Every finding on record at Cortland Center

Based on observation, interview, record review, review of camera video footage and facility policy review, the facility failed to ensure Resident #41 had appropriate transmission-based precautions implemented. This affected one (Resident #41) out of three residents reviewed for infection control. The facility census was 62.Findings include:Review of Resident #41's medical record revealed an admission date of 12/25/25 with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, saddle embolus of pulmonary artery with acute cor pulmonale, urinary tract infection and extended spectrum beta lactamase (ESBL) resistance.Review of Resident #41's physician orders dated 12/25/25 revealed Contact Precautions/Isolation related to ESBL, every day shift and night shift. The orders were active from 12/25/25 through 01/29/26.Review of Resident #41's care plan dated 12/25/25 through 01/28/26 did not reveal evidence Resident #41 had a care plan related to Contact Precautions or Enhanced Barrier Precautions (EBP).Review of Resident #41's care plan dated 12/29/25 included Resident #41 had a problem with skin integrity and had a left elbow skin tear and left FA (forearm) basal cell carcinoma atypical wound. Resident #41's wounds would heal without complications. Interventions included treatment to left elbow per orders; and on 01/29/26 an intervention for EBP's every shift was initiated.Review of Resident #41's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was unable to complete the interview. Resident #41 had impairment on one side of the upper extremity and impairment on both sides of the lower extremities. Resident #41 used a wheelchair and was dependent on staff for toileting and personal hygiene, dressing, bathing and bed mobility. Resident #41 was always incontinent of bowel and bladder. Resident #41 had a PEG (percutaneous endoscopic gastrostomy) feeding tube and received 51 percent or more total calories from tube feeding. Review of Resident #41's urine culture and sensitivity lab report revealed the urine specimen was collected on 01/08/26 and reported on 01/11/26. The report included there were two different groups of GNR (gram-negative rods, the most common cause of bacterial urinary tract infections (UTI's)), and the growth was less than 10,000 CFU (colony forming units) per milliliter, no work up.Review of Resident #41's progress notes dated 01/11/26 at 6:23 P.M. revealed Resident #41's urine culture results were finalized and faxed to Infectious Disease Physician (IDP) #400 and Primary Care Physician (PCP) #401.Review of Resident #41's medical record including physician orders and progress notes dated 01/11/26 through 01/29/26 did not reveal evidence Resident #41 was changed from Contact Precautions to EBP.Review of Resident #41's physician orders dated 01/15/26 revealed enteral-continuous tube feeding: Nutren 2.0 (interchanged with Isosource 1.5 at 40 milliliters per hour for 22 hours (off during ADL care) to provide 880 milliliters in a 24-hour period. Each shift should provide 440 milliliters until 880 total volume reached.Review of Resident #41's video camera footage dated 01/26/26 at about 8:31 A.M. revealed a nurse who appeared to be Licensed Practical Nurse (LPN) #327 was standing next to Resident #41's bed and she was administering medications via Resident #41's PEG tube, and LPN #327 was not wearing an isolation gown while she administered the medications.Review of Resident #41's physician orders dated 01/29/26 at 9:15 A.M. revealed Isolation/Transmission-Based Precautions: EBP's, every shift.Observation on 01/29/26 at 11:07 A.M. of Resident #41's room revealed there was a Contact Precaution sign on her door. There was a second sign stating there was a camera located in Resident #41's room. There were two bins inside the door of the room, one red and one yellow. Resident #41's daughter was sitting in the room and Resident #41 was lying in bed with the head of her bed elevated, and her eyes were closed. When asked about the Contact Precaution sign on the door Resident #41's daughter stated the staff did not wear gowns and did not always wear gloves when they provided care for Resident #41. Resident #41's daughter said the bins were brought in the room this morning, were clean, and did not have any personal protective equipment (PPE) in them. Resident #41's daughter lifted the lids to show that there was nothing in either bin, and stated she knew they were clean and that was why she felt comfortable lifting the lid and showing what was inside of them.Interview on 01/29/26 at 11:08 A.M. of LPN #327 and Registered Nurse (RN) #371 revealed Resident #41 had a feeding tube and that was why she was on transmission-based precautions. LPN #327 stated Resident #41 was on EBP, and when asked why there was a Contact Precaution sign on the door, RN #371 stated Resident #41 was on Contact Precautions at the hospital and when she was admitted to the facility but she was now on EBP. LPN #327 stated Resident #41 was on EBP and the staff, including herself, wore appropriate PPE when caring for Resident #41. RN #371 reviewed Resident #41's physician orders and stated RN/Wound Care Nurse/MDS Nurse (RN/WCN/MDS) #373 placed Resident #41 on EBP today.Interview on 01/29/26 at 11:14 A.M. of RN/WCN/MDS #373 revealed Resident #41 was on EBP, she wrote the order today (01/29/26), and she did not put a Contact Precaution sign on Resident #41's door today (01/29/26). RN/WCN/MDS #373 stated she was double-checking residents' orders for residents receiving wound care, and Resident #41 was not changed from Contact to EBP precautions. RN/WCN/MDS #373 stated Resident #41 had a feeding tube and chronic basal cell carcinoma on her arm and that was why she was placed on EBP. Resident #41 was on Contact Precautions for ESBL in her urine when she was admitted to the facility, but her urine was rechecked on 01/11/26, it was negative for ESBL and both IDP #400 and PCP #401 were notified.Interview on 01/29/26 at 11:23 A.M. of the Director of Nursing (DON) revealed she was filling in for the Infection Preventionist because the Infection Preventionist was newly hired, had just finished her Infection Prevention training, and had not taken over the role of Infection Prevention yet. The DON stated she was also newly hired and was still learning Infection Prevention. Interview on 01/29/26 at 11:47 A.M. of LPN #327 revealed Resident #41 was on Contact Precautions when she was admitted to the facility and stayed on the Contact Precautions until her antibiotic for the ESBL in her urine was completed around the end of December, then she was changed to EBP. LPN #327 confirmed when she reviewed Resident #41's physician orders there were no orders to discontinue Contact Precautions and place Resident #41 on EBP. LPN #327 confirmed on 01/29/26 orders were written to place Resident #41 on EBP.Observation on 01/29/26 at 11:56 A.M. revealed Resident #41 was lying in bed with her eyes closed and the head of her bed was raised about thirty degrees. Resident #41's daughter was sitting in a chair by the end of the bed. When asked if staff wore gowns and gloves when caring for Resident #41, Resident #41's daughter stated yesterday was the first day the nurses and aides used gowns when providing Resident #41's care. When asked if she had video camera footage showing the nurses and aides did not wear gowns and gloves Resident #41's daughter provided camera footage showing a nurse did not wear an isolation gown when providing care.Interview on 01/29/26 at 12:29 P.M. of Maintenance and Housekeeping Supervisor (MHS) #336 revealed today (01/29/26) he was told Resident #41's room needed PPE bins and he brought a red bin and a yellow bin. MHS #336 stated Resident #41's room had bins when she was admitted , but he had not brought any bins for at least one week and it might be two weeks. MHS #336 stated he always provided the red and yellow bins to resident rooms who were on precautions. MHS #336 stated the reason he was not told Resident #41 needed the red and yellow bins in her room might be because the housekeeping staff thought she was no longer on transmission-based precautions. The housekeeping staff rely on the nurses to tell them a resident is on transmission-based precautions.Interview on 01/29/26 at 3:00 P.M of the DON confirmed there was no evidence in Resident #41's care plan dated 12/25/25 through 01/28/26 that she had a care plan initiated for Contact Precautions or EBP. The DON stated an intervention for EBP was initiated on 01/29/26. The DON stated she told RN/WCN/MDS #373 to make sure care plans were updated for transmission-based precautions today (01/29/26). Review of the facility policy titled Enhanced Barrier Precaution Policy, revised 05/19/25, included EBP were intended to prevent the transmission of multi-drug-resistant organisms (MDRO) via contaminated hands and clothing of healthcare workers to high-risk residents during high contact activities. EBP were indicated for high contact care activities for high-risk residents and for all those colonized or infected with a MDRO currently targeted by the CDC. Other MDRO's may be included at the discretion of the facility Infection Control Committee unless required by state guidance. High-risk residents include those with chronic wounds and indwelling devices such as central lines, urinary catheters and trachs and for all those colonized or infected with an MDRO currently targeted by the CDC. High contact care activities that may result in transfer of MDRO's to hands and clothing of healthcare personnel, even when blood and body fluid exposure was not anticipated. These included dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care or use, and wound care. Staff engaging in high-contact activities would don both gloves and gown before initiating the activity and remove PPE before exiting the room or area where the activity occurred. Signage indicating the appropriate type of precautions and indicating that visitors should stop at the Nurse's Station before entering would be placed on the resident's door. Staff would educate visitors regarding donning appropriate Personal Protective Equipment while adhering to the resident's right for privacy protection. This deficiency represents noncompliance investigated under Master Complaint Number 2728869.

Based on record review, staff interview and facility policy review, the facility failed to ensure accurate weights were obtained for Resident #31 and Resident #46. This affected two (Residents #31 and #46) of six residents reviewed for nutrition. The facility census was 62. Findings include: 1. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including iron deficiency anemia, intellectual disabilities, gastro-esophageal reflux, deficiency of B vitamins, hyperlipidemia, [NAME] crisis, depression, dysphagia, and intestinal malabsorption. Review of Resident #31's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #31's cognition was intact and was independent for eating. Resident #31 was 58 inches tall and weighed 115 pounds and had a weight loss of five percent in the last month that was not physician prescribed. Resident #31 was on a mechanically altered therapeutic diet. Review of the Dietary Progress Note dated 05/12/25 revealed Resident #31 triggered a 14-pound weight loss. Resident #31 weighed 115 pounds on 05/07/25 and 129 pounds on 04/07/25. It was noted by the dietitian that Resident #31 was added to weekly weight monitoring and would follow up with any significant change. Review of electronic medical record (EMR), Vital Signs and Weight Record, revealed Resident #31's weight documentation on 05/07/25 115 pounds, on 05/14/25 115.4 pounds, on 05/21/25 114.6 pounds, 06/11/25 113.6 pounds, and 06/17/25 113.6 pounds. The interview with Resident #31 on 06/23/25 at 10:00 A.M. revealed she realized she lost weight and had a poor appetite because the food did not appeal to her. Interview with Registered Dietitian (RD) #573 on 06/25/25 at 9:05 P.M. revealed Resident #31 was assessed for a significant weight loss related to poor appetite and was following weekly weights to ensure Resident #31's weight was stable. RD #573 verified she requested weekly weights, but a physician order was not written, and weekly weights were not provided on 05/28/25 and 06/04/25. Interview with the Director of Nursing (DON) on 06/25/25 at 5:06 P.M. verified the weekly weights were missing from the electronic medical record for the week of 05/28/25 and 06/04/25 and verified an order was not written in the electronic medical record. 2. Resident #46 was admitted to the facility on [DATE]. Medical diagnoses included myocardial infarction, hyperlipidemia, atrial fibrillation, ventricular septal defect, acute respiratory failure, peripheral vascular disease, abdominal aortic aneurysm, type two diabetes, pressure ulcer sacral, dysphagia, cognitive communication deficit, anxiety, depression, and hypotension. Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #46's cognition was intact and was independent for eating. Resident #46 was 61 inches tall and weighed 121 pounds. Resident #46 had a weight loss of 5 percent or more in one month and was not on a physician prescribed weight loss diet. Resident #46 was on a therapeutic diet. Review of the physician order dated 04/15/25 with no end date revealed Resident #46 was to be on weekly weights. Review of the facility EMR, Vital Signs and Weight Record, revealed Resident #46 weighed 121.1 pounds on 04/16/25, 118 pounds on 05/14/25, 120.5 pounds on 05/21/25, 112 pounds on 05/27/25 and 121.9 pounds on 06/04/25. Interview with Resident #46 on 06/25/25 at 9:30 A.M. revealed she was aware she had lost weight and did not like the oral nutrition supplements or diet provided. Interview with Licensed Practical Nurse (LPN) #541 on 06/25/25 at 12:03 P.M. revealed all weekly and monthly weights were only documented in the electronic medical record after the nurse aides obtained the weekly or monthly weight. Interview with RD #573 on 06/25/25 at 1:50 P.M. revealed the nurse or dietitian could input weekly or monthly weights into the electronic medical record, and she assumed the weight input on 05/27/25 was placed in error. Interview on 06/25/25 at 3:24 P.M. with the DON verified a physician order was placed on 04/15/25 that Resident #46 was to be on weekly weights. The DON verified the weekly weight documentation was not available on other facility documents or documented in the electronic medical record for the week of 04/21/25, 04/28/25, 05/05/25, 05/26/25 and 06/16/27. Review of the facility policy titled Weights Policy, dated May 2015, revealed obtaining accurate weights was vital for nutritional assessment, and all weights for each resident including new admission, readmission, monthly and weekly were to be recorded in one central weight record such as the electronic health record and Vital Signs and Weight Record.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #162 had a physician's order for oxygen. This affected one (Resident #162) out of one resident reviewed for respiratory care. This had the potential to affect 18 (Residents #2, #4, #7, #10, #12, #17, #18, #28, #32, #39, #40, #44, #46, #48, #53, #113, #166, and #168) identified by the facility on oxygen. The facility census was 62. Findings include: Review of the medical record for Resident #162 revealed an admission date of 06/20/25 with diagnoses including fracture of right femur, hypertension, chronic kidney disease, and altered mental status. Review of Pulmonologist #901's progress note dated 06/19/25 (while in hospital) revealed Pulmonologist #901 consulted due to pleural effusions and noted Resident #162's oxygen saturation level (percentage of oxygen in the blood) was 99 percent, and she had decreased breath sounds to her lung bases. He recommended oxygen but there was no specified route or rate per the progress note. Review of the June 2025 physician orders revealed Resident #162 did not have an order for oxygen. Review of the After Visit Summary dated 06/20/25 revealed Resident #162 was in the hospital from [DATE] to 06/20/25 and was discharged to the facility with congestive heart failure instructions. The summary, under the area of oxygen therapy, revealed no specific route or rate for oxygen. Review of the oxygen saturation levels dated from 06/20/25 to 06/24/25 revealed on 06/20/24 at 7:15 P.M. Resident #162's oxygen saturation level was 92 percent on three liters per minute of oxygen, on 06/21/25 at 12:05 P.M. her oxygen saturation level was 94 percent on four liters per minute of oxygen, on 06/21/25 at 10:26 P.M. her oxygen saturation level was 94 percent on four liters per minute of oxygen, on 06/22/25 at 11:35 A.M. her oxygen saturation level was 95 percent without oxygen, on 06/22/25 at 8:02 P.M. her oxygen saturation level was 94 percent on four liters per minute of oxygen, on 06/23/25 at 4:15 P.M. her oxygen saturation level was 95 percent on four liters per minute of oxygen, on 06/23/25 at 11:34 P.M. her oxygen saturation level was 94 percent on four liters per minute of oxygen, and on 06/24/25 at 11:11 A.M. her oxygen saturation level was 94 percent on five liters per minute of oxygen. Review of the comprehensive care plan dated 06/23/25 revealed there was nothing in Resident #162's care plan regarding oxygen use. Observation on 06/23/25 at 9:45 A.M. revealed Resident #162 was lying in bed with oxygen at five liters per minute per nasal cannula. Observation on 06/24/25 at 12:22 P.M. with the Director of Nursing (DON) verified Resident #162 was lying in bed with oxygen at 4.5 liters per minute per nasal cannula. Interview on 06/24/25 at 12:22 P.M. with the DON verified Resident #162 did not have a physician's order for oxygen. She also verified the oxygen saturations levels from 06/20/25 to 06/24/25 indicated Resident #162 was on different liter flows since admission as on 06/20/24 at 7:15 P.M. Resident #162 was on three liters per minute of oxygen, on 06/22/25 at 11:35 A.M. she was without oxygen, and on 06/24/25 at 11:11 A.M. she was on five liters per minute of oxygen. She verified the other times that the oxygen saturation levels were documented Resident #162 was on four liters per minute of oxygen. Review of the nursing note dated 06/24/25 at 2:33 P.M. authored by the DON revealed she contacted Primary Care Physician (PCP) #900 who confirmed she had given an order upon admission for Resident #162 to be on four liters per minute if oxygen per nasal cannula continuously. Review of the facility policy labeled, Oxygen Administration (All Routes) revealed licensed clinicians with demonstrated competence would administer oxygen per the specific route as ordered by the physician. The policy revealed, under the procedure, the nurse would verify the physician order.

Based on record review, observation, interview, and facility policy review, the facility failed to use appropriate infection control precautions while providing wound care to Resident #50 who was in enhanced barrier precautions. This affected one Resident #50 but had the potential to affect all 29 residents who were ordered enhanced barrier precautions, Residents #5, #8, #9, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24, #30, #31, #33, #36, #37, #40, #44, #46, #50, #58, #61, #63, and #64. The facility census was 64. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypertension, and heart failure. Review of the care plan dated 06/17/24 revealed Resident #50 had impaired skin integrity on her left breast and left side of her neck. Interventions included providing wound care as ordered and enhanced barrier precautions. Review of the physician's order dated 09/16/24 revealed an order for enhanced barrier precautions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had moderate cognitive impairment. Resident #50 required extensive assistance for all activities of daily living. Observation and interview on 05/22/25 at 11:15 A.M. of wound care for Resident #50 with Registered Nurse (RN) #502 revealed on the front of Resident #50's door signage that she was in enhanced barrier precautions. The sign stated for staff to wear a gown, gloves, and use hand hygiene when providing personal care including wound care. RN #502 entered the room, set up her area, washed her hands, and began performing the wound care. RN #502 maintained good hand hygiene during the wound care and changed her gloves often using hand sanitizer before applying new gloves. After the procedure was over RN #502 cleaned up her area, removed her gloves and washed her hands. Upon exiting the room, RN #502 confirmed Resident #50 was in enhanced barrier precautions and a gown was not worn during the procedure. RN #502 also confirmed that there was signage on Resident #50's door with personal protective equipment. Review of the facility policy infection prevention and control program policy, revised 02/19/24, revealed it is the policy to maintain an organized, effective facility-wide program designed to systemically prevent, identify, control, and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors, and contract healthcare workers; to conduct surveillance of communicable disease and infectious outbreaks; and to monitor employee health. This deficiency represents an incidental finding identified during the complaint investigation.

