Every finding on record at Carroll Healthcare Center Inc

Based on record review, interview, and review of the facility Quality Assurance plan, the facility failed to ensure resident possessions were maintained securely and treated with respect. This affected three residents (#41, #42 and #43) of three closed resident records reviewed.Findings Include:Review of the complaint log revealed the facility lockbox was misplaced affecting Resident's #41 and #42. The result stated it was believed facility lock box was thrown away when the office was cleaned. The resident's families were notified. The Police were notified. The residents' families did not state they felt anything was stolen.The facility was asked for an investigation into the missing lockbox. The paperwork provided included a progress note from Resident #41's record. Review of the progress note indicated the resident expired on [DATE] at 8:45 AM. Eyeglasses, wristwatch and a signet ring were sent with the remains at 1:30 PM. On [DATE] at 4:01 P.M. social service spoke with the resident's granddaughter and resident's son-in-law who came to collect personal belongings. On [DATE] at 11:35 A.M. there was a progress note by Registered Nurse (RN) #51. The progress note revealed:This nurse helped clean out the office when a new social service designee started towards the end of May. There was a medium size lockbox in the cabinet. I set it on top of paperwork to be stored in medical records. This week staff went to look for the lock box and it had been misplaced. I did look with the administrator for the missing lockbox and it has not been found as of now. Resident had a wallet placed in the lock box in March because he was leaving it throughout the facility. We did tell the granddaughter last evening that the lock box has been misplaced and she understood. Today the son-in-law stopped wanting the wallet and the administrator expressed to him that we are doing everything we can to find the lockbox. Son-in-law did express there was nothing significant in the wallet maybe a Social Security card but he did not know what was in there. Will continue to look for lock box.Review of the facility investigation revealed Resident #42's progress notes were included which indicated on [DATE] at 3:20 P.M. the administrator called son to inform him that the facility lockbox that contained the resident's checkbook had been misplaced when the social service designated office was cleaned out for a new social service designee to come in. Resident's son stated he would call the bank and cancel all checks for the time being until a new checkbook could be ordered. Resident's son informed that facility will reimburse for new checkbook. The investigation included a Police report that was obtained on [DATE] that revealed Resident #41's family notified the police of the missing lock box on [DATE]. The facility did not notify the police of the missing lock box. The police report dated [DATE] at 10:15 A.M. included the Administrator believed the lockbox was accidentally thrown out. The police informed the Administrator the family would like the wallet back because of sentimental value.Review of the investigation revealed Housekeeping Staff #53 had an undated written statement in the paperwork provided. The statement included she threw away office garbage, whatever management asked her to. She did not recall throwing away a lock box or brown box. She took labeled boxes for medical records to the basement. She threw away a wooden desk and old vases. She had spent the last one to two weeks looking for the lock box/brown box.Review of facility documentation revealed there was a Quality Assurance and Performance Improvement (QAPI) plan dated [DATE] that included the previous social service designee did not inform new social service designee there was a lockbox with items in it. The new social service designee did not know there was a lockbox in the office with items inside to keep track of it. Social Service office cleaned out by corporate office. No list/log kept of what was in the lock box. Box had not been used/needed in five months. The action plan was the new lock box was to be bolted down. Computerized log kept of when items go in/out, whose items go in/out, whose items are in there, date of when items go in/out, and who is putting in/taking out the items. Two keys given to social services designee and Administrator. Monthly audits of lockbox to ensure items on log are in lockbox. The QAPI plan did not include a new policy for the handling of resident items to be placed in the facility lockbox. There were no in-services to educate staff on the new process. The QAPI plan did not include verifying what is contained in a wallet or purse with the resident and witness before locking in the lock box. Further, there were no guidelines on completing a thorough investigation. Interview with [DATE] at 3:22 P.M. with RN #51 revealed she started in April (2025) cleaning out a social service office for a new hire. Social Service #52 was going to split her time between two buildings and was leaving the office she used to the new Social Service designee. There was a lot of old paperwork in the office. Registered Nurse #51 was going through the cabinets, drawers, room and removing things. She finished cleaning on the last Tuesday in May ([DATE]). She had housekeeping come and remove the trash and take boxes to medical records. Administration #53 indicated she is the one that put the wallet in the lockbox. She said she did not look in the wallet to see what was in there. She revealed there was a checkbook in the lock box and papers under the check book. She did not know what the papers were. Social Service #52 revealed the papers were legal paperwork that belonged to Resident #43 who passed away and her family did not come to pick them up.Interview on [DATE] at 4:42 P.M. with Housekeeping #53 revealed she wrote the statement that day. She revealed she took a clear tall kitchen trash can size bag out. She said she could see through it and did not notice a metal box. She also took the bathroom trash out, and a wooden desk. She said she was handed two vases that she saved in a closet in case a resident would need them. She took about 10 boxes with lids to medical records. Interview on [DATE] at 5:12 P.M. with RN #51 revealed the last day she was cleaning the office she found the lock box in the back of a cabinet. She asked other staff that were in the office what the box was and they said it was a lock box for resident items. She placed the lockbox in a box of medical records that was filled almost to the top on one side. She doesn't recall taking the lockbox out of the medical record box. She doesn't recall moving it or putting a lid on the medical record box that contained the metal box. She verified she looked through the boxes in medical records. On [DATE] at 5:12 P.M. during interview, the Administrator verified there were no witness statements obtained from other staff that were in the office when the lock box was found or from housekeeping until the facility was asked for an investigation. The police were not called by the facility but by a family. The facility did not obtain the police report until asked for the investigation. The Administrator verified there were no statements from all staff that were in the office. The Administrator verified there was no evidence of the lock box being thrown away. The Administrator verified the facility lost items belonging to three residents that were to be safeguarded by the facility in a lock box.This deficiency represents non-compliance investigated under Master Complaint Number 2594375.

Based on observation, interview and policy review, the facility failed to ensure infection control protocols were maintained when performing incontinence care. This affected one resident (#28) of one resident observed for incontinence care The facility identified nine always incontinent residents.Findings Include:Observation on 09/10/25 at 11:02 A.M. of incontinence care for Resident #28 with Certified Nurse Aide (CNA) #50 revealed the CNA washed her hands, and put a barrier on the overbed table. The CNA placed a basin of warm water on the table with towels, washcloths, shampoo and body wash, barrier cream and plastic trash bags. The CNA provided privacy with the use of a bath blanket to cover the resident's pelvic area. The CNA released the incontinence brief, soaked a washcloth with water and applied a body wash. The CNA cleansed the resident from front to back appropriately, changing areas on the washcloth with each wipe and repeated the process with rinse water. The CNA dried the resident with a towel and the resident rolled to her right side and the process was repeated using the professionally accepted standard technique. Once completed, the CNA applied barrier cream, rolled the resident on to her back and fastened her clean incontinence brief. The CNA then pulled the resident's covers up to her chest, handed her the television remote control and used the bed control to lower the bed to the lowest level and elevate the bed all before removing the gloves which she had provided incontinence care with to the resident.Review of the undated facility policy for Incontinence/Perennial care included to rinse the area with warm water, pat dry, apply a small amount of lotion or prescribed ointment. Remove gloves and wash hands then return resident to clean, comfortable position. Clean the resident unit, provide clean linen as needed and return items to the appropriate place. At 11:18 AM interview with CNA #50 verified she did not remove her gloves after providing incontinence care before touching the resident's bed covers television remote control, and bed control. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2564038.

Based on record review, interview, and policy review, the facility failed to ensure a resident received a clear, liquid diet, as ordered by the physician, prior to a scheduled colonoscopy (a medical procedure used to examine the rectum and colon for abnormalities). This affected one resident (#44) of two residents reviewed for discharge. The facility census was 40. Findings include: Review of the closed medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of sigmoid colon, dementia, weakness, and diabetes mellitus. The resident was discharged on [DATE] after leaving the facility against medical advice (AMA). Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 02/18/24, revealed Resident #44 had moderately impaired cognition. The resident required set-up staff assistance for eating. Review of a physician order, dated 03/11/25, revealed the order for a clear liquid diet only on 03/24/25 for colonoscopy scheduled on 03/25/25. Review of nursing progress note, dated 03/24/25 at 9:30 A.M., revealed a message was left for the physician regarding Resident #44 to be on a clear liquid diet on this date, however, resident had three bites of a breakfast sandwich at 7:30 A.M., 24 hours prior to colonoscopy. Asking if colonoscopy should be rescheduled or if this will be okay due to it being 24 hours prior to colonoscopy. Awaiting a return call. Review of nursing progress note, dated 03/24/25 at 10:09 A.M., revealed Resident #44's daughter stated she had spoken with the surgeon, and he said the colonoscopy could not be done due to the resident eating bites of a sandwich. This nurse notified the nurse practitioner that the resident's daughter was taking her home against medical advice (AMA). The resident and daughter refused to sign any discharge paperwork. Interview on 05/06/25 at 11:56 A.M. with the Director of Nursing (DON) revealed an activities aide gave Resident #44 a sandwich in the dining room after she requested food. The DON stated the activities aide should have made sure the resident was allowed food prior to giving her any. The DON stated following the incident, the dietary staff were educated on the policy and procedures that are needed when there is a dietary order in place for clear liquids. If a staff member asks for a resident to have food or drink, they should immediately call a member of the administrative nursing staff to ensure that an order is still in place or has it changed. Review of the facility's policy titled, Clear Liquid and Full Liquid Diet Supplies, undated, revealed individuals will be provided with a liquid diet when needed. A physician order is required.

Based on review of the medical record and interview with staff the facility failed to ensure new nutritional interventions were attempted for a resident with altered nutrition. This affected one resident (#5) of two reviewed for nutrition. Findings included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, dementia, Alzheimer's disease, pre-glaucoma, macular degeneration, cystic mastopathy of the breast, hyperlipidemia, and intermittent explosive disorder. Review of the plan of care dated 07/04/24 revealed Resident #5 had a potential risk for altered nutrition related to declining meals, makes meal selections meal to meal, snack requests and purchases with poor dietary lifestyle, counsel possibly related to irreversible cognitive deficit that denies educational reward or benefits given her inability to comprehend, process and retain information, history of food group refusals and can be easily agitated with attempts to discuss weight and nutrition, history of dementia, Alzheimer's disease, diabetes, anemias, declines to be weighed at times, declines medications, declines meals and menu service yet will submit order on her terms and get food from out of the facility deliveries and snack shop. Her usual body weight was 143 to 152 pounds. She fluctuates loss with rebounding gains which have kept her stable despite intakes recorded a choice of dietary lifestyle. Interventions included diet, education, gentle reminders, denture adhesive strips for her lower dentures, encourage adequate oral intake, educate and encourage need for nutritional supplement, encourage oral intake at meals, cater to known preferences at meals and snacks to promote consumption at the resident's level of ability and choice, food and fluid preferences updated and on tray card as needed, honor food preferences and dietary lifestyles of her choosing, medical nutritional therapy orders, monitor acceptance of diet order, monitor weight loss and gain every month, notify the physician of changes as needed, observe and document daily meal intakes, and offer substitutions. Review of the Nutritional Note dated 01/09/25 revealed Resident #5 did show a loss trend which was unplanned but was not a significant change. Resident #5 had a bout of illness with suboptimal intakes but was rebounding. Review of the February 2025 Meal Intake documentation revealed Resident #5 ate 76 to 100 percent of all meals with two refusals. Review of the March 2025 Meal Intake documentation revealed Resident #5 ate 76 to 100 percent of all meals with two refusals. Review of the April 2025 Meal Intakes documentation revealed Resident #5 ate 76 to 100 percent of all meals with five refusals. Review of the nutritional assessment dated [DATE] revealed the current body weight for Resident #5 was 132 pounds for a loss of three percent in three months and seven percent in six months. Summary included the dietitian would monitor as needed her nutrient intake, skin condition and laboratory results. Her oral intake was 88 percent. Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #5 had intact cognition with behaviors. Resident #5 was independent with eating and weighed 132 pounds with no loss or gain of weight. Review of the Nutritional Note dated 04/17/25 at 2:28 P.M. revealed Resident #5 was on a regular diet with an oral intake of 88 percent, current body weight was 132 with her ideal body weight being 110, and body mass index was 22.6. She was down a negative 7.04 percent in six months. Review of the weights in the medical record revealed Resident #5 weighed 142.2 pounds on 11/02/24, 140 pounds on 12/04/24, 135.8 pounds on 01/01/25, 132.2 pounds on 02/02/25, 132.4 pounds on 03/02/25, 132.4 pounds on 04/02/25 and 129.6 pounds on 05/05/25 for a weight loss of negative 8.9 percent in six months with no new nutritional intervention in place. Review of the May 2025 physicians' orders revealed Resident #5 had a regular diet and the staff were to encourage fluids dated 04/25/25. However, she had no new nutritional interventions in place. On 05/07/25 at 2:10 P.M. an interview with Dietitian #215 revealed she came to the facility every Thursday. She stated she received resident weights from the electronic record. She stated the computer will trigger a warning if someone was a weight loss of more than three percent. She stated the weight for Resident #5 cycles up and down. She stated she did not have any clinical reason to have concerns with the resident's weight loss. She verified Resident #5 had lost weight from 140.0 on 12/04/24 to 132.2 on 02/02/25 with no new nutritional interventions put into place. She stated Resident #5 had a history of her weight going up and down so she did not feel there was a need for an intervention. She stated Resident #5's weight was stable from 02/02/25 through 04/02/25. She stated Resident #5 refused meals and snacks however she verified she documented the resident ate 88 percent of her meals which was good. She stated she received food from outside the facility, and she would buy snacks from the activity department. She stated she had spoken to the dietary staff, and they attempt to cater to the resident's wants and what she wants to eat. She stated she has been following Resident #5 for years and she was unique case, and she may have gotten lackadaisical with her documentation. She verified that 129 pounds was the lowest weight Resident #5 had been, but she was also up walking around more.

Based on observations, medical record review, policy review and staff interview the facility failed to ensure infection control protocols were implemented when a urinary drainage collection device was kept off the floor. This affected one resident (#98) of one residents reviewed for indwelling urinary catheter use. Findings include: Observations on 05/05/25 at 11:50 A.M. revealed Resident #98 sitting in a wheelchair in his room, a urinary collection bag was observed attached underneath the wheelchair and was touching the floor. Additional observation on 05/06/25 at 8:21 A.M. and again at 10:19 A.M. again revealed the resident sitting in a wheelchair with the urinary collection bag under the wheelchair and touching the floor. Review of Resident #98's medical record revealed an admitted [DATE] with diagnoses that included urinary retention, flaccid neuropathic bladder, obstructive and reflux uropathy and benign prostate hypertrophy. Review of physician's orders revealed on 05/05/25 revealed the use of a indwelling urinary catheter to continuous gravity due to urinary obstruction. Review of the facility policy Catheter Care, Urinary revised September 2014 indicated to keep catheter tubing and drainage bag off the floor. On 05/06/25 at 10:28 A.M. interview with Certified Nurse Aide (CNA) #211 verified the urinary collection bag was touching the floor and should be kept off of the floor.

Based on medical record review, hospital record review, policy review and staff interview the facility failed to ensure appropriate indications for use of an antibiotic for Resident #101. This affected one resident (#101) of six residents reviewed for antibiotic use. Findings include: Review of Resident #101's medical record revealed an admitted [DATE] with diagnoses that included fall with left tibia fracture, diabetes mellitus, congestive heart failure and atrial fibrillation. Further review of the medical record including an admission minimum data set (MDS) 3.0 assessment with a reference date of 05/03/25 revealed the resident had an independent and intact cognition level. Additional review of the medical record including physician's orders revealed on 04/29/25 cefdinir (antibiotic) 300 milligrams (mg) twice daily was initiated due to leukocytosis (elevated white blood cell level). Additionally, on 05/01/25 the resident was prescribed cipro 250 mg twice daily for a urinary tract infection. The cefdinir was discontinued when started on cipro. Review of the Certified Nurse Practitioner (CNP) #266 evaluation on 04/29/25 revealed an evaluation for an elevated white blood cell level of 14.1 k/uL (kilo per microliter) from admission bloodwork. No evidence of any signs or symptoms of infection were reported by Resident #101. CNP #266 initiated the use of cefdinir 300 mg twice daily and ordered a urinalysis with culture and sensitivity to be obtained. Review of the hospital admission information for Resident #101 revealed white blood cell levels of 13.4 k/uL on 04/26/25 and 14.9 k/uL on 04/25/25. Review of the urinalysis with culture and sensitivity results obtained on 05/01/25 revealed a positive urine culture of Enterobacter cloacae complex >100,000 colony-forming units per milliliter (cfu/ml). Review of the infection screening evaluation completed on 04/30/25 revealed no evidence of any signs or symptoms of fever, pain, confusion or other symptoms of active infection. The infection screening evaluation did not indicate if met or did not meet criteria for use of an antibiotic. There was no evidence of an infection screening evaluation completed for the use of cipro on 05/02/25. On 05/07/25 at 2:30 P.M. interview with the Director of Nursing and Registered Nurse (RN) #224 verified Resident #101 did not meet criteria for use of antibiotics prescribed on 04/29/25 and 05/01/25. Review of the facility policy Antibiotic Stewardship - Orders for Antibiotics revised December 2016 indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing. Appropriate indications for use of antibiotics include: criteria met for clinical definition of active infection or suspected sepsis; and pathogen susceptibility, based on culture and sensitivity, to antimicrobial.

