the right arm fistula was removed. Resident #24 stated a port was not supposed to be for long term use so last week she had a fistula created on her left upper arm. Interview on 03/26/25 at 1:14 P.M. with Licensed Practical Nurse (LPN) #298 verified Resident #24 had a fistula graph created in her left upper extremity on 03/20/25. LPN #298 also verified the standard of practice was to check the thrill and bruit of a fistula and there was not a place in the system for Resident #24's monitoring to be documented. LPN #298 reported she checked Resident #24's fistula for thrill and bruit but verified there was no direction for others to do the same and no documentation the checks were completed. Review of the facility policy titled, Dialysis Care, revised August 2024 revealed bruit and thrill of the fistula was to be assessed every shift for patency and recorded on the Medication Administration Record. In addition, the facility would complete an assessment of the resident prior to leaving the facility and upon return to the facility for each dialysis visit.

Based on resident interview, medical record review, and staff interview, the facility failed to ensure residents received medications as ordered. This affected two (#21 and #123) of eight residents reviewed for medications. The facility census was 72. Findings include: 1. Review of the medical record for Resident #123 revealed an admitted [DATE] with diagnoses of metabolic encephalopathy, and type 2 diabetes mellitus. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 03/17/25, revealed Resident #123 had intact cognition. Review of a discontinued physician order, active 03/11/25 through 03/19/25, revealed Resident #123 received Lactulose Oral Solution 10 grams (gm) per 15 milliliters (ml). Give 60 ml by mouth three times daily for hyperammonemia (elevated ammonia in the blood). Review of a discontinued physician order, active 03/19/25 through 03/26/25, revealed Resident #123's Lactulose Oral Solution dose increased to 75 ml three times daily. Review of the current physician order, dated 03/26/25, revealed Resident #123's Lactulose Oral Solution dose increased to 85 ml three times daily. Review of a laboratory test collected 03/18/25 and reported 03/18/25 revealed Resident #123's ammonia level was 159 micromols per liter (umol/L). Further review revealed the normal range was 18-72 umol/L. Review of a laboratory test collected 03/20/25 and reported 03/20/25 revealed Resident #123's ammonia level increased to 186 umol/L. Review of the physician office visit progress note dated 03/19/25 revealed Resident #123's hepatic encephalopathy was stable. The physician documented Resident #123's ammonia level was elevated to 189 on that day, and the plan was to increase the lactulose dose to 75 ml three times daily. Review of the March 2025 Medication Administration Record (MAR) for Resident #123 revealed a 5 in the afternoon and a 9 for the evening dose of lactulose on 03/11/25. Further review revealed a 9 for the afternoon and evening dose on 03/24/25 and a 9 for the morning dose of lactulose on 03/25/25. All other doses of lactulose had a checkmark. Review of the Chart Codes for the MAR revealed a 5 indicated hold/see nurse notes, and a 9 indicated other/see nurse notes. Review of a progress note dated 03/11/25 at 6:08 P.M. revealed Resident #123's lactulose was not given because it was on order. Review of a progress note dated 03/11/25 at 9:49 P.M. revealed Resident #123's lactulose was not given because the facility was awaiting delivery. Review of a progress note dated 03/24/25 at 4:40 P.M. revealed Resident #123's lactulose was not given because it was in transit from the pharmacy. Review of a progress note dated 03/24/25 at 9:50 P.M. revealed Resident #123's lactulose was not given because the facility was awaiting delivery. Review of a progress note dated 03/25/25 at 2:38 A.M. revealed the facility contacted the pharmacy regarding Resident #123's lactulose and the pharmacy indicated the lactulose would be delivered 03/25/25. Review of a progress note dated 03/25/25 at 9:59 A.M. revealed Resident #123's lactulose was not given because the facility was waiting on delivery. Interview on 03/24/25 at 9:59 A.M. with Resident #123 revealed she had cirrhosis of the liver and the ammonia level in her blood built up. Resident #123 stated she received lactulose to keep the ammonia levels down. Resident #123 stated she did not receive her full dose of lactulose with her morning medications and was told the facility was out of lactulose. Interview on 03/25/25 at 9:07 A.M. with Resident #123 revealed she had not received her morning medications. Further interview with Resident #123 revealed she did not receive her afternoon or evening doses of lactulose on 03/24/25. Interview on 03/25/25 at 9:47 A.M. with Licensed Practical Nurse (LPN) #400 revealed she received report from the night shift nurse who stated the facility did not have any lactulose for Resident #123. LPN #400 stated the pharmacy was supposed to deliver it on 03/25/25. Interview on 03/25/25 at 2:33 P.M. with LPN #400 revealed no lactulose had been delivered. Observation and interview on 03/25/25 at 3:15 P.M. with LPN #400 revealed she received the lactulose for Resident #123 and was in the process of pouring the 75 ml dose. Interview on 03/27/25 at 3:12 P.M. with the Assistant Director of Nursing (ADON) #301 and concurrent review of the March 2025 MAR for Resident #123 confirmed Resident #123 did not receive the first two doses of lactulose upon admission on 03/11/25. ADON #301 stated sometimes medications were not available the first day of admission. 35031 2. Review of the medical record of Resident #21 revealed an admitted [DATE]. Diagnosis included dysfunctional dyspepsia. Review of the admission MDS assessment dated [DATE] revealed Resident #21 was cognitively intact. Review of the physician order dated 02/21/25 revealed an order for Tenapanor (for irritable bowel syndrome) 25 milligrams by mouth twice daily. Review of the Medication Administration Records for 02/25 and 03/25 revealed Resident #21 had not received the medication. Review of the progress note dated 02/25/25, written by Director of Nursing (DON), revealed Doctor notified that Tenapanor is not available for pharmacy. No further communications with either the pharmacy nor the doctor was located until this surveyor mentioned it. A second progress note dated 03/26/25 at 1:16 P.M. revealed a discussion with the pharmacy regarding the delay in delivery of Tenapanor. The pharmacy stated the medication had fallen off their medication list and needed to be re-ordered. The lack of medication was also reported to the dialysis center, checking to see if this medication was administered at the dialysis center. The dialysis nurse stated that is not one they administer. The doctor was notified of the restart of this medication. Interview on 03/27/25 at 2:40 P.M. with DON provided verification the Tenapanor had not been administered and the lack of communication with the doctor.