Based on observation, record review, facility policy review, and interview the facility failed to ensure Resident #24's left foot was assessed after State tested Nursing Assistant (STNA) #610 bumped her foot on her bedroom doorframe, failed to complete documentation of the incident, and failed to ensure the physician was notified timely. This affected one resident (#24) of three residents reviewed for injuries. The facility census was 51. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), hypertension, and osteoarthritis. Review of the care plan dated 06/13/23 revealed Resident #24 had a self-care deficit and was dependent on staff for activities of daily living. Interventions included custom power chair, mechanical lift with transfers, and assist with activities of daily living (ADL) including transfers. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition. She used a wheelchair for locomotion. She was dependent on staff assist for transfers and bathing. Review of the nursing notes for Resident #24 dated from 11/01/23 to 02/06/24 revealed no documentation regarding Resident #24 bumping her left foot on the doorframe. No documented evidence of an assessment of her left foot after STNA #610 bumped her foot, no documentation of a bruised area to her left great toe and/or notification to the physician of the incident. Review of the Incident Accident Log dated from 11/01/23 to 02/05/24 revealed no incidents involving Resident #24 including staff bumping her left foot on the doorframe were contained on the log. Review of the Bath/ Shower Sheet dated from 12/01/23 to 02/05/24 revealed no documentation Resident #24's left foot was bumped on the doorframe while transferring her to the shower. Review of the Weekly Skin Evaluations dated 01/09/24, 01/16/24, 01/23/24, and 01/30/24 had revealed no documentation regarding any abnormalities to Resident #24's left great toe. Review of the Wound Progress Note dated 02/05/24 completed by Wound Nurse Practitioner (NP) #607 revealed Resident #24 stated her left great toe was bumped and she was concerned about further bruising to her left toes. The note revealed her left great toe was ecchymotic (bruised), stable without drainage, swelling and/or redness. She had no other bruising to her other digits on her left foot. She recommended monitoring her left great toenail for signs of infection and/or instability. Interview on 02/05/24 at 7:52 A.M. with Resident #24 revealed she was a diabetic and felt her left foot was now permanently scarred. She revealed a few months ago STNA #610 was rushing while pushing her in the shower chair and her left foot hit the doorframe causing injury to her foot. She then revealed a few weeks ago the same STNA, STNA #610, hit her left foot again on her bedroom doorframe when she was pushing her in the shower chair out of her room. She revealed STNA #610 laughed and stated, you left enough blood for DNA (deoxyribonucleic acid). She revealed she did not find the incident funny as she was concerned regarding injuries to her feet especially since she was diabetic. She revealed STNA #610 told her that she had reported the incident to Licensed Practical Nurse (LPN) #606. She revealed she did not feel LPN #606 did anything about the incident as she does not feel STNA #610 was disciplined for the incident especially since it was STNA #610's second time hitting her foot on the doorframe causing injury. She revealed she was upset as she did not want STNA #610 to continue to injure her feet when she gave her showers. Interview on 02/05/24 at 9:15 A.M. with LPN #606 revealed there was one time approximately six months or even longer when an aide (she could not remember who) bumped Resident #24's toe while transferring her. She revealed she could not remember the details. She revealed she was not notified of any incident recently within the last month that was brought to her attention of any staff bumping her foot again during care. Observation on 02/05/24 at 10:05 A.M. of wound care for Resident #24 completed by Wound NP #607 and Assistant Director of Nursing (ADON) / Registered Nurse (RN) #600 revealed Resident #24's had bruising to her left great toenail. ADON/ RN #600 had revealed he was not aware she had a bruised left great toenail. Interview on 02/05/24 at 10:10 A.M. with Wound NP #607 revealed the left great toenail was bruised but that the toenail was at this time secured and there were no signs of infection. She revealed she was unsure if Resident #24 would lose her toenail and at this time she recommended the facility to monitor the area. Interview on 02/05/24 at 3:17 P.M. with STNA #610 revealed she had worked at the facility since 08/2022. She revealed after she had first started at the facility, she was pushing Resident #24 in a shower chair to the shower and accidentally bumped her foot (she could not remember which foot) on the doorframe. She revealed Resident #24's foot was bleeding and she had notified the nurse who checked and treated it. She revealed recently approximately two or three weeks ago the same thing had happened. She revealed she was pushing Resident #24 in a shower chair out of her room and her toe bumped the side of the doorframe. She revealed she had checked her toe and there was no bleeding or signs of injury. She revealed she notified the nurse but could not remember the nurses' name that she reported the incident to. She revealed she felt the cause of bumping her foot was she was small in stature, so it was hard to control the shower chair as she pushed it. Interview on 02/05/24 at 3:52 P.M. with the Director of Nursing verified there was no documentation an assessment was completed for Resident #24 after STNA #610 bumped her left great toe on the door frame, no incident report, documentation in the nursing notes, and/or documentation Primary Care Physician #612 was notified of the incident. Review of the personnel file for STNA #610 revealed a hire date of 08/03/22. There was no evidence in her file STNA #610 was re-trained on assisting residents in shower chairs to prevent injuries after the incidents with Resident #24. Review of the facility policy titled Resident Change in Condition, dated 07/02/21, revealed the licensed nurse would recognize and intervene in the event of a change in resident condition. The policy revealed the physician would be notified when there was an accident or incident involving the resident. The policy revealed the nurse would record the information related to the change in condition and subsequent events in the resident's health record. This deficiency represents non-compliance investigated under Complaint Number OH00150107.

Based on observation, interview, record review, review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, and review of the facility policy the facility failed to ensure Resident #2 was able to be transferred from his bed to a padded wheelchair using a mechanical lift when he requested the transfer. This affected one resident (#2) out of three residents reviewed for transfers. The facility census was 55. Findings include: Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses including morbid obesity due to excess calories, congestive heart failure, and chronic obstructive pulmonary disease. Review of Resident #2's physician orders dated 06/20/23 revealed Resident #2's preference to be up from bed around 10:00 A.M. Review of Resident #2's care plan revised 07/17/23 included Resident #2 had a self-care deficit. Resident #2 required extensive assistance with activities of daily living (ADL) and might require more or less assistance at times. Resident #2's needs would be met. Interventions included Resident #2 used a mechanical lift for transfers, assist with ADL, dressing, grooming, toileting, feeding, oral care, transfers, and bed mobility every shift; Resident #2 preferred showers on day shift Monday, Wednesday, and Friday; Resident #2 preferred to be up from bed around 10:00 A.M. Review of Resident #2's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact. Resident #2 was dependent on staff for toileting, bathing, transfers from bed to chair and chair to bed. Observation on 12/07/23 at 11:50 A.M. of Resident #2 revealed he was lying in bed watching television, and the head of his bed was elevated. Interview on 12/07/23 at 11:50 A.M. of Resident #2 revealed the staff were slow to do things, he would put his call light on, and it took a long time for it to be answered at times. Resident #2 stated he asked the nurses and aides to get him out of bed and was told he could not get up because there were no clean mechanical lift pads available. Resident #2 stated this happened frequently. Resident #2 stated he wanted to get up earlier today, but now changed his mind because he was just so tired of not getting up when he asked the staff. Observation on 12/07/23 at 1:15 P.M. with State tested Nursing Assistant (STNA) #239 revealed there were no mechanical lift pads including bariatric lift pads available on either long-term care nursing unit or the skilled nursing unit. Further observation revealed Resident #2 did not have a mechanical lift pad on his padded wheelchair or in his room. Observation of the laundry area revealed five bariatric mechanical lift pads were hanging in the laundry area and were wet. STNA #239 stated Resident #2 needed a bariatric mechanical lift pad, and the mechanical lift pads needed to be dry before they could be used. When asked if Resident #2 wanted to get out of bed now would he be able to, STNA #239 stated Resident #2 would not be able to get up at this time and would need to wait for the mechanical lift pads to dry. Interview on 12/11/23 at 1:12 P.M. of Maintenance Supervisor #200 revealed the bariatric mechanical lift pads could be dried at low temperature. Interview on 12/11/23 at 1:52 P.M. of Assistant Director of Nursing (ADON) #240 revealed mechanical lift pads could be placed in the dryer at low temperature but it was preferred to have them air dry because they lasted longer if they were air dried. Review of the facility policy titled Resident Rights and Facility Responsibilities, revised 09/03/20, included references were CMS, 2017, State Operations Manual, F483.10, Resident Rights. Review of the CMS, 2017, State Operations Manual, F483.10 Resident Rights included the resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This deficiency was an incidental finding discovered during the complaint investigation.

Based on interview, closed record review, review of the facility policy and review of the Centers for Medicare and Medicaid Services (CMS) guidance the facility failed to ensure Resident #56's eye infection was treated while she resided in the facility. This affected one resident (#56) out of three residents reviewed for infections. The facility census was 55. Findings include: Review of Resident #56's closed medical record revealed an admitted [DATE], and a re-entry date of 10/09/23. Resident #56's diagnoses included Alzheimer's Disease, dementia without behavioral disturbance, and fracture of the left pubis. Resident #56 was discharged from the facility on 11/07/23. Review of Resident #56's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had moderate cognitive impairment. Resident #56 required partial assistance from another person to complete bathing, dressing, using the toilet, eating, and walking from room to room. Resident #56 used a walker. Resident #56 had two unstageable pressure ulcer injuries (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) presenting as deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) present upon admission to the facility. Review of Resident #56's facility Discharge Instructions dated 11/07/23 did not reveal documentation that Resident #56's eyes were red and draining or had a discharge. Review of Resident #56's Hospice Face-to-Face Encounter Report dated 11/07/23 included Resident #56 resided at home with a primary hospice diagnosis of late onset Alzheimer's Disease. Resident #56's son was the primary caregiver. Resident #56 was incontinent of bowel and bladder. Resident #56 had a recent fall with a pelvic fracture, was mostly in bed during rehab, was frailer and now mostly in chair. Resident #56 was wobbly and required the assistance of a rollator. Resident #56 required maximum assistance with activities of daily living (ADL). Resident #56 was discharged today (11/07/23) from the facility and had deconditioning (deteriorating condition), extreme weakness, and required assistance of one person for transfers and ambulation and was unsteady. Resident #56 was alert to self and home; her skin was dry and flaky, her right and left eyes were red, and her left eye was draining. A new order was received for Tobramycin (antibiotic) eye drops, give one drop in both eyes four times a day for seven days. Interview on 12/07/23 at 8:54 A.M. of Resident #56's son revealed the resident was admitted to the facility from the hospital for rehabilitation from a fracture. He stated Resident #56 fell at home, had a fracture, and was hospitalized a week before she was admitted to the facility. He stated Resident #56 was fine when she left the hospital and when he picked Resident #56 from the facility she had bedsores on her feet, her eyes were pussed shut, and she had an infection in both eyes, she smelled bad and when he touched her she was incontinent of urine and the urine just drained off of her into his hands when he touched her. He stated Resident #56 wore incontinence briefs. Interview on 12/07/23 at 11:40 A.M. of Hospice Nurse (HN) #268 revealed Resident #56 did look rough when she arrived home from the facility. HN #268 stated Resident #56's hair was disheveled and did not look like it was brushed for days, her face was oily and had dry skin, she had an odor, wounds to both heels and the wounds were pretty bad looking. HN #268 stated Resident #56 had green drainage coming out of the left eye, and the hospice physician prescribed antibiotic eye drops for her. HN #268 stated Resident #56 was discharged from hospice when she was admitted to the hospital and was readmitted to hospice on 11/07/23. HN #268 stated she had [AGE] years' experience as a long-term nurse and she could not believe the condition Resident #56 was sent home in. Interview on 12/11/23 at 3:41 P.M. of Licensed Practical Nurse (LPN) #261 revealed she discharged Resident #56 from the facility on 11/07/23 and did not remember if Resident #56's eyes were red and draining or had a discharge from them. Interview on 12/11/23 at 4:14 P.M. of Assistant Director of Nursing (ADON) #240 revealed he was not aware of Resident #56 having an eye condition. ADON #240 stated staff would notify him of any abnormalities concerning residents, and he could follow-up; he did not receive a notification from any staff member regarding Resident #56's eye infection. Review of the facility policy titled Resident Rights and Facility Responsibilities, revised 09/03/20, included references were CMS 2017, State Operations Manual, F483.10, Resident Rights. Review of the CMS, 2017, State Operations Manual, F483.10 Resident Rights included the resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This deficiency represents non-compliance investigated under Complaint Number OH00148356.

Based on observation, interview, closed record review, and review of the facility policy the facility failed to thoroughly document the appearance of Resident #56's bilateral heel deep tissue injuries (DTI). This affected one resident (#56) out of three residents reviewed for pressure ulcer injuries. The facility census was 55. Findings include: Review of Resident #56's closed medical record revealed an admitted [DATE], and a re-entry date of 10/09/23. Resident #56's diagnoses included Alzheimer's Disease, dementia without behavioral disturbance, and fracture of the left pubis. Resident #56 was discharged from the facility on 11/07/23. Review of Resident #56's progress notes dated 10/09/23 through 11/07/23 did not reveal documentation related to the appearance of Resident #56's bilateral heel DTIs (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear). Further review revealed the discharge instructions dated 11/07/23 at 5:53 A.M. did not reveal instructions for the care of Resident #56's bilateral heel DTIs. Review of Resident #56's care plan dated 10/10/23 included Resident #56 had the potential for skin breakdown related to diagnosis, mobility status, and incontinence. The goal was Resident #56's skin would remain intact through the next review. Interventions included completing skin assessments per protocol, to elevate heels off the mattress per routine and/or as needed as Resident #56 allowed. Review of Resident #56's Weekly Wound assessment dated [DATE] revealed Resident #56 had a DTI of the left heel which was community acquired and present on admission to the facility. The measurements were 3.0 centimeters (cm) in length by 3.0 cm in width by a depth of unable to be determined, and there was no drainage. There was no description of the wound bed or peri wound (skin surrounding the wound) appearance as the wound bed and peri wound appearance were marked as not applicable. The family and physician were notified, and treatment was to apply Skin-Prep (liquid film-forming skin protectant that prepares damaged skin for tapes and adhesive dressings) BID (twice a day) and as needed and a foam dressing to pad and protect. Review of Resident #56's Weekly Wound assessment dated [DATE] revealed Resident #56 had a DTI of the right heel which was community acquired and present on admission to the facility. The measurements were 0.3 cm in length by 0.3 cm in width by a depth of unable to be determined, and there was no drainage. There was no description of the wound bed or peri wound appearance as the wound bed and peri wound appearance were marked as not applicable. The family and physician were notified, and treatment was to apply Skin-Prep BID and as needed and a foam dressing to pad and protect. Review of Resident #56's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had moderate cognitive impairment. Resident #56 required partial assistance from another person to complete bathing, dressing, using the toilet, eating, and walking from room to room. Resident #56 used a walker. Resident #56 had two unstageable pressure ulcer injuries (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) presenting as DTIs present upon admission to the facility. Review of Resident #56's Weekly Wound assessment dated [DATE] revealed Resident #56 had a DTI of the right heel which was community acquired. The measurements were 3.0 cm in length by 2.0 cm in width 2 cm by a depth of unable to be determined, and there was no drainage. There was no description of the wound bed or peri wound appearance as the wound bed and peri wound appearance were marked as not applicable. The wound status was marked as wound was deteriorating. The family and physician were notified. The treatment was applying Skin-Prep BID and as needed and a foam dressing to pad and protect. There was a new order for PRAFO boots (a device worn on the lower leg and foot designed to assist with the management of pressure related problems to the heel and ankles). Review of Resident #56's Weekly Wound assessment dated [DATE] revealed Resident #56 had a DTI of the left heel which was community acquired. The measurements were 3.0 cm in length by 3.0 cm in width by a depth of unable to be determined, and there was no drainage. There was no description of the wound bed or peri wound appearance as the wound bed and peri wound appearance were marked as not applicable. The wound status was marked as unchanged. The family and physician were notified, and the treatment was to apply Skin-Prep BID and as needed, and a foam dressing to pad and protect. There was a new order for PRAFO boots. Review of Resident #56's Weekly Wound assessment dated [DATE] revealed Resident #56 had a DTI of the right heel which was community acquired. The measurements were 2.0 cm in length by 2.4 cm in width by a depth of 0, and there was no drainage. There was no description of the wound bed or peri wound appearance as the wound bed and peri wound appearance were marked as not applicable. The wound status was improving. The family and physician were notified, and the treatment was to apply Skin-Prep BID and as needed, a foam dressing to pad and protect, and PRAFO boots. Review of Resident #56's Weekly Wound assessment dated [DATE] revealed Resident #56 had a DTI of the left heel which was community acquired. The measurements were 3.0 cm in length by 2.4 cm in width by a depth of 0, and there was no drainage. There was no description of the wound bed or peri wound appearance as the wound bed and peri wound appearance were marked as not applicable. The wound status was marked as improving. The family and physician were notified, and the treatment was to apply Skin-Prep BID and as needed, a foam dressing to pad and protect, and PRAFO boots. Review of Resident #56's Weekly Wound assessment dated [DATE] revealed Resident #56 had a DTI of the right heel which was community acquired and measurements were 2.0 cm in length by 2.2 cm in width by a depth of 0, and there was no drainage. There was no description of the wound bed or peri wound appearance as the wound bed and peri wound appearance were marked as not applicable. The wound status was marked as improving, and family and the physician were notified. The family and physician were notified, and the treatment was to apply Skin-Prep BID and as needed, a foam dressing to pad and protect, and PRAFO boots. Review of Resident #56's Weekly Wound assessment dated [DATE] revealed Resident #56 had a DTI of the left heel which was community acquired. The measurements were 2.8 cm in length by 2.1 cm in width by a depth of 0 and there was no drainage. There was no description of the wound bed appearance or peri wound appearance and both were marked not applicable. The wound status was marked as improving. The family and physician were notified, and the treatment was to apply Skin-Prep BID and as needed, a foam dressing to pad and protect, and PRAFO boots. Review of Resident #56's Discharge Instructions from the facility dated 11/07/23 included for the question asking if wounds were present, the No box was marked. Further review did not reveal instructions for the care of Resident #56's bilateral heel DTIs. Review of Resident #56's Hospice Wound Record Report revealed the onset date was 11/07/23, and Resident #56 had bilateral unstageable DTIs to her right and left heels. Further review revealed on 11/09/23 Resident #56's left heel unstageable DTI measured 2.5 cm in length by 3.0 cm in width by a depth of 0, and 26 to 50 percent of the wound had soft black slough and eschar. On 11/09/23 Resident #56's right heel unstageable DTI measured 1.5 cm in length by 2.0 cm width by a depth of 0, and 0 to 25 percent of the tissue was necrotic tissue slough and eschar. Interview on 12/07/23 at 8:54 A.M. Resident #56's son revealed she was admitted to the facility for rehabilitation. He stated Resident #56 had a fall at home, had a fracture, and was hospitalized for about a week for the fracture, then was admitted to the facility for rehabilitation. He stated when he picked Resident #56 up at the facility on 11/07/23, when she was discharged , he was not given instructions on her bilateral bedsores on her feet, and was really upset when he got home and saw how bad the sores on her heels were. He stated in addition to the sores on her feet, her eyes were pussed shut, she smelled very bad and was soaked with urine stating, the urine just ran off Resident #56 into his hands. He stated the facility was supposed to help, not kill Resident #56. Interview on 12/07/23 at 11:40 A.M. of Hospice Nurse (HN) #268 revealed Resident #56 looked rough when she arrived home from the facility. HN #268 stated Resident #56's hair was disheveled and did not look like it was brushed for days, her face was oily and had dry skin, she had an odor, wounds to both heels, and the wounds were pretty bad looking. HN #268 stated Resident #56 had green drainage coming out of the right eye, and the hospice physician prescribed antibiotic eye drops for her. HN #268 stated Resident #56 was discharged from hospice when she was admitted to the hospital and was readmitted to hospice on 11/07/23. HN #268 stated she had [AGE] years' experience as a long-term nurse, and she could not believe the condition Resident #56 was sent home in. Interview on 12/11/23 at 2:18 P.M. of Assistant Director of Nursing (ADON) #240 revealed the facility did not follow a specific protocol for a low air loss mattress. ADON #240 stated if a resident had a wound that was worsening, he would reach out to the resident's physician to see if a low air loss mattress and PRAFO boots would be beneficial. ADON #240 stated Resident #56's DTIs of her left heel got bigger on 10/16/23, and he notified the Director of Nursing (DON). ADON #240 stated on 10/23/23 both of Resident #56's DTIs worsened, and that was when we received orders for Resident #56's low air loss mattress and PRAFO boots. ADON #240 stated before Resident #56 had orders for a low air loss mattress and PRAFO boots, she had interventions to elevate her heels off the bed as tolerated. ADON #240 stated when he noticed Resident #56's left heel was deteriorating he made sure nurses were aware Resident #56's heels needed to be elevated off the bed. ADON #240 stated when Resident #56's bilateral heels deteriorated he told Medical Director #269 and obtained orders for a low air loss mattress and PRAFO boots. ADON #240 stated Resident #56 did not have orders for a low air loss mattress or PRAFO boots when she was first admitted , because he wanted to see if the treatment for pad and protect the heels was effective. ADON #240 stated Resident #56's bilateral DTIs did not become open wounds, and when she was first admitted the heels were deep red in color with some maroon. ADON #240 indicated on 10/23/23 Resident #56's areas on her heels were larger and the same color as when she was admitted . ADON #240 confirmed he did not document the appearance of Resident #56's bilateral heel DTIs wound bed color or peri wound appearance. ADON #240 stated the wound nurse practitioner (WNP) did not evaluate Resident #56's bilateral heel DTIs because they were not open wounds. ADON #240 stated it was not the practice to consult the WNP until the DTI became an open wound. ADON #240 stated the last time he observed Resident #56's DTIs of her heels was on 11/06/23. Interview on 12/11/23 at 3:31 P.M. of Medical Director #269 revealed it was hard to remember details about residents because she had so many patients. Medical Director #269 stated she always looked at resident wounds but did not always document the wounds in her notes. Medical Director #269 stated the last time she saw Resident #56 was on 11/01/23, and she had positive pedal pulses. Medical Director #269 stated she did not document the wound bed appearance of Resident #56's bilateral heel DTIs, or the peri wound appearance in her notes, but she remembered the wound beds were reddish in color. Interview on 12/11/23 at 3:41 P.M. of Licensed Practical Nurse (LPN) #261 revealed she discharged Resident #56 from the facility on 11/07/23. LPN #261 stated she did not remember looking at Resident #56's bilateral heel DTI wounds or giving Resident #56's son instructions on the treatment of Resident #56's bilateral heel DTI wounds before Resident #56 was discharged . Observation on 12/11/23 at 4:14 P.M. of pictures sent by Resident #56's son of her bilateral heel wounds with ADON #240 revealed the pictures were taken on 11/07/23 after Resident #56 was discharged from the facility. Observation of Resident #56's first picture of her heel wounds revealed a large circular area on the heel, and the outer perimeter of the circle was dark, black appearing tissue. The inner wound bed had purple, dark purple, and deep red areas noted. The peri wound tissue appeared red in color. Observation of the second picture of her heel wounds revealed a large circular area on the heel, and the wound bed appeared to have pink, light purple, and a couple dark red areas noted. The peri wound tissue was a dark greyish color with some yellow areas noted. ADON #240 confirmed the appearance of Resident #56's heel wounds in both pictures and stated Resident #56's heels did not look like that on 11/06/23, and if they looked like that, he would have consulted the WNP. ADON #240 stated his documentation showed Resident #56's bilateral heel DTIs were getting smaller and improving. ADON #240 stated the outer edge, which was black and looked like eschar, would be debrided by the WNP. ADON #240 stated he did not discharge Resident #56 from the facility, but Resident #56's responsible party was given a printout of orders for the treatment of Resident #56's bilateral heel DTIs. Review of the facility policy titled Pressure Injury Prevention and Treatment Policy, revised 09/18/23, included pressure injuries identified would be assessed initially and at least weekly thereafter, until closed. All assessments would include the following elements including wound bed color and type of tissue and character including evidence of healing for example granulation tissue, maceration as appropriate, and appearance of surrounding tissue. This deficiency represents non-compliance investigated under Complaint Number OH00148356.