Based on observation, record review, review of physician office visit notes and hospital records and interview, the facility failed to ensure Resident #24, who had an unstable burst fracture of the first lumbar vertebrae with spinal fusion on 10/18/24 and was admitted to the facility for post-operative care and therapy was provided timely, adequate and necessary wound care monitoring and treatment and antibiotic treatment as ordered by the resident's surgeon/physician for management of a surgical wound, to promote optimal healing and to prevent complications post-operatively. Actual harm occurred on 11/17/24 when Resident #24 was discharged home without evidence the surgical wound to his back was stable and without sign of infection and that wound care had been provided as ordered. On 11/18/24 the resident was seen by Surgeon #300 for an outpatient post operative wound care appointment. At the time of this visit, Surgeon #300 identified the wound had developed extensive dehiscence (splitting or bursting open of a wound) and superficial infection. The resident was immediately transferred and admitted to the hospital from the surgeon's office and had surgery (incision and drainage procedure) to the infected post-operative wound on 11/19/24. This affected one resident (#24) of three residents reviewed. Findings include: Review of the closed medical record for Resident #24 revealed the resident was admitted to the facility on [DATE] with diagnoses including unstable burst fracture of the first lumber vertebrae with spinal fusion, history of falls, diabetes, cerebral infarction, hypertension, and chronic kidney disease. The resident was discharged from the facility to his home on 11/17/24. Review of the admission assessment dated [DATE] revealed Resident #24 was admitted with an upper mid vertebrae surgical incision. An Admission Skin assessment dated [DATE] revealed Resident #24 had a spinal incision measuring 17.6 centimeters (cm) in length by 1.0 cm in width with no evidence of infection. The wound had sanguineous/bloody drainage, and the edges were attached. Review of the admission physician's orders revealed Resident #24 had an order (dated 10/24/24) to cleanse the surgical incision to the back with normal saline, apply a clean, dry dressing twice daily and as needed for soiling. Review of surgical visit documentation for Resident #24, dated 10/29/24 (a scheduled follow-up appointment), revealed a handwritten note on the paper indicating an antibiotic (Keflex) had been prescribed by the doctor for wound care/management. Resident #24 had a follow up appointment scheduled 11/07/24. Review of the physician's order dated 10/30/24 revealed an order for Keflex 500 milligrams (mg) twice daily for surgical incision for 10 days. Review of the October and November 2024 Medication Administration Record (MAR) revealed Keflex 500 mg twice daily for 10 days was started at bedtime on 10/30/24 for Resident #24 and was completed on 11/09/24. Review of the Admission Minimum Data Set assessment dated [DATE] revealed Resident #24 had intact cognition and had a surgical wound. He had lower extremity impairment on one side, and he was dependent on staff for bed mobility, personal hygiene, dressing, bathing, and toileting. The resident was receiving antibiotic therapy. Review of the Skin assessment dated [DATE] revealed Resident #24 had a spinal incision measuring 15.1 cm in length by 0.9 cm in width with no evidence of infection. The wound had a moderate amount of sanguineous/bloody drainage, the edges were attached, and there was no swelling. The wound nurse would follow weekly until healed. Resident# #24 had a follow up appointment with Surgeon #300 (10/29/24) and was ordered Keflex 500 mg twice daily through 11/09/24 with a follow-up appointment scheduled for 11/07/24. Review of an Infection Screening form dated 10/30/24 revealed Resident #24 had new skin wound characteristics, increased swelling, pus, serous drainage and he met Loeb's and McGeer's Criteria (criteria used to determine if antibiotic treatment is appropriate for the infection indicated) for treatment of the surgical wound. This assessment was completed by Registered Nurse (RN) #360 Review of a progress note dated 10/31/24 at 10:33 A.M. revealed Resident #24 was on Keflex 500 mg twice daily for 10 days for surgical site infection. Review of a progress note dated 11/04/24 at 10:57 A. M. revealed the Nurse Practitioner was in to visit Resident #24 and had no new orders. Review of the Skin assessment dated [DATE] revealed Resident #24 had a spinal incision measuring 16.5 cm in length by 0.8 cm in width with no evidence of infection. The wound had a light amount of sanguineous/bloody drainage, and the edges were attached. Observation of a facility photograph of Resident #24's wound dated 11/06/24 revealed a wound with approximated edges except for one area, approximately 1/4 of the way down on the incision that was not closed, and the area was approximately one inch in length. Review of a surgical visit note from Surgeon #300's office dated 11/07/24 revealed the resident was to receive Keflex 500 mg twice a day for 10 days and the medication would be sent via mail. The resident had a follow-up appointment scheduled for 11/18/24. Further review of the medical record revealed no evidence the surgeon was contacted for clarification regarding the Keflex order documented on the surgical visit note provided to the facility following the appointment on 11/07/24. There was no follow-up regarding if this Keflex was in addition to the current round he was receiving, why the antibiotic was ordered or why the prescription would be arriving via mail. Review of the plan of care dated 11/07/24 revealed Resident #24 had an unstable burst fracture of the first lumbar. Interventions included treatment to back incision as per order, observe dressing as indicated, observe and document observation of surgical site with dressing changes, monitor for signs and symptoms of infection; redness, drainage, warm to touch, increased pain at site and fever. Review of the physician's order dated 11/13/24 revealed Resident #24 had an order for Keflex 500 mg twice daily for prophylaxis and possible incision infection. Further review of the medical record revealed no documentation as to why the Keflex was implemented on 11/13/24. Review of the November 2024 Medication Administration Record revealed Resident #24 was administered Keflex 500 mg from 11/13/24 to 11/17/24 (discharge) twice daily for prophylaxis and possible infection. Review of the skin assessment dated [DATE] revealed the back incision for Resident #24 measured 14.4 cm in length by 0.7 cm in width by undetermined depth. The assessment included there was no evidence of infection and light sanguineous/bloody drainage with no odor was noted. Observation of a facility wound photograph taken 11/13/24 revealed the surgical area had scattered opens area in the wound with yellow, crust-like areas noted. Review of Physician #355's Discharge Note dated 11/14/24 revealed the resident was admitted to the facility on [DATE] from the hospital. Skilled diagnosis was lumbar fracture status post spinal fusion. Surgical incision to back, dressing in place and treatment orders. The note revealed the resident continued on antibiotics per orthopedics. Reports good pain control. Insurance has issued last covered day of 11/16/24 and the resident will be discharged home on 11/17/24. Oriented times three (person, place and time) and insight appropriate. The resident would be discharging home this weekend and would be following up with his spine surgeon as well. Review of the Treatment Administration Record (TAR) revealed on the morning of 11/15/24, Licensed Practical Nurse (LPN) #367 documented Resident #24 refused his dressing change. Staff had signed off the TAR indicating wound care completed as ordered on the evening of 11/15/24 and morning and evening of 11/16/24. Resident #24 discharged home on the morning of 11/17/24 prior to wound care being completed. Review of the medical record on 11/17/24 at 11:00 A.M. revealed Resident #24 was given discharge instructions and orders. The resident was made aware of follow-up appointments. The resident's wife signed the discharge papers and gathered the resident's personal belonging and medications. Review of information provided by Surgeon #300's office as part of the State agency investigation revealed Resident #24 had presented to the surgeon's office on 11/18/24 for a post operative appointment following a thoracic fusion on 10/18/24. On 11/07/24 the resident had been seen in the office and Surgeon #300 had ordered Keflex due to the incisional area appearing to be starting an infection. However, the office was never updated with the appropriate pharmacy and the medication prescription was sent to the wrong pharmacy and the resident was unable to start the medication. The facility never prescribed the medication and never contacted the office. On 11/18/24 when the resident's dressing was removed from Resident #24's (incision) the dressing was soiled with green purulent fluid with an odor. The dressing that was removed was dated 11/15/24 with the initials for LPN #367. The wound was dehisced and infected. Resident #24 was a direct admit to the hospital with an additional procedure scheduled for the next day. Review of the hospital progress note from Surgeon #300 dated 11/18/24 at 12:58 P.M. revealed Resident #24 was in his office for a follow up appointment. The resident was having moderate pain at the incision site. Management options and their respective risks and benefits were discussed with Resident #24. The hospital note revealed the resident never received his second round of antibiotics (as ordered) and the information was never communicated with his office. Resident #24 now had extensive dehiscence and a superficial infection. Resident #24 would be admitted and scheduled for surgical incision and drainage (I&D) the next day. Review of the hospital surgery note dated 11/19/24 revealed the resident's old incision was opened and immediately purulent discharge was observed in the subcutaneous area. Specimens were obtained for culture. The entire incision was exposed and washed with saline to remove any debris and old sutures. One gram of powdered Vancomycin (antibiotic) was used, and a drain was placed in the wound. Review of the wound culture dated 11/22/24 revealed the wound of Resident #24 had a candida tropicalis (yeast infection) and polymorphonuclear leukocytes (white blood cells). On 12/26/24 at 12:45 P.M. an interview with the Director of Nursing (DON) revealed Resident #24 went to the surgeon on 10/29/24 and received an order for Keflex 500 mg twice daily which was administered from 10/30/24 through 11/09/24. She stated when he went to the surgeon on 11/07/24, the surgeon ordered Keflex 500 mg twice daily for 10 days again but stated the resident was already on the antibiotic. The DON revealed on 11/13/24 Resident #24's significant other brought in a bottle of Keflex stating the surgeon called it in to the pharmacy on 11/07/24 so the DON revealed the facility started the antibiotic again on 11/13/24. The DON stated she did not know if anyone from the facility had reached out to the surgeon on 11/07/24 to let him know the resident was already on the antibiotic or to clarify the order from the visit on 11/07/24. A subsequent interview on 12/26/24 at 1:57 P.M. confirmed there was no documentation or evidence in the medical record Surgeon #300 was contacted to clarify the Keflex order from 11/07/24. On 12/26/24 at 2:25 P.M. an interview with Licensed Practical Nurse (LPN) #302 revealed she was the nurse who went over the discharge instruction with Resident #24 and his significant other on 11/17/24. The LPN revealed she did not know Resident #24 was going home that day until his significant other came to the facility and stated she was taking him home. The LPN revealed she had to hurry up, get all his stuff together, and fill out the discharge paperwork. She stated she went over everything with them both and went over his wound treatments. She stated she did not look at his wound or show them how to clean the wound at the time of discharge. She also stated she did not send any supplies home with them for wound care. On 12/26/24 at 4:26 P.M. an interview with Family Member #400 revealed the facility had sent paperwork with her for Resident #24 for both his follow-up appointments. She stated she brought paperwork back and gave it to the facility both times. Family Member #400 revealed when they went to surgeon's office on 11/18/24 the dressing to Resident #24's back was dated 11/15/24 with the initials for LPN #367. The resident had four steri-strips on his wound that were not there before, and she did not know when they were applied. She stated the nurse from the surgeon's office took a picture and the surgeon was upset the facility had not called him about how bad his wound looked. On 12/26/24 at 4:30 P.M. an interview with Resident #24 revealed concerns that facility staff did not change his dressing every day like they were supposed to, but he stated he could not remember what specific days the dressing had not been changed during his stay in the facility. On 12/30/24 11:14 A.M. RN #360 revealed she never observed Resident #24's surgical wound during the resident's stay in the facility and used hospital documentation to assess if the resident met criteria for antibiotic treatment. She stated she did not review the facility's skin assessment because it had not been completed for 11/13/24. On 01/02/25 at 9:50 A.M. telephone interview with the DON revealed that Surgeon #300's office did call the facility on 11/18/24 but the DON was not working, and Medical Records staff took the call. Medical Records staff then reported to the DON the surgeon's office was concerned because Resident #24's dressing had not been changed and the wound was dehisced. The DON stated she had not called the surgeon's office back, and they called her again on 11/19/24 or 11/20/24, she was unable to remember which date, and the surgeon's office reported the same concerns to her. The DON stated staff had updated the resident's primary care provider (PCP) on the resident's wound (however, this was not documented in the medical record). During the interview, the DON verified the facility was responsible to reach out to the prescriber if there was any confusion with an order. The DON stated the nursing staff were to monitor the condition of wounds and any increase in drainage, they would let the wound nurse know and the wound nurse would follow weekly. Lastly, the DON verified LPN #302 did not provide the resident and family education regarding wound care prior to discharge. Attempts to interview/contact RN #310 and LPN #311 during the complaint investigation were unsuccessful as neither nurse was available or returned phone calls to the surveyor. Review of the facility policy titled Dressings, Dry/Clean with a revision date of 03/26/21 indicated to verify that there was a physician's order for this procedure and to apply the ordered dressing and secure with tape or bordered dressing per order. Label with date and initial to the top of dressing. This deficiency represents non-compliance investigated under Complaint Number OH00160077 and Complaint Number OH00160049.