Based on a review of pharmacy recommendations, record review, and staff interview, the facility failed to ensure timely response to pharmacy recommendations for residents on psychotropic medications. This affected three (#11, #60, and #62) of five residents reviewed for pharmacy recommendations. The facility census was 72. Findings include: 1. Review of the medical record of Resident #11 revealed an admitted [DATE]. Diagnoses included anxiety disorder, schizoaffective disorder, major depressive disorder, paranoid schizophrenia, long-term use of opiate analgesic, and chronic pain syndrome. Review of the, Physician Recommendation Forms, the facility failed to ensure a physician addressed the recommendations of the pharmacist. On 03/09/24 the pharmacist indicated hydroxyzine 25 milligrams (mg) was ordered twice daily and was due for an evaluation for continued use. On 04/10/24 the pharmacist indicated a quarterly review was due for further use of Trazadone 150 mg at bedtime, per State and Federal regulations. On 06/21/24 per the guidelines for psychotic drug therapy, the antipsychotic Quetiapine 150 mg twice daily was due for evaluation for continued use. On 07/05/24 a quarterly review was due for further use according to State and Federal regulations for Trazadone 150 mg at bedtime. On 08/12/24 per the guidelines for psychotic drug therapy, Buspirone 10 mg three times daily was due for the semi-annual review for continued use. On 10/08/24 a quarterly review was due for the psychoactive medication Trazadone 150 mg at bedtime for continued use as per State and Federal regulations. On 01/13/25 the antipsychotic medication Quetiapine 100 mg at bedtime was due for the semi-annual review for continued use per State and Federal regulations, and a quarterly review of Trazadone 150 mg at bedtime. On 02/18/25 the antidepressant medication Duloxetine 30 mg daily was due for a semi-annual review for continued use. None of the forms had been signed by a physician. Interview on 03/27/25 at 2:40 P.M. with Director of Nursing provided verification none of the forms had been signed/addressed by the physician. 44815 2. Review of the medical record for Resident #60 revealed an admitted [DATE] with diagnoses of dementia and heart disease. Review of the quarterly MDS assessment, dated 01/19/25, revealed Resident #60 had impaired cognition, and received medications for anxiety and depression. Review of a pharmacy recommendation dated 08/12/24 revealed a recommendation for Resident #60 to have laboratory tests drawn every six months. Further review revealed the physician agreed, and the agreement to order laboratory tests was noted 09/20/24. Review of the laboratory test results completed for Resident #60 revealed they were drawn on 09/24/24. 3. Review of the medical record for Resident #62 revealed an admitted [DATE] with diagnoses of Alzheimer's disease, dementia, and psychotic disorder with delusions. Review of the quarterly MDS assessment dated [DATE] revealed Resident #62 had impaired cognition and received antipsychotic medications. Review of a pharmacy recommendation, dated 11/20/24, revealed Resident #62 received olanzapine 5 mg twice daily. Further review revealed a recommendation for a gradual dose reduction. Review of a nursing progress note dated 02/14/25 revealed the Nurse Practitioner ordered olanzapine be decreased from 5 mg twice daily to 5 mg in the morning and 2.5 mg in the evening. Review of the current physician order, dated 02/15/25, revealed Resident #62 received olanzapine (an antipsychotic medication), 5 milligrams (mg) every morning and 2.5 mg every night. Interview on 03/27/25 at 2:40 P.M. with the Director of Nursing confirmed the facility did not respond timely to the pharmacy recommendations for Resident #60 and Resident #62.

Based on resident interview, record review, staff interview, and policy review, the facility failed to ensure residents received insulin as ordered by the physician. This affected one (#123) of eight residents reviewed for medications. The facility census was 72. Findings include: 1. Review of the medical record for Resident #123 revealed an admitted [DATE] with diagnoses of metabolic encephalopathy and type 2 diabetes mellitus. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 03/17/25, revealed Resident #123 had intact cognition. Review of the baseline care plan dated 03/13/25 revealed Resident #123 had diabetes. Review of the current physician order dated 03/11/25 revealed Resident #123 received Humalog KwikPen Subcutaneous Solution Pen-Injector 100 units per milliliter (ml) (Insulin Lispro), inject 8 units subcutaneously (SQ) three times a day for diabetes mellitus (DM). The scheduled dosing times were 8:00 A.M., 11:00 A.M. and 5:00 P.M. Review of the current physician order dated 03/13/25 revealed Resident #123 received Humalog Injection Solution (Insulin Lispro) per sliding scale for type 2 DM, AC (before meals) and HS (bedtime). The scheduled dosing times were 7:30 A.M., 11:00 A.M., and 4:00 P.M. Interview on 03/25/25 at 9:07 A.M. with Resident #123 revealed she had not received her morning medications. Interview on 03/25/25 at 9:47 A.M. with Licensed Practical Nurse (LPN) #400 revealed she worked for an agency and worked infrequently at the facility. LPN #400 confirmed she had not provided Resident #123's medications yet. Continued interview and concurrent review of the electronic medical record (EMR) for Resident #123 with LPN #400 revealed the orders Resident #123's two Humalog insulin injections were overdue. Interview on 03/25/25 at approximately 5:15 P.M. with Regional Clinical Support Nurse (RCSN) #396, and concurrent review of the EMR for Resident #123, confirmed the morning Humalog doses for Resident #123 were given at 9:55 A.M. and both medications were overdue. 2. Review of the hospital discharge orders for Resident #123, dated 03/11/25, revealed Resident #123 should receive Tresiba FlexTouch (insulin) 200 unit per ml, give 9 units into the skin daily. Review of the physician office visit progress note dated 03/19/25 revealed Resident #123's blood glucose levels had been fluctuating, with several readings in the high 200's and 300's. Further review revealed the physician ordered an increase in Tresiba from 9 units SQ daily to 11 units SQ daily. Review of the current physician orders on 03/25/25 at 3:15 P.M. for Resident #123 revealed no active orders for Tresiba. Interview on 03/25/25 at 3:19 P.M. with the Director of Nursing (DON) and concurrent review of Resident #123's EMR revealed Resident #123 received one dose of Tresiba, 9 units, on 03/11/25 and did not receive any other doses. The DON confirmed the order for Tresiba, 9 units, was initiated 03/11/25 and discontinued on 03/11/25. Further, the DON confirmed the order for Tresiba, 11 units, was initiated 03/21/25 and discontinued on 03/21/25 and Resident #123 received no dose of Tresiba at 11 units. Follow-up interview on 03/25/25 at 4:59 P.M. with the DON revealed the pharmacy who provided the facility's medication canceled the order for Tresiba with the intention of replacing it with a generic version. The DON stated the pending order for the generic version was never confirmed and therefore, Resident #123 did not receive Tresiba as ordered after 03/11/25. Review of the undated policy, Medication Dispensing System, revealed medications are administered in a timely fashion as specified by policy.

Based on observation, staff interview, and policy review, the facility failed to ensure staff wore gloves when administering injections. This affected three residents (#21, #122, and #123) observed for insulin injections. Additionally, the facility staff did not disinfect a glucometer between resident use. This affected two residents (#21 and #122). Further, the facility failed to ensure staff wore proper personal protective equipment and practiced appropriate hand hygiene. This affected two residents (#122 and #123). The facility census was 72. Findings include: 1. Review of the medical record of Resident #21 revealed an admitted [DATE]. Diagnoses included type II diabetes mellitus. Review of the medical record of Resident #122 revealed an admitted [DATE]. Diagnoses included type II diabetes mellitus. Review of the medical record of Resident #123 revealed an admitted [DATE] Diagnoses included type II diabetes mellitus. Observation on 03/26/25 at 8:05 A.M. revealed Licensed Practical Nurse (LPN) #400 administered seven units of Humalog insulin subcutaneously (sq) to Resident #21 without wearing gloves. At 8:30 A.M. LPN #400 administered 12 units Humalog insulin sq to Resident #123 without wearing gloves. At 8:44 A.M. LPN #400 administered 14 units Lantus insulin sq to Resident #122 without wearing gloves. Interview on 03/26/25 at 9:00 A.M. with LPN #400 provided verification she had not worn gloves while administering insulin injections to Residents #21, #122, and #123. 2. Observation on 03/26/25 at 8:00 A.M. revealed Licensed Practical Nurse (LPN) #400 exit the room of Resident #21 with a glucometer. LPN #400 placed the device into the drawer of the medication cart, without disinfecting, a second device was in the drawer. At 8:40 A.M. LPN #400 obtained a glucometer from the drawer and used it to obtain a blood sugar reading on Resident #122. Interview on 03/26/25 at 9:00 A.M. with LPN #400 provided verification she had not disinfected the glucometer between use on Residents #21 and #122. Review of the policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 10/18, revealed equipment will be cleaned and disinfected before use by another resident. 44815 3. Review of the medical record for Resident #122 revealed an admitted [DATE] with congestive heart failure, bacteremia, and methicillin susceptible staphylococcus aureus (MSSA) infection. Review of the Nursing Admission Evaluation, dated 03/19/25, revealed Resident #122 was alert and oriented to self, time, and place. Review of the physician order dated 03/20/25 revealed Resident #122 received cefazolin sodium injection solution (an antibiotic) for MSSA bacteremia. Review of the physician order dated 03/24/25 revealed Resident #122 was in contact precautions due to an infection of his wound. Observation on 03/24/25 at approximately 2:40 P.M. revealed an orange sign posted on Resident #122's door reading Contact Precautions. Wear gown and gloves upon entering. Further observation revealed a plastic set of drawers in the hallway outside Resident #122's door containing disposable gowns, gloves, and masks. Interview and observation on 03/24/25 at approximately 2:45 P.M. with Resident #122 revealed he had a dark substance under his fingernails. Resident #122 stated he often scratched at his scabs and verified the substance under his nails could be blood. Resident #122 further stated he was able to independently wash and clean his own fingernails. Additional observation revealed Resident #122 holding his cellular phone during the interview. Observation on 03/24/25 at 2:55 P.M. revealed the Director of Nursing (DON) entering Resident #122's room without first putting on a disposable gown or gloves. The DON picked up a tie from the Surveyor's disposable gown from the ground and placed it in the trash. The DON then began to discuss with Resident #122 difficulties regarding arranging transportation to an appointment. Resident #122 handed his phone to the DON to show the DON a text conversation between Resident #122 and the transportation company. The DON held Resident #122's phone, read the information, and handed Resident #122's back to him. Continued observation revealed the DON left Resident #122's room, without performing hand hygiene, walked into the hall, and walked directly into Resident #123's room whose call light was on. The DON walked into the bathroom to assist Resident #123 who was seated on the toilet. Before the DON began to assist Resident #123, Certified Nursing Assistant (CNA) #345 entered the room and offered to assist Resident #123. The DON then left the bathroom and walked out of Resident #123's room. Interview on 03/24/25 at approximately 3:00 P.M. with the DON confirmed she did not put on a gown or gloves before entering Resident #122's room, confirmed she picked up a tie from the ground with her bare hands in Resident #122's room, held Resident #122's cellular phone in her hands, and did not perform hand hygiene before entering Resident #123's bathroom to provide personal care. The DON confirmed she should have put on a gown and gloves before entering Resident #122's room. The DON further stated she planned to wash her hands in Resident #123's bathroom before providing assistance. Review of the undated policy, Hand Hygiene, revealed staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of pratice.