Based on interview, observation and record review, the facility failed to ensure meals served looked appetizing and were served at palatable temperatures. This had the potential to affect all residents receiving meals from the kitchen with the exception of Residents #1 and #10 who received no nutrition by mouth. The facility census was 49. Findings include: Interview on 07/17/23 at 2:08 P.M. with Resident #3 revealed hot foods were served cold upon meal service. Interview on 07/17/23 at 2:21 P.M. with Resident #45's sister revealed while at the facility, Resident #45 did not eat the food because Resident #45 said it did not taste good. Interview on 07/17/23 at 2:32 P.M. with Resident #19 revealed the food was overcooked, soggy and terrible. Observation of a test tray on 07/17/23 at 5:45 P.M. with Dietary Manager (DM) #210 revealed the meal consisted of chicken tenders, french fries, zucchini and mandarin oranges. Temperatures were obtained with the chicken tenders revealing a temperature of 119 degrees Fahrenheit (F) and the zucchini revealing a temperature of 126 degrees F. The french fries were noted to be undercooked and soft. Interview on 07/17/23 at 5:50 P.M. with DM #210 revealed DM #210 stated all hot foods should be served above 140 degrees F. Interview on 07/18/23 at 9:15 A.M. with Resident #46 revealed the food was often cold and tasteless. Review of the facility policy titled Food Temperature Policy dated 08/28/19 revealed hot foods should not fall below 135 degrees while holding after cooking and hot food should be palatable when delivered.

Based on observation, interview, and facility policy review, the facility failed to ensure proper hand hygiene was completed during medication administration including hand washing and wearing gloves. This affected three Residents (Residents #4, #32, and #101) out of seven residents administered medications. The facility census was 49. Findings include: Observations made on 07/19/23 from 7:59 A.M. to 12:30 P.M. of medication administration by Licensed Practical Nurse (LPN) #223, LPN #234, and LPN #265 of 25 administrations made for seven residents (Residents #4, #14, #16, #32, #35, #101 and #103) revealed LPN #223 did not perform hand hygiene before or after administering medications to Resident #4. LPN #223 was observed dispensing medication into her bare hand then placing them into a medication cup, crushing them, placing in applesauce, and then administered the medications to Resident #4. Additional observation of LPN #223 revealed she did not perform hand hygiene before or after, or wear gloves while administering insulin to Resident #101. Observation during Medication Administration of LPN #265 revealed she did not wear gloves or perform hand hygiene before or after administering insulin to Resident #32. Interview conducted on 07/19/23 at 8:45 A.M. with LPN #223 revealed she did not perform hand hygiene before or after administering medications to Resident #4. Interview conducted on 07/19/23 at 11:30 A.M. with LPN #265 confirmed she did not perform hand hygiene before or after administering insulin to Resident #32. LPN #265 also confirmed she did not wear gloves while administering the insulin to Resident #32. Interview conducted on 07/19/23 at 12:00 PM with LPN #223 confirmed she did not perform hand hygiene before or after administering insulin to Resident #101. LPN #223 also confirmed she did not wear gloves while administering the insulin to Resident #101. Review of facility policy titled General Dose Preparation and Medication Administration, last revised 01/01/22 revealed the facility staff failed to follow their policy for medication administration under Procedure headline, bullet point number two Prior to preparing or administering medications, authorized and competent facility staff should follow facility's infection control policy, including hand hygiene, and under bullet point number 3.4 Facility staff should not touch the medication when opening the bottle or unit dose package.

Based on interview, review of staffing schedules, and review of the Benefits Improvement and Protection Act (BIPA) daily staffing postings, the facility failed to maintain the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of the facility staffing schedules and daily BIPA staffing postings dated between 11/13/21 and 12/13/21 revealed no RN was present working in the facility on 11/14/21, 12/04/21, 12/11/21, and 12/12/21. Interview with Human Resources (HR) #511 on 12/13/21 at 10:20 A.M. verified the facility did not have a RN on duty in the facility on 12/11/21 and 12/12/21. Interview with the Administrator on 12/13/21 at 2:54 P.M. verified the lack of an RN in the facility on 11/14/21, 12/04/21, 12/11/21, and 12/12/21. Review of facility policy titled Staffing revised April 2007, revealed the facility would maintain adequate staffing on each shift to ensure that residents' needs were met. Licensed registered nursing and licensed nursing staff were available to provide and monitor the delivery of resident care services. This deficiency substantiates Complaint Number OH 855.

Based on observation, interview and record review the facility failed to ensure housekeeping staff wore the proper Personal Protective Equipment (PPE) while cleaning transmission-based precaution rooms. This affected two residents (Resident's #7 and #44) and had the potential to affect 33 residents (Resident's #1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #13, #14, #15, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48 and #49) who resided on the Walnut and Cherry nursing units. The facility census was 47. Findings include: 1. Record review of Resident #7 revealed a readmission date of [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 3.0 assessment was still progress. The resident's orders and nursing progress notes were silent in regard to infection or transmission-based precautions. Review of the order requisition dated 09/14/20 for Resident #7 COVID-19 test swab revealed the collection date was 09/14/20. Observation on 09/15/20 at 11:32 A.M. revealed a housekeeping cart outside of Resident #7's room located on the Cherry nursing unit, also the observation unit. Posted on the door of Resident #7's was a droplet contact precaution sign. Observation of Housekeeper (HSK) #300 exiting the resident's bathroom and come into the hall wearing a mask, face shield and gloves. HSK #300 removed the gloves and then the face shield. Interview at this time with HSK #300 confirmed she was supposed to have on a gown but did not. HSK #300 confirmed the sign posted on the door that read among the list of PPE, Gown before entering room. HSK #300 stated she was cleaning the bathroom and walked in there without the gown. Review of the facility's policy titled Guidance for Removal of Transmission-Based Precautions for COVID-19 Patients, undated, revealed for new admissions should remain isolated in the facility's observation area and in a private room for 14 days after admission or may be tested day seven or later after admission and moved off of observation unit after negative test results are received. 2. Record review of Resident #44 revealed a readmission date of [DATE]. [DIAGNOSES REDACTED]. The quarterly MDS 3.0 assessment dated [DATE] revealed the resident had an intact cognition and required extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and extensive assistance of one staff for toilet use. The resident also had an indwelling catheter and a multidrug resistant organism. Review of nursing notes were silent for infection. Review of the physician orders [REDACTED]. Review of the Care Plan dated 01/14/19 and revised on 10/29/19 for CRE in the urine. Intervention included isolation per protocols. Observation on 09/15/20 at 12:11 P.M. revealed a housekeeping cart outside of Resident #44's room, which was located on the Walnut nursing unit. Posted on the door of Resident #44's was an orange contact precautions sign. Observation of Housekeeper (HSK) #301 mopping the floor wearing a mask and gloves but no gown. Interview on 09/15/20 at 12:15 P.M. with HSK #301 confirmed she didn't wear gown while mopping the floor due to there wasn't a gown in the bin. HSK #301 stated usually she would ask nursing for gowns if there were none in the bin and they would get gowns. HSK #301 stated she normally wears a gown, but her mind was scattered today. Interview on 09/15/20 at 1:28 P.M. with Infection Control Preventionist (ICP) stated the signs on the door included what should be followed, and they should have worn the appropriate PPE. ICP stated Resident #44's room was an isolation room due to CRE in the urine, and the resident was a new admit and the resident's COVID-19 test was recently taken and awaiting results. ICP stated she wouldn't expect housekeeping to know clinically what's going on with the residents. Review of the facility's policy titled Transmission-Based Precautions Policy revised on 06/29/20 revealed under contact precautions, gowns are worn whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the resident. Under droplet precautions section it states gowns, gloves, eye protection are worn adhering to Standard Precaution guidelines.

Based on interview and record review the facility failed to implement their abuse policy and procedure by ensuring personnel, who lived outside of Ohio within the last five years, received a federal background check prior to starting employment including Registered Nurse #105. This had the potential to affect the 19 residents (Resident's #2, #3, #7, #11, #13, #19, #20, #22, #26, #27, #37, #38, #40, #43, #45, #46, #49, #50 and #51) residing on the skilled unit. Findings include: Review of the application, not dated, but date available to start work was 01/07/20, for Registered Nurse (RN) revealed her most recent employer was at a nursing facility in Gettysburg, PA. Further review of the background check log revealed there was no evidence of a federal background check being completed as required. On 03/09/20 at 11:30 A.M., interview with the Administrator verified the above and verified a Federal background check should have been completed. Review of the abuse policy, revised July 2019, revealed to conduct a criminal background check in accordance with the State Law and facility policy. The policy referred to the employee background screening policy. Review of the employee background screening policy, revealed 07/16/19, revealed all applicants must produce five years proof or residency in the state they are seeking employment. If an applicant had not been a resident of the state for the previous five years or cannot provide proof of residency, a criminal background check from the Federal Bureau of Investigation must be completed. This deficiency substantiated Complaint Number OH 404.

Based on record review, observation and interviews the facility failed to store foods brought in from outside the facility for the residents were under sanitary and safe conditions. This had the potential to affect all 38 residents ( #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#12,#13,#15,#16,#17,#18,#19,#20,#21,#22,#23,#24,#25,#26,#28,#29,#31,#32,#33,#34,#35,#37,#39,#41,#43,#44,#48,#203) and also affected Resident #204 residing on the Walnut and Maple units in the facility. The facility census was 56. Findings included: Interview was conducted from 9:23 [NAME]M. to 9:25 [NAME]M. on [DATE] with State tested Nursing Assistant (STNA) #400 and STNA #401 who revealed if foods are brought in from family and visitors they are to write the resident's name on it, the date it was brought in and place the food in the refrigerator in the employee break room for those residents who resided on the Maple and Walnut units and for those residents who resided on the Cherry unit those items are stored in the kitchenette fridge on the Cherry unit. Interview was conducted on [DATE] at 9:36 [NAME]M. with Dietary Manager (DM) #800 who revealed if visitors and family bring food in for the residents it is to be kept in the refrigerator in the employee break room for residents on Maple and Walnut units and in the kitchenette fridge on the Cherry unit. Observation was conducted on [DATE] from 9:37 [NAME]M. to 9:51 [NAME]M. with Registered Dietitian (RD) #900 of the refrigerator freezer unit located off the Maple and Walnut units in the employee break room where resident food was stored. There was no temperature log on or around the freezer for (MONTH) 2020 and that was verified with RD #900 at 9:37 [NAME]M. The top freezer portion of the unit contained an internal thermometer reading at 14 degrees Fahrenheit (F). The bottom floor of the freezer unit was heavily coated with food particles, brown and yellow sticky substances as if it had not been cleaned recently. Within the freezer portion were two pints of ice cream from a popular creamery dated ,[DATE] and labeled with Resident #204's last name, a cup of unlabeled, white ice cream with nuts and a heavy accumulation of freezer frost on top of it, an unlabeled piece of pie from a popular fast food restaurant and an unlabeled, half full large, clear, plastic cup of brown substance with a plastic straw frozen within the substance. In the refrigerator section there was an internal thermometer reading at 38 degrees F. There were multiple outdated and compromised food items and items that were not labeled with a name and/ or date as follows: a box of pizza with Resident #17's name but no date, on a Styrofoam plate that was open to air there was what appeared to be an approximate one cup portion of cheese potato with two spots of black, fuzzy mold growth on it, a metal fork that was stuck to the foam plate and no name or date. That plate was sitting on top of yogurt containers labeled for Resident #22; a large Styrofoam cup filled with a pink substance without a name or date, a small foam box contained pasta in red sauce and a yellow pie-type dessert with whip topping dated [DATE] looked like it had a shiny biofilm on the filling part of the dessert. There was a bag of seven fresh oranges covered with brown spots on the oranges with no name or date, a plastic bag with no name or date contained two pieces of white cheese wrapped in tin foil and a plastic container of what RD#900 described as pasta Alfredo. There was a gallon of unopened apple cider with a manufacturer use by date of [DATE] and a half pint of milk with an expiration date of [DATE]. Resident #22 had multiple outdated foods in the refrigerator with her name on them that were expired such as five cup-size yogurts with manufactures expiration dates of [DATE], [DATE], [DATE], [DATE], [DATE], one vanilla chai protein shake with a manufactures expiration date of [DATE] and two vanilla bean protein plus shakes with facility date labels reading [DATE] and [DATE] with manufacturer expiration dates of [DATE] and [DATE]. RD#900 was present throughout the observation and verified all of the above findings. RD#900 said she did not know who was responsible for making sure the food items and cleanliness of the refrigerator freezer were maintained in safe and sanitary condition. Observation was conducted on [DATE] at 9:53 [NAME]M. with RD#900 of the Cherry unit fridge used to store resident foods. The unit was found to be clean with no outdated or unlabeled foods. A temperature log was up to date and documented acceptable temperatures averaging 38 degrees F. Interview was conducted on [DATE] at 10:07 [NAME]M. with Dietary Manager (DM) #800 who revealed nursing services was responsible for labeling and dating the residents food before putting it in the refrigerator freezers on the units for the residents. DM#800 explained the sanitation of each refrigerator was to be maintained daily by dietary staff or housekeeping staff but there was no planned system for who the designated staff person was to check the fridge on a day by day basis. DM#800 shared she would typically check it but she was down a few positions in the kitchen and had been filling in as a cook in the kitchen. DM#800 said she did not know where the (MONTH) 2020 refrigerator temperature log was for refrigerator freezer unit in the employee break room. An interview was conducted on [DATE] at 10:19 [NAME]M. with the Administrator to inform him of the findings and ask who was responsible to maintain the refrigerator freezer units. The Administrator revealed he was not sure of who should have been doing it but would find out. Record review was conducted of the facility policy titled Food Brought in From Outside the Facility, date revised [DATE]. The policy stated food would be stored in a clean, sealed container labeled with the name of the food item, resident name, dated and placed in a non-dietary refrigerator. Food dated by facility staff will be discarded within seven days from the date mark.

Based on record review, observation and interviews the facility failed to ensure Resident #40 received adequate pain management when routine pain medication was not given per a physician order. This affected one of three residents reviewed for pain (Resident #40). The facility census was 56. Findings included: Record review was conducted for Resident #40 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact, needed extensive assistance by staff for bed mobility, transfers, toileting and hygiene, was on a scheduled pain medication regimen and took opioids daily. The Plan of Care with a date initiated of 12/11/19 identified Resident #40 had a problem with generalized pain and listed interventions as administer pharmacological interventions as indicated per physician order, assess for verbal and nonverbal signs of pain, implement non-pharmacological interventions to release the pain, provide education to the resident and family and provide rest periods. A physician order [REDACTED].#40 was to be administered [MEDICATION NAME] HCL ( a narcotic pain pill ) 10 milligrams (mg) four times a day straight. Record review was conducted of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED].M., 6:00 [NAME]M., 12:00 P.M. and 6:00 P.M. The MAR indicated [REDACTED]. Fifty (50)of 75 pain assessments between 01/01/20 to 01/23/20 indicated Resident #40's pain was between a five to nine. On 01/23/20 the 12:00 [NAME]M. dose was not given and reader should refer to the nurses note authored by Registered Nurse (RN) #601. Review of the Medication Administration Note authored by RN#601 at 3:19 [NAME]M. revealed Resident #40 was sleeping so the pain medication was not given to her. Record review was conducted of the Medication Administration Note dated 01/21/20 authored by RN#601 at 1:51 [NAME]M. revealed Resident #40 woke up around 1:00 [NAME]M. and asked if she could have her pain pill. Review of the MAR indicated [REDACTED].M. authored by LPN#500 revealed Resident #40 did not receive her pain medication. The resident was not in the facility for the 6:00 P.M. dose on 01/20/20 as she was still out for her brain procedure and returned after 8:00 P.M. that evening. Observation was conducted on 01/21/20 at 10:55 [NAME]M. of Resident #40 who was found laying in her bed with two bandages on each side of her forehead, rapidly shaking her left foot and frowning. She was alert and oriented to person, place, time and conversation. The surveyor asked Resident #40 if she was having pain and Resident #40 revealed she had brain surgery the day before, her head was hurting and she was waiting for her pain medication to be given soon and did not feel like talking to the surveyor. Resident #40 said the staff was aware she needed her pain medication. Observation and interview were conducted on 01/23/20 at 11:55 [NAME]M. with Resident #40 who was found sitting up on the side of her bed with her head down to her chest and arms to her sides pressing up on the bed frame as to alleviate pressure on her bottom. Resident #40 indicated her pain was a level eight and she had told State tested Nurse Aide (STNA) #402 about an hour prior that she needed her pain medication. When asked if her pain medication was effective she revealed she did not always get her medication when she needed it but if she did it helped a lot but she had chronic pain. When asked for further detail she said the staff will not wake her for the pain medication if she is sleeping. She said it had happened on a few occasions with the same nurse ( resident named RN#601 ) or if she asked for her pain medication an hour early they would leave her waiting for an hour or more because they were too busy to bring it to her. Resident #40 shared she wanted to be woken up to receive her pain pill or else when she did wake up her pain would be to the point where she could not function. Resident #40 shared she had a [MEDICAL CONDITION] spine and it was really hurting her and she was upset it had been almost an hour since she told STNA#402 to tell the nurse she needed her pain pill. Interview was conducted on 01/23/20 at 12:13 P.M. with LPN#500 and RN#600 who were both at the medication carts at the nurses station. LPN#500 identified herself as the nurse caring for Resident #40. When asked if STNA#402 had told her about the residents pain LPN#500 revealed STNA#402 told her 40 minutes ago and she knew it was 40 minutes ago because she looked at the clock but could not get her pain pill because she was busy doing an admission. She stated she knew her pain pill was scheduled at noon. When asked what pain pill the resident needed she verified it was [MEDICATION NAME] HCL to be given every 6 hours straight. When asked if the resident was sleeping would she give the [MEDICATION NAME] LPN#500 said if the resident was sleeping they must not be in pain so no she would not wake them to give the pain pill even though the order stated every six hours. When RN#600 was asked the same question she replied if the physician order [REDACTED]. under control. At 12:14 P.M. LPN#500 said she was going to give Resident #40 her pain pill. Interview was conducted on 01/23/20 at approximately 12:29 P.M. with the Director of Nursing (DON) to review the concern with the MAR indicated [REDACTED]. The DON replied Resident #40 had been out of the facility on 01/20/20 for a brain procedure and the daughter had expressed to her she wanted her mom to get rest so the nurse probably let her sleep to get rest. The DON verified the order for the [MEDICATION NAME] HCL was to be given straight every six hours. The DON verified there was no pain medication sent with the Resident #40 nor given when she returned to the facility on [DATE]. The DON stated RN#601 was a new nurse and she would educate her about following the doctor's order, and that she would look into possibly changing the administration times for Resident #40 so she did not have to be woke up. Record review was conducted of the facility policy titled Pain Management and Pain Protocol, dated 05/21/15. The policy stated the facility would ensure pain management for any resident identified as having a potential for pain per the plan of care.

Based on record review and interview the facility failed to ensure a minimum of eight hours of registered nurse (RN) coverage per day for two of the seven days reviewed for staffing from 10/28/18 to 11/03/18. This had the potential to affect all 55 residents residing in the facility, the census was 53 on 10 /28/18 and 52 on 11/03/18, the days without adequate RN coverage. Findings include: Review of the daily staffing sheets for 10/28/18 and 11/03/18 revealed there was no RN working on 10/28/18 and only six hours of RN coverage on 11/03/18. Interview on 11/20/18 8:46 A.M. with the Director if Nursing (DON) and Human Resource Manager (HR) #601 and review of the facility staffing from 10/28/18 to 11/03/18 revealed there was no RN coverage on 10/28/18 and only six hours of RN coverage on 11/03/18. The DON verified the lack of RN coverage and stated the facility was aware of the problem and had recently hired two RN's to provide adequate coverage.