Based on medical record review and interview, the facility failed to ensure timely notification of a physician regarding a resident's change in condition. This affected one resident (#42) of three residents reviewed for change in condition. Findings include: Review of Resident #42's closed medical record revealed diagnoses including right hip fracture, type two diabetes mellitus, protein calorie malnutrition, anxiety disorder, adjustment disorder, and hypertension. Resident #42 was hospitalized from [DATE] to [DATE] after sustaining a fall and broken hip. A nursing note dated [DATE] at 5:30 A.M. indicated Resident #42's respiratory rate was 48 at 2:00 A.M. Blood pressure recording was ,d+[DATE], heart rate was 82 and oxygen saturation level was 92%. The On Call service was notified but no return phone call was received. At 3:30 A.M., Resident #42's respiratory rate was 44 and her oxygen saturation was 91%. The On Call service was contacted again but never returned a call. A nursing note dated [DATE] at 8:04 A.M. indicated Resident #42 expired at 6:26 A.M. A nursing note dated [DATE] at 8:57 A.M. indicated at 2:00 A.M. a state tested nursing assistant reported Resident #42 was breathing really fast. Vital signs were obtained. Another nurse also checked Resident #42. Oxygen was increased from two liters to 3.5 liters. The note indicated the family did not want Resident #42 sent out to the hospital. At 2:15 A.M. the head of the bed was elevated higher. Resident #42's respiratory rate was 44 and her oxygen saturation was 92%. At 2:30 A.M., Resident #42 was repositioned. Respiratory rate and oxygen saturation remained the same. At 2:45 A.M., Resident #42's respiratory rate was 44 but her oxygen saturation was 93%. At 3:00 A.M., the respiratory rate was 44, oxygen saturation was 91% and resident #42 was repositioned and a cool cloth was applied to the forehead. At 3:15 A.M., Resident #42's respiratory rate was 42 and oxygen saturation was 92%. At 3:30 A.M., the respiratory rate remained 42 and the On call services was notified again. At 4:00 A.M., Resident #42's respiratory rate was 44 and oxygen saturation was 91%. At 5:00 A.M., Resident #42 was repositioned. Respiratory rate remained 42 and oxygen saturation was 91%. At 6:20 A.M., Resident #42 was absent of vital signs with a second nurse verifying. Time of death was listed as 6:26 A.M. The family and physician were notified. On [DATE] at 12:17 P.M., during interview the Director of Nursing (DON) verified on [DATE] the nurses were unable to get the On Call physician service to respond to their phone calls related to Resident #42's change in condition. The DON stated the nurse could have phoned her and she could have attempted to contact the physician. However, nurses did not notify her of the failure of the On Call services physician to return calls. The DON indicated when she spoke to the physician he let the On Call services company know it was not acceptable for nurses phone calls not to be responded to. The DON reiterated the family did not want Resident #42 sent to the hospital. Review of the facility's Change in a Resident's Condition or Status policy (revised [DATE]) revealed the nurse would notify the resident's attending physician or physician on call when there had been a significant change in a resident's physical condition and there was a need to alter the resident's medical treatment significantly. Review of the facility's Emergency and/or Alternative Physician Care policy (revised [DATE]) revealed should an emergency arise and the resident's attending physician was not available, the emergency on-call must be contacted. Back up coverage may be provided by another licensed physician or physician group or an appropriately licensed and supervised mid-level practitioner, consistent with state regulations. Staff were to use appropriate procedures to contact physicians, depending on arrangements and the urgency of a situation. If a physician and his/her back up coverage did not respond in a timely or appropriate manner to facility notification of medical issues, the nursing staff were to contact the medical director for assistance. This deficiency represents non-compliance investigated under Complaint Number OH00155390.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility-reported incident (FRI) including investigation, observations, staff and resident interviews and review of policies, the facility failed to ensure a resident's narcotic pain medication was not misappropriated. This affected one resident (#4) of one resident reviewed related to a FRI. Findings include: Review of Resident #4's medical record revealed diagnoses included diabetes mellitus and chronic pain syndrome. An order with a start date of 12/25/23 was written for percocet (narcotic pain medication) 10/325 milligrams (mg) every six hours as needed for pain. The January 2024 Medication Administration Record (MAR) revealed Resident #4 was interviewed regarding pain every shift. The January 2024 MAR indicated the percocet was administered 14 times between 01/01/24 and 01/25/24. The morning of 01/26/24 a pain severity level of four on a scale of 0-10 was recorded. The MAR indicated percocet 10/325 milligrams was administered on 01/26/24 at 7:23 A.M. Review of facility FRI #243501 dated 01/26/24 revealed an allegation of misappropriation of Resident #4's narcotics by Licensed Practical Nurse (LPN) #150. The allegation was made by the Director of Nursing (DON) and Unit Manager #120. The report indicated there was a possible documentation discrepancy that was inconsistent with standard nursing practice. Review of witness statements obtained during the facility's investigation revealed Registered Nurse (RN #115) wrote he worked 01/24/24 from 6:00 A.M. to 6:00 P.M. When RN #115 administered percocet to Resident #4 at 6:45 A.M. there were more tablets remaining and the card was placed back into the medication cart. A witness statement with an illegible signature indicated the nurse worked the night of 01/25/24 and she noticed a change in the narcotic count from the day before but she did not take any cards/sheets out of the cart or the narcotic count book. When she flipped the sheet over there were several lines where LPN #150 had signed in and out several narcotic sheets. Some of the entries had the signature of another nurse who verified the information but one entry for Resident #4's percocet had a scribbly initial that was illegible. The statement indicated the nurse did not think much of it because of the second signature. The nurse indicated she did not witness removal of an narcotic sheets with LPN #150. RN #110 indicated she reported to work on 01/26/24 and did narcotic count with LPN #150 who then returned to south wing. RN #110 indicates she was questioned about the narcotic count sheet as it was missing but she reported it had been in the book when she and LPN #150 reconciled narcotics (The sheet in which the number of cards were verified.) During an interview on 07/29/24 at 12:57 P.M., the DON stated on 01/26/24 it was reported to her that a narcotic count sheet was turned in for Resident #4 indicating the card had been used but there still should have been some percocet on the card. A search for the card revealed the card was gone. The narcotic count sheet was also missing. Both RN #110 and LPN #150 stated they had reconciled the narcotics and signed the sheet. During the course of the investigation it was found that LPN #150 was signing out narcotics but not documenting administration of the narcotics on the MAR on a consistent basis. The facility's cameras were reviewed. Images were not the clearest but they looked to see who might have approached the medication cart and removed the narcotic count sheet. The only one who was identified at the cart after the count was completed was LPN #150. At 1:49 P.M., the DON clarified when RN #110 counted narcotics with LPN #150 there was no percocet card in the drawer for Resident #4 and it had been signed off as removed by LPN #150 so she did not identify any discrepancies. Review of the facility's Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy (copyright 2016) indicated misappropriation of resident property was identified as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings without the resident's consent. Review of the facility's Controlled Substances policy revealed only authorized licensed nursing and/or pharmacy personnel should have access to Schedule II controlled drugs maintained on premises. Review of the facility's Controlled Substance Records for the Medication Cart (dated 01/15/24) indicated immediate reporting of any unresolved discrepancy was to be made to the DON or designee and pharmacy. As a result of the incident, the facility took the following actions to correct the deficient practice by 04/27/24: 1. Immediately following the report of the missing narcotics, the DON verified the discrepancy between the narcotic count sheet and lack of percocet available. The discrepancy was reported to the Administrator. 2. On 01/26/24 at approximately 9:00 A.M., the DON initiated a review of all narcotics for availability/correct count. 3. On 01/26/24 at approximately 9:20 A.M., it was noticed there was a shift change narcotic count sheet missing from the mid-morning nurse change over on south wing between RN #110 and LPN #150. 4. On 01/26/24 around 9:45 A.M., the DON interviewed Resident #4 to check her pain level and determine if any pain medication was needed. Resident #4 denied pain. 5. On 01/26/24 at approximately 10:00 A.M., RN #110 was interviewed regarding the missing shift change sheet. RN #110 reported she signed the shift change sheet on south wing with LPN #150 at approximately 8:50 A.M. 6. On 01/26/24 at approximately 10:03 A.M., the DON attempted to contact LPN #150 for interview. A return call was received and LPN #150 was interviewed at approximately 10:55 A.M. LPN #150 stated she signed the narcotic shift change with RN #110 before leaving. 7. On 01/26/24 at approximately 11:15 A.M., the DON and Administrator watched camera footage showing after RN #110 and LPN #150 signed off on the narcotic count sheet on south wing at approximately 8:52 A.M., LPN #150 returned tot he south wing med cart at 9:01 A.M. for a brief period and left the facility at approximately 9:02 A.M. It was seen on the camera footage that LPN #150 appeared to be folding a piece of paper as she was exiting the building. RN #110 did not appear to return back to the south wing med cart after the shift count. Between 9:02 A.M. and 9:18 A.M. when the missing narcotic count sheet was noticed, no other staff members had gone over to the south wing med cart. 8. On 01/26/24 at approximately 3:00 P.M., the DON notified Resident #4's daughter-in-law to notify of possible discrepancy and get permission to test for percocet in Resident #4's system. 9. On 01/26/24 at approximately 3:55 P.M., RN #110 submitted to a reasonable suspicion drug test. The test showed negative results. 10. On 01/26/24 at approximately 4:00 P.M., the Corporate [NAME] President (VP) of Operations and the Corporate Clinical Director informed the pharmacy of possible discrepancy. 11. On 01/26/24 at approximately 4:33 P.M., LPN #150 submitted to a drug test. The results were negative. LPN #150 was suspended until the conclusion of the investigation. 12. On 01/26/24 at approximately 5:30 P.M., new narcotic count sheets were initiated on the floor and staff were educated on the Controlled Substance policy via [NAME] Learning. 13. On 01/30/24, an audit was run for all residents on percocet. Three residents (Residents #4, #11 and #12) were identified. Resident #4 had one narcotic count sheet from 12/19/23 unaccounted for. A second sheet delivered on 12/21/23 for 30 tablets was turned in with five unaccounted pills. A third sheet was started on 01/25/24 at 2:00 P.M. by LPN #150. Resident #12's percocet counts were all accounted for with no issues identified. Resident #11 had four narcotic count sheets unaccounted for. 14. On 01/30/24, an audit form for narcotic count sheets was initiated to be completed by the DON or designee. 15. On 01/30/24 at approximately 1:00 P.M., LPN #150 was called in for a second interview. 16. On 01/30/24 at approximately 2:15 P.M., LPN #150 arrived for a second interview with the Administrator, DON, Corporate VP of operations and Corporate Clinical Director. 17. On 01/31/24 at approximately 10:45 A.M., the Administrator notified local police department of the drug discrepancy. The police office stated they would send an officer to the facility to start a report. 18. On 01/31/24 at approximately 11:15 A.M., the DON called and spoke to Resident #11's husband and let him know there was missing documentation sheets for narcotics. The husband was told errors did exist and an investigation was completed. Resident #11's husband was informed the MAR indicated all scheduled doses of the percocet were administered. 19. On 01/31/24 at approximately 1:40 P.M., a police officer arrived and dropped off statement sheets and asked the facility to gather all documentation the facility could provide pertaining to the incident so he could piece together his timeline and report. 20. On 01/31/24 at approximately 1:53 P.M., the Administrator filed a complaint through the board of nursing regarding LPN #150. 21. On 02/01/24 at approximately 9:20 A.M., LPN #150 was terminated due to nursing practices identified during the investigation. 22. On 02/01/24 at approximately 11:24 A.M., the Administrator contacted the police department to inform him the requested information was ready for retrieval. An officer arrived at approximately 2:12 P.M. and information was provided. 23. On 02/01/24, results from Resident #4's drug test revealed percocet was found in Resident #4's system. 24. Review of Quality Assurance (QA) topic sheets revealed narcotics and the plan of correction was reviewed monthly from February through May 2024. 25. Review of audit sheets revealed the narcotic audits were begun 01/28/24 three times a week to check that all narcotics were accounted for and documentation on the MARs and narcotic count sheets matched. The audits continued three times a week through the end of March 2024. On 03/31/24 the audits were decreased to weekly and continued through 04/27/24. No further discrepancies were identified. During the survey on 07/29/24 between 7:45 A.M. and 4:55 P.M., all narcotics were reconciled with no discrepancies identified. No residents were overheard complaining of or exhibiting signs of pain. Resident interviews with Residents #4, #22, #31, #32, #36, #37 and #41 revealed no concerns related to pain or availability of medication. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00155390.

Based on observation, interviews and facility policy review, the facility failed to ensure the kitchen was clean and sanitary and items were dated. This had the potential to affect all residents except Resident #33, who was identified as receiving nothing by mouth. The facility census was 40. Findings include: Observation on 05/01/23 from 8:12 A.M. to 8:30 A.M. with Dietary Manager #144 of the kitchen and outside area where the walk-in cooler and freezer were located revealed the following concerns: In the three door reach-in in freezer was observed one gallon storage bag of six breadsticks undated, one half of an opened and resealed factory bag of peas and carrots undated, one half of an opened and resealed factory bag of spinach undated, four individual servings of sauerkraut wrapped in plastic wrap not labeled or dated, one gallon storage (one half full) of mushrooms undated, and one half of a box of hamburger patties open to air. Observation of the walk-in freezer located on the outside of the building revealed an accumulation of black dust blowing from the condenser fans. Observation of the walk-in cooler revealed an offensive odor coming from the unit. The floor of the unit had numerous black corrosion spots. Observed under the shelves of the thawing meat was a pool of black liquid. Sitting on the shelves near the back wall was observed to be one gray standard utility tub which contained one bag of sausage links, one bag of pork chops, and one bag of ground sausage which was undated when pulled; one brown standard utility tub which contained 14 individually sealed Swiss steaks which was not dated when pulled; and one black standard utility tub which contained three bags of chicken which was not dated when pulled. Observed on the shelf on the right-hand side of the walk in cooler was one three fourth, opened and resealed with plastic, log of sliced Swiss cheese undated. Observation of the reach in ice cream freezer located in the kitchen area revealed no thermometer. Observation of the microwave revealed a buildup of multicolored splatter marks on the top inside of unit. Observation of the stand mixer revealed there were white food splatters observed on the metal bowl guard and an accumulation of white and brown food splatters on the base of the unit. At the time of observation, Dietary Manager #144 confirmed the findings. Review of facility policy Food Receiving and Storage, revised July 2014, revealed food service department would always maintain clean food storage areas; all foods stored in the refrigerator or freezer would be covered, labeled and dated; and uncooked and raw animal products and fish would be stored in drip proof containers. Review of facility policy Sanitation, revised October 2008, revealed all kitchens, kitchen areas and dining areas would be kept clean, all equipment would be kept clean.

Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure Resident #18, who was highly visibly impaired and dependent on staff, was able to locate call light, and Resident #142's call light was within reach. This affected two residents (#18 and #142) of 16 residents screened for call lights. The facility census was 40. Findings include: 1. Review of medical record for Resident #18 revealed an admitted [DATE] and pertinent diagnoses included cerebral infarction (stroke) due to thrombosis (blood clot) of right posterior cerebral (brain) artery, major depressive disorder, restless and agitation, and repeated falls. Review of care plan dated 12/29/22 revealed Resident #18 required limited to extensive assistance, had a potential risk for falls related to poor safety awareness and repeated falls, was blind related to cataracts. Interventions included explaining use of call light and assess ability to use as needed. Review of optometrist exam on 02/27/23 revealed Resident #18 was evaluated for decreased vision in the left and right eye, had decreased vision which affected both near and far vision, and the condition was constant and significant. The exam revealed Resident #18 had changed in retinal vascular appearance and had developed visibly significant age-related cataracts. Review of quarterly Minimum Data Set (MDS) assessment, dated 04/06/23, revealed Resident #18 had highly impaired vision and was dependent on staff for all activities of daily living. Observation and interview on 05/03/23 at 7:50 A.M. revealed Resident #18 sitting in wheelchair with the bed to his right. White call light cord was observed wrapped around the white positioning bar on the bed. When asked where his call light was, Resident #18 stated I don't know. When asked to show where the call light was located, Resident #18 took his right hand and touched around the top part of bed where the pillow was located and stated, I don't know. Observation and interview on 05/03/23 at 8:18 A.M. revealed State tested Nursing Assistant (STNA) #146 told Resident #18 his call light was located to his right. The call light was observed wrapped around the positioning bar at the top of bed to the right of Resident #18. At the time of observation, along with STNA #146, Resident #18 was asked by the surveyor to locate the call light. Resident #18 touched the pillow and stated it was right there on the pillow. STNA #146 confirmed at the time of observation, Resident #18 could not locate the call light which was wrapped around the positioning bar. Interview on 05/03/23 at 8:26 A.M. with the Director of Nursing (DON) revealed for those with impaired vision, the facility had used colored tape on the call light to help residents better locate the call light. Observation and interview on 05/03/23 at 11:20 A.M. revealed Resident #18 sitting in a wheelchair, and the bed was to his right. The white call light cord was observed laying on top of a red Ohio State blanket in the middle of his bed. When asked where the call light was, Resident #18 stated I don't know. 35765 2. Review of the medical record revealed Resident #142 was admitted to the facility on [DATE]. Diagnoses included intracerebral hemorrhage, hemiplegia, peripheral vascular disease, and chronic pain syndrome. Review of the Five-day Medicare Minimum Data Set assessment dated [DATE] revealed Resident #142 had severely impaired cognition. She required extensive assistance of two staff members for bed mobility, dressing, toilet use and personal hygiene. Observation on 05/01/23 at 9:33 A.M. revealed Resident #142 was in bed and her touch pad call light was hanging up clipped to the call light outlet on the wall. An interview at 9:35 A.M. with Licensed Practical Nurse #178 verified Resident #142's call light was hanging up on the wall outlet and she was unable to reach it while laying in her bed. Review of the undated facility policy titled, Call Light, Use of, revealed the purpose was to respond promptly to resident's call for assistance and to ensure call system was in proper working order. When providing care to a resident, be sure to position the call light conveniently for the resident to use. Tell the resident where the call light was and show them how to use the call light. Be sure all call lights were placed within the reach of each resident.

Based on medical record review, staff interview, resident interview and review of facility policy the facility failed to ensure a physician ordered appointment for an orthopedic consult for Resident #20 was scheduled timely to address her chronic pain and failed to assess the effectiveness of her pain medications. This affected one resident (Resident #20) of 12 residents reviewed for pain management. The facility census was 41. Findings include: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #20 had intact cognition, required supervision for all activities of daily living (ADLs), had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She received scheduled pain medications, had pain present, the pain was almost constant and the resident rated the pain at a level of six (on a scale from one to 10 with 10 being the worst pain), and received opioids for seven days. Review of the June 2021 physicians orders revealed Resident #20 had orders for, [MEDICATION(S)]-acetaminophen (narcotic pain medication) 10/325 milligrams (mg) four times daily for chronic pain dated 02/21/20, Aspercreme (analgesic cream) with [MEDICATION(S)] four percent to the left hip every morning for pain dated 07/23/20, Aspercreme with [MEDICATION(S)] patch four percent topically to the lower back every morning for pain dated 07/24/20, and acetaminophen 500 mg two tablets twice daily for [CONDITION(S)], (named facility) Orthopedic consult for bilateral knee pain dated 02/25/21, and Aspercreme with [MEDICATION(S)] four percent to the right hip topically every six hours as needed for pain dated 05/22/21. Review of the June 2021 vital signs, pain levels record revealed Resident #20's pain level was consistently rated at a level of six to eight. Review of the May 2021 vital signs, pain levels record revealed Resident #20's pain level was consistently rated at a level of five to eight. Review of the April 2021 vital signs, pain levels record revealed Resident #20's pain level was rated anywhere from a level three to a level 10. Review of the May and June 2021 Medications Administration Records revealed Resident #20 was administered [MEDICATION(S)] 10/325 mg four times daily and acetaminophen 500 mg twice daily with the pain level before administration documented however, there was no documentation of how effective the medication was for relief of pain. Review of the physician's progress notes dated 02/25/21 revealed Resident #20 had left hip, back and bilateral knee pain secondary to [CONDITION(S)], x-rays of the left hip, lumbar spine and bilateral knees showed no acute findings but the resident continues to utilize [MEDICATION(S)] 10/325 mg four times daily and acetaminophen 500 mg two tablet twice daily and the nursing staff reports these are effective. The plan was to get an orthopedic consult. Review of the plan of care dated 02/26/21 revealed Resident #20 was at risk for pain related to chronic kidney disease, chronic pain, [CONDITION(S)], and [CONDITION(S)] in bilateral knees. Interventions included notify the physician promptly if interventions were ineffective for pain relief, pain assessment quarterly and as needed, monitor for side effects pf pain medications, call light within reach and answer timely, assist and reposition as needed for comfort, medications as ordered, encourage activity attendance to keep busy, and arrange skilled therapy as indicated with physician's order. Review of the nurse practitioner progress notes dated 03/01/21 revealed the visit was due to family concerns of back pain and requesting a consultation with a specific physician at (a named hospital) Pain Management. Review of the facility LTC charting dated 03/18/21, 03/19/21, and 03/23/21 revealed Resident #20 had pain, almost constantly, it did not affect her sleep, did not affect her day-to day activities and she had a pain level of eight. The resident indicated the non-pharmacological interventions effective in alleviating pain were one on one, repositioning and [MEDICATION(S)] patch and crème to back and left hip. Review of the facility LTC charting dated 03/20/21, revealed Resident #20 had pain, almost constantly, it did not affect her sleep, did not affect her day-to day activities and she had a pain level of five. The resident indicated the non-pharmacological interventions effective in alleviating pain were one on one, repositioning and [MEDICATION(S)] patch and crème to back and left hip. Review of the facility LTC charting dated 03/21/21 and 03/22/21 revealed Resident #20 had pain, almost constantly, it did not affect her sleep, did not affect her day-to-day activities and she had a pain level of four. The resident indicated the non-pharmacological interventions effective in alleviating pain were one on one, repositioning and [MEDICATION(S)] patch and crème to back and left hip. Review of the facility LTC charting dated 03/24/21, 04/03/21, and 04/04/21 revealed Resident #20 had pain, almost constantly, it did not affect her sleep, did not affect her day-to day activities and she had a pain level of six. The resident indicated the non-pharmacological interventions effective in alleviating pain were one on one, repositioning and [MEDICATION(S)] patch and crème to back and left hip. Review of the facility LTC charting dated 04/01/21, 04/02/21, 04/05/21, and 04/07/21 revealed Resident #20 had pain, almost constantly, it did not affect her sleep, did not affect her day-to day activities and she had a pain level of seven. The resident indicated the non-pharmacological interventions effective in alleviating pain were one on one, repositioning and [MEDICATION(S)] patch and crème to back and left hip. Review of the 04/06/21 pain assessment revealed the resident was in constant pain, the pain did not affect her functioning and she rated her pain level at a six. Interview on 06/07/21 at 2:05 P.M. revealed Resident #20 indicated she was in constant pain in her back, hips, and legs. She indicated she had an appointment with the orthopedic doctor but someone came in her room and took the paper down with the appointment on it that was hanging up in her room and never put a new one up so she had no idea what was going on. She indicated her pain would ease up some when she first took her pain medication, or the nurse applied the cream, but it was not long before the pain was back. She indicated she was never without pain and she wanted something done about it. She indicated it did not affect her daily activities, but it was painful to walk sometimes because her hips hurt so bad. Interview on 06/07/21 at 2:20 P.M. with Licensed Practical Nurse (LPN) #16, who was responsible to set up resident appointments and transportation, indicated she had an appointment set for Resident #20 on 07/22/21 for (named facility) Orthopedics but nothing set up for 05/06/21. Interview on 06/07/21 at 2:38 P.M. revealed Registered Nurse (RN) #15 indicated she documented the resident's pain assessment on paper. She stated she would ask the residents the questions and that was how she determined how to code the MDS. She indicated she kept all the paper assessments in a separate file in her office. Interview on 06/07/21 at 3:20 P.M. revealed the Administrator indicated the facility was attempting to accommodate the readmission of another resident who required [CONDITION(S)] and need the transport van for her [CONDITION(S)] appointments. He indicated they had canceled and rescheduled some other residents' appointments and Resident #20 had been one of the residents who had been rescheduled. He indicated he had called the daughter of Resident #20 to ask her to transport the resident to the 05/06/21 appointment however, she was unable to do so. He indicated they had to reschedule Resident #20's orthopedic consultation appointment from 05/06/21 to 07/22/21. He verified her appointment had been ordered on 02/25/21 and was not able to be scheduled until 05/06/21, and then they canceled and rescheduled the appointment for 07/22/21 causing the resident to wait almost five months to see the orthopedic physician. He stated at the time they rescheduled the appointment he was unaware it had taken two months to get her the first appointment with the orthopedic physician. Interview on 06/07/21 at 4:18 P.M. revealed the Administrator indicated at the time Resident #20's appointment was rescheduled they were unable to use another transport company because the transport company was not testing their drivers for COVID, they refused to allow the facility to test their drivers, and per Centers for Medicare and Medicaid Services (CMS) guidance the facility was responsible for the well-being of all their residents. He indicated he did not feel it was safe for the resident to be transported by anyone but the facility van. He verified the resident had been vaccinated for COVID-19 in January 2021. Interview on 06/07/21 at 5:00 P.M. revealed the Administrator indicated the resident's primary care physician was starting to do pain management in the facility by administrating injections however, Resident #20 had not received any injection yet. Interview on 06/08/21 9:42 A.M. revealed RN #15 verified there was no evidence of documentation of the effectiveness of pain medication for Resident #20, only her pain lever prior to administration. Review of the facility policy, Pain Assessment and Management, dated 03/15 revealed the purpose was to help staff identify pain in the resident and to develop interventions that were consistent with the resident's goals and needs and that address the underlying causes of pain. If pain had not been adequately controlled, the multidisciplinary team, including the physician should reconsider approaches and make adjustments as indicated. Document the resident's reported level of pain with adequate detail, enough information to gauge the status of pain and the effectiveness of the interventions for pain as necessary and in accordance with the pain management program.