Based on medical record review, staff interview, and review of facility policy, the facility failed to follow their policy titled Weight Management Program and Weight Loss by ensuring the physician was notified of significant weight loss. This affected three (#10, #56 and #78) out of three residents reviewed for weight loss. The facility census was 79. Findings Include: 1. Review of the medical record for Resident #56 revealed an admitted [DATE] with a diagnosis of multi-system degeneration of autonomic nervous system. Review of the physician orders for 01/23 revealed a diet order of regular mechanical soft, chopped meat diet with thin liquids and house supplement two times per day. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #56 required set-up for meals and was identified for weight loss and required a mechanically altered diet. Review of the care plan revised 10/23 for Resident #56 revealed she was care planned for nutritional problems. Review of the dietician note dated 12/06/23 revealed weight loss of 7.6 % in three month, a slow and steady decline, intakes vary widely from over the past 30 days and has decreased to 25%-50%. Resident #56 receiving hospice services, and the Director of Nursing (DON) was notified. There was no documentation regarding physician notification regarding Resident #56's weight loss. 2. Review of the medical record for Resident #10 revealed an admitted [DATE] with a diagnosis of Alzheimer's disease. Review of the physician orders for 01/23 revealed a diet order of regular pureed diet with nectar thickened liquids and house supplement three times per day. Review of the quarterly MDS dated [DATE] revealed the Resident #10 required maximum assist with eating and was identified for weight loss and required a mechanically altered diet. Review of the care plan revised 01/24 for Resident #10 revealed she was care planned for nutritional problems. Review of the dietician note dated 12/06/23 revealed weight loss of 6.9 % in one month, a recent decline, intake regularly 75%-100% and two episodes of decreased intake each episode lasting a few days. Resident #10 receiving hospice services, and the Director of Nursing DON was notified. There was no documentation regarding physician notification regarding Resident #10's weight loss. Review of the quarterly dietary assessment dated [DATE] revealed Resident #10 is consuming approximately 50%-100% of the supplement. 3. Review of the medical record for Resident #78 revealed an admitted [DATE] with a diagnosis of protein-calorie malnutrition. Review of the physician orders for 01/23 revealed a diet order of mechanical soft diet with honey thickened liquids. Review of the quarterly MDS dated [DATE] revealed the Resident #78 required supervision with eating and was identified for weight loss and required a mechanically altered diet. Review of the care plan revised 12/23 for Resident #78 revealed he was care planned for nutritional problems. Review of the dietician note dated 12/06/23 revealed sudden weight loss of 12% in one month, with the last month of weight being stable, intake varying widely from 25%-50% and accepts snacks. Resident #78 receiving hospice services, and the DON was notified. There was no documentation regarding physician notification regarding Resident #78's weight loss. Interview on 01/11/24 at 3:50 P.M. with the DON confirmed there was no documentation in the charts for Resident #56, Resident #78 and Resident #10 regarding notifying the physician of significant weight loss for the past three months identified by the registered dietician. Interview on 01/11/24 at 4:00 P.M. with the Administrator stated, notifications to the physician of weight loss is usually by fax, for December 2023 someone dropped the ball and notifications weren't completed. Review of the facility policy titled Weight Management Program and Weight loss Policy undated revealed the facility will consider five percent weight loss or gain in 30 days, seven and half percent weight loss or gain in 90 days, and 10% weight loss or gain in six months, will be considered a significant change. The Physician and responsible party will be notified of weight loss per above criteria. This deficiency represents non-compliance investigated under Complaint Number OH00149399.

Based on medical record review, resident interview, staff interview, review of the shower schedule, and review of resident shower sheet documents, the facility failed to provide bathing as desired and as schedule. This affected two (#63 and #92) of three residents reviewed for showers. The facility census was 80. Findings include: 1. Review of the medical record for Resident #63 revealed an admitted [DATE] with diagnoses of hemiplegia and hemiparesis, history of falls, and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had intact cognition, required extensive assistance of one person for hygiene, and was totally dependent on one person for bathing. Review of the shower schedule revealed Resident #63 received showers on Wednesdays and Fridays. Review of shower sheet documentation for Resident #63 revealed none were completed after 05/10/23. Interview on 05/22/23 at 3:25 P.M. with Resident #63 stated did not receive a shower the previous Friday as scheduled and wished he had. Resident #63 confirmed he received a shower the previous Wednesday. Interview on 05/24/23 at approximately 10:00 A.M. with the Assistant Director of Nursing (ADON) confirmed there were no additional shower sheets completed for Resident #63. 2. Review of the medical record for Resident #92 revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease and difficulty walking. Resident #92 discharged to another long-term care facility on 05/16/23. Review of the most recently completed MDS assessment, dated 05/10/23, revealed Resident #92 had intact cognition, required extensive assistance of two people for transfers, extensive assistance of one person for bed mobility, dressing, toileting, and hygiene, and supervision with setup for eating. There was no assessment of Resident #92 rejecting care during the review period. Review of the activity assessment dated [DATE] revealed Resident #92 preferred a bed bath in the morning. Review of the shower schedule revealed Resident #92 received showers on Mondays and Thursdays. Review of the shower sheet documentation provided by the facility revealed bathing was not provided on 05/04/23 because Resident #92 had not been evaluated by therapy. Further review revealed Resident #92 received a shower or bath on 05/08/23 and 05/11/23, and there was no documentation of any bathing that occurred on 05/15/23. Interview on 05/24/23 at approximately 10:00 A.M. with the Assistant Director of Nursing (ADON) confirmed no additional shower sheet documentation was completed for Resident #92. Interview on 05/24/23 at approximately 11:00 A.M. with the Director of Nursing (DON) confirmed shower sheets were the only way to track if a resident received showers or baths. Interview on 05/24/23 at 5:44 P.M. with the Regional Nurse stated the facility had no shower policy, and stated showers were expected to be completed as requested and per the shower schedule. This deficiency represents non-compliance investigated under Complaint Number OH00142977.

Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure a resident's mattress maintained in a clean and sanitary manner. This affected one (#63) of four residents reviewed for a clean environment. The facility census was 80. Findings include: Review of the medical record for Resident #63 revealed an admitted [DATE] with diagnoses of hemiplegia and hemiparesis, history of falls, and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had intact cognition, required extensive assistance of one person for hygiene, and was totally dependent on one person for bathing. Observation on 05/22/23 at 3:25 P.M. revealed Resident #63 lying in bed with a bolstered (high cushioned sides) mattress without bed sheets. There was staining visible on the mattress near the resident's left knee. Interview and observation on 05/22/23 at 3:40 P.M. with State tested Nurse Aide (STNA) #103 confirmed Resident #63's mattress was stained. Observation and interview on 05/24/23 at 12:00 P.M. with Resident #63 revealed his mattress was without bed sheets and the mattress was stained near his left knee. Interview with Central Supply #100 on 05/24/23 at 12:00 P.M., during the observation and interview with Resident #63, confirmed Resident #63's mattress was stained. Interview on 05/24/23 at 12:16 P.M. with Resident #63 stated it bothered him that his mattress was stained, and stated the facility used to clean it, but they did not seem to clean it anymore. Interview and observation on 05/24/23 at 12:30 P.M. with the Director of Nursing (DON) and Unit Manager #104 confirmed Resident #63's mattress was stained. Interview at that time with Resident #63 revealed he had not been out of bed since his shower on 05/17/23. Unit Manager #104 confirmed Resident #63 needed to be out of the bed to clean the mattress. This deficiency represents non-compliance investigated under Complaint Number OH00143021.

Based on observation, medical record review, resident interview, and staff interview, the facility failed to provide timely assistance with shaving. This affected one (#63) of three residents reviewed for activities of daily living. The facility census was 80. Findings include: Review of the medical record for Resident #63 revealed an admitted [DATE] with diagnoses of hemiplegia and hemiparesis, history of falls, and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had intact cognition, required extensive assistance of one person for hygiene, and was totally dependent on one person for bathing. Observation on 05/22/23 at 3:25 P.M. revealed Resident #63 lying in bed with an unshaven face. Interview at that time with Resident #63 stated his facial hair was several days growth, and Resident #63 stated he wanted his face to be shaved. Interview on 05/24/23 at 11:41 P.M. with Central Supply #100 stated she spoke with Resident #63's wife the previous day who requested Resident #63 be shaved. Central Supply #100 relayed the request to the two nurse aides working the afternoon of 05/23/23. Observation and interview on 05/24/23 at 12:00 P.M. with Central Supply #100 revealed Resident #63 was still unshaven. Central Supply #100 confirmed Resident #63 remained unshaven. Interview on 05/24/23 at 12:30 P.M. with Unit Manager (UM) #104 stated she was told by both nurse aides working the afternoon of 05/23/23 Resident #63 refused to be shaved by either one of them. UM #104 stated historically Resident #63 only felt comfortable with certain staff shaving him and the two nurse aides working at that time were agency and Resident #63 was unfamiliar with them. Interview on 05/24/23 at 12:35 P.M. with Resident #63 stated he was not offered to be shaved by any staff on 05/23/23, and stated he would have accepted the shave even though he did not know the nurse aides. This deficiency represents non-compliance investigated under Complaint Number OH00142977.

Based on medical record review and staff interview, the facility failed to obtain a release of medical records prior to sending resident medical records to another nursing facility. This affected one (#8) of three residents reviewed for transfers. The facility census was 85. Findings include: Review of the medical record revealed Resident #8 was admitted on [DATE]. Diagnoses included unspecified fracture of shaft of the right fibula and tibia, generalized anxiety disorder, muscle weakness, essential (primary) hypertension, hypothyroidism, Alzheimer's disease with late onset, nonexudative age-related macular degeneration, and mixed hyperlipidemia. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of power of attorney (POA) documentation dated 04/08/22 verified Resident #8 had family named as the power of attorney. Review of a progress note dated 02/28/23 revealed the Administrator and social services met to review an increase in Resident #8's physical aggression, increase in calling, and attention seeking behavior. Facility staff spoke with Resident #8's POA regarding possible placement in a facility with more specialized dementia care. Resident #8's POA voiced agreement and asked for names of possible facilities for alternate placement. Review of a progress note dated 02/28/23 revealed it was expressed to Resident #8's POA of the possibility of the behaviors advancing to where the resident was no longer appropriate for the facility. Resident #8's POA was informed social services would investigate possible options for alternate placement when it was decided that was Resident #8's best option. Review of a progress note dated 03/01/23 revealed Resident#8's POA was in agreement with a transfer to a psychiatric hospital in another facility and provided a list of three facilities in order of preference. Review of a progress note dated 03/01/23 revealed social services called the psychiatric facility Resident #8's POA was in agreement with and nurses notes and a medication list was sent. Further review of the progress note revealed the facility indicated they would call back if they would accept Resident #8. Review of a progress note dated 03/03/23 revealed the psychiatric facility called requesting progress notes from the last couple of days, and Resident #9's family was contacted for verbal approval to send the additional documentation. Review of a progress note dated 03/03/23 revealed Resident #8's family went to the psychiatric facility to take a tour, and the facility received a follow-up call from Resident #8's family reporting they visited the facility and Resident #8 was not accepted at the psychiatric facility until Resident #8 had behaviors. Interview on 05/01/23 at 12:52 P.M. with Admissions Coordinator (AC) #301 stated between the former Director of Nursing (DON) and former Assistant Director of Nursing (ADON) they talked to another nursing facility in a different location which was not communicated to Resident #8's family or POA. AC #301 stated the facility at that location was larger and the facility staff thought it would be a better fit. The facility staff talked to staff members of the other facility, who were previous employees of Resident #8's current facility, and they said to send Resident #8's medical record information to them. AC #301 confirmed she sent Resident #8's medical record information to the other nursing facility, and did not know if Resident #8's POA gave approval to send the medical record information there. AC #3021 stated she was not aware the date the medical information was sent to the other facility, and verified she does not obtain or verify release of information prior to sending information. Review of the medical record for Resident #8 was silent for a release of information or verbal approval to send medical record information to the nursing facility that was not discussed with Resident #8's POA. Interview on 05/01/23 at 1:19 P.M. with Resident #8's POA stated the facility was threatening to discharge Resident #8 due to behaviors, and stated the facility did talk about admitting Resident #8 to a psychiatric facility for short-term care but that facility would not accept Resident #8. Resident #8's POA stated the only nursing facility Resident #8's POA considered was a local facility close to family. Resident #8's POA stated they never contacted any other facilities as a potential option for Resident #8's placement. Resident #8's POA reported the other facility Resident #8's current facility sent medical documents to called her to discuss Resident #8's potential admission to that facility. Resident #8's POA stated she never considered the possibility of transferring Resident #8 to the facility where the medical records were sent, and verified they did not provide approval for release of information to the facility. Interview on 05/01/23 at 2:15 P.M. with the Administrator and Corporate Registered Nurse (RN) #302 verified the facility did not have any documentation of verbal or written approval to send Resident #8's medical information to the nursing facility which received medical records from AC #301. This deficiency represents non-compliance investigated under Complaint Number OH00142213.