Based on observation, record review and interview the facility failed to ensure a shared blood glucose monitoring machine was properly cleaned and disinfected after use for Resident #39 to prevent the spread of infection. The facility also failed to ensure Resident #36 and #37's respiratory equipment was maintained in a clean sanitary manner to prevent the spread of infection. This had the potential to affect four residents (Resident #27, #33, #34 and #37) who received blood glucose monitoring on Maple Run hallway who used the same glucometer and two residents (Resident #36 and #37) of six residents sampled for sanitary condition of their respiratory equipment. The facility census was 55. Findings include: 1. Record review revealed Resident #39 had an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #39's physician orders, dated 11/03/18 revealed the resident was in contact/droplet isolation per facility policy. The resident also had a physician order, dated 11/06/18 for a fasting blood glucose at hour of sleep for [MEDICAL CONDITION] with no coverage. Review of Resident #39's care plan, initiated 11/05/18 revealed the resident had a communicable infections disease- [MEDICAL CONDITION] with interventions that included isolation per policy, and review necessity of infection control measures. Interview on 11/19/18 at 1:46 P.M. with Licensed Practical Nurse (LPN) #602 revealed that each cart had a blood glucose monitor machine and that she used the super Sani wipe to clean the monitor between each resident including those resident's in isolation for [MEDICAL CONDITION]. Interview on 11/19/18 at 1:26 P.M. with LPN #600 currently working the hall Resident #39 was residing revealed the nurses use the super Sani- cloth germicidal disposable wipe in the purple top container to clean the blood glucose monitor. LPN #600 revealed that she uses the blood glucose monitor in the cart on all residents on the hall including Resident #39 and uses this wipe between each use including for anyone on isolation with [MEDICAL CONDITION]. Interview on 11/19/18 at 1:53 P.M. with LPN #603 revealed that she uses the super Sani wipe in the purple top container to clean the glucometer between each resident including those on isolation for [MEDICAL CONDITION]. Interview on 11/19/18 at 2:44 P.M. with LPN #604 revealed that she uses alcohol wipes to clean the blood glucose monitor between each resident use but if a resident is in isolation then she uses the super Sani wipe with the purple top including those residents that have [MEDICAL CONDITION]. Review of super Sani-Cloth Germicidal Disposable Wipe manufacturing label revealed bacterial organisms' efficacy that were killed by this wipe, however, the [MEDICAL CONDITION] bacteria was not listed as an organism that was killed by this wipe. Interview on 11/19/18 at 4:33 P.M. with the Director of Nursing verified the super Sani wipe that the nurses were using to disinfect the blood glucose monitor does not kill the [MEDICAL CONDITION] bacteria and that Resident #39 had a [MEDICAL CONDITION] infection and received a blood glucose monitoring every night. The Director of Nursing verified the blood glucose monitors were shared between each resident including Resident #39 and Resident #27, #33, #34 and #37 who resided on the same hallway. Review of the policy, dated (MONTH) (YEAR) titled, Blood Glucose Meter; Cleaning Of Equipment revealed the facility would ensure proper technique was conducted to reduce and prevent infections using glucometer meters. The procedure included if using super Sani - Cloth germicidal wipe that the wipe was effective against antibiotic resistant organisms' [MEDICAL CONDITION]-resistant staphylococcus Aureus, [MEDICATION NAME]-resistant [MEDICATION NAME], extended spectrum beta- lactamases, and escherichia coli. The policy does not include how to clean a glucometer against the bacteria [MEDICAL CONDITION]. 2. Record review revealed Resident #36 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. Record review revealed the resident utilized respiratory therapy. Resident #36 had a physician order [REDACTED]. Review of a care plan for Resident #36, initiated 06/23/17 revealed he used a [MEDICAL CONDITION] (respiratory therapy machine) at night. Observation on 11/18/18 at 10:59 A.M. of Resident #36 revealed his [MEDICAL CONDITION] mask was laying on the dresser had a whitish film in the inside of the mask. Observation on 11/18/18 at 5:22 P.M. of Resident #36 revealed his [MEDICAL CONDITION] mask was on his bed under towels and continued to have a whitish film in the inside of the mask. Interview on 11/18/18 at 5:22 P.M. with Resident #36 revealed the nurse had not cleaned his [MEDICAL CONDITION] mask today and that the nurses rarely clean his [MEDICAL CONDITION] mask. Interview on 11/18/18 at 5:31 P.M. with Licensed Practical Nurse (LPN) #605 revealed that she did not realize the physician order [REDACTED].#36's [MEDICAL CONDITION] mask and that she did not clean the mask today. LPN #605 revealed that she signed off that she had cleaned the mask by mistake but had not cleaned it. Interview on 11/19/18 at 11:58 A.M. with Director of Nursing verified Resident #36's [MEDICAL CONDITION] mask and tubing should be cleaned daily per physician order. 3. Record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. Place on resident at 12:30 A.M. every night shift related to [MEDICAL CONDITION]. Observation on 11/18/18 at 9:12 A.M. revealed the aerosol mask was sitting on Resident #37's dresser with a white film in the inside of the mask and his bilevel position airway pressure ([MEDICAL CONDITION]) mask laying in his bed with a yellowish film to the inside of the mask. Observation on 11/18/18 at 05:25 P.M. revealed the aerosol and [MEDICAL CONDITION] mask in the same location and condition. Interview on 11/18/18 at 5:25 P.M. with Resident #37 revealed the nurse did not clean his respiratory masks today and that staff rarely clean his aerosol or [MEDICAL CONDITION] mask. Interview on 11/18/18 at 5:31 P.M. with Licensed Practical Nurse (LPN) #605 revealed she was Resident #37's nurse and that she did not clean Resident #37's neubulizer mask or [MEDICAL CONDITION] mask today. Interview on 11/19/18 at 11:58 A.M. with Director of Nursing verified that Resident #37 does not have a physician order [REDACTED].

Based on record review, review of a facility self-reported incident, review of manufacturer instructions for the use of gait belts, and family and staff interviews, the facility failed to ensure two residents (Residents #31 and #52) were free from physical restraints, not required to treat medical symptoms. Gait belts (a belt used by staff to assist with transferring) were used to physically restrain Residents #31 and #52 in wheelchairs. This resulted in Immediate Jeopardy for Residents #31 and #52 when the nursing supervisor, Registered Nurse (RN) #196, restrained the residents in their wheelchairs with gait belts for staff convenience. The use of a gait belt as a restraint posed a significant risk for injury, strangulation, death and a high likelihood of harm. This affected two of four residents reviewed for abuse, The facility census was 51. On 05/30/18 at 3:40 P.M. the administrator, director of nursing (DON) and corporate quality assurance nurse, RN #200 were notified Immediate Jeopardy began on 05/11/18 at 9:00 P.M. when RN #196 applied gait belts to restrain Residents #31 and #52 in wheelchairs in the dining room for staff convenience. The gait belts were not ordered by the physician or assessed for use as a restraint. The manufacturer instructions for gait belts indicated a gait belt was not for use as a restraint and should never be used as restraint, as a seat belt or to position a person in a chair. The Immediate Jeopardy was removed on 05/16/18 at 5:00 P.M. when the facility implemented the following corrective action. · On 05/14/18 at 5:00 P.M., all interviewable residents were interviewed by the DON to ensure they had not been abused or restrained and felt safe in the facility. · On 05/15/18 at 3:00 P.M. Social Service Designee #164 began monitoring residents for any emotional needs that required intervention. · Between 05/14/18 at 11:15 A.M. and 05/15/18 at 12:30 P.M. head toe assessments were completed on each resident by the DON to ensure there were no unidentified injuries that could be attributed to restraint use. · Between 05/14/18 at 11:15 A.M. and 05/16/18 at 3:00 P.M. each staff member was interviewed by the administrator or DON to determine if they were aware of the definition of restraints, had witnessed inappropriate use of restraints and knew who to report to if they witnessed inappropriate restraint use or abuse. · Between 05/14/18 at 1:30 P.M. and 05/16/18 at 2:00 P.M. the DON and/or Administrator in-serviced all facility staff including 75 employees and three agency staff on restraint use protocol, acceptable types of restraints, the protocol for emergency use of restraints; the facility's abuse policy and procedures, ambulation policy and procedure, gait belt policy and procedure; and dementia and the lower functioning resident. Completion of in-services was verified by staff sign in sheets. · Between 05/14/18 at 6:15 P.M. and 05/15/18 at 5:30 P.M. all residents with similar behaviors were reassessed by the DON and their care plans were revised as appropriate. · On 05/16/18 at 5:00 P.M. the DON and Acting Director of Nursing began audits for timely reporting of all incidents. The audits were to continue weekly for two weeks then randomly through use of risk tools. All findings would be reported to the quality assurance committee. The DON and Acting Director of Nursing also began audits for proper use of gait belts and to ensure no unauthorized use of restraints. The audit revealed no restraint use and gait belts were being used per facility policy and procedure for transfers of residents only. The audits were to continue for two weeks for four weeks, then randomly by the administrator and the DON. All findings would be reported to the quality assurance committee. · On 05/18/18 at 9:00 P.M. On 05/18/18 RN #196 was terminated from employment. · Interview on 06/01/18 at 1:30 P.M. with the corporate quality assurance nurse, RN #200, revealed all new agency staff would be in-serviced prior to starting their shift by reading an in-service packet. The in-service packet included emergency restraint use protocol, types of acceptable restraints and the facility's abuse policy and procedure. The supervisor would obtain the staff's signature indicating they had read and understood the material and would answer any questions. · Interviews on 05/30/18 at 5:32 P.M. and 06/01/18 at 1:55 P.M. with STNAs #126, #146, #198, and #201 revealed they were knowledgeable about proper use of gait belts, restraints and the abuse policy and procedure. Although the Immediate Jeopardy was removed on 05/16/18 at 5:00 P.M. the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their auditing tools to ensure the appropriate use of gait belts and emergency use of restraints. Findings include: Medical record review of Resident #31 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Evaluation dated 05/11/18 indicated Resident #31 was a high risk for falls. Review of physician orders dated 05/11/18 revealed the resident was ordered an antipsychotic, Quetiapine [MEDICATION NAME] 25 milligram (mg) a day and an antidepressant, [MEDICATION NAME] 20 mg daily, and physical therapy and occupational therapy evaluations. The physical therapy evaluation note dated 05/11/18 indicated the resident presented with increased debility, and decreased functional mobility. There was no physician order or assessment for the use of a restraint. Review of the progress notes from 05/11/18 to 05/31/18 indicated Resident #31 had not sustained any falls since admission. There was no documentation indicating the resident had behaviors. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #31 was rarely/never understood, and had inattention that was continuously present and did not fluctuate. Medical record review of Resident #52 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Evaluation dated 05/03/18 indicated Resident #52 was a high risk for falls. Review of progress notes dated 05/03/18 through 05/25/18 revealed there was no documentation indicating Resident #52 had behaviors or sustained any falls. There was no physician order or assessment for the use of a restraint. On 05/25/18 the resident was discharged to an assisted living facility Review of a facility self-reported incident, tracking number 0, initiated on 05/14/18 revealed the Administrator was alerted to a concern regarding gait belt use during a staff education meeting on 05/14/18. The Administrator was told at that time, that a state tested nurse aide (STNA) observed what she felt were gait belts being utilized as seat belts on wheelchairs. The STNA stated during interview that when she came to work at 10:00 P.M. she observed two residents in their wheelchairs at the nurses' station with gait belts around their waists only. The facility initiated an investigation and suspended employees who were involved with residents' care during the time identified. The DON completed head to toe assessments on both residents and did not discover any suspicious marks or bruises. Resident #31 was recently admitted to facility. She had a documented history of falls, poor balance and severe cognitive impairment with episodes of physical aggression. Interview with the nurse caring for the resident at the time of occurrence, RN #196, revealed the resident had just been admitted to facility earlier that shift and was very confused. The resident was very difficult to keep safely positioned in the chair. RN #196 stated that she made several attempts at redirection and one to one interventions that were ineffective. RN #196 stated she applied the belt with only one loop at the back of the chair to remind Resident #31 of safe boundaries. Resident #52 was admitted to the facility a week prior with Metabolic [MEDICAL CONDITION], dementia and urinary tract infection. According to interviews, Resident #52 was observed sitting in her wheelchair with a gait belt around her waist. Staff members indicated the gait belt appeared to be on her waist so that it could be used if she self-transferred and it was necessary to assist her with transfer/ambulation. However, when an STNA returned her to bed she found the gait belt had been secured to the back of the wheelchair. Review of the facility investigative summary and staff statements revealed a statement dated 05/12/18 (no time) from STNA #201 indicating when she began her shift on 05/11/18 at 10:00 P.M. she saw Resident #52 sitting by the nurses' station in her wheelchair. There was a gait belt around her waist and the wheelchair. STNA #201 untied Resident #52 and took her to her room and put her to bed. STNA #201 indicated she was unaware of the facility restraint policy so she mentioned what she saw to another staff member and was advised to report what she had seen regarding Resident #52 being secured in the wheelchair. A statement dated 05/14/18 (no time) from Hospitality Aide (HA) #199 indicated, in reference to using gait belts to restrain residents, she heard the STNA state she does that all the time. A statement dated 05/16/18 (no time) from STNA #126 revealed when she and STNA #201 walked on shift there were three residents up, Resident #31, Resident #52 and Resident #8. She got a quick report from STNA #146 and started answering call lights. When she went to Resident #52 to put her to bed at 10:15 P.M. she noticed that the gait belt was secured around her waist and around the back of the wheelchair's arm rest. STNA #126 had not noted the gait belt was secured around the wheelchair when the resident was previously observed self-propelling the wheelchair around the floor. STNA #201 thought the gait belt had been secured around the resident's waist. She put the resident to bed and told the nurse that the gait belt had been secured around the wheelchair. The nurse said okay. STNA #201 thought the nurse heard her even though she seemed busy at the time. A statement dated 05/16/18 (no time) from RN #196 revealed the resident (Resident #52) was confused, a fall risk, unable to ambulate on her own requiring the assistance of two to ambulate. After multiple attempts to redirect Resident #52 to stay in the wheelchair she was worried about the resident falling. She took the resident on rounds with her but was unable to monitor her safety while in other resident rooms. At approximately 9:00 P.M. RN #196 placed a gait belt loosely to remind Resident #52 to stop and not get up by herself. The gait belt was only looped once, not tied tight. The statement indicated the resident would be able to get out if she had tried. Further review of the investigation revealed there was not a witness statement from STNA #146 who worked the second shift with RN #196 on 05/11/18 and gave report to the oncoming STNAs. Review of the Investigative Summary of the Incident dated 05/14/18 (no time) revealed the administrator was notified by an STNA (unnamed) during a staff education meeting on 05/14/18 at approximately 11:00 A.M. that two residents, Resident #31, and Resident #52, may have been inappropriately restrained on the evening of 05/11/18 with the use of gait belts in their wheelchairs. On 05/14/18 at approximately 11:15 A.M. the DON completed a head to toe assessment on both residents. There were no suspicious marks or abnormalities observed. On 05/14/18 at approximately 12:00 P.M. the residents' physicians were notified of the accusations and the pending investigation. No new orders were generated from the notification. Resident #31's son was notified of the ongoing investigation and stated that he was in the facility on Friday (05/11/18) and just assumed the facility was using the seat belt because she was using a seat belt at a previous facility. Resident #52's daughter was notified and stated, Whatever it takes to keep my mother safe. Interview on 05/30/18 at 10:40 A.M. with the Administrator, DON and Corporate Quality Assurance Nurse, RN# 200 revealed two STNAs and one RN were suspended pending investigation. The DON stated the residents were newly admitted and having behaviors which included trying to get out of their wheelchairs. The DON said they were initially unsure who had placed the gait belts on the residents. When the supervisor, RN #196, was initially questioned she indicated she did not know who placed the gait belts on the residents. At a later date, during a private meeting with the DON and RN #196, RN #196 revealed she had placed the gait belts on the residents. The DON indicated RN #196 stated she had to walk with Resident #31 and provide her with one to one intervention to calm her down but that it did not work so she put the gait belt on her to remind her not to get up. The DON stated they terminated RN #196 because they did not feel they could trust her because she originally did not confess she had applied the gait belts to the residents. Interview on 05/30/18 at 5:32 P.M. with STNA #146 revealed she worked the second shift on 05/11/18 and was present when the gait belt was applied. STNA #146 said Resident #52 kept trying to get up, was self-propelling the wheelchair up and down the halls and they had to keep bringing her back to the dining room. The resident was trying to pick up invisible things from the floor. STNA #146 said Residents #31 and #52 were both wearing gait belts which were tied to the wheelchairs. STNA #146 indicated at the time she did not think using the gait belts were considered restraints but now realized the gait belts restricted the residents' freedom of movement and were therefore restraints. STNA #146 did not state what time the restraints were applied or when she noted they had been applied. Observation of Resident #31 on 05/30/18 at 2:50 P.M. revealed a very thin elderly female seated in a wheelchair in the dining room with five other residents. Resident #31 was not interacting with her peers and was not interviewable due to cognitive impairment. Resident #31 was not restrained, nor was she making any attempts to rise from the wheelchair. Observation of Resident #31 on 05/31/18 at 6:45 A.M. revealed the resident lying in bed on her right side. The bed had bilateral grab bars and was in the lowest position. The room was darkened and the resident was resting quietly with her eyes closed. Interview with STNA #126 on 05/31/18 at 8:17 A.M. revealed Resident #31 was found by STNA #126 on 05/11/18 seated in a wheelchair and when she attempted to assist Resident #31 to stand up from the wheelchair she realized the resident was secured to the wheelchair by the gait belt. STNA #126 had to lower Resident #31 back into the wheelchair to untie the gait belt. The gait belt was around the resident's waist, looped around the right arm of the wheelchair, and tied behind the back of the chair with a slip knot. STNA #126 also said Resident #52 was found by STNA #201 on 05/11/18 seated in a wheelchair beside the nurses' station with a gait belt around her waist and tied to the wheelchair. The gait belt was removed, and the resident was ambulated to her room. STNA #126 did not identify a specific time frame. On 05/31/18 at 9:41 A.M. a phone call was placed to RN #196. RN #196 refused to speak with the surveyor under the advice from her attorney. Interview with Resident #31's son via phone on 05/31/18 at 11:53 A.M. revealed when he visited his mother on 05/11/18 sometime after 1:30 P.M. (he could not be more precise with the time frame), he observed a white belt around her waist that was tied to the back of the wheelchair. He stated sometime after that someone from the facility called him and apologized for the resident being restrained in the wheelchair and that the nurse who applied the gait belt would be spoken to because the restraint was inappropriate. HA #199 was a no call, no show for work and was terminated from employment. Attempts to contact HA #199 on 05/31/18 at 4:13 P.M. and 06/01/18 at 2:04 P.M. via phone were unsuccessful. Review of the Abuse Policy and Procedure dated 03/03/17 revealed restraints (physical or chemical) were to only be used per physician order and in compliance with regulations and guidelines of the restraint policy and procedure. Review of the Gait Belt Policy and Procedure dated November, (YEAR) revealed a gait belt would be used during transfers and ambulation unless otherwise determined by the physician and/or identified in the resident's care plan. Review of the gait belt manufacturer instructions dated February, (YEAR) revealed a gait belt was not for use as a restraint on wheelchairs, chairs or beds. The instructions indicated gait belts were to be used in strict accordance with your facility's written procedures for approved assisted transfer, lifting, and walking procedures. This deficiency substantiates Complaint Number OH 007.