Based on observation, record review, policy review and interview the facility failed to honor Resident #30, #35 and #50's preferences/choices in regard to showers, and meal preferences. This affected three residents (Resident #30, #35 and #50) of four residents reviewed for activities of daily living and three resident (Resident #30, #35 and #50) of six residents reviewed for nutrition. The facility census was 54. Findings include: 1. Review of Resident #50's medical record revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the 09/22/19 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was severely impaired for daily decision making, extensive assist of one for eating and totally dependent of two for personal hygiene and bathing. Physician orders [REDACTED]. Observation of the lunch meal 12/30/19 at 12:40 P.M. revealed the resident was in assisted dining. There was no coffee provided on the tray. Subsequent review of the lunch meal slip revealed standing orders for coffee at all meals. Interview 12/30/19 at 12:47 P.M. with State tested Nurse Aide (STNA) #60 verified the resident was not provided coffee and double portions as per preference. Interview 12/30/19 at 3:17 P.M. with Diet Tech #61 reveled the family requested coffee with each meal and double portions. Review of the 09/25/18 resident Preference for Everyday Living Inventory (PELI) plan of care revealed the resident required limited to extensive assist of one or two staff for showering and bathing. Review of the Activity of Daily Living plan of care revealed the resident chose to have a shower on Monday, Wednesday and Friday. Review of the STNA task documentation revealed the resident only received one shower the week of 12/22/19 on 12/23/19. Interview 12/30/19 at 4:10 P.M. with Registered Nurse (RN) #62 revealed the resident was taken to the shower room on 12/27/19 at 6:59 [NAME]M. but it was not documented. RN #62 verified only two showers were provided the week of 12/22/19 not three as per preference. Review of the facility Shower/Bed Bath Protocol revealed the residents were asked their preference of time of day/night to receive their showers/bed bath per PELI interview. Staff would ask the residents their preference of time and day to receive their shower/bath. This preference would be care planned and communicated on the STNA task list. If the resident refused, the STNA must inform the nurse to document the refusal. If the resident wanted to change their time/day they were encouraged to inform the DON, Unit Manager, or Nursing Supervisor. Resident preferred times/days regarding changes will be reflected by a telephone order and PELI care plan. Review of the Resident Food Preferences policy revised 12/2008 indicated Nutritional Assessments would include an evaluation of individual food preferences. Upon admission, or as soon as practicable after his/her admission, the Dietitian/Designee or nursing staff would identify a resident's food preferences. When possible, this would be done by direct interview with the resident. The resident's clinical record (orders, care plan, or other appropriate locations) would document the resident's likes and dislikes and special dietary instructions or limitations such as altered food consistency and caloric restriction. 2. Review of Resident #35's medical record revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the 12/02/19 Quarterly MDS revealed the resident was severely impaired for daily decision making, supervision for eating and extensive assist of one for personal hygiene and bathing. Physician orders [REDACTED]. Observation of the lunch meal 12/30/19 at 12:20 P.M. revealed the resident was in assisted dining. There was no water or soup provided on the tray. Review of the lunch meal slip revealed standing orders for water and soup at all meals. Interview 12/30/19 at 12:47 P.M. with (STNA)#60 verified the resident was not provided water and soup as per preference. Interview 12/30/19 at 3:17 P.M. with Diet Tech #61 revealed on 04/26/19 the family requested soup, salad and water be provided with each meal due to their concern with weight gain. Review of the 10/03/18 resident PELI plan of care revealed the resident required limited to extensive assist of one or two staff for showering and bathing. Review of the Activity of Daily Living plan of care revealed the resident chose to have a shower on Monday, Wednesday and Friday. Review of the STNA task documentation revealed the resident only received two showers the week of 12/01/19 and 12/22/19. There was no evidence of a shower being provided on Monday 12/02/19 or Friday 12/27/19. Interview 12/30/19 at 4:10 P.M. with RN #62 verified only two showers were provided the weeks of 12/02/19 and 12/22/19 not three as per preference. RN #62 included night shift should of given a shower 12/27/19. 3. Review of Resident #30's medical record revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the 11/13/19 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was severely impaired for daily decision making, totally dependent of one for eating and totally dependent of two for personal hygiene and bathing. Physician orders [REDACTED]. Observation of the lunch meal 12/30/19 at 12:39 P.M. revealed the resident was in assisted dining. There was no sandwich provided on the tray. Review of the lunch meal slip revealed standing orders for a sandwich all trays with meals. Interview 12/30/19 at 12:47 P.M. with STNA #60 verified the resident was not provided a sandwich as per preference. Interview 12/30/19 at 3:17 P.M. with Diet Tech #61 revealed the speech therapist would of requested the sandwich at all meals. Review of the 08/07/19 activity of daily living plan of care revealed the resident was totally dependent of one or two staff for showering and bathing. Review of the Activity of Daily Living plan of care revealed the resident chose to have a shower on Monday, Wednesday and Friday on dayshift. Review of the STNA task documentation revealed the resident only received one shower the week of 12/22/19 on 12/23/19. Interview 12/30/19 at 4:10 P.M. with RN #62 revealed the resident was taken to the shower room on 12/27/19 at 7:59 [NAME]M. but it was not documented. RN #62 verified only two showers were provided the week of 12/22/19 not three as per preference. This citation substantiates Complaint OH 980.

Based on record review and interview the facility failed to implement a comprehensive and effective antibiotic stewardship program to prevent the use of antibiotics for residents who did not meet the criteria for administration of the antibiotic. This affected four residents (Resident #6, #29, #37 and #45) of five sampled residents reviewed for antibiotic use and had the potential to affect all 60 residents residing in the facility. Findings include: 1. Review of the facility's infection control log dated (MONTH) (YEAR) to (MONTH) 2019 revealed no evidence an antibiotic stewardship program had been implemented. There was no documented evidence the residents had been reviewed to ensure they meet the criteria for antibiotic treatment. There was no indication on the log as to whether a resident met criteria for the use of the antibiotic. Review of the (MONTH) (YEAR) infection control log revealed there were 17 infections. Five of the seventeen indicated a culture was obtained. All seventeen infections were treated with an antibiotic. Review of the (MONTH) (YEAR) infection control log revealed there were 16 infections. Six of the sixteen indicated a culture was obtained. All sixteen infections were treated with antibiotics. Resident #6 was started on the antibiotic, [MEDICATION NAME], for a suspected urinary tract infection prior to a urine culture being completed. The urinalysis culture showed no growth and the antibiotic was discontinued. Review of the (MONTH) (YEAR) infection control log revealed 15 infections. Six of the fifteen indicated a culture was obtained. All fifteen infections were treated with an antibiotic. Resident #6 was started on [MEDICATION NAME] for a suspected urinary tract infection prior to a urine culture. The urinalysis culture showed no growth and the antibiotic was discontinued. Review of the (MONTH) 2019 infection control log revealed 10 infections. Five of the ten indicated a culture was obtained. All ten infections were treated with an antibiotic. Resident's #29 and #37 were started on an antibiotic, for suspected urinary tract infections prior to a urine culture. The urinalysis culture showed organisms to which the antibiotic were resistive and they needed to have their antibiotics changed to a receptive antibiotic. Interview on 03/14/19 at 2:34 P.M. with Registered Nurse (RN) #100 confirmed the facility did not have a comprehensive antibiotic stewardship program in lace. She reported the facility was to use the McGeer criteria, however she could not provide documentation the residents were reviewed to see if they met the criteria for treatment. RN #100 verified residents were on antibiotics prior to obtaining cultures and without obtaining cultures. RN #100 verified residents received antibiotics that were not receptive to the bacteria grown in cultures and the antibiotics were changed to an antibiotic that was susceptible to the organism. Review of the undated policy, titled Antibiotic Stewardship-Orders for Antibiotics revealed antibiotics were to be prescribed and administered to residents under the guidance of the facility antibiotic stewardship program. Appropriate indications for use of antibiotics included: criteria met for clinical definition of active infection and pathogen susceptibility based on culture and sensitivity to antimicrobial (or therapy begun while culture was pending). 2. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #45's nursing note, dated 12/19/18 revealed dark yellow urine with no apparent odor or sediment was obtained via straight catherization. Resident #45 had complaints of lower back pain, burning with urination, and an urinalysis and culture and sensitivity (C&S) was ordered. No other signs or symptoms of a UTI was documented. Review of the UA (urinalysis) Complete lab, dated 12/20/18 revealed moderate blood with trace bacteria. Review of the record revealed no documented evidence a urine C&S was indicated or completed. Review of Resident #45's physician orders, dated 12/22/18 revealed to administer Bactrim DS (antibiotic) 800/160 milligrams (mg) twice a day for seven days for a UTI. Further review of Resident #45's Nursing Notes revealed the following: On 12/22/18, urinalysis results reviewed with Physician #110 and the physician ordered Bactrim DS twice a day for seven days. The resident was afebrile, denied urinary pain or discomfort and was continent of urine. On 12/23/18, the resident was afebrile with no complaints of pain or urinary discomfort. On 12/24/18, no complaints of urinary pain; however, resident did complain of generalized body pain and was medicated with Tylenol. On 12/26/18, Resident #45's negative urinalysis results were reviewed with Physician #110 and he was asked to clarify whether to discontinue or complete the course of Bactrim DS. Physician #110 ordered to complete the antibiotic. Review of the Physician Medical Visit electronically signed 12/26/18 revealed no [MEDICAL CONDITION] assessment or evaluation of the residents UTI or antibiotic use was completed. Review of the Medication Administration Record [REDACTED]. On 03/14/19 at 9:38 A.M., interview with Registered Nurse (RN) #172 verified Resident #45's urinalysis was negative on 12/22/18 and did not require a C&S. RN #172 verified there was no evidence the resident met criteria of an UTI and the resident continued to receive an antibiotic. On 03/14/19 at 2:29 P.M., interview with RN #100 verified she the antibiotic stewardship protocol had not been followed. Review of the undated policy, titled Antibiotic Stewardship revealed antibiotics were to be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose was to monitor the use of antibiotics and the appropriate indications for use including criteria met for an active infection and pathogen susceptibility based on culture and sensitivity, or therapy begun while culture was pending. When antibiotics were prescribed over the phone, the prescriber or designee was to assess the resident within 72 hours of the telephone order. When a culture was ordered, results were to be treated as a high priority and lab results were to be communicated, as soon as available, to determine if antibiotic therapy should be started, continued, modified, or discontinued based on culture and sensitivity C&S. The consultant pharmacist should also be advised of all new antibiotic orders, changes in duration, unplanned discontinuation of antibiotic orders and any suspected adverse events. 3. Record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with an indwelling urinary (Foley) catheter and it was discontinued on 03/12/19. Review of Resident #29's progress notes revealed on 01/29/19 the resident complained of pain and an inability to urinate. The resident's urine was noted to be foul smelling without copious amount of sediment. The urinary test strip was completed and showed [MEDICATION NAME], blood, protein, [MEDICATION NAME], and getter than 500 leukocytes. The physician was notified, and a new order was received [MEDICATION NAME] milligrams (mg) every twelve hours for ten days for urinary tract infection [MEDICAL CONDITION]. There was no evidence the urine was sent for urinalysis or culture. The resident [MEDICATION NAME] mg from 01/29/19 to 02/08/19. On 02/24/19 new orders were received [MEDICATION NAME] mg every 12 hours for 10 days and urinalysis and culture and sensitivity (C&S) to be performed. On 02/25/19 the urine was collected for urinalysis and C&S. The urine was yellow in color, visible sediment noted. Results of the C&S revealed the bacteria was resistant [MEDICATION NAME] E-coli was present. The physician was notified, and new orders were received to stop [MEDICATION NAME] start [MEDICATION NAME] 500 mg three times daily for seven days. Review of Resident #29's medication administration records (MAR), dated 02/2019 to 03/2019 revealed the resident [MEDICATION NAME] mg twice daily from 01/29/19 to 02/08/19 and 02/24/19 to 02/27/19. Review of Resident #29's laboratory testing dated 02/27/19 revealed the resident urine C&S showed the organism was Escherichia coli [MEDICATION NAME] resistant to the organism. Interview on 03/11/19 at 6:58 P.M., with Resident #29 revealed the resident believed the physician did not properly treat his UTI. Interview on 03/14/19 at 10:13 A.M. and 11:39 A.M., with Registered Nurse (RN) #171 verified the resident was started [MEDICATION NAME] 01/29/19 for a urinary tract infection, because he had a positive urine dip, however the urine was not sent for C&S to ensure proper antibiotic treatment. Sixteen days later, on 02/24/19 the resident was started on another round [MEDICATION NAME] a urinalysis and C&S was obtained. The C&S was received by the facility on 02/27/19 and it indicated the bacteria was resistant [MEDICATION NAME] the resident had to be switched to another antibiotic. She verified the first urine should have been sent for C&S to ensure [MEDICATION NAME] appropriate and the second round [MEDICATION NAME] have not been started till the C&S returned. During the interview, RN #171 confirmed the facility did not have a comprehensive infection control program in-place, however they were going to follow the McGeer surveillance criteria. The McGeer criteria indicated laboratory testing would be performed. If a urinary catheter was in place for greater than 14 days, then change catheter prior to collecting specimen. To meet criteria the resident had to at least 100,000 cfu/ml of any number of organism and one of the following signs and symptoms of UTI: A. fever, rigors, or new-onset [MEDICAL CONDITION] B. acute change in mental status or acute functional decline C. new-onset suprapubic pain or costovertebral angle pain or tenderness D. purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate. Review of the undated antibiotic stewardship- review and surveillance of antibiotic use and outcomes revealed antibiotic therapy was not justified if the organism was not susceptible to antibiotic chosen or therapy was started awaiting culture. The appropriate indication for use of antibiotics included: criteria met for clinical definition of active infection and pathogen susceptibility, based on C&S. Changes to antibiotic order based on C&S would be reviewed by the facilities infection preventions or a pharmacist.