Based on medical record review, staff interview and policy review, the facility failed to issue written notification of a room change to three (#8, #18, and #7) of three residents reviewed for room changes. The census was 66. Findings include: 1. Review of the medical record for Resident #8 revealed the resident was admitted [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) 3.0 assessment for Resident #8, dated 09/20/22, revealed the resident had severe cognitive impairment. Review of the medical record indicated Resident #8 was moved into a different room on 09/27/22 after being in his original room since 03/12/20. The record included no evidence the resident or representative was provided a written notice of the change. 2. Review of the medical record for Resident #18 revealed the resident was admitted [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment for Resident #18, dated 07/22/22, revealed the resident had a moderate degree of cognitive impairment. Further review of the record for Resident #18 revealed the resident was moved to a different room on 09/23/22. The record included no evidence the resident or representative was provided a written notice of the change. 3. Review of the medical record for Resident #7 revealed the resident was admitted [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment for Resident #7, dated 07/12/22 revealed the resident had no cognitive impairment. Further review of the record for Resident #7 revealed the resident was moved to a different room on 09/22/22 and again on 09/27/22. The record included no evidence the resident or representative was provided a written notice of the change on 09/22/22. The record indicated the move on 09/27/22 was requested by the resident. Interview on 10/04/22 at 4:25 P.M. with Social Services Director (SSD) #15 revealed the facility did not provide written notice for room or roommate changes for these three (#8, #18, and #7) residents. Interview on 10/05/22 at 11:52 A.M. with the Director of Nursing (DON) confirmed it was not facility policy to provide written notice of a room or roommate change. Interview on 10/05/22 at 1:00 P.M. with the Administrator, further confirmed it was not facility practice to provide written notice upon room or roommate change. Review of a policy titled, Room/Roommate, undated, revealed it was policy for the facility to notify resident(s) of a room or roommate change, but the policy was silent to the manner in which notification would be made. Review of a facility form titled, Notice of Room or Roommate Change (undated) revealed it included various reasons for a room or roommate change, next to which the author could indicate the reason for the change. The form included a designated line for the resident's or representative's signature. This deficiency substantiates Master Complaint Number OH 258.

Based on observation, staff interview, and policy review, the facility failed to ensure appropriate sanitation when serving meals and failed to keep pureed meat at a safe holding temperature to potentially prevent foodborne illness. This had the potential to affect 62 of 62 residents. The facility census was 62. Findings include: 1. Observation on 07/25/22 at 11:12 A.M., of Assistant Dietary Supervisor (ADS) #467 checking the holding temperature of pureed fish revealed the temperature of the fish on the holding steam table was 120 degrees Fahrenheit. Interview of ADS #467, at the time of the observation, verified the pureed fish was 120 degrees. ADS #467 stated she set the temperature on the holding table at 175 degrees Fahrenheit but she was unsure of what the hot food holding temperature should be to prevent foodborne illness. ADS #467 stated the pureed fish had set outside of the steam table a little longer while she was getting other food ready. ADS #467 was unsure how long the pureed fish had been left sitting before placing on the holding table. 2. Observation on 07/25/22 at 11:15 A.M., of lunch tray line service revealed ADS #467 don gloves before plating resident's lunches. With her left, gloved hand, ADS #467 picked up a plate and placed it on the serving counter. ADS #467 used the same left, gloved hand to guide peas onto the plate. Without changing her gloves, ADS #467 picked up pieces of fish and placed one piece on each of five plates. Wearing the same gloves, ADS #467 continued to touch serving utensils and use her left hand to guide peas and fried potatoes onto each of the five plates, making contact with the peas and potatoes with her left, gloved hand as she plated each plate. ADS #467 placed each plate onto a cart and pushed the cart toward the exit from the kitchen, grabbed an empty cart and moved it closer to the serving area. Interview of ADS #467, at the time of the observation, verified she touched food and non-food items with the same gloves hands, stating she used to her hands to make sure the foods did not touch each other when she plated the food. ADS #467, without changing her gloves, returned to the holding table and began plating four meals, again using her hands to guide food onto the plates. 3. Observation on 07/25/22 at 11:33 A.M., of lunch tray service on the 300 Hall revealed State tested Nurse Aide (STNA) #417 enter Resident #4's room with a lunch tray. STNA #417 assisted Resident #4 with meal set up, including uncovering food items and cutting up fish. STNA #417 exited Resident #4's room, without performing hand hygiene, removed a tray from the cart, and entered Resident #42's room and delivered the lunch tray. STNA #417 exited Resident #42's room, without performing hand hygiene, and delivered a lunch tray to Resident #24. STNA #417 did not perform hand hygiene, removed a tray from the cart and delivered the lunch meal to Resident #31, removing the plate cover and plastic wrap from Resident #31's dessert. STNA #417 removed a tray from the cart and entered Resident #47's room. STNA #417 assisted Resident #47 with meal set up, including removing coverings from food items and cutting up the fish. STNA #417 exited the room, without performing hand hygiene, and pushed the meal cart to the end of the hall. STNA #417 delivered a meal tray to Resident #34, picked up the last meal tray from the cart, and entered Resident #1's room. STNA #417 assisted Resident #1 with meal set up, including uncovering food items and cutting up fish. Upon exiting Resident #1's room, STNA #417 performed hand hygiene. Interview on 07/25/22 at 11:40 A.M., of STNA #417 verified she did not perform hand hygiene while delivering meal trays and providing set up assistance, stating she must have missed it a couple of times. Review of the undated policy titled Dietary, revealed the dietary manager will ensure all staff practice proper hand washing techniques and proper glove use. In addition, dietary staff will ensure that all foods are held at appropriate temperatures, greater than 135 degrees for holding hot foods.

Based on observation, staff interview, infection control log review, [CONDITION(S)] risk assessment review, review of personnel files, and review of a facility policies, the facility failed to monitor for trends and patterns of infections in the facility based on facility policy, failed to sanitize hands and wear appropriate personal protective equipment (PPE) during resident care interactions, and failed to ensure the facility followed their [CONDITION(S)] risk assessment in monitoring staff for potential [CONDITION(S)] infections. This deficiency had potential to affect 62 of 62 residents residing in the facility. The census was 62. Findings include: 1. Review of infection control logs from May, June, and July 2022 revealed each resident with an infection was placed on a spreadsheet and the following information documented: the unit the resident resided on the date of the infection, the resident's name, room number, signs and symptoms including the date, the site of the infection, if the infection was a urinary tract infection did the resident have a urinary catheter, culture or organism if applicable, antibiotic use with stop and start date, if placed on isolation, if symptoms were present on admission, if the infection was acquired in the facility, and if the antibiotic usage met McGeer criteria (nationally-recognized infection surveillance criteria). Further review of the infection control log spreadsheets revealed each entry was documented in alphabetical order by the resident's last name with no method to identify trends of infections in the facility by date, infection type, or location. There was no documentation of any tracking or trending of infections in the space designated for such data at the end of each infection control log spreadsheet. There were no identifiable trends of infections identified on the May, June, and July 2022 infection control logs. Interview on 07/27/22 at 12:55 P.M., with Director of Nursing (DON) #1 verified she was in charge of the infection control program, but that duty had been shared many times over the last year. DON #1 stated the facility used to use a map of the facility with color coding of infections to identify potential trends of infections in the facility but had not done that since at least the