Based on record review, review of a facility self-reported incident (FRI) and interviews, the facility failed to ensure Residents #31 and #52 were free of abuse from physical restraints which were not required to treat medical symptoms. This affected two of four residents reviewed for abuse. The facility census was 51. Findings include: Medical record review of Resident #31 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Evaluation dated 05/11/18 indicated Resident #31 was a high risk for falls. Review of physician orders dated 05/11/18 revealed the resident was ordered an antipsychotic, Quetiapine [MEDICATION NAME] 25 milligram (mg) a day and an antidepressant, [MEDICATION NAME] 20 mg daily, and physical therapy and occupational therapy evaluations. The physical therapy evaluation note dated 05/11/18 indicated the resident presented with increased debility, and decreased functional mobility. There was no physician order or assessment for the use of a restraint. Review of the progress notes from 05/11/18 to 05/31/18 indicated Resident #31 had not sustained any falls since admission. There was no documentation indicating the resident had behaviors. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #31 was rarely/never understood, and had inattention that was continuously present and did not fluctuate. Medical record review of Resident #52 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Evaluation dated 05/03/18 indicated Resident #52 was a high risk for falls. Review of progress notes dated 05/03/18 through 05/25/18 revealed there was no documentation indicating Resident #52 had behaviors or sustained any falls. There was no physician order or assessment for the use of a restraint. On 05/25/18 the resident was discharged to an assisted living facility Review of a facility self-reported incident, tracking number 0, initiated on 05/14/18 revealed the Administrator was alerted to a concern regarding gait belt use during a staff education meeting on 05/14/18. The Administrator was told at that time, that a state tested nurse aide (STNA) observed what she felt were gait belts being utilized as seat belts on wheelchairs. The STNA stated during interview that when she came to work at 10:00 P.M. she observed two residents in their wheelchairs at the nurses' station with gait belts around their waists only. The facility initiated an investigation and suspended employees who were involved with residents' care during the time identified. The Director of Nursing completed head to toe assessments on both residents and did not discover any suspicious marks or bruises. Resident #31 was recently admitted to facility. She had a documented history of falls, poor balance and severe cognitive impairment with episodes of physical aggression. Interview with the nurse caring for the resident at the time of occurrence, Registered Nurse (RN) #196, revealed the resident had just been admitted to facility earlier that shift and was very confused. The resident was very difficult to keep safely positioned in the chair. RN #196 stated that she made several attempts at redirection and one to one interventions that were ineffective. RN #196 stated she applied the belt with only one loop at the back of the chair to remind Resident #31 of safe boundaries. Resident #52 was admitted to the facility a week prior with Metabolic [MEDICAL CONDITION], dementia and urinary tract infection. According to interviews, Resident #52 was observed sitting in her wheelchair with a gait belt around her waist. Staff members indicated the gait belt appeared to be on her waist so that it could be used if she self-transferred and it was necessary to assist her with transfer/ambulation. However, when an STNA returned her to bed she found the gait belt had been secured to the back of the wheelchair. Review of the facility investigative summary and staff statements revealed a statement dated 05/12/18 (no time) from STNA #201 indicating when she began her shift on 05/11/18 at 10:00 P.M. she saw Resident #52 sitting by the nurses' station in her wheelchair. There was a gait belt around her waist and the wheelchair. STNA #201 untied Resident #52 and took her to her room and put her to bed. STNA #201 indicated she was unaware of the facility restraint policy so she mentioned what she saw to another staff member and was advised to report what she had seen regarding Resident #52 being secured in the wheelchair. A statement dated 05/16/18 (no time) from STNA #126 revealed when she and STNA #201 walked on shift there were three residents up, Resident #31, Resident #52 and Resident #8. She got a quick report from STNA #146 and started answering call lights. When she went to Resident #52 to put her to bed at 10:15 P.M. she noticed that the gait belt was secured around her waist and around the back of the wheelchair's arm rest. STNA #126 had not noted the gait belt was secured around the wheelchair when the resident was previously observed self-propelling the wheelchair around the floor. STNA #201 thought the gait belt had been secured around the resident's waist. She put the resident to bed and told the nurse that the gait belt had been secured around the wheelchair. The nurse said okay. STNA #201 thought the nurse heard her even though she seemed busy at the time. A statement dated 05/16/18 (no time) from RN #196 revealed the resident (Resident #52) was confused, a fall risk, unable to ambulate on her own requiring the assistance of two to ambulate. After multiple attempts to redirect Resident #52 to stay in the wheelchair she was worried about the resident falling. She took the resident on rounds with her but was unable to monitor her safety while in other resident rooms. At approximately 9:00 P.M. RN #196 placed a gait belt loosely to remind Resident #52 to stop and not get up by herself. The gait belt was looped once, not tied tight. The statement indicated the resident would be able to get out if she had tried. Review of the Investigative Summary of the Incident dated 05/14/18 (no time) revealed Resident #31's son was notified of the ongoing investigation and stated that he was in the facility on Friday (05/11/18) and just assumed the facility was using the seat belt because she was using a seat belt at a previous facility. Resident #52's daughter was notified and stated, Whatever it takes to keep my mother safe. During an interview on 05/30/18 at 10:40 A.M. with the Administrator, director of nursing (DON) and Corporate Quality Assurance Nurse, RN# 200 the DON stated the residents were newly admitted and having behaviors which included trying to get out of their wheelchairs. The DON said they were initially unsure who had placed the gait belts on the residents but during a private meeting with the DON and RN #196, RN #196 revealed she had placed the gait belts on the residents. The DON indicated RN #196 stated she had to walk with Resident #31 and provide her with one to one intervention to calm her down but that it did not work so she put the gait belt on her to remind her not to get up. Interview on 05/30/18 at 5:32 P.M. with STNA #146 revealed she worked the second shift on 05/11/18 and was present when the gait belt was applied. STNA #146 said Resident #52 kept trying to get up, was self-propelling the wheelchair up and down the halls and they had to keep bringing her back to the dining room. The resident was trying to pick up invisible things from the floor. STNA #146 said Residents #31 and #52 were both wearing gait belts which were tied to the wheelchairs. Observation of Resident #31 on 05/30/18 at 2:50 P.M. revealed a very thin elderly female seated in a wheelchair in the dining room with five other residents. Resident #31 was not interacting with her peers and was not interviewable due to cognitive impairment. Resident #31 was not restrained, nor was she making any attempts to rise from the wheelchair. Observation of Resident #31 on 05/31/18 at 6:45 A.M. revealed the resident lying in bed on her right side. The bed had bilateral grab bars and was in the lowest position. The room was darkened and the resident was resting quietly with her eyes closed. Interview with STNA #126 on 05/31/18 at 8:17 A.M. revealed Resident #31 was found by STNA #126 on 05/11/18 seated in a wheelchair and when she attempted to assist Resident #31 to stand up from the wheelchair she realized the resident was secured to the wheelchair by the gait belt. STNA #126 had to lower Resident #31 back into the wheelchair to untie the gait belt. The gait belt was around the resident's waist, looped around the right arm of the wheelchair, and tied behind the back of the chair with a slip knot. STNA #126 also said Resident #52 was found by STNA #201 on 05/11/18 seated in a wheelchair beside the nurses' station with a gait belt around her waist and tied to the wheelchair. The gait belt was removed, and the resident was ambulated to her room. Interview with Resident #31's son via phone on 05/31/18 at 11:53 A.M. revealed when he visited his mother on 05/11/18 sometime after 1:30 P.M. (he could not be more precise with the time frame), he observed a white belt around her waist that was tied to the back of the wheelchair. Review of the Abuse Policy and Procedure dated 03/03/17 revealed restraints (physical or chemical) were to only be used per physician order and in compliance with regulations and guidelines of the restraint policy and procedure. This deficiency substantiates Complaint Number OH 007.

Based on review of a facility reported incident (FRI) and staff interview the facility failed to ensure their abuse policy and procedure was implemented in relation to the timely reporting of abuse for Residents #31 and #52. This affected one of three FRIs reviewed and one of four residents reviewed for abuse. The facility census was 51. Findings include: Review of FRI # 0 revealed the administrator was notified on 5/14/18 at 11:00 A.M. by a state tested nurse aide (STNA) that two residents, Resident #31, and Resident #52, may have been inappropriately restrained in their wheelchairs on the evening of 05/11/18 with the use of gait belts. Review of the Investigative Summary of the Incident dated 05/14/18 (no time) revealed the administrator was notified by an STNA (unnamed) during a staff education meeting on 05/14/18 at approximately 11:00 A.M. that two residents, Resident #31, and Resident #52, may have been inappropriately restrained on the evening of 05/11/18 with the use of gait belts in their wheelchairs. Review of staff statements revealed a statement dated 05/12/18 (no time) from STNA #201 indicating when she began her shift on 05/11/18 at 10:00 P.M. she saw Resident #52 sitting by the nurses' station in her wheelchair. There was a gait belt around her waist and the wheelchair. STNA #201 untied Resident #52 and took her to her room and put her to bed. STNA #201 indicated she was unaware of the facility restraint policy so she mentioned what she saw to another staff member and was advised to report what she had seen regarding Resident #52 being secured in the wheelchair. Interview on 05/30/18 at 10:40 A.M. with the Administrator, Director of Nursing and Corporate Quality Assurance Nurse (RN#200) confirmed Residents #31 and #52 had been restrained to their wheelchairs on 05/11/18 without a physician order [REDACTED]. Review of the Abuse Policy and Procedure dated 03/03/17 revealed restraints (physical or chemical) were to only be used per physician order [REDACTED]. The policy and procedure indicated any suspicion of abuse was to be reported immediately.

Based on record review, interview, review of wound clinic notes, and review of the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Stages resource, the facility failed to timely follow a physician's orders [REDACTED].#55) of thee residents reviewed for pressure ulcers. Harm occurred when Resident #55 did not receive the physician ordered wound care consult (ordered on [DATE]) until 02/08/18. During the 14-week delay for the physician ordered wound consult, for an infected stage four pressure ulcer to the right ischium, the resident acquired an additional in-house pressure ulcer which progressively deteriorated, and not identified until she was assessed at the wound care clinic on 02/08/18. The facility census was 51 residents. Findings include: Review of the closed medical record for Resident #55 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed she was cognitively intact with no behaviors. She was independent for eating and wheelchair locomotion. She was totally dependent for all other activities of daily living (ADL)'s. She had a supra pubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) and a [MEDICAL CONDITION] (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon). She had a stage four pressure ulcer present on admission. Review of the NPUAP Pressure Injury Stages resource defines a pressure ulcer as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Review of the NPUAP Pressure Injury Stages resource defines a stage four pressure ulcer as a full thickness tissue loss with exposed bone, tendon or muscle. Slough (yellow, tan, gray, green or brown) or eschar (tan, brown or black) may be present on some parts of the wound bed. Often include undermining and tunneling (undermining is less extensive, while tunneling penetrates more deeply into the tissue). Review of the closed medical record revealed the resident was having her wound to the right ischium assessed weekly by a in-house wound care consultant through 10/24/17. Review of the physician order [REDACTED]. Review of the medical record revealed the resident did not receive the wound care consult as ordered by the physician, until 02/08/18. Review of a weekly wound assessment, written by former Assistant Director of Nursing (ADON) #202, dated 11/21/17, revealed a new wound to the left thigh/left ischium, described as an abrasion, measuring 2.5 centimeters (cm) in length by 3.0 cm in width by 0.1 cm in depth. The wound bed was pink tissue. Review of the weekly wound assessment dated [DATE], written by former ADON #202, revealed the wound to the left thigh/left ischium measured 2.5 cm in length by 3.0 cm in width by 0.1 cm in depth. The wound bed now contained slough, and was described as unchanged. According to the NPUAP Pressure Injury Stages resource, the wound description should have been changed to reflect a stage three pressure ulcer, not an abrasion as described. This resource defines a stage three pressure ulcer as Full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle are not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling. Review of the weekly wound assessment dated [DATE], written by former ADON #202, revealed the left thigh/left ischium now measured 2.5 cm in length by 3.0 cm in width and now had a depth of 0.4 cm. The wound bed still contained slough tissue. The wound was described as unchanged. The wound was still described as an abrasion. Review of the weekly wound assessment dated [DATE], written by former ADON #202, revealed the left thigh/left ischium now measured 2.5 cm in length by 3.0 cm in width and now had a depth of 0.6 cm. The wound bed still contained slough tissue. The wound was described as unchanged. The wound is still described as an abrasion. Review of a physician's orders [REDACTED]. Review of the wound clinic consult note dated 02/08/18, revealed this was the resident's first visit to the wound care clinic. There was a wound to the sacrum, not previously identified by the facility, and wounds to the left and right ischiums. Review of a weekly wound assessment, written by former ADON #202, dated 02/13/18, revealed a new wound, described as moisture associated skin damage (MASD), to the sacrum/natal cleft measuring 0.4 cm in length by 0.4 cm in width, by 0.3 cm in depth. The assessment stated the wound was in-house acquired, identified on 02/09/18. This is the first documentation describing the wound, noted as being identified on 02/09/18. According to the NPUAP Pressure Injury Stages resource, this wound would be classified as a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough). Review of a progress note dated 02/22/18 revealed the resident's wound care consultation appointment was cancelled due to facility transportation issues. Review of the weekly wound assessment dated [DATE], written by former ADON #202, revealed the left thigh/left ischium now measured 2.5 cm in length by 3.0 cm in width and now had a depth of 1.0 cm with 3.0 cm tunneling at 12 o'clock. The wound bed still contained slough tissue. The wound was still described as an abrasion. Review of the weekly wound assessment dated [DATE], written by former ADON #202, revealed the wound to the sacrum/natal cleft measured 2.0 cm in length by 2.3 cm in width by 1.0 cm in depth. The wound base contained slough tissue and pink tissue. The wound was still being described as MASD. Review of the weekly wound assessment dated [DATE], written by former ADON #202, revealed the left thigh/left ischium now measured 2.5 cm in length by 3.0 cm in width and now had a depth of 1.0 cm with 5.0 cm tunneling at 12 o'clock. The wound bed still contained slough tissue. The wound was still described as an abrasion. Review of the closed medical record revealed the resident was transferred to the hospital on [DATE] and admitted for a [DIAGNOSES REDACTED]. Interview on 05/01/18 at 4:30 P.M. with corporate Registered Nurse (RN) #201 verified that the wound to the sacrum/natal cleft was identified by the wound clinic on 02/08/18 and verified that the wound was a stage two pressure ulcer, not MASD. She verified that the first documented assessment of the wound to the sacrum/natal cleft by the facility was 02/13/18, five days after it was identified by the wound clinic. She also verified that the area to the left thigh/left ischium was a deteriorating pressure ulcer, not MASD as described by the facility. She stated the original wound care consultant the resident had from admission through 10/24/17 had quit, and the facility was unable to get another wound care consultant to see the resident in-house. She verified it was not until 01/23/18 the facility obtained an order to send the resident out to a wound care clinic, despite having an order for [REDACTED]. She also verified the facility cancelled a scheduled wound care consult on 02/22/18 due to facility transportation issues. This deficiency substantiates Complaint Number OH 506, Complaint Number OH 467, and Complaint Number OH 430.

Based on observation, record review and interviews, the facility failed to provide appropriate care and treatment for [REDACTED]. This resulted in harm when Resident #32 developed a urinary tract infection [MEDICAL CONDITION] contaminated with escherichia coli (E.coli) bacterium requiring a course of intramuscular antibiotics. Resident #32 developed a second UTI, also contaminated with E.coli bacterium, on 07/29/17 requiring the insertion of a midline catheter and a course of intravenous antibiotics. This affected one of three residents reviewed for indwelling urinary catheters. The facility census was 62 residents. Findings include: Review of the medical record indicated Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3.0 Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 was intact for cognition based on a brief interview of mental status (BIMS) score of 14. The assessment indicated Resident #32 was always incontinent of bowel and had an indwelling urinary catheter for urine. A urinary catheter is a tube inserted into a person's bladder and allows the person's urine to drain freely from the bladder for collection. The MDS assessment indicated Resident #32 required extensive assistance of two persons for toileting/incontinence care. A plan of care was in place for Resident #32's catheter that indicated a goal for Resident #32 to have no infections related to her catheter. Review of a Nursing Progress Note dated 06/14/17 at 7:20 P.M., revealed cloudy, blood tinged, foul smelling urine was noted in Resident #32's catheter. Urine culture result dated 06/17/17 (from urine collected on 06/14/17) revealed the growth of greater than 100,000 escherichia coli extended-spectrum beta-lactamases (E.coli-ESBLS) bacterium. E.coli bacteria is normally found in the colon. An infection typically occurs when bacteria that live inside the bowel find their way to the urinary tract. Persons with indwelling urinary catheters coupled with bowel incontinence are at high risk for the development of UTIs associated with improper catheter care and/or improper incontinence care. A physician's orders [REDACTED]. [MEDICATION NAME] is a type of antibiotic used to treat severe infections, including infections of the urinary tract. Review of Nursing Progress Note dated 07/29/17 at 5:41 A.M., revealed Resident #32's catheter was draining cloudy, discolored urine. Urine culture result dated 07/31/17 (from urine collected on 07/29/17) revealed growth greater than 100,000 E.coli-ESBL bacterium. A physician's orders [REDACTED]. A midline catheter is inserted into a patient's vein. A larger vein is used than those for standard intravenous therapy. The midline catheter is between three to eight inches in length and may remain inserted for up to thirty days. On 09/06/17 beginning at 2:37 P.M., State tested Nurses Aide (STNA) #205 was observed providing incontinence care for Resident #32. Assistant Director of Nursing/Registered Nurse (RN) #200 was also present in the room during the observation. STNA #205 gathered supplies, washed her hands and donned gloves. STNA #205 placed several washcloths in a basin of warm water. STNA #205 removed Resident #32's blanket and raised her gown. The STNA removed one wet, folded washcloth from the basin of water and wrung it out. STNA #205 used a section of the wash cloth and wiped downward between the top of Resident #32's right upper thigh and perineum. She did not turn the washcloth to a fresh area. STNA #205 wiped downward between the top of Resident #32's left upper thigh and perineum. She did not turn the washcloth to a fresh area. STNA #205 wiped downward,over Resident #32's labia. At that point, RN #200 instructed STNA #205 to turn the washcloth. STNA #205 turned the washcloth and cleansed the catheter tubing with one stroke from the insertion point (urethra) outward approximately six to eight inches. STNA #205 placed the soiled washcloth on a towel near the bottom of the bed, on the mattress. STNA #205 removed a second washcloth from the basin, squirted shampoo and body wash onto the cloth, and cleaned between Resident #32's right upper thigh and perineum, between her left upper thigh and perineum and her labia, turning the cloth after each stroke. STNA #205 cleansed the catheter tubing, from the insertion point outward and without lifting the washcloth from the tubing, wiped the tubing again going backwards toward the urethra and then outward again. STNA #205 placed the contaminated washcloth on the towel at the bottom of the bed and removed another wet washcloth from the basin of water. STNA #205 rinsed between Resident #32's right upper thigh and perineum, between her left upper thigh and perineum, labia and catheter tubing, turning the cloth after each stroke. STNA #205 placed the contaminated washcloth on the bottom of the bed. STNA #205 dried Resident #32 in the same manner and placed the towel on the bottom of the bed, on the mattress. During an interview on 09/06/17 at 2:59 P.M., STNA #205 verified she did not turn the washcloth after each stroke while providing urinary catheter care for Resident #32, until she had been coached to do so by RN #200. STNA #205 acknowledged, while cleaning the catheter tubing, she inappropriately made a forward, then backward stroke, without turning the cloth. STNA #205 verified she placed the contaminated washcloths and towel on Resident #32's mattress after use. Review of the facility's policy and procedure entitled Catheter Care Male-Female, (effective February 2011) indicated the purpose of the policy was to prevent infection of the resident's urinary tract along with daily visualization of the catheter site. The procedure indicated that for a female: to use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. With a clean washcloth, rinse with warm water using the above technique. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. During an interview on 09/08/17 at 10:46 A.M., the Director of Nursing verified Resident #32 sustained two E.coli UTIs, one each in June 2017 and July 2017.