Based on observation, record review and interview the facility failed to honor Resident #53's preferences/choices in regard to showers, meal substitutes and meal preferences. This affected one resident (Resident #53) of one resident reviewed for activities of daily living and one resident (Resident #53) of three residents reviewed for nutrition. Findings include: Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Diet Requisition form, dated 02/06/19 revealed the resident was to receive a regular 1800 calorie American Diabetic Association diet and thin liquids. Review of the physician's orders [REDACTED]. Review of the 02/07/19 resident Preference for everyday living inventory (PELI) plan of care revealed the resident chose to have a shower every other morning. Review of the 02/07/19 Activity of Daily Living plan of care revealed the resident required extensive assist of one or two staff for personal hygiene. The resident was diabetic so the nurse was to check his nail length, clean and trim on shower/bath day. Review of the 02/11/19 PELI form revealed it was very important to the resident to shower in the morning every other day and very important to choose what to eat. Review of the admission 02/13/19 Minimum Data Set (MDS) 3.0 assessment revealed the resident was independent for daily decision making, required extensive assist of two staff for bed mobility, transfers, dressing, toilet and personal hygiene. During an interview with the resident on 03/11/19 at 07:31 P.M. the resident indicated he had only been shaved three times since admission. He said staff only cut his fingernails once. Observation revealed the nail beds had dark debris under them. The resident shared that he had some issues with diarrhea at home and was lactose intolerant. The resident revealed they were bringing him regular milk. Staff brought him supper that evening and he didn't like it. They told him they would bring him a grilled cheese sandwich but they never brought it to him. During the interview at 7:55 P.M. State tested Nurse Aide (STNA) #108 was observed to bring him in a peanut butter and jelly sandwich. She said she had gone down a couple of times and asked for the grilled cheese sandwich but now the kitchen was closed. Observation of the breakfast meal 03/12/19 at 08:07 A.M. revealed the resident received regular 2% milk. He remained unshaved and his fingernails remained dirty. The resident's meal ticket did not list any food likes or dislikes. The meal ticket did not identify the resident as lactose intolerant. The diet was listed as low concentrated sweets and no added salt. There was a typed sign, posted 02/24/19, on the residents closet door to shave resident daily. There were three slash marks indicating the number of times shaven since 02/24/18. Review of the STNA TASK documentation revealed the resident received a shower on 02/07/19, refused a shower on 02/12/19, and had a shower 02/26/19, 03/04/19, 03/05/19 and 03/12/19. Review of the STNA Kardex revealed a shower every other morning was listed. Review of the TASK list revealed shower with out a time or frequency indicated. Review of the shower list posted in the shower room revealed Resident #53 was scheduled for a shower once a week on Tuesdays. Interview on 03/12/19 at 06:07 P.M. with STNA #108 revealed around 4:45 P.M.-5:00 P.M. on 03/11/19 she took the resident his supper. Around 5:00 P.M. - 5:30 P.M. she noticed he didn't eat. He said he would take a grilled cheese. She said she ordered one from the kitchen and checked twice and it wasn't done. STNA #108 indicated the kitchen staff would usually bring the food to the floor if they were not there to get it. They couldn't bring it so they threw it away because they said it was cold. She stated she made him a peanut butter and jelly sandwich which she brought in to him when the surveyor was in the room with him. Interview on 03/13/19 at 11:24 A.M. STNA #168 revealed her job was to give showers. STNA #168 verified she did not offer Resident #53 a shower every other day. STNA #168 revealed shaving and nail care were to be provided when showered or bathed. STNA #168 indicated she shaved the resident on 03/12/19 when she showered him. STNA #168 verified more frequent shaving and nail care would of been provided if the showers were provided per preference. On 03/13/19 at 11:30 A.M. interview with Activity Director #119 revealed she interviews using the PELI for preferences and constructs a plan of care. She completed the PELI for the resident and it indicated a shower every other day. The plan of care also said that there was to be a shower every other morning. The TASK information included there was to be a shower without clarification. The KARDEX said every other morning but it did not carry over to the TASK. Activity Director #119 indicated when she entered the PELI information in the computer it was to carry over to the TASK list to make the STNA's aware of preferred frequency. Activity Director #119 indicated she was entering the information in the wrong area and it was not carrying over to the TASK list. Interview with the Dietary Manager #127 on 03/31/19 at 2:24 P.M. revealed she had not yet completed a food preference form for Resident #53. She indicated the staff that takes orders talks to them a little bit before she can get around. Normally she would conduct the food preference interview and then type the information in the computer to get on the diet tickets. Dietary Manager #127 verified the diet slip for Resident #53 did not have food preferences likes or dislikes. The Resident Food Likes and Dislikes Survey form included likes and dislikes including beverages such as milk. Dietary Manager #127 verified if the preference sheet was completed it could of captured the lactose intolerance. Review of the facility Shower/Bed Bath Protocol revealed the residents were asked their preference of time of day/night to receive their showers/bed bath per PELI interview. Staff would ask the residents their preference of time and day to receive their shower/bath. This preference would be care planned and communicated on the STNA task list. If the resident refused, the STNA must inform the nurse to document the refusal. If the resident wanted to change their time/day they were encouraged to inform the DON, Unit Manager, or Nursing Supervisor. Resident preferred times/days regarding changes will be reflected by a telephone order and PELI care plan. Review of the Resident Food Preferences policy revised 12/2008 indicated Nutritional Assessments would include an evaluation of individual food preferences. Upon admission, or as soon as practicable after his/her admission, the Dietitian/Designee or nursing staff would identify a resident's food preferences. When possible, this would be done by direct interview with the resident. The resident's clinical record (orders, care plan, or other appropriate locations) would document the resident's likes and dislikes and special dietary instructions or limitations such as altered food consistency and caloric restrictions.

Based on record review and interview the facility failed to ensure ordered fall prevention safety devices were in place for Resident #57 to prevent falls. This affected one resident (Resident #57) of two residents reviewed for accidents. Findings include: Review of Resident #57's medical record revealed the resident was admitted [DATE] with current [DIAGNOSES REDACTED]. Record review revealed a high risk for falls plan of care had been in place since 12/29/17 due to the resident's history of frequent falls, impulsiveness, poor decision making, [MEDICAL CONDITION] with hallucinations, depression [MEDICAL CONDITION], attention and concentration deficit, disorder of motor function and weakness. Record review revealed the resident had a history of [REDACTED]. The resident had one fall on 01/13/19 and two falls on 01/14/19 resulting in a fractured left femur. The resident had nine falls since the [MEDICAL CONDITION]. Three of the fall investigations revealed the safety alarm, ordered for the resident was not in place at the time of the falls. Review of the current physician's orders [REDACTED]. 02/19/19 physical therapy issued elastic shoelaces this date, on 02/20/19 bed alarm to notify staff of unassisted transfer, monitor for proper placement and function every shift and as needed, on 02/24/19 Dycem to recliner chair-monitor placement every shift and as needed, on 02/25/19 hipsters at all times, clip alarm to recliner. Monitor placement and proper functioning every shift, and as needed, chair alarm to recliner, monitor placement and proper functioning every shift and as needed, on 02/26/19 gripper socks at all times, on 02/28/19 weight bearing as tolerated, on 03/01/19 toilet after meals and assist resident into the recliner or bed and on 03/05/19 mat to floor. Review of a 02/05/19 Fall Risk Evaluation revealed the resident was at high risk for falls related to three or more falls within the last six months, intermittent confusion, elimination with assistance, medications including antidepressants, [MEDICATION NAME], antipsychotics, and narcotics. The resident ambulates with staff assistance with stability, and/or gait impairment or wheelchair, needs help to transfer. The resident had communication barriers and impaired vision. Review of the nurse's note revealed on 02/09/19 at 8:35 P.M. staff entered the room and saw the resident on the floor on backside, urinal spilled on floor. The resident was assessed to have a two by two abrasion to the knee and stated he was trying to use the bathroom. The resident voiced complaints of pain when on the floor, no further complaints when transferring from floor to wheelchair and into bed. There was no evidence of the ordered clip alarm sounding. Review of witness statements revealed the resident had been wheeled back into the facility after smoking and left in his wheelchair. Review of an Employee Warning Notice revealed State tested Nurse Aide (STNA) #155 was given a written warning for not ensuring the safety clip alarm was in place prior to leaving the resident in room. The resident was left in a wheelchair without the alarm on. The employee statement included she did not know about the alarm. Review of a nursing note, dated 02/14/19 at 7:56 P.M. revealed the resident was found on floor. Resident stated pain in left hip but none was voiced when he was asked to move legs on own accord and did so without difficulty. The resident was assisted by two staff with a gait belt back into wheel chair and clip alarm securely applied. Right knee skin tear cleansed. There was no evidence of the ordered clip alarm sounding at the time of the fall. Review of the witness statements revealed staff heard a loud sound and found him on floor in room. Alarm was not clipped. There was no evidence of education or discipline related to the safety alarm not being in place as ordered. Review of the 02/16/19 30 day Minimum Data Set (MDS) 3.0 assessment revealed the resident was severely impaired for daily decision making, required extensive assist of two staff for bed mobility, and transfers, had lower extremity functional limitations on one side and had two or more falls without major injury since the last assessment. Review of the nurse's note, dated 03/01/19 at 6:10 P.M. revealed this nurse heard resident yell out that he had to use the bathroom. The nurse entered the room and the resident was laying on his backside beside wheelchair. Abrasion noted to right scapula, 2 centimeters (cm) by 4 cm, yellow/blue bruise noted surrounding abrasion measuring 9 cm x 2 cm. Review of the witness statements revealed on 03/01/19 at 6:10 P.M. the resident was found on the floor on mat in front of wheelchair. Alarm not sounding. There was no evidence of education, discipline or investigation related to the safety alarm not sounding/or being in place as ordered. Interview on 03/14/19 at 12:43 P.M. with the Director of Nursing revealed staff were educated/ warned for not putting on the safety alarm when the resident was brought back from smoking. The DON indicated the STNA did not review the Kardex to learn what care needs changed since she last worked. Interview on 03/14/19 at 02:09 P.M. with the Director of Nursing verified falls occurred on 02/09/19, 02/14/19 and 03/01/19 without the safety alarm being on as ordered.

Based on record review and interview the facility failed to do proper laboratory testing to ensure an appropriate antibiotic was ordered to treat Resident #29's urinary tract infection. This affected one resident (Resident #29) of one resident reviewed for urinary tract infections. Findings include: Record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with an indwelling urinary (Foley) catheter and it was discontinued on 03/12/19. Review of Resident #29's progress notes revealed on 01/29/19 the resident complained of pain and an inability to urinate. The resident's urine was noted to be foul smelling without copious amount of sediment. The urinary test strip was completed and showed [MEDICATION NAME], blood, protein, [MEDICATION NAME], and getter than 500 leukocytes. The physician was notified, and a new order was received [MEDICATION NAME] milligrams (mg) every twelve hours for ten days for urinary tract infection [MEDICAL CONDITION]. There was no evidence the urine was sent for urinalysis or culture. The resident [MEDICATION NAME] mg from 01/29/19 to 02/08/19. On 02/24/19 new orders were received [MEDICATION NAME] mg every 12 hours for 10 days and urinalysis and culture and sensitivity (C&S) to be performed. On 02/25/19 the urine was collected for urinalysis and C&S. The urine was yellow in color, visible sediment noted. Results of the C&S revealed the bacteria was resistant [MEDICATION NAME] E-coli was present. The physician was notified, and new orders were received to stop [MEDICATION NAME] start [MEDICATION NAME] 500 mg three times daily for seven days. Review of Resident #29's medication administration records (MAR), dated 02/2019 to 03/2019 revealed the resident [MEDICATION NAME] mg twice daily from 01/29/19 to 02/08/19 and 02/24/19 to 02/27/19. Review of Resident #29's laboratory testing dated 02/27/19 revealed the resident urine C&S showed the organism was Escherichia coli [MEDICATION NAME] resistant to the organism. Interview on 03/11/19 at 6:58 P.M., with Resident #29 revealed the resident believed the physician did not properly treat his UTI. Interview on 03/14/19 at 10:13 A.M. and 11:39 A.M., with Registered Nurse (RN) #171 verified the resident was started [MEDICATION NAME] 01/29/19 for a urinary tract infection, because he had a positive urine dip, however the urine was not sent for C&S to ensure proper antibiotic treatment. Sixteen days later, on 02/24/19 the resident was started on another round [MEDICATION NAME] a urinalysis and C&S was obtained. The C&S was received by the facility on 02/27/19 and it indicated the bacteria was resistant [MEDICATION NAME] the resident had to be switched to another antibiotic. She verified the first urine should have been sent for C&S to ensure [MEDICATION NAME] appropriate and the second round [MEDICATION NAME] have not been started till the C&S returned.

Based on observation, record review, and interview the facility failed to ensure Resident #23's nutritional plan of care was followed, and dietary assessments were comprehensive. This affected one resident (Resident #23) of two residents reviewed for nutrition. Findings include: Record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident required limited assistance of one staff for eating and was totally dependent on staff for transfers. Review of Resident #23's dietary assessments completed from 02/04/19 to 03/06/19 revealed the physician wanted the resident's weights maintained without excessive [MEDICAL CONDITION]. The resident had history of refusing dietary supplements, however was offered snacks selected by the resident's preference. On 03/06/19 the resident was identified to have a significant weight loss in the last three months (12.9 pounds and 18.6 percent in 6 months). The resident's current body weight was 175 and body mass index was 28.2 (over weight). His meal intakes were documented to be 0-50%; however, his wife does bring in meals. Weight loss was planned as resident continues [MEDICATION NAME] (water pill) and [MEDICAL CONDITION]. He continues 1500 milliliter (ml) fluid restriction (1140 ml dietary and 360 ml nursing) Resident accepts eight ounces of 2% milk at breakfast and lunch. This fits within the fluid restriction to help maintain weight. Re-calculation of estimated needs were 1508-1885 calories, 64-80 grams, 1600-2000 ml of fluids. The following nutritional concerns were identified during the review of Resident #23: A. Review of Resident #23's current orders, meal ticket, and plan of care revealed the resident was on a 1500 ml fluid restriction. The meal ticket standing orders revealed for meals the resident would receive 840 ml of fluids with his meals. The resident would receive an additional 240 ml of fluids with snack. The resident was receiving the total of 1,080 in fluids from dietary. Observation on 03/11/19 at 7:11 A.M. and 03/12/19 from 9:55 A.M. to 2:25 P.M., revealed the resident had a thermal bottle with ice water. Interview on 03/12/19 at 3:56 P.M., with State tested Nurse's Aide (STNA) #159 and Registered Nurse (RN) #175 revealed neither staff member who were providing care to the resident knew the breakdown of fluids that nursing was responsible to provide in 24-hour period. STNA #159 reported the STNA's were giving the resident two 16 ounces (946.353 ml) of water daily. RN #175 reported the physician order [REDACTED].#23's order did not indicate the breakdown of fluids. Interview on 03/12/19 at 4:05 P.M., with Dietician Technician (DT) #129 revealed nursing was responsible for 360 ml's and dietary 1140 ml's in a 24-hour period. She confirmed the physician order [REDACTED].#23's order, meal ticket, nor the care plan indicated the breakdown of fluids in the 24 hours period. She reported she would clarify the order and educate staff. Nursing reported they were giving 946.353 ml of fluids in a 24-hour period and dietary was giving 1,080 totaling 2,026.535 ml in a 24-hour period. Interview on 03/13/19 at 1:26 P.M., with RN #171 revealed she provided education to the Resident #23's wife and the facility was going to provide her with a sheet with measurement of each cup because she was having difficulty understanding the measurements. B. Review of Resident #23's progress notes, dated 01/17/19 to 03/12/19 revealed the resident had several emesis, nausea, and [MEDICATION NAME] was consulted was ordered. On 01/31/19 the gastrointestinal doctor ordered [MEDICAL CONDITION] and adjusted medication. Interview on 03/11/19 at 7:11 P.M., with Resident #23 revealed his weight loss was related to his stomach issues. He reported he frequently gets nauseated and had emesis frequently. Review of the medical records and dietary notes revealed no evidence of the resident current [DIAGNOSES REDACTED]. Interview on 03/13/19 at 9:40 A.M., with DT #129 confirmed her assessments for the resident's significant weight loss did not include the resident gastrointestinal concerns. C. Review of resident snack intakes dated 01/2019 to 03/2019 revealed the only snack intake that was being recorded for the resident was yogurt. Interview on 03/13/19 at 9:40 A.M., with DT #129 reported the snack intakes should have been recorded in the resident's medical record, however there was no evidence they had been recorded except for the yogurt. She confirmed the percentage of snacks consumed would have affected the nutritional assessment. D. Review of the resident's care plans revealed the resident [MEDICAL CONDITION] was to avoid foods that irritate the [MEDICAL CONDITION] lining such as acidic foods, encourage the resident to avoid over eating, eat at 90-degree angle for one hour after meals either in chair or bed. The [MEDICAL CONDITION] care plan indicated 1500 ml fluid restriction, encourage adequate nutrition offering small frequent feedings, monitor intakes and outputs, monitor/document for signs and symptoms of malnutrition. Do not force resident to eat. Offer small frequent feedings. Review of Resident #23's meal ticket reveled fluid restriction 1500 ml, low concentrated sweets, no added salt, double portions of meat at breakfast and lunch, black handled silverware, thermal cups with lids for hot drinks, no citrus, no tea or [MEDICATION NAME] beverages, no creamed soups, dislikes bread, spaghetti, and fish. There was no evidence of small frequent meals. Review of the snack list 03/12/19 revealed Resident #23 was to receive peanut butter and jelly sandwich in the morning, cottage cheese 1/2 cup at 2:00 P.M., Danish at night, chocolate ice cream 1/2 cup at night, and four ounces lemonade at night. Observation on 03/12/19 at 8:55 A.M., revealed the resident had bread and orange juice on his breakfast tray. The resident ate everything on his tray except the bread. Observation on 03/12/19 at 2:25 P.M., revealed Resident #23 had not received his 2:00 P.M., snack (1/2 cup cottage cheese). The resident reported he did not always get the cottage cheese every day. Interview on 03/12/19 at 2:30 P.M., with STNA #108 revealed the snacks had not been delivered to the floor and the STNA went to the kitchen a retrieved the 2:00 P.M. snacks for the hall. Interview on 03/13/19 at 8:35 A.M., with DT #129 revealed she was not sure why the resident could not have citrus; however, it was his right to have whatever he wanted. She stated she would educate dietary staff to check with nursing first before giving residents items that say no. She confirmed the care plan interventions for small frequent meals was not communicated to dietary department. Interview on 03/13/19 at 11:29 A.M., with Registered Dietician (RD) #111 revealed she doesn't document her assessments and only reviews the DT notes for residents at high risk and provides recommendations if needed. She reported there seemed to be a lack of communication between dietary and nursing after reviewing the above findings with her.