beginning of 2022. DON #1 verified there was no analysis of infections completed at any time during the month and no tracking or trending data completed as well. DON #1 stated there were no trends or patterns of infections in the facility for at least all of 2022. Observation between 07/25/22 and 07/28/22 between 8:00 A.M. and 4:00 P.M., revealed no residents in the facility on ordered infection control precautions. Review of an undated policy titled, Infection Control Protocol and Tracking, revealed the infection control nurse designee will complete the monthly infection summary to monitor trends. When the resident acquires an infection, the infection control nurse/designee will update the surveillance map by reviewing the location the location the resident resides and type and location of infection. If there is a pattern, this will be discussed in the weekly quality assurance programs meeting 2. Observation of incontinent care on 07/26/22 at 3:45 P.M., revealed State tested Nursing Assistant (STNA) #455 removed a wet incontinent brief from Resident #20. STNA #455 cleasened the anterior and posterior peri areas with wipes. She disposed of the wipes and the wet brief in the trash can close to the bed. She applied a protective cream to the resident's buttocks. She placed a clean incontinent brief under the resident. She removed her gloves and disposed of them in the trash can by the bed with the wipes and the wet brief. She removed the liner from the trash can and tied the top of the liner placing it on the floor. The resident had an unopened container of jello on the over bed table which the resident stated she wanted. STNA #455 opened the jello set it down on the over bed table and stated she would feed Resident #20 the jello as soon as she got another liner for the trash can. She went into the bathroom obtained a liner for the trash can and placed it in the trash can . She obtained a spoon from the over bed table and began feeding the resident the jello. After she fed the resident the jello see washed her hands in the resident's bathroom. The entire time STNA #455 was in the room providing care and feeding the resident jello her surgical mask did not cover her nose. The top of the mask rested on her upper lip. Interview with STNA #455 on 07/26/22 at 3:55 P.M., she verified she did not wash her hands following incontinent care and before feeding Resident #20 jello. She stated she didn't think about it. Interview with Licensed Practical Nurse (LPN) #435 on 07/26/22 at 4:00 P.M., verified STNA #455 was wearing a surgical mask just covering her mouth and not covering her nose. She stated she is constantly reminding staff to wear their masks properly covering their mouth and nose. Interview with Registered Nurse (RN) #457 on 07/26/22 at 4:05 P.M., verified STNA #455 was wearing a surgical mask just covering her mouth and not covering her nose. She stated she is constantly reminding staff to wear their masks properly covering their mouth and nose and at times just to wear a mask. 3. Review of State tested Nurse Aide (STNA) #431's personnel record revealed a hire date of 09/09/20. The record contained evidence of a two-step mantoux [MEDICATION(S)] skin test (TST) completed upon hire. The record was silent for annual TST testing. Review of STNA #447's personnel record revealed a hire date of 09/02/20. The record contained evidence of a two-step TST completed upon hire. The record was silent for annual TST. Review of STNA #455's personnel record revealed a hire date of 09/03/20. The record contained evidence of a two-step TST completed upon hire. The record was silent for annual TST. Interview on 07/28/22 at 2:29 P.M., with the Administrator verified there was no evidence STNAs #431, #447, or #455 were tested , or screened, annually for [CONDITION(S)] (TB), with the last TST completed upon hire. Review of the facility's TB risk assessment and control plan, dated 03/28/22, revealed healthcare workers would be tested for TB upon hire and annually.

Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure medications were administered as ordered. This affected five (#2, #12, #14, #56, and #59) of five residents observed during medication administration. A total of 15 medications errors were observed out of 28 medications administered which resulted in a medication error rate of 53.57 percent (%). The census was 62. Findings include: 1. Review of Resident #56's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 11:00 A.M. and between 7:00 P.M. and 11:00 P.M. daily. Resident #56's [MEDICATION(S)] was scheduled to be given at 9:00 A.M., 2:00 A.M., and 8:00 P.M. daily; and Resident #56's [MEDICATION(S)] sulfate was scheduled to be given at 8:00 A.M., 2:00 P.M., and 8:00 P.M. Observation on 07/25/22 at 12:46 P.M., revealed Resident #56 was administered her [MEDICATION(S)], famotadine, [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] sulfate by Registered Nurse (RN) #462. 2. Review of Resident #14's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 11:00 A.M. and between 7:00 P.M. and 11:00 P.M. daily. Observation on 07/25/22 at 12:49 P.M., revealed Resident #14 was administered her potassium chloride and [MEDICATION(S)] by RN #462. 3. Review of Resident #12's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 11:00 A.M. and between 7:00 P.M. and 11:00 P.M. daily. Observation on 07/25/22 at 12:53 P.M., revealed Resident #14 was administered her [MEDICATION(S)] by RN #462. 4. Review of Resident #59's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 2:00 P.M., and 8:00 P.M. daily, and [MEDICATION(S)] was scheduled to be administered between 7:00 A.M. and 11:00 A.M. daily. Interview on 07/25/22 at 12:56 P.M., with RN #462 stated Resident #59's [MEDICATION(S)] was not available in the medication cart and Resident #59 would not receive the medication on 07/25/22 because it needed to be ordered. Observation on 07/25/22 at 12:58 P.M., revealed Resident #59 was administered her [MEDICATION(S)] by RN #462. 5. Review of Resident #2's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 2:00 P.M., and 8:00 P.M. and Resident #2's [MEDICATION(S)] and [MEDICATION(S)] were scheduled to be administered between 7:00 A.M. and 11:00 A.M. and between 7:00 P.M. and 11:00 P.M. daily. Observation on 07/25/22 at 1:05 P.M., revealed Resident #2 was administered her Tylenol, [MEDICATION(S)], and [MEDICATION(S)] by RN #462. Interview on 07/25/22 at 12:37 P.M., with RN #462 verified she was the nurse assigned to the secured unit on 07/25/22 and stated this was the first she was able to make it back to the unit. RN #462 stated the wound physician needed her to make rounds so she was at least two hours behind on her medication administration and the secured unit was the last unit she needed to finish. RN #462 stated another nurse usually went with the wound physician on wound rounding days but that nurse was assisting the administrative team at that time. RN #462 verified all of Resident #2, #12, #14, #56, and #59's medications were administered late. Review of the policy titled, Medication Administration, dated 2020, revealed nurses should administer medications as ordered in accordance with manufacture specifications. The medication should be administered within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician.

Based on observations, medical record review, review of hospital records, staff interviews, review of the National Institute of Health United States National Library of Medicine/Medline Plus website, review of the National Institute of Standards and Technology website, and review of facility policy, the facility failed to ensure a resident's environment was free from accident hazards to [MEDICAL CONDITION] two (#01 and #02) of two residents reviewed for burns. This resulted in Actual Harm for Resident #01 and Resident #02 when Resident #01 was discovered with her feet against the electric heater which caused second and third [MEDICAL CONDITION] and Resident #02 sustained [MEDICAL CONDITION] her right shoulder and back when she was found lying beside the electric baseboard heater. Nineteen residents (#03, #07, #23, #24, #26, #28, #29, #34, #36, #42, #44, #49, #53, #54, #56, #57, #59, #63, and #66) were observed to reside in rooms with an electric baseboard heater with a surface temperature observed to be greater than 118 degrees Fahrenheit. The facility census was 55. Findings include: 1.Review of the closed medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 02/08/20, revealed Resident #01 had long and short term memory issues. The resident required extensive assistance with all activities of daily living (ADLs). Review of the Nursing Admission Assessment, dated 02/01/20, revealed Resident #01 was usually understood, had disorganized thinking, and had short and long term memory issues. It revealed the resident required assistance of two staff for bed mobility and transfers. Review of nursing progress notes entry time stamped on 02/29/20 at 7:23 A.M., revealed Resident #01 was found with her legs hanging off the bed and her feet touching the baseboard heater. The foot of the bed was moved a small space away from the wall. Staff lifted the legs back into bed and [MEDICAL CONDITION] both