Based on record review and interview the facility failed to prevent an avoidable decline in Resident #59's bladder continence. Actual harm occurred when Resident #59 declined from being totally continent of urine to being frequently incontinent of urine due to staff not providing timely assistance to her to use the toilet. Resident #59 was not placed on any type of individualized toileting schedule to attempt to improve her urinary continence. This affected one resident (Resident #59) of two residents reviewed regarding bladder function. The census was 43 residents. Findings include: Resident #59 had [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) admission assessment dated [DATE] revealed Resident #59 was cognitively intact, alert and oriented, and was always continent of bowel and bladder. Review of the evaluation for continence and retraining/scheduled toileting dated 02/17/16 revealed Resident #59 was occasionally incontinent of bladder. The resident was to be placed on a scheduled toileting program. Review of the toileting delivery/results record for March, 2016 indicated Resident #59 was to be offered toileting upon arising, before and after meals, at night and as needed throughout the night. Resident #59 required staff to assist her to the toilet. The resident had incontinent episodes of bladder. The facility was to promote bladder continence. Review of the care plan dated 03/31/16 revealed Resident #59 had an activities of daily living self-care performance deficit and required staff assistance. The care plan dated 03/31/16 indicated the resident was occasionally incontinent of bladder and had a mix of stress incontinence and urge incontinence. The care plan indicated Resident #59 required staff to assist her to the toilet. Review of the MDS assessment dated [DATE] indicated Resident #59 was moderately cognitively impaired and frequently incontinent of bladder. This assessment revealed Resident #59 had a decline in cognitive status and bladder function. Review of the physician orders [REDACTED].#59 was to receive restorative toileting services which was scheduled toileting upon rising, before and after meals, at bedtime and as needed throughout the night. An interview with the restorative Registered Nurse (RN) #32 on 07/07/16 at 9:55 A.M. verified Resident #59 was on a restorative toileting program. RN #32 verified the MDS assessments revealed Resident #59 experienced a decline in bladder continence. RN #32 verified there was no documentation which indicated Resident #59 was on an individualized toileting program. An interview with RN #32 on 07/07/16 at 10:30 A.M. verified there was no documentation that indicated the resident was receiving restorative toileting. RN #32 verified the resident was alert and oriented. The RN stated she just started at the facility in March, 2016 and was not aware of the restorative program the resident should be on to maintain her bladder function. She stated she was the only person who addressed the restorative programs. On 07/07/16 at 11:30 A.M. interview with the Resident #59 revealed she was incontinent because she required assistance to go to the bathroom and had to frequently wait for staff assistance. Resident #59 stated when she was independent with toileting she had no problems. She stated she had to wear an incontinence brief because she had accidents now due to waiting for assistance from the staff. An interview with State tested Nurse Aide (STNA) #33 and STNA #34 on 07/07/16 at 12:00 P.M. revealed there were books available to them with information regarding the care of each resident. STNA #33 and #34 indicated all of the residents had the same toileting schedule. The books with the resident's kardex (information card) and the restorative programs were reviewed with the STNAs and revealed all the residents who required assistance for toileting were on the same toileting schedule: upon arising, before and after meals, at night and as needed during the night.

Based on medical record review, staff interviews, review of facility laboratory results, review of facility PT/INR ([MEDICATION NAME] Time/International Normalized Ratio)/[MEDICATION NAME] ([MEDICATION NAME]) Flowsheet, review of facility medication administration records, and review of WebMD.com, Drugs and Medication, the facility failed to ensure medications were administered accurately and according to physician's orders [REDACTED].#15, #34, #71, #41, #82, and #10. This resulted in Immediate Jeopardy for seven (#32, #15, #34, #71, #41, #82, and #10) of nine sampled residents reviewed for [MEDICATION NAME] (blood thinning) medication administration. Additionally, one residents (#2) was placed at risk for more than minimal harm that is not Immediate Jeopardy due to the facility's failure to ensure antidiabetic medication was administered as ordered. A total of 12 residents were reviewed for medication errors, including the eight aforementioned residents reviewed for medication administration. On 04/30/15 at 4:30 P.M., the Administrator, Director of Nursing (DON), and Regional Nurse #1, were notified that Immediate Jeopardy began on 03/23/15, when the facility failed to hold Resident #32's [MEDICATION NAME] as ordered by Physician #94. Review of the PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) flow sheet revealed an entry documented by Licensed Practical Nurse (LPN) #90 on 03/23/15, indicating Physician #94 was notified of Resident #32's PT/INR results, and the physician instructed the nurse to hold the resident's [MEDICATION NAME]. However, there was no evidence of a corresponding physician's telephone order to hold the resident's medication order for [MEDICATION NAME], 4 milligrams (mg) daily. As a result, Resident #32 continued to receive [MEDICATION NAME] 4 mg daily from 03/23/15 at 8:00 P.M. through 03/28/15 at 8:00 P.M. On 03/29/15 at 4:00 A.M., Registered Nurse (RN) #93 documented in nurses notes that Resident #32 had multiple ecchymotic (bruises) patches to bilateral lower extremities. LPN #91 then documented on 03/29/15 at 11:00 A.M. that Resident #32's dressing to the groin was changed and a small amount of bleeding was present. A nurse's note documented by LPN #91 on 03/29/15 at 1:00 P.M. indicated Physician #94 was notified and ordered a STAT PT/INR. These laboratory results, dated 03/29/15, revealed a PT of 59.6 and critically high INR of 23.42. Physician #94 was notified and gave a new order to LPN #92 on 03/29/15 at 4:20 P.M. to hold the [MEDICATION NAME] until PT/INR was good, draw PT/INR laboratory tests daily for one week, administer Vitamin K, 10 milligrams (mg) intramuscular (IM) and apply pressure to the injection site. The DON was not notified of this incident when it occurred, and the facility failed take corrective actions at that time to address their medication administration system and prevent subsequent incidents of significant medication errors with [MEDICATION NAME] administration. The Immediate Jeopardy continued on 03/30/15, when Resident #15's physician wrote an order to alternate [MEDICATION NAME] 9 mg (even days) and 7 mg (odd days) every other day. However, [MEDICATION NAME] 9 mg was administered on 03/30/15, and 6 mg was administered on 03/31/15, instead of 7 mg. The Immediate Jeopardy continued on 03/31/15, when Resident #34's physician gave an order for [REDACTED]. In addition, [MEDICATION NAME] 5 mg was administered to the resident on 04/16/15 at 8:00 P.M. without evidence of a corresponding physician's orders [REDACTED].#71 ' s physician wrote an order to continue a one-time dose of [MEDICATION NAME] 8 mg on 04/12/15. However, there was no evidence this [MEDICATION NAME] dose was administered on 04/12/15, or a physician's orders [REDACTED]. The Immediate Jeopardy continued on 04/13/15 when Resident #41's scheduled dose of [MEDICATION NAME] 4 mg, to be given at 8:00 P.M., was held on 04/13/15. However, there was no evidence of a physician's orders [REDACTED]. The Immediate Jeopardy continued on 04/18/15 when Resident #82's physician gave an order dated 04/18/15, to administer [MEDICATION NAME] 4 mg daily at 8:00 P.M. However, there was no documented evidence that [MEDICATION NAME] 4 mg was administered on 04/18/15 at 8:00 P.M. The Immediate Jeopardy continued on 04/23/15, when Resident #10 was given [MEDICATION NAME] 3 mg, when according to physician's orders [REDACTED]. The Immediate Jeopardy was removed on 04/30/15 at 10:00 P.M. when the facility implemented the following corrective actions: · On 04/30/15, the director of nursing (DON) and Regional Nurse #96 identified all of the residents receiving [MEDICATION NAME] therapy, and audited their medical records to ensure accuracy of medication orders with the Medication Administration Record [REDACTED]. · On 04/30/15, LPN #97 audited the physician's orders [REDACTED]. A physician(s) order for a PT/INR laboratory test was obtained if a resident's PT/INR was not drawn on 04/30/15 or not scheduled to be drawn on 05/01/15. · On 04/30/15, the DON or designee began auditing for all residents receiving [MEDICATION NAME] therapy, the PT/INR flow sheets, medication administration records (MAR), physician's orders [REDACTED]. This auditing is to occur three times a week for two months, and will continue as directed by the Quality Assurance (QA) committee. · On 04/30/15 at 1:00 P.M., the administrator notified the medical director of the Immediate Jeopardy, and scheduled a Quality Assurance (QA) meeting to review the facility's corrective action plan, which the medical director attended. This QA meeting was held on 05/01/15 at 11:00 A.M. · On 04/30/15 at 10:00 P.M., the DON and Regional Nurse #96 completed inservices for all 14 nursing staff, including three RNs and 11 LPNs, on the facility Anticoagulation Protocol; physician notification for a change in resident condition; documentation of telephone orders; compliance with physician's orders [REDACTED]. The nurses were not permitted to work until they attended the inservice training and passed the written competency test. LPN #90 attended this inservice and passed the written competency test. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as a significant medication error occurred on 05/04/15 when Resident #2 was given an incorrect dose of 26 units of [MEDICATION NAME]at the incorrect time. Findings include: 1. A review of Resident #32's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 13, indicating the resident was cognitively intact. A review of the medical record indicated that the resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] with orders for a PT/INR on 03/19/15. An untimed telephone order dated 03/19/15 indicated to resume the hospital dose of [MEDICATION NAME] 4 mg by mouth daily, and obtain a PT/INR on 03/23/15. laboratory results dated [DATE] indicated the resident had a PT of 42.9 (normal 18.2-23.5) and an INR of 3.7 (normal 2.0-3.5). This laboratory's standard anticoagulant values for INR were 2.0 - 3.0, and the aggressive anticoagulant values were 2.5 - 3.5. The laboratory results were faxed to the facility on [DATE] at 1:54 P.M. The PT/INR flow sheet completed by LPN #90 indicated that the physician was notified of the laboratory results and instructed nursing to hold the [MEDICATION NAME]. On the flow sheet, the section for the next PT/INR date had need date? written in that field. According to Resident #32's MAR, [MEDICATION NAME] 4 mg was administered at 8:00 P.M. on 03/23/15, 03/24/15, 03/25/15, 03/26/15, 03/27/15, and 03/28/15. According to WebMD.com, Drugs and Medication, [MEDICATION NAME] is a medication used to decrease the blood clotting time and can cause very serious (possibly fatal) bleeding. To decrease the risk for bleeding, monitoring of INR results is recommended to ensure the individual is taking a safe and therapeutic dose of [MEDICATION NAME]. Review of the laboratory results for March 2015 revealed no PT/INR's were completed for the resident between 03/24/15 and 03/28/15, when Resident #32 continued to receive [MEDICATION NAME] 4 mg daily. A nurse's note documented by RN #93 on 03/29/15 at 4:00 A.M. stated that Resident #32 had multiple ecchymotic (bruises) patches to bilateral lower extremities. A nurse's note documented by LPN #91 on 03/29/15 at 11:00 A.M. stated that the resident's dressing to the groin was changed and a small amount of bleeding was present. A nurse's note documented by LPN #91 on 03/29/15 at 1:00 P.M. stated that Resident #32 had a PT/INR on 03/23/15 with no new orders for follow-up PT/INR noted. Physician #94 was notified and ordered a STAT PT/INR. A review of the laboratory results dated [DATE] revealed a PT of 59.6 and critically high INR of 23.42. A nurse's noted documented by LPN #92 dated 03/29/15 at 4:20 P.M. indicated that Physician #94 was notified of the PT/INR results and gave a new order to hold the [MEDICATION NAME] until PT/INR was good; draw PT/INR daily for one week; and administer Vitamin K 10 mg intramuscular (IM) and apply pressure to the injection site. A review of the Medication Administration Record [REDACTED]. A review of the laboratory results dated [DATE] indicated Resident #32 had a PT of greater than 128 and an INR of greater than 10. A review of a nurse ' s notes documented by LPN #90 on 03/30/15 at 10:45 A.M. revealed the laboratory results were faxed to Physician #94. A nurse ' s note documented by RN #98 on 03/30/15 at 2:30 P.M. stated a new order was received for Vitamin K 10 mg IM (one time now), apply pressure at injection site, daily PT/INR, and continue to hold [MEDICATION NAME]. A review of the MAR indicated [REDACTED].M. A review of the laboratory results dated [DATE] indicated a PT of 113.1 and an INR of 8.9. A review of the nurse's note documented by LPN #90 on 03/31/15 at 11:15 A.M. indicated Physician #94 was faxed and called with the PT/INR results. A nurse's note documented by RN #98 on 03/31/15 at 1:00 P.M. stated that new orders were received. An untimed telephone order documented by RN #99 dated 03/31/15 stated to give Vitamin K, 10 mg IM (one time now), apply pressure at injection site, continue daily PT/INR, and continue to hold [MEDICATION NAME]. A review of the MAR indicated [REDACTED].M. by LPN #90. Interview with the Regional Nurse #96 on 04/30/15 at 10:55 A.M. verified the findings on the PT/INR flow sheet, and the physician had been notified of the PT/INR results on 03/23/15 and at that time had ordered the [MEDICATION NAME] to be held. She verified that there was no order written on 03/23/15 to hold the [MEDICATION NAME] or for a repeat PT/INR. She also verified that in the flow sheet column titled Next Date PT/INR, need date? was documented by LPN #90. She verified that LPN #90 should have written a telephone order to hold the [MEDICATION NAME] and ensure the next PT/INR date was obtained by the physician. According to interview with Regional Nurse #96 on 04/30/15 at 6:35 P.M. the DON and Regional Nurse #96 audited the medical records on 04/30/15 to identify all of the residents receiving [MEDICATION NAME] therapy. They identified eight additional residents receiving [MEDICATION NAME] therapy (#10, #15, #33, #34, #41, #62, #71, #82). According to interview with Regional Nurse #96 on 04/30/15 at 6:35 P.M., LPN #97 and LPN #104 audited all of the physician's orders [REDACTED]. They identified the date of the last PT/INR drawn and the date of that the next PT/INR was scheduled. If a PT/INR had not been drawn on 04/30/15, or was not scheduled to be drawn on 05/01/15, they notified the physician to obtain an order for [REDACTED].#34, #41, #62, #71, #82) who were on [MEDICATION NAME] therapy. A second PT/INR Audit was completed (to validate the results of the first audit) on 04/30/15 by LPN #104 and RN #102 for the nine residents (#10, #15, #32, #33, #34, #41, #62, #71, #82) who were on [MEDICATION NAME] therapy. The results of the audits revealed no errors at this time with the lab and [MEDICATION NAME] physicians' orders and the completion dates of the lab draws. The interview with Regional Nurse #96 on 04/30/15 at 6:35 P.M. also revealed the DON and Regional Nurse #96 would in-service all licensed nursing staff on the anticoagulation policy, notification of change in resident's condition, documentation of telephone orders and compliance with physician's orders [REDACTED]. The nurse's would not be permitted to work until they had signed off on the educational training and passed the competency. A review of the signed educational training and competency revealed that the DON, RN's #93, #98, #102, and #112 and LPN's #90, #92, #93, #97, #100, #104, #107, #108, #110, #111, and #113 had received the educational training and passed the competency on 04/30/15. An interview with the DON on 05/06/15 at 11:30 A.M. indicated that four per diem nurses who have not yet completed the educational packet and passed the anticoagulation therapy competency test would not be permitted to work until this was completed. Interview with Regional Nurse #96 on 04/30/15 at 6:35 P.M. revealed the administrator notified the medical director of the Immediate Jeopardy on 04/30/15 at 4:42 P.M., and was to schedule a Quality Assurance (QA) meeting to review the corrective measures. The QA meeting was held on 05/01/15 at 11:00 A.M. with the medical director in attendance. On 05/06/15, review of the PT/INR Audit's revealed that daily PT/INR audits were completed by the DON from 05/01/15 to 05/06/15. Interviews were completed with six licensed nurses on 05/07/15 between 11:10 A.M. and 12:40 A.M. Registered Nurses (RN) #98 and #102 and Licensed Practical Nurses (LPN) #90, #100, #104 and #105 verified they had been inserviced on the anticoagulation policy and procedure including obtaining and documenting physician orders, monitoring PT and INR levels, administering the medication, as ordered, and notification of the physician with any change in resident condition. Six of six licensed nurses revealed knowledge of the policy and procedures and responded appropriately to related scenarios. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating the resident is cognitively intact. A review of the medical record revealed a telephone order dated 03/30/15 at 10:30 A.M. with an order to hold [MEDICATION NAME] 4 mg today on 03/30/15, administer [MEDICATION NAME] 2 mg times one on 03/30/15, and then obtain a PT/INR on 04/01/15; resume [MEDICATION NAME] 3 mg every other day and 4 mg every other day. However, there was no evidence in the medical record that the PT/INR was obtained on 04/01/15 according to the physician's orders [REDACTED].>The medical record also included a laboratory report dated 04/23/15 with results of a PT 33.9/INR 2.9. A notation on the PT/INR laboratory report dated 04/23/15 indicated to give [MEDICATION NAME] 3 mg today and then resume alternating 3 mg every other day and 4 mg every other day. The MAR indicated [REDACTED]. However, according to the physician's orders [REDACTED]. There was no evidence of a physician's orders [REDACTED]. An interview with the DON on 05/05/15 at 10:55 A.M. verified that there was no PT/INR obtained on 04/01/15 per physician's orders [REDACTED]. 3. Resident #15 was admitted to the facility on [DATE]. She had current [DIAGNOSES REDACTED]. There was a physician's order [REDACTED]. The March 2015 MAR indicated [REDACTED]. This was verified with the DON on 05/01/15 at 12:05 P.M. 4. Resident #34 was admitted to the facility on [DATE]. The resident had current [DIAGNOSES REDACTED]. There was a PT/INR completed 03/31/15 with an INR result of 1.3. There was a physician's orders [REDACTED]. The March 2015 MAR indicated [REDACTED]. This was verified with the DON on 05/05/15 at 3:48 P.M. The PT/INR dated 04/16/15 indicated an INR result of 2.4. A notation on the PT/INR laboratory report dated 04/16/15 indicated to continue the same dose of 5 mg of [MEDICATION NAME] per doctor order. The April 2015 MAR indicated [REDACTED].M. There was no evidence of a physician's orders [REDACTED]. This was verified with the DON on 05/05/15 at 3:46 P.M. 5. Resident #71 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. Continue PT INR daily - 04/11/15. Review of the MAR indicated [REDACTED]. Review of the PT INR report dated 04/11/15 revealed an abnormal, elevated level. Review of the same form revealed a handwritten OK Stay Review of the physician order [REDACTED]. Review of the MAR indicated [REDACTED]. During interview on 05/15/15 at 11:12 A.M., the DON verified there was no evidence [MEDICATION NAME] was administered on 04/12/15 or a physician order [REDACTED]. A review of the facility ' s General Dose Preparation and Medication Administration last revised 01/01/13 states that prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, and for the correct resident. The facility staff should confirm that the MAR indicated [REDACTED] 6. Resident #41 was admitted to the facility on [DATE]. She had current [DIAGNOSES REDACTED]. The resident had a PT/INR completed 04/13/15 with INR results of 3.3. The laboratory report dated 04/13/15 and the facility's PT/INR [MEDICATION NAME] ([MEDICATION NAME]) Flow sheet indicated to hold the [MEDICATION NAME] on 04/13/15, then resume at 4 mg. Review of the MAR indicated [REDACTED]FYI. The [MEDICATION NAME] 4 mg dose scheduled at 8:00 P.M on 04/13/15 was circled and noted as held. There was no evidence of a physician's orders [REDACTED]. This was verified with the DON on 05/01/15 at 12:05 P.M. 7. Resident #82 was admitted to the facility on [DATE] at 10:55 A.M. with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].M. A telephone order dated 04/18/15 for a PT/INR daily starting on 04/19/15. A review of the Medication Administration Record [REDACTED].M. per the physician's orders [REDACTED]. An interview with the DON on 05/05/15 at 9:57 A.M. verified that the PT/INR was not drawn on 04/19/15 per physician's orders [REDACTED].M. on 04/18/15 per physician's orders [REDACTED].M. on 04/18/15. The DON verified that the nurse would have been expected to call the physician to get an order to administer the medications at 10:00 P.M. rather than not getting his medications. 8. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 8, indicating the resident had moderate cognitive impairment. A review of the physician's orders [REDACTED]. The MAR indicated [REDACTED].M. and the evening dose was to be given at 8:00 P.M. A review of the May 2015 MAR indicated [REDACTED].M. as ordered by the physician. The MAR indicated [REDACTED].M. However, the physician order [REDACTED]. During a review of the facility's medication errors on 05/06/15 at 10:45 A.M. the DON verified that on 05/04/15 at 4:30 P.M., LPN #99 gave an incorrect dose of 26 units of [MEDICATION NAME] subcutaneously (SQ) to Resident #2 at the incorrect time.