Based on observation, record review and interview the facility failed to adequately maintain a continuous positive airway pressure ([MEDICAL CONDITION]) machine for Resident #9. This affected one resident (Resident #9) of one resident in the facility who utilized a [MEDICAL CONDITION] machine. Findings include: Review of Resident #9's medical record revealed the resident had a [DIAGNOSES REDACTED]. Review of the 03/06/17 plan of care for impaired oxygen exchange revealed an intervention dated 11/01/18 for Cleaning [MEDICAL CONDITION] 1. Hose: soapy water, rinse, hang to dry 2. Mask: soapy water, rinse, air dry 3. Filter: remove flick to remove dust. Review of the physician's orders [REDACTED]. The resident also had an order to clean [MEDICAL CONDITION] mask daily prior to placement on resident and on 07/19/18 Cleaning [MEDICAL CONDITION] 1. Hose: soapy water, rinse, hang to dry 2. Mask: soapy water, rinse, air dry 3. Filter: remove flick to remove dust every night shift on Sunday. Review of the 12/03/18 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was severely impaired for daily decision making, required extensive assist of two staff for bed mobility, was totally dependent of two staff for transfers and had upper and lower extremity impairment. The assessment also noted the resident utilized oxygen. Observation on 03/11/19 at 07:21 P.M. revealed Resident #9 was in bed on her left side. The bed had a cushioned side rail. The oxygen condenser was on at 3 liters per minute with a humidifier bottle dated 03/10/19. The resident had a [MEDICAL CONDITION] mask on her face. The [MEDICAL CONDITION] machine did not have a filter in place, ramp or EPR settings. Review of the (MONTH) 2019 treatment sheets revealed Cleaning [MEDICAL CONDITION] 1. Hose: soapy water, rinse, hang to dry 2. Mask: soapy water, rinse, air dry 3. Filter: remove flick to remove dust were being signed off weekly. [MEDICAL CONDITION] at 10 centimeters (cm) on when in bed, settings ramp 40, EPR level 3, oxygen at two liters per minute every shift related to [MEDICAL CONDITION] and apply [MEDICAL CONDITION] when in bed during the day and at night was being signed off twice a day as completed. Review of the REMstar Auto M Series revealed the [MEDICAL CONDITION] machine utilized a white paper type filter and a gray foam filter. Review of the cleaning instructions included: Under normal usage, you should clean the gray filter at least every two weeks and replace with a new one every six months. The white ultra-fine filter was disposable and should be replaced after 30 nights of use or sooner if it appears dirty. DO NOT clean the ultrafine filter. Wash the gray foam filter in warm water with a mild detergent. Rinse thoroughly to remove all detergent residue. Allow the filter to air dry completely before reinstalling it. If the foam filter was torn, replace it. (Only Respironics-supplied filters should be used as replacement filters). Operating the device with a dirty filter may keep the system from working properly and may damage the device. On 03/13/19 at 06:07 P.M. the Director of Nursing (DON) and Registered Nurse #174 verified there was not a white or gray filter in the machine. The filter compartment was empty. The DON and RN #174 verified the filters were missing and they could not determine for how long. RN #174 revealed the resident initially used her personal [MEDICAL CONDITION] machine for the 10/06/16 [MEDICAL CONDITION] settings. RN #174 looked at the supplies and discovered the only filters they had in the facility were for the old [MEDICAL CONDITION] machine, a different brand. RN #174 indicated the resident was now renting a different model. On 03/14/19 at 08:41 A.M. the DON verified staff were documenting signing off they removed the filter to remove dust when a filter was not present in the machine. The DON also verified staff were incorrectly documenting the [MEDICAL CONDITION] at 10 cm on when in bed, settings ramp 40, EPR level 3, oxygen at two liters per minute every shift related to [MEDICAL CONDITION] twice a shift for settings on the old (YEAR) machine. Interview on 03/14/19 at 4:02 P.M. with the Administrator revealed Resident #9 began renting the current REMstar Auto M Series [MEDICAL CONDITION] machine on 01/17/17. The Administrator provided paperwork that indicated the last time the machine was serviced was 01/30/19. The paperwork indicated the last time the filter was replaced was 01/09/19.

Based on observation, record review and staff interview the facility failed to ensure Resident #40 received the correct dose of the anti-anxiety medication, [MEDICATION NAME]. This affected one resident (Resident #40) of six residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was ordered [MEDICATION NAME] 0.5 milligrams (mg) one twice daily for anxiety. Observation on 03/11/19 at 10:45 P.M., of the south medication cart with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #144 revealed a discrepancy in Resident #6 and Resident #40's [MEDICATION NAME] count. Resident #6's count sheet indicated the resident had 28 [MEDICATION NAME] one mg, however there was only 27 one mg [MEDICATION NAME] tablets in the blister pack. Resident #40's control sheet indicated there were 22 [MEDICATION NAME] 0.5 mg, however there were 23 tablets in the blister pack. The LPN and DON confirmed the findings during the observation. Interview on 03/12/19 at 11:05 A.M., with the DON revealed she had completed an investigation and determined the discrepancy in the [MEDICATION NAME] was related to a medication error. The DON indicated the nurse had administered Resident #6's [MEDICATION NAME] medication to Resident #40 resulting in the resident receiving one mg of the medication instead of the 0.5 mg that was ordered. Review of the Medication Administration policy, dated 06/21/17 revealed to read the label comparing to the Medication Administration Record [REDACTED]. Identify the resident before administering medication and explain the type of medication to be administered.

Based on closed record review, review of facility provided photographs and interview the facility failed to ensure adequate interventions were in place to prevent the deterioration of pressure injuries/ulcers for Resident #72 and failed to ensure timely and accurate assessments of the ulcers. Actual harm occurred when Resident #72, who was at risk for skin breakdown and had Stage II pressure injuries/ulcers (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible) to his bilateral heels experienced a decline in the ulcers to deep tissue injuries and then unstageable pressure injuries due to a lack of interventions. This affected one (Resident #72) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #72's closed medical revealed an admission date of [DATE] and discharge date of [DATE]. Resident #72's [DIAGNOSES REDACTED]. Review of Resident #72's most recent quarterly Minimum Data Set 3.0 (MDS) assessment, dated 07/03/17 revealed Resident #72 was severely cognitively impaired. Review of Resident #72's MDS 3.0 assessment revealed she required extensive assistance of one person for bed mobility and toileting. The MDS 3.0 assessment revealed Resident #72 did not have any pressure ulcers but was at risk for developing pressure ulcers. The MDS 3.0 assessment revealed pressure reducing devices were in place for the bed and chair of the resident with no other interventions noted. Review of Resident #72's plan of care created on 01/26/17 revealed Resident #72 required one to two staff extensive assistance with the majority of her activities of daily living. The interventions included assist of one to two staff with bed mobility. Review of Resident #72's care plan initiated 01/26/17 revealed Resident #72 had potential for pressure ulcer development with interventions including two assist with turning and reposition and supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Review of Resident #72's treatment administration record and nursing aide task documentation revealed from 07/01/17 through 07/17/17 there was no evidence Resident #72's heels were elevated. Review of the nutritional meal intake documentation revealed from 07/06/17 through 07/12/17 Resident #72 had an intake of 0-25% during 13 of the documented meals. Review of Resident #72's meal intake for the same date range revealed three meals that were taken 76-100% and three resident refusals for meals and two meal intakes of 26% to 50% and none documented as 51-75%. Review of the progress note dated 07/12/17 at 2:31 P.M. by Licensed Practical Nurse (LPN) #10 revealed Resident #72's heels had blisters on them. The note revealed the wound nurse received new orders to apply skin prep daily and Resident #72 was not to wear shoes until the blisters were healed. Review of the progress notes, nutritional progress notes, nutritional evaluations and wound assessment revealed no evidence a nutritional supplement was discussed, recommended or implemented from 07/12/17 until 09/06/17 Review of the wound assessment dated [DATE] at 11:32 A.M. revealed Resident #72 had a new blister that was acquired in-house with measurement including 3.9 cm in length by 4.2 cm wide. The wound bed was 100% [MEDICATION NAME] tissue and the temperature was cool. The note revealed the resident was not to wear shoes until healed and heels were to be raised. Resident 72 was seen by the certified nurse practitioner (CNP) due to podiatry not in the facility that week. Review of the wound assessment dated [DATE] at 11:34 A.M. revealed Resident #72 had a blister to the left heel that was acquired in house. The wound measurements were 2.4 cm in length by 3.4 cm wide and the wound temperature was cool. The note written by the CNP revealed the resident was not to wear shoes until healed and heels were to be raised. Review of the wound management services progress note date of service day of 07/17/17 revealed Resident #72 had a Stage II pressure injury on her left heel. The measurements were 3.0 cm in length by 3.5 cm wide with .05 cm depth. The wound had no signs or symptoms of infection and was an intact fluid filled blister with 100% of the wound covered and the surface intact. The wound edges were distinct, outlined clearly visible attached and even with the wound base. The note revealed Resident #72 additionally had a right heel pressure injury that was an intact fluid filled blister with measurements of 2.5 cm in length by 2.8 cm width with .05 cm depth. The wound assessment revealed 100% of the wound surface was intact. The wound edges were distinct outlined, clearly visible, attached, even with the wound base. The assessment and plan indicated bilateral lower extremities were to be elevated when sitting as tolerated by the patient and to offload/float heels when in bed. The note revealed the current interventions included dietary supplements. Review of Resident #72's medical record revealed no evidence of dietary supplements being ordered or recommended from dietary from 07/12/17 through 09/06/17. There was no evidence of notification to dietary of the wound. Review of the podiatry note dated 07/19/17 revealed Resident #72 was seen for a deep tissue injury on each heel. The note revealed the right heel measured 3.0 cm in length by 3.3 cm width and indicated a blister. The note revealed the left heel with measurement of 3.7 cm in length and 4.2 cm in width and indicated a blister. The note revealed the area was unstageable. The note revealed appearance of fluid filled blisters. The assessment revealed the pressure ulcers of the right heel and left heel were Stage II ulcers and Resident #72 had unspecified [MEDICAL CONDITION] of native arteries of extremities of the bilateral legs. There was no ultrasound at this time. There was no evidence of recommendations at this time for nutritional supplement on the physician progress notes [REDACTED]. Review of the wound assessment dated [DATE] at 6:51 A.M. revealed Resident #72,s wound was a blister with length of 2.8 cm in length by 1.8 cm width and was 100% [MEDICATION NAME] tissue with surface intact and the attached edge appears flush with wound bed or as a sloping edge. the surrounding tissue is blister and dark reddish brown and the wound temperature was warm with non-[MEDICAL CONDITION] extends greater than 4 cm around the wound. The assessment revealed the wound was improving. There was no evidence of recommendations at this time for nutritional supplement on the physician progress notes [REDACTED]. Review of the wound assessment dated [DATE] at 6:54 A.M. revealed Resident #72 wound was a blister on the right heel with length of 3.3 cm by width of 2.5 cm. The wound had 100% of the wound covered with [MEDICATION NAME] tissue and the surface was intact. The edges of the wound appeared flush with wound bed or as a sloping edge with the surrounding tissue blistered and dark reddish brown. There was non-[MEDICAL CONDITION] greater than 4.0 cm around the wound and the wound was warm and status indicated it was improving. There was no evidence of recommendations at this time for nutritional supplement on the physician progress notes [REDACTED]. Review of Resident #72's nutritional meal intake record from 07/13/17 through 07/25/17 revealed 23 meal intakes of 0-25%. Review of the meal intakes for this date range revealed four meal intakes for 25% to 50 %, three meal intakes from 51% to 75%, three 76-100% and five resident refusals. Review of Resident #72's plan of care created 07/24/17 revealed Resident #72 had impaired skin integrity bilateral heel blisters from poor fitting new shoes. with interventions including encourage good nutrition and hydration in order to promote healthier skin. Review of Resident #72's comprehensive metabolic panel dated 07/24/17 revealed Resident #72's [MEDICATION NAME] was low at 2.5 grams (gm)per deciliter (dl) with normal from 3.2 to 5.0 gm/dl. Review of the arterial ultrasound of the right and left lower extremities dated 07/28/17 revealed an impression of mild to moderate atheromatous changes bilaterally. No obstruction or high-grade stenosis was identified. Review of the attending physician's progress note dated 08/02/17 revealed on 07/28/17 Resident #72 had an arterial duplex doppler report reviewed. There was no obstruction or high-grade stenosis noted. The note revealed the resident had non-healing blisters of the lower extremities. The note revealed the patients comprehensive metabolic panel was within normal limits except for [MEDICATION NAME]. There was no evidence of recommendations at this time for nutritional supplement on the physician progress notes [REDACTED]. Review of the physician progress notes [REDACTED].#72 was seen for a follow up of a pressure ulcer to each heel. The wound appearance was a blister. The note revealed the right heel with length of 3.0 cm by width of 6.5 cm and depth of a blister. Review of the note revealed the left heel was 3.5 cm in length by 4.5 cm width with a depth of a blister. The assessment revealed a pressure ulcer of the right heel Stage II and of the left heel Stage II. There was no evidence of recommendations at this time for nutritional supplement on the physician progress notes [REDACTED]. Review of the physician progress notes [REDACTED].#72 was seen for continued care of an ulcer on each heel. The note revealed the right heel with measurements of 3.3 cm in length by 6.2 cm width by depth of eschar (a thick, leathery, frequently black or brown in color, necrotic(dead) or devitalized tissue that has lost its usual physical properties & biological activity). The note revealed a left heel measurement of 3.2 cm in length by a width of 5.1 cm by a depth of eschar. The assessment revealed both the right heel and left heel were unstageable pressure ulcers. There was no evidence of recommendations at this time for nutritional supplement on the physician progress notes [REDACTED]. Review of the nursing note dated 08/24/17 at 1:18 P.M. revealed the podiatrist was in on this date and debrided Resident #72's bilateral heels. Interview on 09/29/17 at 1:38 P.M. with Family Member #15 revealed new shoes were not brought in for Resident #72 during her stay. The interview revealed Resident #72's shoes were to tight due to swelling and were not put on her for at least six months prior to the wounds on Resident #72's bilateral heels developing. Family Member #15 revealed nursing staff told her the wounds were because of Resident #72's poor nutrition and indicated she was not eating well for the staff at the nursing home. Family Member #15 revealed Resident #72 was wheelchair bound and required staff assistance to transfer and was left in bed the majority of the time. Interview on 09/29/17 at 2:41 P.M. with Registered Nurse (RN) #14 revealed Unit Manager #13 was present when the wound was found on Resident #72's foot. RN #14 indicated she did care for Resident #72 after the wound was found and confirmed the resident was not eating well and had to be coaxed into taking her medication for her UTI that was ordered on [DATE]. RN #14 indicated the resident was pretty independent when she first came in but did have a decline in her functional ability due to a decline in her cognition. Interview on 09/29/17 at 3:18 P.M. with the Director of Nursing (DON) revealed Resident #72's wound was not truly pressure when caused by shoes. The DON revealed she was not a physician and did not question the physician related to this matter. The DON confirmed there was no evidence the resident's heels were elevated prior to 07/18/17. Interview on 09/29/17 at 3:42 P.M. with LPN #10 revealed her documentation of the wound on 07/12/17 was accurate to her knowledge. LPN #10 revealed she could not remember the circumstances around finding the wound. LPN #10 revealed the only thing she remembered about the resident's shoes were they were to small at one point. LPN #10 indicated she could not remember if the resident had or did not have on shoes when the wound was found. LPN #10 stated the wound nurse informed Resident #72 not to wear the shoes when the wounds were identified. Interview on 09/29/17 at 5:07 P.M. with Registered Dietician #12 revealed she was informed of pressure injuries and if a wound was not healing. As to her knowledge the wounds for resident #72 were not pressure and were healing per the documentation she reviewed in the medical record. Registered Dietician #12 confirmed there was no notification that Resident #72's wounds were not healing nor that Resident #72 had a pressure injury. Registered Dietician #12 confirmed the nutritional supplement was not started until 09/06/17 when the wound was debrided. RD #12 indicated if Resident #72 had a pressure injury, supplements should have started immediately and if any wounds were not healing dietary should be notified to implement appropriate interventions. Review on 09/29/17 at 5:15 P.M. with Licensed Practical Nurse (LPN) #11 of photographs of Resident #72's wounds revealed the following: The photograph on 07/12/17 of both the left and right heel wounds revealed they were serous filled blisters that were intact with no evidence of purple discoloration. Both blisters were present on the back portion of the heel that would lay on a surface if the resident was laying down on her back or had her legs extended on a flat surface. The blisters were both circular with a distinct edge. LPN #11 verified this observation and indicated Unit Manager #14 was covering because LPN #11 was on vacation when the wounds were found. LPN #11 revealed Unit Manager #14 was responsible for the observation and was the staff member who photographed the wound. After review of the assessment documentation compared to the photograph the wound appeared to be accurately assessed per the documentation present in the wound assessment dated [DATE] and appeared to present as the documentation that was provided per the nurse practitioner of a Stage II pressure ulcer. The photograph of the left heel dated 07/21/17 was observed to be an absorbing blister with the upper most portion with some fluid and the bottom most portion of the wound being dark purple similar to the look of a bruise, the area was flat. This observation was confirmed by LPN #11. The photograph of the right heel dated 07/21/17 revealed a deep purple flat area on the heel. This was confirmed by LPN #11. This wound appeared to be a suspected deep tissue injury. There were no further photographs of the wound until 08/25/17 which LPN #11 indicated was because the facility system was down and staff were unable to take pictures of the wounds and upload them into their wound care system. The photograph of the left heel dated 08/25/17 revealed black eschar comprising the majority of the wound. This was confirmed by LPN #11. The photograph of the right heel dated 08/25/17 revealed some black eschar noted to the bottom most portion of the wound. This was confirmed by LPN #11. At this assessment the area appeared to be an unstageable pressure ulcer. LPN #11 confirmed there was no evidence of dietary notification of the wound documented on either of the above assessments. LPN #11 confirmed during this observation the wounds were debrided (removal of devitalized/necrotic tissue) of some of the eschar on 08/24/17. LPN #11 indicated the podiatrist indicated the wound was not pressure related and that was why the wound was not staged. LPN #11 confirmed the nurse practitioner identified the wound initially as a Stage II pressure injury and the podiatrist documentation indicated the wound was a pressure ulcer on the assessments completed prior to 09/11/17. LPN #11 revealed she was not aware the physician was documenting the areas as pressure injuries until after the resident was discharged due the facility not having any of the podiatrists notes. Review of the undated(NAME)health care center wound care management protocol revealed a pressure injury was a localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. The policy revealed a Stage two pressure injury was partial-thickness skin loss with exposed dermis. The wound bed may present as an intact or ruptured serum-filled blister. These injuries commonly result from adverse microclimate and shear in the heel. The policy revealed bruising indicates suspected deep tissue injury (DTI). The policy revealed an unstageable pressure injury was obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Stable eschar on the heel should not be softened or removed. The policy revealed a deep tissue pressure injury was a persistent non-blanchable deep red, maroon or purple discoloration. this type of pressure injury the injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury. Suspected deep tissue injury purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or eschar. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. This deficiency substantiates Complaint Number OH 505.