feet. The nurse assessed [MEDICAL CONDITION] called for an order to send the resident to the emergency room (ER) for evaluation and treatment. The nursing progress note documented the resident returned to the facility around 6:00 A.M. with new orders. Review of hospital notes dated 02/29/20 revealed Resident #01 was assessed for second [MEDICAL CONDITION] both feet. The notes documented the ER had been informed the resident had been sitting next to the heater with her feet dangling against the heater. The resident ' s right foot had a burn with blister to the lateral area. There was an area of callus and blister rupture/ulcer near the fifth metatarsal phalangeal with slight redness to the entire plantar surface. The left great toe was blistered to just below the joint. The ER discharging [DIAGNOSES REDACTED]. Review of the Skin Grids dated 02/29/20 revealed Resident #01 had a burn to the top of the right foot measuring 8.5 centimeters (cm) by 1.4 cm which was a white blister. The right great toe had a burn documented but not measured. The top of the right second toe had a red burn that was 4 cm by 2 cm in size. The top of the right third toe had a red burn that was 3 cm by 3 cm in size. The top of the fourth toe had a red burn that was 3 cm by 2 cm in size. The left great toe was identified to have a burn but there was no description or measurements of the area. Review of physician orders dated 02/29/20 revealed the physician ordered the antibiotic Keflex for ten days, follow up with wound care on Monday, [MEDICATION NAME] 5-325 milligrams (mg) every six hours as needed for pain, and treat the affected burn areas with silver [MEDICATION NAME] three times a day until healed. On 03/02/20 the treatment to [MEDICAL CONDITION] changed to Xeroform dressings daily. Review of a wound care progress note dated 03/04/20, written by Nurse Practitioner #240, documented Resident #01 was assessed [MEDICAL CONDITION] both feet. The resident had significant full [MEDICAL CONDITION] the right lateral and plantar foot including the toes with the largest area on the lateral foot and ankle measuring 17 centimeters (cm) by 10.5 cm with an indeterminate depth. The wound bed was 50 percent white, 10 percent black and 40 percent red with open blistering and moderate serous (bloody) drainage. The right great toe had an intact serous filled blister measuring 3 cm by 6 cm. The second dorsal toe had a yellow wound bed measuring 3.5 cm by 2 cm with an undetermined depth. The third dorsal toe had a yellow wound bed and measured 3.5 cm by 2.5 cm with an undetermined depth. The fourth dorsal toe burn measured 2 cm by 2 cm with an undetermined depth. There was a dark purple area to the left great toe, the left second toe, and the left third toe, but the skin was intact. Most of the burn was a second degree burn with part of it being a third degree burn. The wounds were cleansed, debrided and dressed. The treatment was changed to cleanse the areas daily and apply [MEDICATION NAME] gel on gauze, and cover with an ABD dressing. Review of the record revealed on 03/09/20, Resident #01 transferred to an assisted living facility. Review of a facility investigation revealed Resident #01 was found on 02/29/20 at 2:15 A.M. by STNA #13 with her legs dangling off the bed and her feet touching the baseboard heater. The foot of the bed was close to the exterior wall where the baseboard heater was located. The investigation was unclear on how the bed was moved as staff thought the bed was locked when they left the room on the prior resident check. Staff lifted Resident #01 ' s legs back onto the bed.[MEDICAL CONDITION] discovered on the resident ' s feet and the resident was sent to the emergency room . Immediate interventions by the facility included the resident ' s bed was immediately moved away from the baseboard heater. A wound consult was ordered and a pain assessment was conducted. Review of the witness statement provided by STNA #13, dated 02/29/20, revealed she had checked on Resident #01 between 12:30 A.M. and 1:00 A.M. The resident had been fidgety that night. When she next checked on Resident #01, she found the resident ' s legs off the bed and on the heater. The STNA immediately removed the resident ' s legs from the heater and got LPN #11. LPN #11 did not provide a witness statement during the facility investigation. Review of witness statement by LPN #80, dated 02/29/20, revealed LPN #11 reported to LPN #80 that STNA #13 had checked on Resident #01 and noticed her legs over the bed and against the heater. LPN #11 had checked on the resident and discovered both feet were burned, had blisters, in some areas skin was peeled back, and some areas were fluid filled. The resident ' s legs were red and warm. The resident was sent to the ER for an assessment by LPN #11. Interview with CRN #12 on 12/16/20 at 11:15 A.M. verified Resident #01 was found by the nursing staff to have her feet dangling off the bed against the baseboard heater. She further verified the resident sustained [REDACTED]. She verified the baseboard heaters had a very hot surface temperature but the facility had not been able to find a method to fix the issue. Observation on 12/16/20 at approximately 9:30 A.M. revealed the temperature of the electric baseboard heater in room [ROOM NUMBER] was 175 degrees F. room [ROOM NUMBER] was the room Resident #01 resided in at the time of her burn. Observation of the temperature of the electric baseboard heater in room [ROOM NUMBER] on 12/17/20 at approximately 8:30 A.M. revealed the temperature to be 189 degrees F. 2. Review of the closed medical record for Resident #02 revealed the resident was admitted to the facility on [DATE] and was discharged on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly MDS 3.0 assessment, dated 09/04/20, revealed Resident #02 had short and long term memory problems, with moderately impaired cognitive skills for decision making and fluctuating attention. The resident required extensive assistance with bed mobility, transfers, walking, locomotion, toileting and personal hygiene. Review of the nursing progress notes dated 11/24/20 documented around 7:20 P.M. staff heard Resident #02 calling for help. The resident was found lying on the floor between the bed and baseboard heater by STNA #225. It was unclear if the resident was touching the heater when she was found. The resident was assessed and had no visible injury or pain. Resident #02 complained of pain in the right shoulder and of her back burning. The nurse found reddened areas measuring 1 cm by 1 cm, 1 cm by 2 cm, 3 cm by 2 cm, 2 cm by 4.5 cm, and 5 cm by 13 cm to the right shoulder and back. The largest burn had a white area present. The resident was assisted to the bathroom and back to bed. The physician, DON and family were notified. Orders were received to monitor the resident ' s back and right shoulder every shift until healed and apply [MEDICATION NAME] cream to the areas. Review of nursing progress notes dated 11/25/20 at 7:30 A.M. revealed the nurse was informed Resident #02 was not transferring due to complaint of right knee pain. During an assessment of the resident, a large open reddened area was observed on the posterior left shoulder, two smaller reddened areas approximately the size of a 50 cent piece were on the mid upper back, and one area approximately 5 cm by 3 cm was present on the mid back. All areas were open and draining serosanguinous fluid. There were also five scattered blisters to the mid upper back. The areas were cleansed, liberal amounts of A and D ointment was applied while awaiting delivery of [MEDICATION NAME], and a non-adherent dressing was applied. The physician was notified of the areas. Nursing progress notes dated 11/25/20 at 3:20 P.M. revealed a physician was in the facility to assess the resident. Review of the physician progress notes [REDACTED].