Based on observation, record review, and interview, the facility failed to provide appropriate assistance for bed mobility to prevent a fall for Resident #41. Harm occurred when Resident #41 fell from the bed during care by staff and sustained a fractured humerus. The facility also failed to ensure safety measures were in place as ordered to prevent falls for Resident #68. This affected two of three residents (Residents #41 and #68) reviewed for falls. The facility census was 47 residents. Findings include: 1. Resident #41 was originally admitted to the facility on [DATE] and readmitted on [DATE]. She had current [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #41 was frequently incontinent of bowel and bladder and was totally dependent on two or more staff for bed mobility. The activities of daily living care plan indicated an intervention dated 07/14/14 for the resident to be 2 assist while changing r (resident) and during bed mobility. The fall care plan dated 10/23/13 indicated the resident was at risk for falls with interventions in place including a perimeter mattress dated 08/26/14, and grab bars added on 02/19/15. Review of the nursing communication form and progress note dated 01/10/15 indicated on 01/10/15 at 2:00 A.M. State tested Nurse Aide (STNA) #115 reported to the nurse that he was providing perineal care to the resident. The resident reached for her end table and rolled out of bed onto the floor, face down. The resident was awake and alert with mild confusion. Her limbs were anatomically correct and she complained of pain to the right shoulder, neck, right fingers, right knee, bilateral hips and left rib area. She had a large hematoma to her left forehead and bruising to both knees. Her left pupil was slightly larger than the right and slightly slower to respond. The resident was transferred to bed per mechanical lift and four staff members. The resident was transferred to the hospital for evaluation. The facility's Investigation Summary Sheet, dated 01/12/15, indicated the resident had left-sided weakness and paralysis. Following the incident, the resident suffered an impacted fracture of the surgical head of the right humerus. The hospital emergency room applied a sling to the resident's right arm and ordered the resident to have a follow-up with an orthopedic surgeon in 1-2 days. Interview with the director of nursing (DON) and regional Registered Nurse (RN) #96 on 04/29/15 at 4:45 PM revealed the care plan for Resident #41 indicated she required two staff assistance for turns and positioning in bed. The nurse on duty at the time of the incident was RN #93 and the state tested nurse aide (STNA) who provided care to the resident, without a second staff assist, was STNA #115. Both staff received written disciplinary action. Review of the Disciplinary Action Form dated 01/13/15 indicated STNA #115 received discipline for creating and/or contributing to unsafe condition, failure to use safety devices and failure to follow policies of governing resident care. STNA #115 was providing care to the resident in bed and turned the resident to the right side. The resident reached for the over bed table and rolled out of bed onto the floor. STNA #115 was educated regarding the use of care cards. Review of the Disciplinary Action Form dated 01/13/15 indicated RN #93 received discipline for creating and/or contributing to unsafe condition, failure to correct unsafe conditions which are observed as failure and failure to follow policies of governing resident care. RN #93 was educated on the need to monitor STNAs and ensure provision of care per the resident care cards. The CNA-ADL (certified nurse aide-activities of daily living)Tracking Form for Resident #41 for January 2015 for bed mobility was reviewed. The documentation indicated Resident #41 was totally dependent for bed mobility and received one staff assist from 01/01/15 through 01/28/15 on the first shift, received extensive assistance with only one staff assist from 01/01/15 through 01/23/15 on the second shift. It was verified with RN #96 on 05/01/15 at 4:45 P.M. that Resident #41 was not provided the appropriate amount of assistance for bed mobility during the month of January 2015. On 04/29/15 at 11:05 A.M., Resident #41 was observed in bed on her back with grab bars elevated. The resident had a discolored bluish-gray area noted under her left eye and to her left forehead. On 04/30/15 at 8:30 A.M. the resident was observed in her high back wheelchair in her room. Interview with the resident revealed she was tired. Her voice was very soft and weak. She admitted to falling out of bed and injuring her arm, but unable to recall any details. She kept closing her eyes. 2. Resident #68 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 had severe cognitive impairment. Review of an admission Fall Risk assessment dated [DATE] and updated 02/10/15, revealed Resident #68 was at a high risk for falls. The assessment identified risk factors including a history of falls within the past 90 days, a decline in cognition, assistance required for elimination, ambulation with balance problems, an unsteady gait requiring physical assistance, diagnoses, impulsive behaviors and medications. Review of a Fall Risk care plan dated 12/10/14 included interventions requiring grippy socks at all times and maintaining a safe environment. Review of a physician order [REDACTED]. A Fall Investigation review was completed. Resident #68 had seven falls since admission on 12/10/14. On 12/12/14 at 2:50 P.M., Resident #68 attempted to stand, unassisted, and fell on to her buttocks. The investigation revealed no evidence non-skid footwear was in place. On 04/30/15 at 9:49 A.M., the DON verified there was no evidence Resident #68 was wearing non-skid footwear. On 12/13/14 at 3:15 A.M., Resident #68 was in the main lounge area for increased supervision due to multiple attempts to get out of her bed. Resident #68 slid out of her wheelchair onto the floor. The investigation revealed no evidence non-skid footwear was in place. On 04/30/15 at 9:49 A.M., the DON verified there was no evidence Resident #68 was wearing non-skid footwear. On 01/03/15 at 4:15 A.M., Resident #68 was in the main lounge area for increased supervision due to multiple attempts to get out of her bed and ambulate unassisted. The nurse was sitting at the nurse's station and heard ouch and looked up to see Resident #68 sitting on the floor in front of her wheelchair. The investigation revealed Resident #68 was very impulsive and does not wait for assistance. There was no evidence Resident #68 was wearing non-skid footwear. On 04/30/15 at 9:49 A.M., the DON verified there was no evidence Resident #68 was wearing non-skid footwear. On 01/17/15 at 11:45 A.M., Licensed Practical Nurse (LPN) #91 assisted Resident #68 to a sitting position on the side of her bed. LPN #91 left the room to obtain medication from the medication cart in the hallway. LPN #91 left the resident unattended. When LPN #91 turned around to walk back into the room, Resident #68 was on the floor. The resident said she was trying to get up to go to the bathroom. The same investigation revealed no evidence of inservice education for LPN #91 related to leaving the resident unattended on the side of the bed. The same investigation revealed no evidence Resident #68 was wearing non-skid footwear. On 04/30/15 at 9:49 A.M., the DON verified there was no evidence LPN #68 was inserviced and no evidence Resident #68 was wearing non-skid footwear. On 01/27/15 at 8:45 A.M., Resident #68 was in her room and was heard yelling for assistance. Resident #68 was found sitting on the floor between her bed and her wheelchair. Resident #68 said she was transferring herself from the bed to the chair. The same investigation revealed no evidence Resident #68 was wearing non-skid footwear. On 04/30/15 at 9:49 A.M., the DON verified there was no evidence LPN #68 was inserviced and no evidence Resident #68 was wearing non-skid footwear. On 03/19/15 at 11:00 A.M., Resident #68 yelled out. Resident #68 was found on the floor kneeling next to her bed. She was wearing non-skid footwear. She said she was transferring herself back to bed from the wheelchair. The same investigation revealed no new intervention to address the fall. On 04/30/15 at 9:49 A.M., the DON verified there was no new intervention to address the frequent falls. During the same interview, the DON said she had not attempted non-skid strips at the bedside because, at times, Resident #68 resisted transferring from the bed. The DON believed this could increase the resistance. The DON verified she had never attempted the use of a sensor alarm because she believed the noise would agitate Resident #68.

Based on observations, record reviews and interviews, the facility failed to ensure adequate pressure ulcer reduction interventions were implemented, prompt identification, assessment and treatment was provided, and appropriate wound care was delivered to promote healing and prevent infections for Resident #73 resulting in a decline in wound status. This affected one resident (Resident #73) of three residents reviewed for pressure ulcers of eight residents identified with pressure ulcers. Also, the facility failed to ensure adequate pressure ulcer reduction interventions were implemented, prompt identification, assessment and treatment was provided, and appropriate wound care was delivered to promote healing and prevent infections for Resident #50. Additionally, the facility failed to adequately monitor Resident #53's status related to the development of a wound infection, failed to provide treatment as ordered and failed to investigate the cause of the resident's wound infection. The facility also failed to ensure nutritional interventions were provided to promote wound healing for Resident #38 and #55. This affected five of eight residents reviewed for pressure ulcers. The facility census was 42. Findings include: 1. Resident #73 was admitted to the facility 12/06/12 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #73 had moderate cognitive impairment. The MDS assessment indicated Resident #73 was totally dependent for all care, including bed mobility. The MDS assessment indicated Resident #73 was admitted to the facility with a Stage Three pressure ulcer. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissues. A Stage Three pressure ulcer presents as a full thickness tissue loss. A Stage Three pressure ulcer may include undermining or tunneling. The current altered skin integrity plan of care indicated a low air loss mattress was added on 01/03/13. The plan of care included an intervention to observe skin every day during care, note any areas of concern and report to the physician/nurse practitioner, as warranted. Review of the Wound Evaluation Flow Sheet from admission on 12/06/12 indicated a 2.0 centimeter (cm) by 1.0 cm by 1.0 cm deep coccyx wound with 100 percent (%) slough tissue. The Wound Evaluation Flow Sheet indicated the wound was a Stage Three pressure ulcer with no exudates, or odor and the surrounding tissue was pink. Review of a Wound Consultant report dated 12/11/12 confirmed Resident #73 had a Stage Three pressure ulcer to her coccyx measuring 2.0 cm by 1.0 cm by 0.6 cm deep. The report indicated there were no signs and symptoms of infection. The wound had pale pink drainage with no slough tissue identified. The wound was described as 75 to 100% beefy red tissue. The Wound Consultant report was signed by Certified Nurse Practitioner (CNP) #29. Wound Consultant reports dated 12/18/12 and 12/31/12 indicated the wound was unchanged. The Wound Consultant report dated 01/08/13 indicated the nursing department reported the wound had worsened, measuring 3.0 cm by 1.7 cm. The wound bed was described with 25 to 50%, loose, adherent yellow slough. Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist and stringy, at times. Review of the Wound Consultant report dated 01/15/13 indicated the wound had increased in size measuring 3.0 cm by 2.7 cm with 25 to 50% yellow, slough wound bed. The Wound Consultant report dated 01/29/13 indicated the wound measured 2.6 cm by 2.0 cm with a depth of 3.0 cm and 25% of the wound bed with yellow slough. The report revealed the wound deteriorated with undermining of 2.0 cm at twelve o'clock and 0.9 cm at nine o'clock. Undermining is the destruction of tissue or ulceration extending under the skin edges, so that the pressure ulcer is larger at its base than at the skin surface. The Wound Consultant/Nurse Practitioner wrote orders for the use of a [DEVICE]. The Wound Consultant report dated 01/29/13 indicated the wound had improved measuring 2.6 cm by 2.0 cm by 3.0 cm with the tunneling unchanged. The wound continued with 25% loose, yellow slough. The Wound Consultant report dated 02/05/13 indicated the wound was improving, with an increased undermining at twelve o'clock to 3.9 cm and the [DEVICE] continued. The Wound Consultant report dated 02/19/13 indicated the wound had further worsened. The note indicated the [DEVICE] had been discontinued due to an inability to maintain negative pressure. The wound had undermining at twelve o'clock that measured 4.2 cm and three o'clock that measured 2.0 cm. laboratory results dated [DATE] (from a specimen collected 02/19/13) revealed Resident #73's wound was positive for a [MEDICAL CONDITION] (MRSA) infection. physician's orders [REDACTED]. physician's orders [REDACTED]. On 02/26/13 at 10:35 A.M., the Director of Nursing (DON) indicated that CNP #29 was present in the facility assessing all residents with wounds. The DON revealed, however, that observation of the CNP providing wound care would not be possible due to the facility's policy prohibiting such. The DON explained CNP #29 would remove the wound dressings, assess and measure all the residents' wounds. The DON revealed, however, that CNP #29 would not apply any of the new wound treatments for the residents. The DON explained the floor nurses would provide the wound treatments when they had the opportunity. The surveyor requested to observe the wound treatment for [REDACTED]. On 02/26/13 at 1:26 P.M., The DON indicated the South Hall floor nurse, would not be providing wound care for Resident #73. The DON verified the dressing had been taken off earlier that day by CNP #29 and the dressing remained off. The DON indicated she would complete the dressing change herself. At 1:40 P.M., the DON indicated the floor nurse from the North Unit would complete the dressing change, after lunch. On 02/26/13 at 2:05 P.M., Licensed Practical Nurse (LPN) #14 and the DON were observed donning gloves and gowns from the isolation cart outside of Resident #73's room. The nurses entered the room and prepared to provide wound care for the resident. The DON indicated that she was present to assist holding the resident during care. The nurses rolled Resident #73 to her left side. A moderate amount of soft stool was noted on the resident's anal area, lower buttocks and on the disposable incontinence pad under the resident. LPN #14 removed the stool and cleaned the resident. No wound treatment was in place over Resident #73's Stage Three coccyx wound. A four by four gauze pad was observed inside the deep wound. The wound was observed to be approximately 3.0 centimeter in diameter, circular shaped with an undetermined depth. The wound bed was dark brown, and foul smelling. Necrotic (dead) or devitalized tissue presents frequently as brown or black and has lost usual physical properties and biological activity. The gauze pad was saturated with a pinkish drainage. LPN #14 removed the gauze pad from inside the wound, and provided wound treatment maintaining acceptable infection control measures. LPN #14 indicated that she was finished providing care and began to cover the resident. The surveyor inquired about three, small open areas that were observed on the left buttock, two on the lower buttock and one on the upper buttock. LPN #14 and the DON acknowledged the presence of the three newly developed pressure areas. LPN #14 stated that she provided Resident #73's wound care the previous day and the areas were not present at that time. The DON stated that she would instruct the next shift (afternoon shift) nurse assess, measure and provide treatment to the wounds. LPN #14 and the DON experienced some difficulty removing the dirty incontinence pad and re-positioning Resident #73 in the bed, as she was noted to be sinking down into the mattress. The surveyor indicated the air mattress was not functioning as evidenced by no light was on the control box to indicate the air mattress had been turned on. LPN #14 reached behind the bed and plugged the air mattress cord into the electrical outlet, and the air mattress began to inflate. Review of the Wound Consultant report dated 02/26/13 indicated the wound had worsened. The coccyx wound measured 3.0 cm by 2.5 cy by 2.8 cm deep, with increased undermining at twelve o'clock of 4.8 cm and 3.3 cm at three o'clock. The wound bed was described as adherent, soft, black eschar with a purulent, foul thick exudate, with odor. Review of nurse's notes dated 02/26/13 lacked assessment of the three newly opened pressure areas for Resident #73. On 02/27/13 at 3:52 P.M., State tested Nurse Aide (STNA) #17 was observed providing indwelling Foley catheter care for Resident #73. Upon entering the room a noticeable odor of stool was evident. STNA #17 provided catheter care and covered Resident #73 with a sheet and blanket. STNA #17 was asked to turn the resident to the side. Resident #73 was observed with a large amount of stool covering her buttocks and saturating the coccyx dressing. There was no wound treatment in place to the three newly opened areas identified the previous afternoon. During an interview on 02/27/13 at 4:02 P.M., the DON verified that on 02/26/13 three new open pressure ulcers were identified on Resident #73's left buttocks. The DON acknowledged that she had planned for the afternoon shift nurse on 02/26/13 to measure the wounds and begin wound treatment. The DON explained that she had forgotten to pass the information along to afternoon shift on 02/26/13 and verified that no wound treatment had been initiated. Review of nurse's notes dated 02/27/13 at 7:00 P.M. indicated a new order had been received for two new open areas to Resident #73's left buttock. The nurses notes lacked assessment of the third pressure area identified on 02/26/12. Review of Wound Evaluation Flow Sheets dated 02/27/13 identified two new facility acquired pressure ulcers to Resident #73 left buttocks identified on 02/26/13. The left middle buttock pressure ulcer measured 0.8 cm by 0.8 cm by less than 0.1 cm. The left, lower medial buttock pressure ulcer measured 0.5 by 0.5 by less than 0.1 cm. Although a stage of the pressure ulcers was not included in the assessments, the wounds were consistent with Stage Two pressure ulcers. A Stage Two pressure ulcer is a partial thickness skin loss presenting as a shallow open ulcer with a pink wound bed, without slough. No Wound Evaluation Flow Sheet was provided for the third pressure area on the upper left buttock identified on 02/26/12. On 02/28/13 at 09:55 A.M. LPN #15 was observed providing wound care for Resident #73. LPN #15 gathered dressing supplies and placed them on Resident #73's over-bed table. LPN #15 washed her hands and donned two pairs of clean gloves. LPN #15 pulled back Resident #73's covers and a small amount of liquid tan drainage was noted to be oozing from beneath the dressing. LPN #15 removed the dressing and copious amounts of liquid, tan, foul smelling drainage spilled from the wound. LPN #15 used multiple gauze pads to absorb the drainage and discarded them into a plastic bag. LPN #15 removed only her top pair of gloves. She picked up bullets of normal saline solution and gauze pads to clean the wound. She squirted the normal saline solution into the wound and used gauze to clean. After cleaning the wound LPN #15 removed her gloves and washed her hands. A small [MEDICATION NAME] ([MEDICATION NAME] occlusive dressing) was observed covering the two lower left buttock open areas. The upper left buttock open area had no dressing in place. Two newly open areas were noted to the right buttock, area with dark, necrotic wound beds. LPN #15 washed her hands and left the room, indicating that she was getting the DON. LPN #15 and the DON returned to the room. The DON observed the wounds and verified the upper left buttock wound that had been identified on 02/26/13 had not yet been measured or had a treatment initiated. A Wound Evaluation Flow Sheet was initiated on 02/28/13 that indicated the left upper buttock pressure ulcer was identified on 02/26/13. The wound measured 2.0 cm by 0.7 cm by less than 0.1 cm. Although the wound had not been staged, the description was consistent with a Stage Two pressure ulcer. A Wound Evaluation Flow Sheet initiated on 02/28/13 indicated the right medial inner buttocks pressure area was unstageable. The wound measured 0.6 cm by 0.2 cm with a 100% black wound bed. The wound was considered unstageable since the wound bed was not visible, and therefore the depth of the wound bed could not be measured. A Wound Evaluation Flow Sheet was initiated on 02/28/13 and indicated the right medial outer buttock pressure ulcer was unstageable. The wound measured 0.2 cm by 0.5 cm with a 100% black wound bed. Review of the facility's Skin and Wound Care Guidelines dated July, 2012 indicated that all open wounds should be covered to prevent nosocomial infection and promote a moist, healing environment. Wound assessments should include location, size, appearance, color of wound bed, signs and symptoms of infection, odor, exudates, peri-wound, undermining/tunneling and presence and/or absence of pain. The policy indicated the wounds should be measured in centimeters on admission, upon identification, weekly and as needed. The policy indicated the physician should be notified and treatment orders obtained. The technique for wound treatment indicated that gloves were to be changed between the removal of the old dressing and the application of the new dressing. 2. Resident # 50 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was in isolation for [MEDICAL CONDITIONS]. The admission pressure ulcer risk assessment dated [DATE] indicated the resident was a moderate risk for development of pressure ulcers. The current physician's orders [REDACTED]. There were new pressure areas identified to the left ischial, left lateral maleolus, left lateral foot and left medial great toe base. The orders were to pad and protect and check daily for drainage. There was no indication of how the wounds were to be cleansed. Review of a clarification order written 02/26/13 for the coccyx wound indicated NPWT 175 mmHg with black foam, change every Tuesday, Thursday and Saturday. The clarification contained no indication of how to cleanse the wound. The previous order for the coccyx dated 02/19/13 also did not include cleansing information. Resident #50 had physician orders [REDACTED]. Interview with the DON on 02/26/12 at 11:50 A.M. revealed she and CNP #29 had removed all the dressings from residents the CNP saw that day. The DON stated they remove the dressings and when the floor nurses are done with their work they will put the dressings back in place. The DON stated the floor nurses were passing medications currently and they would do the dressing changes when they got to them. The DON stated the wounds were left open. She indicated the CNP saw seven residents. Resident # 50's wound care was observed on 02/26/13 at 12:30 with LPN # 2 and STNA # 20. The resident was in contact isolation for C- diff. LPN # 2 stood outside the resident's door and stated she had already washed her hands before she came down to the room. LPN #2 and STNA # 20 donned gowns and LPN # 2 obtained the wound supplies, took them into the room, obtained a paper towel from the bathroom, placed it on the overbed table and put the supplies on the overbed table. LPN #2 did not clean the overbed table. LPN # 2 then washed her hands and applied gloves. Resident #50 was observed lying in bed on her left side. The resident's left leg and foot were directly on the bed. There was a pillow between her knees and her left and right medial bunions were touching the bed. The left bunion area had a purple deep tissue injury. Resident #50 was rolled on her left side by STNA # 20 and the resident's buttocks/coccyx area was observed. The resident was laying on a disposable paper incontinence pad that had brown/yellow foul smelling drainage on it from the open wound. The resident's coccyx wound was not covered and was directly on the pad LPN # 2 rolled the contaminated pad under the resident, then washed her hands and applied new gloves. LPN # 2 rinsed the open wound with normal saline twice, wiped with gauze and then opened the [DEVICE] pack and laid it directly on the bed. LPN # 2 took scissors off the overbed table and without cleansing them attempted to cut the foam dressing which was to be packed directly into the open wound. She was stopped by this surveyor and instructed to clean the scissors. LPN #2 then cleansed the scissors and cut the foam to size and packed it in the wound. While attempting to apply the vacuum to the area, LPN # 2's gloves became stuck to the dressing and she had start over again with the dressing change. LPN # 2 repeated the dressing change. When she cut the foam dressing she placed the scissors and alcohol pads directly on the bed with the resident. LPN # 2 completed the dressing change and placed the pillow between Resident #50's knees and under her left leg. LPN # 2 picked the scissors and alcohol pads off the resident's bed and placed them on the overbed table. LPN # 2 did not apply any dressing to the resident's left lateral maleolus/foot. LPN #2 removed her gloves and gown, put the scissors and alcohol in her pocket and finished the dressing change at 1:15 P.M. This surveyor asked LPN #2 what she was going to do next and she stated she had charting to do and phone calls to make. The DON was interviewed on 02/26/13 at 2:38 P.M. and verified Resident #50 had new pressure areas on left lateral maleolus, left lateral foot and left medial base of the great toe (bunion area). The DON stated it is the CNP's practice to not put the dressing back on the wound and have the floor nurses apply the dressings when they were able. This surveyor entered Resident #50's room with the DON. The DON did not don any gown or gloves or wash her hands. She pulled the covers up over the resident ' s legs and feet and verified the resident's heels were directly on the bed. The resident had a pillow between her knees but the bunion areas were in direct contact with the bedding. The DON also verified there was no dressing in place on the left foot. Wound care was observed for Resident #50 on 02/28/13 at 10:50 A.M. with LPN # 15. The resident was lying on her right side. The right hip dressing completed. This surveyor observed a dressing in place on the resident's left arm/elbow. The dressing was dated 02/25/13. LPN #15 stated the dressing was supposed to be completed daily. LPN # 15 stated she had initiated the dressing because the area was reddened and the last time she saw the area it was a red Stage One pressure ulcer. LPN # 15 remove the dressing and revealed two unstagable pressure ulcers covered in black eschar with dried brown drainage on the dressing. LPN # 15 measured the areas. The left lateral elbow necrotic unstageable area was 1.2 centimeters (cm) wide by 1.2 cm in length. The left proximal elbow area was 1.7 cm wide by 1.8 in length. During review of nurses notes dated 02/06/13 LPN # 15 verified she had written the left elbow was reddened and a new order was obtained to wrap left elbow with kerlix and change daily to protect elbow. LPN # 15 verified there were no wound grids or tracking completed for the elbow area. The DON was interviewed on 02/28/13 at 4:14 PM. The DON verified the new area was found on the resident's left lateral elbow on 02/06/13 and verified the skin grid was not initiated until 02/28/13. Interview with the DON on 03/04/13 at 2:32 P.M. verified CNP #29's care orders were unclear on how to cleanse Resident #50's wounds. The DON stated the nurses cleansed the resident's coccyx wound like they did other wounds the CNP wrote orders for. The DON stated she spoke CNP #29 about not writing the orders clearly, but still had not clarified the orders. 3. Resident #53 was admitted to the facility on [DATE] at 1:00 P.M. from another nursing facility. The resident had [DIAGNOSES REDACTED]. The resident was noted to have an indwelling Foley catheter in place at the time of admission. An admission skin assessment revealed the resident had multiple open areas, bruising, red petechiae and superficial scrapes. Nurse's notes indicated the areas were all measured, assessed and re-dressed. The resident was no longer in the facility and this was a closed record review. Review of the admission Minimum Data Set (MDS) 3.0 assessment with an assessment reference date of 11/23/12 revealed the resident exhibited short term memory loss, no recall ability and severely impaired decision making skills. The resident was assessed to be non-ambulatory and required total dependence from staff for bed mobility, transferring and personal hygiene. The resident was assessed to be at risk for pressure ulcers and had an indwelling Foley catheter in place. Review of the admission Skin Wound Evaluation Flow Sheet documentation, dated 11/14/12 revealed the resident had a Stage 4 pressure ulcer to his left buttocks (inferior) which measured 12 centimeters by six centimeters with less than 0.2 centimeters depth. The ulcer was noted to have tan slough with black necrotic tissue with a moderate amount of tan thin serous drainage. On admission Resident #53 was also assessed, to have a Stage 4 pressure ulcer to his left lateral chest which measured 12 centimeters by five centimeters with 0.6 centimeters to 2.2 centimeters depth. The ulcer was assessed to have slough and necrotic tissue present with a moderate amount of tan serous drainage. Review of treatment administration records and physician orders [REDACTED]. The treatment was documented as being completed from 11/14/12 through 11/20/12. Weekly wound measurements, dated 11/20/12 revealed both of the above pressure ulcers had deteriorated. The left lateral chest was assessed to be more necrotic, the left inferior buttocks ulcer was assessed to be enlarging with thick yellow slough tissue and black necrotic tissue present. Both pressure ulcers were assessed to be unstageable at that time. Record review revealed on 11/20/12 a new treatment order was obtained for the left buttocks and left lateral side pressure ulcers. The treatment to the left lateral side was to cleanse with wound cleanser, then normal saline solution and cover with [MEDICATION NAME] gauze. The dressing was ordered to be completed every three days and as needed (prn) if soiled. Record review revealed although the treatment was ordered on [DATE], the treatment was not initiated until 11/25/12 per the treatment administration records. The treatment to the left buttocks pressure ulcer, obtained on 11/20/12 was to cleanse with wound cleanser and normal saline and then apply [MEDICATION NAME] gauze. Record review revealed although the treatment was ordered on [DATE], it was not initiated until 11/23/12. Record review revealed the resident was seen by hospice on 11/23/12. Hospice wound documentation reflected the most recent dressing change had been completed on 11/20/12 (three days prior). The pressure ulcer assessments, completed by hospice noted the pressure ulcers to the left buttocks and left lateral chest were positive for odor. The ulcers were all noted to be Stage 4 pressure ulcers at this time. Review of nurse's notes, dated 11/24/12 at 11:00 P.M., revealed the resident had increased wound drainage and very foul odor. No additional pressure ulcer assessment was noted to have been completed at that time and (there was no documentation of measurements or assessment of the drainage. The nurse's note revealed hospice was called and an order was obtained for cultures to be completed. Record review revealed cultures of resident's buttocks wound and wound were obtained on 11/25/12. On 11/27/12 wound culture results were positive for [MEDICATION NAME] cloacae- heavy growth and morganella morganii- moderate growth. A new order was obtained on 11/27/12 for intravenous antibiotics ([MEDICATION NAME]) every eight hours. Record review revealed the antibiotic order was not initiated until 11/29/12 (two days after the culture results were obtained). However, the antibiotics were not initiated or administered as ordered because the facility was unable to start an intravenous line for the medication administration. Record review revealed no physician notification related to the delay in the antibiotic being initiated or inability to start an intravenous line. Additionally, review of the administration records from 11/29/12 through 12/13/12 revealed the antibiotic was not administered as ordered on [DATE], 12/04/12, 12/05/12 and 12/11/12. There was missing documentation contained in the resident's medical record and nurse's notes related to why the medication was not administered as ordered and no indication the physician was notified that the medication was not being administered as ordered. Record review revealed on 12/12/12 the buttocks wound and left chest wound were recultured. Wound results, dated 12/15/12 revealed the resident continued to have [MEDICATION NAME] cloacae- heavy growth in the buttocks wound and moderate growth in the chest wound. On 02/27/13 at 7:30 A.M., interview with LPN #10 verified Resident #53 was admitted with pressure ulcers to his left buttocks and left lateral chest. When asked to review documentation to ensure the resident's pressure ulcers were being comprehensively monitored and/or assessed by the facility between 11/14/12 and 11/24/12 (when the cultures were ordered), no information was provided. LPN #10 verified the lack of written documentation to ensure wound care dressing changes were initiated timely following the new orders obtained on 11/20/12 and also verified the resident developed infections to both the left buttock wound and left lateral chest wound while residing in the facility. LPN #10 verified the [MEDICATION NAME] antibiotic was not administered as ordered and also verified the physician was not notified of the inability to administer the medication. When asked if the facility had completed any type of investigation to determine the cause of the resident's infection, source of the infection or mode of transmission, the LPN indicated that would be the responsibility of the DON. LPN #10 indicated the current DON was not employed at the time Resident #53 resided in the facility. When asked if she was aware or able to locate any written information related to an investigation, the LPN #10 indicated she would check. No additional information was provided during the annual survey. On 02/27/13 at 9:13 A.M., during an interview with Registered Nurse(RN) #12 the concern was shared related to Resident #53, who acquired a nosocomial infection while residing in the facility. The concern was also shared related to the facility's failure to adequately monitor the resident's status related to the development of the wound infection and failed to provide treatment as ordered. The concern was shared that the facility also failed to conduct any type of investigation to determine the cause and/or mode of transmission of the infection. No additional information was provided during the annual survey. Review of information provided via the web from the National Institute of Health revealed [MEDICATION NAME] cloacae is not a primary human bacteria but an important cause of "nosocomial infections". 4. Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed on 01/22/13 an order was obtained for Prostat (an oral liquid protein supplement) 30 cubic centimeters twice a day (scheduled at 8:00 A.M. and 4:00 P.M.) to increase protein and promote healing of bilateral heel wounds. A nutrition assessment note, dated 01/29/13 reflected the resident's admission to the facility on [DATE]. The assessment note revealed the resident had unstageable pressure ulcers to her bilateral heels. The note also revealed the resident's intake was "so-so". The resident was educated on the importance of eating well and the note also reflected protein intake to aid in wound healing. The resident's [MEDICATION NAME] level (blood level indicative of nutritional status) was noted to be low. Review of the medication administration records (MAR) from February, 2013 revealed the resident did not receive the Prostat supplement as ordered from 02/02/13 through 02/07/13. On 02/25/13 at 3:07 P.M., interview LPN #26 revealed the facility had run out of the Prostat supplement during the beginning of February, 2013. LPN #26 indicated there were a few residents who did not receive the supplement as ordered during that time because there wasn't any. On 02/27/13 at 11:19 A.M., interview with DON revealed she was unaware the facility had run out of Prostat the beginning of February, 2013. 5. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed on 12/24/12 the resident developed a Stage II pressure ulcer to his left medial heel while residing in the facility. On 01/15/13 a physician order [REDACTED]. A nutrition progress note, dated 02/19/13 revealed the resident was receiving Prostat 30 cc's three times per day to aid in healing. The nutritional progress note revealed the Prostat provided an additional 45 grams of protein each day. Review of Resident #38's MAR from February, 2013 revealed the resident did not receive the Prostat supplement as ordered from 02/02/13 through 02/07/13. Neither the MAR indicated [REDACTED]. On 02/25/13 at 3:07 P.M., interview with LPN #26 verified Resident #38 had not received the Prostat supplement as ordered from 02/02/13 through 02/07/13. LPN #26 indicated the facility had run out of the supplement during that time period and explained that was reason it had not been given. On 02/27/13 at 11:19 A.M., interview with the DON revealed she was unaware the facility had run out of Prostat the beginning of February, 2013.