Based on observation, medical record review, review of visiting wound service center notes, review of facility pressure ulcer skin breakdown clinical protocol, interview with the wound care nurse practitioner, resident and staff interviews, review of manufacturer ' s medication guidelines and the National Pressure Ulcer Advisory Panel guidelines, the facility failed to complete comprehensive skin assessments, failed to implement pressure reducing interventions and failed to initiate or consistently provide physician ordered treatments for six residents (Residents #125, #130, #132, #39, #91 and #44) of six residents reviewed for pressure ulcers. This resulted in Immediate Jeopardy for three residents, Residents #125, #130 and #132. Actual harm occurred when Resident #125 acquired three preventable unstageable (obscured full-thickness skin and tissue loss-full-thickness skin and tissue loss in which the extent of tissue damage with the ulcer cannot be confirmed because it is obscured by slough or eschar) pressure ulcers and one Stage II (partial thickness skin loss with exposed dermis: partial-thickness loss of skin with exposed dermis) pressure ulcer with increased pain without evidence of a timely assessment, lack of pressure reducing interventions and lack of physician notification to obtain treatment orders and failure to implement physician orders. Actual harm occurred for Resident #130 when the facility failed to prevent the development of an unstageable pressure ulcer to the resident ' s coccyx. Following the development of the pressure ulcer, the facility failed to provide treatment and pressure reduction interventions resulting in ulcer deterioration requiring mechanical debridement. Actual harm occurred for Resident #132 when the facility failed to provide the necessary care and services to prevent a decline in pressure ulcers to the right and left buttocks to unstageable pressure ulcers. In addition, the facility failed to provide nutritional interventions as ordered to promote pressure ulcer healing for Resident #39, failed to ensure an ordered [DEVICE] (vac) was applied at the correct setting to promote wound healing for Resident #91 and failed to provide ordered wound treatment and accurately assess an in-house acquired pressure ulcer for Resident #44. The facility identified six residents with pressure ulcers, three residents (Resident #39, #44, and #130) were identified to have developed pressure ulcers in the facility and three residents (Resident #125, #132 and #91) were admitted with pressure ulcers. The facility census was 77. On 10/19/16 at 2:45 P.M. the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 10/04/16 when Resident #130, developed an avoidable unstageable pressure ulcer to the coccyx with no evidence treatment and interventions were initiated timely. The Immediate Jeopardy continued on 10/12/16 when Resident #132 was admitted to the facility with pressure ulcers with no documented Stage or appearance to her left and right buttocks with a lack of treatment and pressure reducing interventions being implemented. The Immediate Jeopardy continued on 10/15/16 when Resident #125, was readmitted to the facility with a Stage 1 (non-blanchable redness of intact skin) pressure ulcer to the coccyx with no treatment or interventions in place resulting in the deterioration of the ulcer to unstageable and the development of additional avoidable pressure ulcers. The Immediate Jeopardy was removed on 10/21/16 when the facility implemented the following corrective actions: · On 10/19/16 at 4:00 A.M., the DON and Registered Nurse (RN) #179 initiated a new pressure ulcer risk assessment (Braden Scale) for all current in-house residents. All risk assessments were reviewed and validated as complete by the DON on 10/20/16 by 7:00 A.M. · On 10/19/16 at 5:23 P.M., Resident #130 was discharged to the hospital for an acute change in condition status [REDACTED].M., Resident #125 was discharged to the hospital for an acute change in condition related to infection status [REDACTED]. · On 10/20/16 at 6:00 A.M., the DON, RN #179, Licensed Practical Nurse (LPN) #187, RN #11, LPN #106, LPN #103, LPN #167, LPN #111 initiated head-to-toe skin assessments (skin sweeps) on all current in house residents. The skin sweeps were completed 10/21/16 at 12:30 PM. One Resident (Resident #50) was identified with a Stage 2 pressure ulcer to the buttocks on 10/20/16 at 3:47 P.M. The physician was immediately notified and new treatment and nutritional orders were implemented. · On 10/20/16, the DON, Corporate Minimum Data Set (MDS) Coordinator #115, RN #11 and Activities Director #130 provided in-service education to 43 facility State tested Nursing Assistants (STNAs) on pressure ulcer management, with emphasis on locating resident care information on the Kardex, turning and repositioning, and documentation. Forty three of 45 STNAs received in-service education in person or by phone by 10/21/16 at 11:00 A.M. Two remaining as needed (PRN) STNAs, (STNA #201 and STNA #184) and 1 full-time STNA, (STNA #128) were notified of the requirement to attend the mandatory in-service and will not be scheduled to work until completed. · Effective 10/20/16 at 6:45 P.M, the DON will complete audits for all new admissions to assure skin assessments are accurate and complete, and treatment orders are obtained for pressure ulcers as indicated. Audits will continue through the correction period daily for seven days then weekly for four weeks. · On 10/20/16 from 1:00 P.M. to 8:00 P.M., Wound Consultant (WC) #401 evaluated all residents with pressure ulcers, including Resident #132, #44, #91, and #39 to assure appropriate treatment orders were effective, (Residents #130 and #125 remained in the hospital). The DON shared the State Agency pressure ulcer findings with WC #401 for collaboration and continuity with the contracted wound care entity. WC #401 will serve as the facility wound consultant effective 10/20/16. · On 10/20/16 from 8:00 A.M. to 10/21/16 at 11:00 A.M., Corporate MDS #115 audited all residents ' records at risk for pressure ulcers (based on Braden Scale score of 18 or less) to assure all recommended interventions were accurately recorded in the electronic health record. · From 10/20/16 at 8:00 A.M. to 10/21/16 at 11:00 A.M., Corporate MDS #116, RN #402 and RN #403 audited all residents' records at risk for pressure ulcers (based on Braden of 18 or less) to assure pressure ulcer plans of care were in place. · On 10/20/16 by 5:00 P.M., Registered Dietitian (RD) #102 reviewed all residents with pressure ulcers to ensure nutritional support was planned and provided to promote wound healing. RD #102 also validated all nutritional orders were accurately recorded in the electronic health record. RD #102 evaluated one additional resident (Resident #50) on 10/21/16 at 9:00 A.M. as a result of skin sweep audit findings. · On 10/20/16 at 7:00 P.M., an ad hoc quality assurance and performance improvement (QAPI) committee meeting was held to review the recommended Immediate Jeopardy (IJ) findings and develop and evaluate the internal IJ removal action plan. Attendees included Medical Director #110, Administrator, DON, Corporate MDS Coordinator #115, Corporate MDS #116, Owner #404 and Compliance Consultant (CC) #405. · On 10/20/16 at 8:00 A.M, the DON, Corporate MDS #115, Corporate MDS Nurse #116, RN #11, Social Worker (SS) #165 and/or designees provided in-service education to all facility nurses on pressure ulcer management, with emphasis on admission skin assessments and documentation; immediate communication with the physician about wounds and treatment orders; administration of treatments and accurate documentation; and awareness of nurse aide duties and responsibilities (e.g., POC, Kardex, turning and repositioning). Twenty-six of 27 nurses received in-service education in person or by phone by 10/21/16 at 11:00 A.M. One remaining PRN nurse, (LPN #110) was notified of the requirement to attend the mandatory in-service and will not be scheduled to work until completed. · On 10/20/16 at 7:00 P.M., the wound nurse's, (LPN #100) employment was terminated by the Administrator. On 10/20/16 at 7:00 P.M., a new wound nurse, LPN #406 was reassigned from a sister facility to assume wound care responsibilities in the facility, effective 10/21/16. ·On 10/21/16 Corporate nurses RN #403, RN #407 and RN #408 conducted interview audits between 7:30 A.M. and 8:30 A.M. with return demonstration from all staff working on 10/21/16, (STNA #178, STNA #196, STNA #200, STNA #175, STNA #204, STNA #192, STNA #169, STNA #176, STNA #209 and STNA #132), to evaluate the effectiveness of the education. · On 10/21/16 at 1:00 P.M. the interdisciplinary team (IDT) met to review all current pressure ulcer cases. The IDT will conduct daily Wound Risk meetings for seven days and then weekly thereafter until otherwise directed by the QAPI committee. Although the Immediate Jeopardy was removed on 10/21/16, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as all staff had not been in-serviced on skin and wound management and the facility was in the process of implementing weekly audits to monitor for on-going compliance. Findings include: 1. Review of Resident #130's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #130 was at risk for developing pressure ulcers. Review of Resident #130's admission assessment dated [DATE] revealed Resident #130 had constant pain (throbbing and burning) to the right lower extremity. Elevation, movement, and pressure made the pain worse. There was no evidence the resident had any pressure ulcers present on admission. A wound evaluation flow sheet, dated 10/04/16 revealed Resident #130 had developed an in house acquired unstageable distal coccyx (middle) pressure ulcer measuring 2.4 centimeters (cm) in length by 0.5 cm width with 0.1 cm depth. The ulcer was assessed to have thin clear scant drainage (exudate) with slough tissue present in the wound bed. The resident was assessed to have pain to the area. The wound margins were distinct and surrounding tissue was red and blanchable. Treatment orders were received for silver alginate with foam dressing. Orders were also received for an air mattress to the bed, cushion to the chair, and a turn schedule every two hours. A corresponding nursing note, dated 10/05/16 documented the unstageable pressure ulcer to the distal coccyx as a Stage II pressure ulcer. Review of Resident #130 ' s electronic weekly wound observation tool revealed the wound found on 10/04/16 was first documented in the resident ' s electronic medical record on 10/10/16. The resident ' s coccyx wound was assessed on 10/10/16 to be unstageable with 100% slough tissue present. The current plan of treatment was for a sliver alginate with foam dressing and wound nurse consult. The measurements were noted to be the same as the measurements completed on 10/04/16 when it was classified as a Stage II pressure ulcer. Review of the MDS assessment dated [DATE] revealed Resident #130 ' s cognition was intact. He was at risk for developing pressure ulcers, had a pressure reducing device for the chair and bed, was on a turning and repositioning program, pressure and surgical ulcer care, and had surgical wounds. Resident #130 was identified to require extensive assistance from one staff for bed mobility, transfers, toilet use, and personal hygiene. There was no evidence of rejection of care. The MDS assessment revealed Resident #130 had one unstageable pressure ulcer measuring 2.4 cm by 0.5 cm by 0.1 cm with slough. Record review revealed the facility implemented a new computerized charting system in October, 2016. The electronic medical record orders from 10/01/16 to 10/10/16 revealed on 10/05/16 orders were initiated for an air mattress to Resident #130 ' s bed, pressure redistribution cushion to the wheelchair and dressing to the distal coccyx wound. The treatment orders included to cleanse the wound with normal saline and gauze, apply Calcium Alginate Ag to the wound bed, cover with foam dressing and secure with hypofix tape on Monday, Wednesday, and Friday. On 10/10/16 new orders for a wound consult for the coccyx wound and to cleanse wound with normal saline and gauze, apply Mesalt to wound bed, cover with foam, secure with Hypofix tape daily. On 10/14/16 new orders were received to discontinue the resident ' s indwelling Foley catheter. The electronic treatment administration records (TAR) from 10/01/16 to 10/10/16 revealed on 10/01/16 encourage resident to turn and reposition as tolerated /needed. The air mattress to bed and pressure redistribution cushion to wheel chair was initiated on 10/05/16. On 10/05/16 treatment orders indicated cleanse distal wounds to coccyx, cleanse wound with normal saline and gauze, apply Calcium Alginate AG (antimicrobial highly absorbent wound dressing) to wound bed, cover with foam dressing, secure with hypofix tape until healed. Change on Monday, Wednesday, and Friday. The order was discontinued on 10/10/16. On 10/10/16 new orders were received to cleanse distal coccyx wound daily with normal saline and gauze, apply Mesalt to the wound bed, (supports the cleansing of moderately to heavily discharging wounds), cover with foam, and secure with hypofix. Review of a dietary note dated 10/10/16 revealed Resident #130 had a Stage II pressure ulcer to the coccyx. The resident ' s pre-[MEDICATION NAME] and complete blood count values were low requiring high protein supplement. Interventions included the nutritional supplement, Boost three times daily and adequate oral intake to prevent significant weight changes and aide in the prevention of skin breakdown and promote healing. A wound evaluation flow sheet, dated 10/10/16 revealed the unstageable distal coccyx pressure ulcer measured 2.2 cm in length by 0.7 cm width with 0.1 cm depth. The ulcer was assessed to have scant clear thin exudate. The wound bed was 25% [MEDICATION NAME] tissue and 75% slough tissue with wound margins distinct and surrounding areas red and blanched. The treatment was changed to Mesalt with foam. No other new interventions were noted. Review of the electronic weekly wound observation tool revealed the weekly skin assessment for 10/10/16 was entered into the system on 10/17/16. The coccyx wound was described as 75% slough, unstageable, and indicated the current plan was for a Mesalt with foam dressing daily. The measurements of the wound remained the same as the hard copy assessment of the same date. Review of the electronic orders for 10/11/16 through 10/17/16 revealed orders to encourage the resident to change position frequently, encourage the resident to turn and reposition every two hours and as needed, pressure redistribution mattress and cushion in wheelchair, and Chamosyn ointment to the perineum topically every shift for skin prevention. There was no evidence of orders for treatment to the distal coccyx pressure ulcer or Boost supplement three times daily on the electronic record for that time period. Review of the 10/11/16 through 10/17/17 TAR revealed the same orders with no evidence the treatment to the coccyx was provided as ordered during this time period. Review of the wound management services notes, completed by Consultant Nurse Practitioner (NP) #101 dated 10/10/16 revealed Resident #130 was noted to have a coccyx wound on 10/06/16. He was noted to have a Foley catheter and muscle weakness to the right lower extremity. NP #101 reported the unstageable pressure ulcer was present on admission, measuring 2.20 cm by 0.7 cm by 0.1 on the middle coccyx-distal. There was moderate serous (thin, watery, clear) exudate with no granulation tissue present and loosely adherent yellow slough. The wound was mechanically debrided at that time. Treatment orders included Mesalt with foam daily, reposition every two hours, redistribution gel/foam, limit up in chair for two hours at a time, and alternating pressure mattress. Review of the wound management service notes, completed by NP #101, dated 10/17/16 revealed Resident #130 had complaints of burning when the Mesalt dressing was applied and for up to several hours thereafter. Review of Resident #130 ' s nursing progress notes, dated 10/10/16 to 10/17/16 revealed no evidence the physician or NP #101 were notified of Resident #130 ' s complaints of burning when the Mesalt was applied and for up to several hours thereafter. The wound was reportedly to have deteriorated in the past week. The coccyx wound had thick adherent slough tissue present which had deteriorated slightly, but the slough had loosened. The plan was for the treatment to be changed due to the resident ' s complaints of pain upon application and the wound deterioration. The coccyx pressure ulcer measured 2.5 cm in length by 0.5 cm width with 0.1 cm depth. The area was noted to have mild pain, large amount of serous exudate, no granulation tissue present and 75-100% of loosely adherent yellow slough. The area was mechanically debrided. Review of NP #101 ' s written telephone order, dated 10/17/16 revealed to discontinue the current treatment to the coccyx. New orders to pack sliver alginate into the coccyx wound, cover with foam and secure with hypofix change daily and as needed. Review of the Activity of Daily Living (ADL) turn and repositioning tracking record, dated 10/05/16 to 10/18/16 revealed inconsistent documentation to support the resident was being turned and repositioned every two hours. Staff routinely entered the same time for the entire shift to note the turning. There was no evidence the resident refused to turn and reposition. Review of Resident #130 ' s plan of care revealed no plan had been developed related to the development of the pressure ulcer or risk for skin breakdown. There was no plan in place that indicated the resident was non-compliant with care. Review of Resident #130 ' s nutrition ADL records dated 10/01/16 to 10/19/16 revealed Resident #130 did not receive and/or was not offered the Boost supplement, three times daily on 10/02/16, 10/03/16, 10/04/16, 10/05/16, 10/06/16, 10/07/16, 10/10/16, 10/11/16, 10/12/16, 10/13/16, 10/15/16 and 10/17/16. On 10/19/16 at 8:17 A.M., interview with LPN #100 and observation of Resident #130 ' s wound revealed the LPN had sent a text message to NP #101 to verify wound treatment orders as there was a discrepancy in the orders on the wound notes regarding the frequency of the dressing change. Resident #130 ' s coccyx pressure ulcer was observed covered with 100% slough tissue and was approximately 2.5 cm in length by 1.0 cm width. Due to the presence of the slough tissue, a depth could not be determined. There was scant amount of serous drainage on the old dressing dated 10/18/16. The resident had an air mattress and a gel cushion in the wheelchair. LPN #100 reported she was unware of NP #101 ' s recommendation to not have Resident #130 sit up for more than two hours at a time and confirmed it was noted in NP #101 ' s progress notes dated 10/10/16. On 10/19/16 at 8:35 A.M., interview with STNA #125 reported Resident #130 ' s pressure interventions were an air mattress, cushion in a chair, turn schedule, and elevate legs. STNA #125 reported she did not have access to the care plans to confirm Resident #130 ' s interventions. On 10/19/16 at 10:15 A.M. interview with the DON and LPN #100 revealed Resident #130 was not on the list provided by the facility of all residents with pressure ulcers. The DON and LPN #100 verified at the time the resident was admitted , on 10/01/16, his skin was intact. The resident was found to have an unstageable pressure ulcer to the coccyx on 10/04/16. The physician was not notified until 10/05/16. The DON verified the nursing progress note, dated 10/05/16 inaccurately reflected the ulcer was a Stage II when in fact it was unstageable. The DON also verified issues with the transfer of orders and administration of care between different electronic charting systems. The DON verified the wound orders were not transferred over to the new system and the resident did not receive daily treatments of Mesalt from 10/11/16 to 10/16/16. This resulted in the need for a mechanical debridement on 10/17/16 due to deterioration of the wound. The DON verified there was no care plan for pressure ulcers or limiting chair time to two hours, per NP #101 ' s orders. Review of Resident #130 ' s wound and wound care also identified the facility wound nurse was not assessing the resident ' s wounds but rather using NP #101 ' s weekly assessments to complete facility skin grids. The DON reported she was unware the wound nurse was not performing her own assessments of the wound. LPN #100 revealed she was not documenting depth on the unstageable pressure ulcer because she was using NP #101 ' s measurements. The DON revealed the STNAs had not been trained on the new electronic system and would not know where to access care plans for residents. The DON and LPN #100 revealed NP #101 was in the facility on Monday, and any wounds requiring assessment and staging, would not be completed until the Monday the NP was in the facility. If a resident had a pressure ulcer they had to wait until Monday for the NP to stage and write orders for treatment. LPN #100 reported she had a verbal standing order from the NP that she could use Chamosyn, a skin protectant on any stage pressure ulcer until the NP could see the resident. The DON also confirmed Resident #130 did not receive nutritional supplements per orders as noted above. On 10/20/15 at 3:56 P.M., interview with the DON revealed Chamosyn was incorrectly entered in the electronic record as being ordered on [DATE] and started on 10/04/16. However, the order was not initiated on the TAR until 10/13/16. On 10/21/16 at 11:32 A.M., interview with RD #102 revealed Boost supplement three times a day was a nursing order and not a physician order [REDACTED].`Boost was not offered or given three times a day per nursing orders. RD #102 confirmed she wrote a telephone order on 10/12/16 for a protein supplement, [MEDICATION NAME]. However, as of 10/21/16 the supplement had not been initiated. RD #102 verified Resident #130 was not receiving adequate protein to aid in the wound healing process which could be a factor in the decline of the wound. 2. Review of Resident #132 ' s medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #130 was at high risk for developing pressure ulcers based on a skin risk assessment, Braden scale, dated 10/14/16. Review of Resident #132 ' s admission assessment, dated 10/12/16 revealed the resident was in full capacity to make decisions. The assessment revealed the resident required extensive assistance from two plus staff with bed mobility, transfers, dressing, eating, toileting and personal hygiene. Resident #132 ' s skin was assessed as normal in color, warm, dry and with normal skin turgor. There was no evidence of pressure areas noted per the assessment. Under the general appearance of feet section, documentation revealed wounds were present and measured by the treatment nurse. Resident #132 was alert and oriented to person, place, time, situation, and verbally appropriate. Review of Resident #132 ' s hard chart and electronic medical record dated 10/12/16 to 10/17/16 revealed no evidence Resident #132 had a pressure ulcer, with the exception of a skilled nursing note, dated 10/15/16 which indicated yes for pressure but did not indicate where or include any wound measurements. Review of a nurse ' s note dated 10/12/16 revealed the resident was admitted from the hospital and the treatment nurse assessed the resident ' s skin. New orders were received for low air loss mattress and wound consult. On 10/17/16 at 3:45 P.M. LPN #100 was asked if there was any documentation related to any type of skin breakdown identified for the resident. LPN #100 provided a scrap piece of paper, not part of the resident ' s medical record, dated 10/13/16 with the following information: lt 3 x 1 x 0.1 Rt 3 x 1.5 .0.1. inner thighs red-intact . Review of a wound management service note, completed by NP #101, dated 10/17/16 revealed Resident #132 had one unstageable ulcer to the right buttock and one unstageable pressure ulcer to the left buttock. The right buttock measured 2.0 cm in length by 1.5 cm width with 0.1 cm depth noted. The ulcer was assessed to have 25% granulation, 25-50% epithelization, and 25-50% necrotic tissue. The left buttock measured 1.0 cm in length by 1.0 cm width with 0.1 cm depth with 25-50% [MEDICATION NAME] and 50-75% necrotic tissue present. Interventions included to reposition every two hours, alternating air mattress, check for incontinence and change every one hour, house moisturizer cream to all extremities, no briefs and use pull-ups. New orders were received for hydrogel with silver alginate/hydro fiber with foam three times weekly and as needed. Review of Resident #132 ' s TAR dated 10/12/16 to 10/18/16 revealed no evidence of any treatment to the left buttock or evidence the resident was checked for incontinence or changed every hour. On 10/14/16 Chamosyn ointment (barrier cream) was initiated and applied to the bilateral buttocks topically every shift for [MEDICAL CONDITION]/pressure injury. The low air loss mattress, ordered on [DATE] was not initiated until 10/13/16. On 10/14/16 the protein supplement, [MEDICATION NAME] was added two times a day for vitamin deficiency. On 10/18/16 a new treatment for [REDACTED]. Review of Resident #132 ' s skilled charting note, dated 10/14/16 revealed the resident was alert and oriented to person place, time, and situation. Further review revealed Resident #130 did not have any pressure ulcers or other skin issues. Resident #132 required extensive assistance of two staff for bed mobility, transfers, and total dependence for toileting. Review of Resident #132 ' s skilled charting note, dated 10/15/16 revealed Resident #132 did have a pressure ulcer and moisture associated skin [MEDICAL CONDITION] (MASD). The skilled charting note, dated 10/16/16 revealed Resident #132 did not have any pressure ulcers but did have MASD. Review of a list of residents with pressure ulcers the facility identified on 10/17/16 revealed no evidence Resident #132 had a pressure ulcer. Review of Resident #132 ' s telephone orders from NP #101 dated 10/17/16 revealed no briefs were to be used due to a possible allergy and to use pull ups. Additional orders to cleanse right buttocks wound with normal saline and gauze, apply small amount of hydrogel to silver alginate foam and secure with hypofix three times weekly. Apply A&D ointment to left buttocks wound area twice daily. Review of Resident #132 ' s turn and repositioning ADL flow sheet dated 10/12/16 to 10/18/16 revealed Resident #132 was not turned every two hours from 10/13/16 to 10/18/16. Review of Resident #132 ' s plan of care revealed a plan in place regarding impaired skin integrity of bilateral buttocks due to dehydration, decrease in mobility, an alteration in independence in ADL ' s weakness, and pain. Interventions included one to two staff assist to turn and reposition every two hours and as needed, keep skin clean and dry, use lotion on dry skin, and don ' t apply lotion on [MEDICAL CONDITION] to bilateral buttocks. Monitor/document location, size, and treatment of [REDACTED]. Use pressure reducing cushion to protect the skin while up in chair and low air mattress in bed. Weekly treatment documentation was to include measurements of each area of skin breakdown with width, length, depth, type of tissue and exudate and any other notable changes or observation documented. On 10/18/16 at 2:50 P.M., interview with Resident #132 revealed staff do not turn her every two hours. The resident also indicated staff had not applied a dressing to her buttocks from 10/12/16 until 10/17/16. Resident #132 reported she had come to the facility with a dressing on her buttocks however the facility removed it when they showered her and never replaced it until 10/17/16. On 10/17/16 at 3:45 P.M., interview with LPN #100 revealed she had not documented Resident #130 ' s pressure ulcers on the wound evaluation flow sheets or in the paper or electronic medical record. LPN #100 verified the scrap piece of paper she provided was the only documentation she had. LPN #100 revealed the resident currently had two unstageable pressure ulcers, one on the left and one on the right buttocks. LPN #100 revealed she usually uses Chamosyn, a skin protectant on all wounds until the nurse practitioner could evaluate them. On 10/19/16 at 7:35 A.M. interview with LPN #100 revealed she was going to apply a hydrogel and foam dressing to both areas on Resident #132 ' s buttock. When asked for clarification of the treatment order, LPN #100 reviewed the wound management service progress notes, completed by NP #101 and then the telephone orders in Resident #132 chart. LPN #100 confirmed there was a discrepancy in the orders and wound progress notes for the pressure ulcer on the left buttocks. LPN #100 texted NP #101 and NP #101 confirmed the written telephone orders were incorrect and not to apply A&D ointment to the pressure ulcer on the left buttocks. LPN #100 stated she usually goes by the wound notes and doesn ' t look at the orders. On 10/19/16 at 7:50 A.M., interview with Physician #409 revealed he was unware Resident #132 had unstageable pressure ulcers. Physician #409 reported he was unaware pressure ulcer treatments were not being initiated until NP #101 saw residents or in this case, he would have previously initiated treatment. Physician #409 confirmed A&D ointment was not an appropriate treatment for [REDACTED]. On 10/19/16 at 8:05 A.M. observation of Resident #132 ' s pressure ulcers revealed one unstageable ulcer on the left buttock and one on the right buttock. Both areas had a dry crust covering the wound bed and the areas sounding the wounds were dark purple and blanchable. There was no dressing on either area present at the time of the observation. LPN #100 reported the dressings had fallen off earlier. Resident #132 had complaints the area was itchy during the observation. On 10/19/16 at 10:41A.M. interview with the DON and LPN #100 confirmed Resident #132 was admitted to the facility on [DATE] and there was no evidence Resident #132 had any pressure ulcers present at that time, per the hard chart or electronic medical record documentation. The DON confirmed Resident #132 ' s care plans were not up to date and the STNA turning documentation did not indicate the staff were turning the resident every two hours. LPN #100 confirmed there was no treatment initiated for the pressure ulcers until 10/17/16 when NP #101 saw the resident. LPN #100 reported she had a verbal standing order from NP #101 to use Chamosyn on all wounds until she was able to see them. LPN #100 confirmed the Chamosyn tube indicated to use on peri-wound skin and was for external use only. LPN #100 confirmed NP #101 ' s telephone orders written on 10/17/16 were inaccurate and the new orders for the left buttocks were not transcribed onto the TAR. LPN #100 confirmed she reported to the survey team previously that Resident #132 did not have any pressure areas prese