#02 had a first degree burn to the right shoulder measuring 5 cm by 7 cm in size. There was no documentation by the physician regarding the [MEDICAL CONDITION] the resident ' s right shoulder or [MEDICAL CONDITION] the resident ' s back. Review of the wound assessment and summary sheets dated 11/24/20 revealed Resident #02 had five areas on her right upper back. All five areas were documented as partial thickness burns. Wound number one was measured 3 cm by 2 cm and 0.1 depth. There was scant amount of serous (mostly clear or slightly yellow) drainage and the surrounding skin was reddened. Wound number two measured 2 cm by 1 cm by 0.1 cm deep. There was scant serosanguinous drainage (drainage that has a light red or pink tinge) and the surrounding skin was red. Wound number three measured 4.5 cm by 2 cm by 0.1 cm with a scant serosanguinous drainage and the surrounding skin was red. Wound number four measured 1 cm by 1 cm by 0.1 cm depth, reddened in color with a scant amount of serosanguinous drainage. Wound number five measured 13 cm by 5 cm by 0.1 cm depth, was red in color, and had scant serosanguinous drainage. Review of the wound assessment and summary sheets dated 12/08/20 revealed Resident #02 continued to have five burn areas on her right upper back. Wound number one measured 6 cm by 1.5 cm. Wound number two measured 1.2 cm by 0.5 cm and was pink. Wound number three was 4 cm by 0.1 cm and identified as a scab. Wound number four was 4.5 cm by 1.5 cm and the surrounding skin was identified as hardened and pink. Wound number five was 6 cm by 3.5 cm and identified to have slough (yellowish, tan dead tissue) present. Review of the facility investigation, dated 11/24/20, revealed STNA #225 reported he was in Resident #02 ' s room around 6:30 P.M. Approximately 7:00 P.M., STNA #225 and LPN #11 heard Resident #02 yelling out. STNA #225 went to check on her and found the resident on the floor between the bed and the exterior wall beside the baseboard heater. STNA #225 reported this to LPN #11, who assessed the resident and reported no visible injuries. LPN #11 and STNA #225 assisted the resident to the bathroom and then to bed. On the way back to the bed, they observed what appeared to be a burn and LPN #11 conducted a further assessment. The DON, physician and family were notified of the burn areas. Orders were received for treatment to the area. Review of a written statement from LPN #11 dated 11/24/20 at 7:10 P.M. revealed Resident #02 had reddened areas and the start of blistering on her back upon assessment. Review of the investigation revealed a written statement by LPN #11, dated 11/24/20, which indicated around 7:20 P.M. she heard yelling coming from a room. Resident #02 was found lying on her back between her bed and the baseboard heater and LPN #11 was unsure if the resident was touching the baseboard heater. The resident complained of burning and a burned area was observed to the right upper back and right shoulder. The physician was notified and orders were received for [MEDICATION NAME] cream to the burns. Review of the investigation revealed a written statement from STNA #225, dated 11/24/20, noting around 7:00 P.M. he heard Resident #02 yelling out for help. The STNA found Resident #02 laying on the floor beside her bed next to the wall heater but did not appear to be touching the heater. The resident ' s back looked like it had a bad burn. The resident was assisted to the bathroom so she could be cleaned up and so the nurse could assess her better. Resident #02 stated the only thing that hurt was the burn. The statement revealed STNA #225 had last been in Resident #02 ' s room around 6:30 P.M. Review of the investigation revealed a written statement by the DON, dated 11/25/20 at 2:05 P.M., which documented she had spoken with STNA #225 on the phone at 2:00 P.M. The STNA stated when they got Resident #02 up after the fall, he told the nurse at that time the burn looked like raw bacon and they discussed how the skin was already peeling. The investigation conclusion was the bed was three and a half feet from the heater and the resident was laying between six to twelve inches from the heater and was not touching the heater at the time she was found on the floor. Interview on 12/16/20 at 10:37 A.M., LPN #90 revealed she was the nurse who came on duty the next shift after the [MEDICAL CONDITION] discovered. She stated she was told by LPN #11 that Resident #02 had fallen onto the heater and she had a couple of white areas on her shoulder, but they had improved. She stated she was still in report and a STNA informed her the resident was not transferring. She stated this was not normal for the resident, so she went to assess the resident. The resident complained of right knee pain and as they were repositioning her, LPN #90 noticed the resident ' s bed was wet. When the resident was rolled over, LPN #90 observed a bad burn to the resident ' s right shoulder with subcutaneous tissue peeled showing a full thickness burn. She stated there were two round areas in the mid shoulder blades area which were blistered and opened along with four areas that were blistered and opened on the shoulder. She stated the resident had red marks on her back from the heater. The wounds were weeping onto the bed. LPN #90 reported this assessment to the physician. Interview with LPN #195 on 12/17/20 at 11:00 A.M. revealed she cared for Resident #02 after the resident had sustained the burns. She stated the resident did have [MEDICAL CONDITION] her right back and shoulder. Observations were conducted of each resident room on 12/16/20 between 9:20 A.M. and 9:50 A.M. Surface temperatures of each electric baseboard heater were obtained by Maintenance Director #60 using a digital infrared thermometer. Resident #29 ' s heater was 195 degrees F, Resident #07 and Resident #34 ' s heater was 164 degrees F with the bed of Resident #34 located against the heater. Maintenance Director #60 immediately moved the bed. Resident #03 ' heater was 119 degrees F, Resident #54 and Resident #57 ' s heater was 212 degrees F, Resident #26 ' s heater was 122 degrees F, Resident #49 ' s heater was 175 degrees F, Resident #24 ' s heater was 157 degrees F, Resident #42 and Resident #63 ' s heater was 185 degrees F, Resident #23 and Resident #53 ' s heater was 196 degrees F and had a vinyl/leather like recliner against the heater located by the second bed of Resident #23. The recliner was immediately moved by Maintenance Director #60. Resident #36 ' s heater was 130 degrees F, and Resident #28 and #44 ' s heater was 145 degrees F. Maintenance Director #60 verified each temperature at the time the measurements were obtained. Interview on 12/16/20 at 9:50 A.M., Maintenance Director #60 revealed the baseboard heaters cycled on and off at varied intervals, depending on how the thermostat was set in the rooms. The warmer the resident wanted the room, the warmer the baseboard heater would be. He stated the baseboard heater may be very hot at one time and the next time it could be cool. He verified the surface temperatures of baseboard heaters were at dangerously high levels and could easily burn skin. He further stated he had attempted to place deflectors, shields and insulation in the heaters but was not successful in decreasing the surface temperatures. Maintenance Director #60 further stated there was no specific monitoring or maintenance of these heaters. Interview with the Administrator on 12/16/20 at 11:30 A.M. verified the electric baseboard heaters did have surface temperatures that were dangerously hot at times. She stated they had tried to apply deflectors and use furnace insulation to decrease the temperatures, but it had not worked. She further verified Resident #02 did sustain a burn after she fell on the floor near the heater. She further stated she did not know if the resident fell on to the heater or if it was [MEDICATION NAME] heat that caused the burn. She stated after Resident #02 sustained a burn, she was informed that earlier in the year Resident #01 had [MEDICAL CONDITION] coming into contact with the baseboard heater in her room. A tour of the facility with Maintenance Director #60 on 12/17/20 between 8:20 A.M. and 8:45 A.M. revealed surface temperatures of each electric baseboard were re-checked. Resident #29 ' s heater was 180 degrees F, Resident #66 ' s heater was 184 degrees F, Resident #54 and Resident #57 ' s heater was 168 degrees F, Resident #26 ' s heater was 133 degrees F, Resident #56 ' s heater was 192 degrees F, Resident #49 ' s heater was 189 degrees F, Resident #42 and Resident #63 ' s heater was 209 degrees F, Resident #23 and Resident #53 ' s heater was 176 degrees F, and Resident #59 ' s heater was 134 degrees F. Maintenance Director #60 verified each temperature at the time the measurements were obtained. Review of the facility policy titled Resident Rights and Facility Responsibilities Policy - Ohio, dated 11/2016, revealed residents had the right to a safe and clean-living environment. Review of the National Institute of Health, United States National Library of Medicine/Medline Plus website https://medlineplus.gov/ency/article/ 0.htm, [MEDICAL CONDITION] there are three levels of burns: First-[MEDICAL CONDITION] only the outer layer of the skin. They cause pain, redness, and swelling. Second-[MEDICAL CONDITION] both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. They are also called partial thickness burns. Third-[MEDICAL CONDITION] the deep layers of skin. They are also called full thickness burns. They cause white or blackened, burned skin. The skin may be numb. [MEDICAL CONDITION]: Third-degree burns, Second-[MEDICAL CONDITION] than two to three inches (5 to 7.5 centimeters) wide, Second-[MEDICAL CONDITION] the hands, feet, face, groin, buttocks, or over a major joint.[MEDICAL CONDITION] the face, hands, feet, and genitals can be particularly serious. Review of the National Institute of Standards and Technology website https://www.nist.gov/el/fire-research-division- /firegov-fire-service/fire-dynamics revealed 111 degrees F is the temperature when human skin feels pain, 118 degrees F is the human skin temperature causing first degree burns, 131 degrees F is the human skin temperature with blistering and second degree burns, 141 degrees F is the temperature when burned human tissue becomes numb, and 162 degrees F is the human skin temperature when tissue is instantly destroyed. This deficiency substantiates Master Complaint Number OH 228, Complaint Number OH 968, and Complaint Number OH 945.