Based on observation, policy review, medical record review, and staff interview, the facility failed to provide ordered dietary supplements to an underweight resident with poor intakes. This affected one resident (Resident #44) of five residents reviewed for nutrition. Harm occurred to Resident #44 on 09/05/16 after staff failed to implement physician orders [REDACTED]. Findings include: Review of Resident #44's medical record revealed the resident was admitted to the to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan initiated 06/27/16 indicated Resident #44 was under-weight related to recent hospitalization and acute illness. Goals included for Resident #44's weight to return to an ideal body weight between 95 and 105 pounds and to consume 50% of two of three meals per day. Interventions included monitoring and recording food intake at each meal, monitoring and evaluating any weight loss and determining the percentage lost, following facility protocol for weight loss, contacting the physician and dietician immediately if weight decline persisted, giving supplements as ordered and alerting the nurse and dietitian if Resident #44 was not consuming the supplement on a routine basis. A care plan dated 06/27/16 indicated Resident #44 had a potential for pressure injury development related to activity intolerance, impaired mobility, muscle weakness, muscle wasting and atrophy, underweight status, pain, incontinence, and age-related cognitive decline. Interventions included monitoring nutritional status, serving the diet as ordered, and monitoring and recording intake. Resident #44's weight was recorded as 91 pounds on 07/01/16. On 07/11/16, Resident #44's weight was recorded as 81.8 pounds. On 07/12/16 at 2:28 P.M., a dietary note indicated Registered Dietician (RD) #102 met with Resident #44's daughter in law at an interdisciplinary meeting. Resident #44's daughter in law expressed concern that Resident #44 had poor intake which started prior to admission. RD #102 indicated intakes were recorded at 25-50% of meals with eight meals refused in the prior seven days. A list of likes and dislikes were obtained. The dietitian documented bedtime snacks would be started and snacks would be sent so Resident #44 could graze on during the night as she was up at night. Half portions would be provided at all meals. The note indicated Resident #44 did not like health shakes and they would be discontinued and cranberry juice with two scoops of protein powder would be provided twice a day to provide 240 kilocalories (kcal) and 24 grams of protein. RD #102 documented Resident #44's family was to discuss feeding tube placement wishes. RD #102 documented a weight loss of 10% in 14 days which was significant, unplanned, and undesired. On 07/14/16 at 12:15 P.M., RD #102 documented the family decided no feeding tube was to be placed if and when Resident #44 refused most or all meals. A dietary note dated 07/26/16 at 5:05 P.M. indicated Resident #44's intake was recorded at 25% or less of meals with six meals refused in the past seven days with 50-100% of supplements being consumed. RD #102 documented a weekly weight of 79.6 pounds which reflected a weight loss of 11% in 30 days. Weight loss was significant, unplanned, and undesired. The note indicated a history of failure to thrive as evidenced by poor intake and significant weight loss. RD #102 indicated supplements were needed. A nursing note dated 08/10/16 at 9:00 A.M. indicated Resident #44 was admitted to the hospital with [REDACTED].#44 was readmitted to the facility 08/12/16. The Admission /Readmission assessment dated [DATE] indicated Resident #44 's skin was fragile, dry, and intact. The re-admission assessment indicated Resident #44 was dependent on staff for eating and reluctant to eat. Resident #44 was assessed with [REDACTED]. Resident #44's weight was recorded as 87.2 pounds on 08/12/16 and 91.8 pounds on 08/15/16. On 08/15/16 an order was written to start cranberry juice with two scoops of protein powder twice a day. However, this order was not transcribed to the Medication Administration Record [REDACTED] Review of a Wound-Weekly Observation Tool dated 08/16/16 indicated Resident #44 had a Stage II pressure ulcer (shallow) to the coccyx which measured 1.5 centimeters (cm) in length by 1.5 cm width with 0.1 cm depth. Nutritional interventions were listed as protein powder. On 08/19/16, RD #102 documented Resident #44 had a significant weight gain which was planned and desired. RD #102 documented the plan of care including cranberry juice with two scoops of protein powder twice a day provided by nursing would continue. The supplement provided an additional 240 kilocalories and 24 grams of protein daily. Intakes were recorded at 26-50% in the prior seven days. Review of a pressure ulcer assessment on the wound evaluation flow sheet dated 08/25/16 indicated the Stage II pressure ulcer to the coccyx measured 2.5 cm in length by 2.5 cm width with 0.1 cm depth with a scant amount of thin serous drainage with 25% [MEDICATION NAME] and 75% granulation tissue. Wound margins were distinct and surrounding tissue was red and blanched. The pressure ulcer was assessed as deteriorating. A dietary note dated 08/26/16 at 12:40 P.M. indicated Resident #44's appetite was poor and she had a Stage II pressure ulcer. RD #102 documented Resident #44's ideal body weight was 100 pounds and her body mass index was 18.5. The note indicated staff would encourage fluids and intake to prevent significant weight change, aide in the prevention of skin breakdown, and promote healing. Review of a Wound-Weekly Observation Tool dated 08/31/16 indicated the coccyx pressure ulcer was improving. Review of a second Wound-Weekly Observation Tool dated 08/31/16 revealed the development of a new Stage II pressure ulcer to the distal coccyx. The ulcer measured 0.5 cm in length by 0.5 cm width with 0.1 cm depth. The pressure ulcer was assessed with [REDACTED]. On 09/05/16, Resident #44's weight was recorded as 82.5 pounds. A dietary note, dated 09/09/16 at 3:35 P.M. indicated Resident #44 had a significant weight loss which was expected because Resident #44 had [MEDICAL CONDITION] on admission with a significant weight gain. RD #102 documented cranberry juice with two scoops of protein powder provided by nursing twice a day provided an additional 240 kcal and 24 grams of protein each day. RD #102 documented Resident #44 had a BMI of 16.6 which was indicative of underweight status. The note indicated supplements were needed. Wound evaluation flow sheets dated 09/07/16, 09/15/16, 09/19/16 and 09/19/16 revealed the resident continued to have a Stage II pressure ulcer to the coccyx. The ulcer either improved or stayed the same with each assessment. A dietary note dated 09/26/16 at 3:00 P.M. indicated Resident #44 was treated and followed by the wound nurse for Stage II pressure ulcers to the coccyx and distal coccyx that were improving. The note indicated Resident #44's supplements provided an additional 240 kcal and 24 grams of protein. The note indicated Resident #44 had a history of [REDACTED]. There was no documentation on the August 2016 or September 2016 Medication Administration Record [REDACTED]. A wound evaluation flow sheet dated 10/06/16 indicated the Stage II pressure ulcer on the coccyx showed signs of improvement. A wound evaluation flow sheet dated 10/11/16 indicated the Stage II pressure ulcer on the coccyx was assessed to have deteriorated. The October 2016 MAR indicated [REDACTED]. Review of a dietary note dated 10/13/16 at 2:29 P.M. indicated Resident #44 had a significant unplanned weight loss which was undesired and had a body mass index (BMI) of 15.2 (very severely underweight). RD #102 indicated Resident #44's juice with protein powder would be discontinued and a trial of cranberry juice with 30 cubic centimeters (cc) of Prostat/pro-source plus would be initiated to provide an additional 320 kilocalories and 30 grams of protein daily. RD #102 documented weekly weight assessments would be initiated. On 10/14/16, an order was written for Pro-stat 30 cc's mixed with cranberry juice twice a day. On 10/19/2016 at 7:31 A.M., the Director of Nursing (DON) verified Resident #44's skin was intact upon re-admission on 08/12/16. On 10/19/2016 at 9:20 A.M., the DON stated she was not aware of Resident #44 having a history of pressure ulcers prior to 08/12/16 but that she had fragile skin. On 10/19/2016 at 9:38 A.M., the DON verified the 08/15/16 order for cranberry juice with two scoops of protein powder twice a day was not placed on the Medication Administration Record [REDACTED]. The DON verified RD #102 was documenting her assessments based on the order for the cranberry juice with two scoops of protein and nobody was checking the intake of the supplement as nobody had identified the order had not been transcribed. Licensed Practical Nurse (LPN) #100, who was present, stated she believed she documented slough on Resident #44's wound evaluation 09/07/16 in error as the ulcer had never progressed beyond Stage II. LPN #100 indicated she was not aware Resident #44 was not receiving her ordered supplements. On 10/19/2016 at 1:12 P.M., RD #102 was interviewed and stated she visited the facility a minimum of three days per week. Resident #44 was originally started on cranberry juice with protein powder due to her under-weight status. RD #102 verified she had not been checking records for intake of the cranberry juice with protein powder and was unaware Resident #44 was not receiving the ordered supplement. RD #102 verified she documented and believed the protein powder would have helped maintain skin integrity and promote wound healing. RD #102 verified Resident #44 started receiving supplements on 10/12/16 and had gained 2.4 pounds since 10/01/16. On 10/21/16 at 12:40 P.M., Resident #44 was observed eating her meal. With encouragement of the family, Resident #44 ate less than 10%. Review of the facility's policy, Resource: Significant Weight Changes (dated 2010) identified weight change of 1-2% in one week, 5% in one month, 7.5% in three months, or 10% in six months as significant. Weight changes of greater than 1-2% in one week, greater than 5% in one month, greater than 7.5% in three months, or greater than 10% in six months was considered severe. Review of the facility's policy, Tracking Weight Changes, dated 2010, revealed the care team was responsible for reviewing and documenting on all significant weight changes with appropriate referrals to the physician and dietitian. The dietitian was responsible for reviewing all significant weight losses and referrals and taking action as necessary.