Based on observation, record review and interviews, the facility failed to ensure treatment was initiated upon the discovery of a Stage I pressure ulcer on Resident #43's buttocks. Treatment was not initiated for eight days and the Stage I pressure ulcer deteriorated to an unstageable pressure ulcer. The facility failed to update the pressure ulcer care plan to include the left buttock pressure ulcer. This affected one (Resident #43) of four residents reviewed with pressure ulcers out of five residents identified with pressure ulcers. Findings include: Resident #43 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The 3.0 Minimum Data Set (MDS) comprehensive assessment dated [DATE], indicated Resident #43 was severely impaired for cognitive skills including both short and long term memory impairment. The assessment indicated Resident #43 was incontinent of bowel and bladder and totally dependent for all activities of daily living, including bed mobility. The same MDS assessment indicated Resident #43 had no pressure ulcers at that time. The pressure ulcer risk assessment dated [DATE] indicated Resident #43 was at high risk for the development of pressure ulcers. The pressure ulcer plan of care was updated on 09/19/11 and indicated the resident was at risk for pressure ulcers related to incontinence and decreased mobility. The plan of care indicated the resident's skin would be assessed for reddened areas and the physician would be notified of any changes, as needed. "Shower/Tub Bath/Bed Bath Sheet" dated 10/01/11 indicated Resident #43's skin was intact with no redness noted. "Shower/Tub Bath/Bed Bath Sheet" dated 10/03/11 identified a reddened area to the resident's buttocks. The bath sheet was signed by a state tested nurses aide (STNA), and by the charge nurse. A Stage I pressure ulcer is an observable, pressure-related alteration of intact skin, including a defined area of persistent redness. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). "Shower/Tub Bath/Bed Bath Sheet" dated 10/05/11 confirmed that the reddened area remained on Resident #43's buttocks. The bath sheet was signed by an STNA and by the charge nurse. Corresponding nurses' notes contained no documentation of the newly identified area. "Nurse's Notes" dated 10/11/11 at 11:00 P.M., indicated the nurse, along with an STNA, found a 1.5 centimeter (cm) by 1.0 cm open pressure ulcer to Resident #43's left buttock area during routine incontinence care. The physician was notified and wound treatment orders were received, which included the application of calcium alginate to the wound bed. A calcium alginate wound dressing is indicated for moderate to heavy exudating (draining) partial thickness and/or full thickness pressure ulcer. The corresponding "Wound Evaluation Flow Sheet" dated 10/11/11 revealed the wound bed was yellow slough tissue. Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, & stringy (at times). The presence of slough made the wound unstageable, since the wound bed was not visible. The pressure ulcer plan of care was not updated to include the presence of the unstageable pressure ulcer and/or the physician ordered wound care treatment. "Wound Evaluation Flow Sheets" dated 10/24/11 measured the wound at 1.8 cm by 1.2 cm by less than 0.1 cm with thick, yellow slough. "Wound Evaluation Flow Sheets" dated 11/07/11 measured the wound at 2.0 cm by 0.5 cm (no depth charted) with a red wound bed. On 11/09/11 at 2:40 P.M., Resident #43's left buttock wound was observed with the director of nursing (DON). The wound measured approximately 2.0 cm by 0.5 cm, with a pale yellow wound bed. During an interview on 11/09/11 at 4:14 P.M., the DON verified the reddened area/Stage I pressure ulcer on Resident #43's buttocks was identified on 10/03/11 and 10/05/11, per the "Shower/Tub Bath/ Bed Bath Sheets." The DON indicated it was the expectation of the nurses to assess and measure any newly identified skin alteration and to notify the physician of such. The DON acknowledged the nurses were remiss in not assessing the pressure area and notifying the resident's physician. The DON confirmed Resident #43's physician was not notified and wound treatment did not begin until 10/11/11 when the wound had deteriorated to unstageable. The DON verified the pressure ulcer plan of care had yet to be updated to include the unstageable wound and treatment modality.

Based on review of the medical record, review of facility policy, review of hospital laboratory results, review of hospital emergency department records, review of Laboratory Diagnostic Tests with Nursing Implications (5th edition) and interviews with staff, the facility failed to ensure physician ordered laboratory tests were completed to monitor the effectiveness of oral anticoagulant therapy ([MEDICATION NAME]) and detect increased risk for bleeding; and failed to withhold [MEDICATION NAME] as ordered by the physician. This resulted in Immediate Jeopardy for one of five sampled residents (Resident #46) receiving anticoagulant medication. Additionally, the facility failed to complete laboratory testing as ordered by the physician and failed to ensure the physician was notified of laboratory results which placed three of five sampled residents (Resident #6, #31 and #42) at risk for more than minimal harm that is not Immediate Jeopardy. Nine of 43 residents in the facility were receiving anticoagulant therapy. On 05/02/11 at 2:33 P.M., the administrator, the director of nursing (DON), Registered Nurse (RN) #8, and the licensed practical nurse supervisor (LPN #1), were notified that Immediate Jeopardy began on 02/19/11 when the licensed nursing staff administered [MEDICATION NAME] 5 milligrams (mgs) daily to Resident #46 without monitoring [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) blood levels per physician orders. On 03/03/11 at 2:00 P.M., Resident #46 began passing gross blood in her stool. The physician was notified and Resident #46 was transferred to the emergency department and treated for [REDACTED]. The Immediate Jeopardy was removed on 04/02/11 after the facility implemented the following corrective actions: ? On 03/03/11 at 2:20 P.M., Resident #46 was transported to the hospital and provided medical treatment for [REDACTED]. ? On 04/01/11 the facility reassessed all nine residents (Residents #1, #2, #4, #6, #13, #14, #25, #31 and #42) on anticoagulant therapy. The corporate regional RN verified all orders pertaining to anticoagulant therapy were implemented as prescribed by the physician. ? On 04/02/11, the corporate regional RN verified staff were implementing the following interventions: the "PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" was used to ensure all laboratory tests were completed for residents on anticoagulant therapy; a red sheet of paper was used on the medication administration record to alert the staff that the resident was receiving anticoagulant therapy; and a separate medication administration record was completed for residents on anticoagulant therapy. ? On 04/02/11, LPN #1 verified that each resident receiving anticoagulant therapy had a card in the laboratory file box. This card identified the resident's current order for PT/INR testing and the date for repeat PT/INR testing. This system was used to compare the laboratory results with the resident's card to ensure each ordered PT/INR test was completed and to determine when the next PT/INR was due. ? On 04/02/11, the corporate regional RN revised the resident admission checklist to ensure admission PT/INR laboratory orders were obtained and requisitions were sent to the laboratory. Although the Immediate Jeopardy was removed when the facility reassessed the nine residents receiving anticoagulant therapy to ensure all required laboratory tests were obtained as ordered and residents were free of signs and symptoms of bleeding, 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) until it was corrected on 04/04/11 when the facility implemented the following corrective actions: ? On 04/04/11, the facility conducted an emergency quality assurance committee meeting with the medical director. Implementation of the following facility action plans were reviewed: anticoagulant therapy; PT/INR's; physician PT/INR protocols for each attending physician; compliance with physician orders; lab tickler file; admission/readmission checklist; nursing documentation; medication pass; notification of physician; and compliance with physician orders. ? On 04/04/11, the facility implemented a new protocol, "PT/INR Protocol, Cortland Physicians." This protocol listed the specific action(s) to be taken, as requested by each attending physician, when PT/INR results were received for their residents. ? On 04/04/11, the corporate regional RN conducted mandatory in-service training for all licensed nursing staff, including the new interim DON, regarding the facility's Anticoagulant Therapy policy and procedure including Physician PT/INR protocols for each attending physician; compliance with physician orders; timely notification of physician; lab tickler file; admission/readmission checklist; nursing documentation using the "PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flowsheet "; and anticoagulant medication administration. ? On 05/02/11, the surveyors reviewed three additional records for residents (#2, #4, and #25) on anticoagulant therapy and found adequate monitoring by the facility. On 05/02/11 at 9:16 A.M. and 9:43 A.M, the surveyors interviewed LPN's #5 and #2 and both confirmed accurate knowledge of the facility's new anticoagulation therapy monitoring procedures. The DON was interviewed on 05/02/11 at 1:00 P.M. and validated the quality audit mechanisms that were in place. Findings include: 1. Review of Resident #46's medical record revealed she was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The "Short Term Problems Need List" and interim care plan for Resident #46 was developed on 02/11/11. The resident was identified as being "At risk for abnormal bleeding R/T (related to) [MEDICATION NAME] use" and interventions included administering [MEDICATION NAME] as ordered, lab testing as ordered, notify the physician of laboratory results or abnormal bleeding, and monitor for abnormal bleeding. A nursing progress note dated 02/11/11 at 7:00 A.M. revealed Resident #46 pulled out her gastrostomy tube (GT) at 5:00 A.M. and at 5:30 A.M. she was sent back to the hospital for evaluation and re-insertion of the GT. Resident #46 was readmitted to the nursing home on 02/18/11 and the interim care plan developed 02/11/11 was not revised upon readmission. A copy of the laboratory results from the hospital dated 02/18/11 revealed Resident #46's PT level was elevated at 28.5 (normal range: 9.4-11.7 seconds) and her INR was 2.8 (normal range: 2.0-3.0). Readmission physician orders dated 02/18/11 stated PT/INR monitoring was to be completed twice a week, and [MEDICATION NAME] 5 mg was to be administered daily after Resident #46's INR level went below 2.5. Review of Resident #46's medication administration record revealed the resident was administered [MEDICATION NAME] 5 mg daily on 02/19/11 - 03/01/11 without PT/INR testing. Resident #46's "PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" was blank. The PT/INR/[MEDICATION NAME] Flowsheet was used to track laboratory test results, dosage of [MEDICATION NAME], physician notification, changes in dosage of medication, and the date of the next PT/INR test. Resident #46's medical record indicated the first PT/INR's laboratory testing since readmission on 02/18/11 was completed 03/02/11. Review of the laboratory report dated 03/02/11 revealed the PT level was "HI" (high) at 140.0 seconds (normal range 10.0 -11.5 seconds) and the INR was "VH" (very high) at greater than 10 (normal range: 2.0-3.0). On the laboratory report, LPN #2 documented and initialed, "the physician was called, D/C [MEDICATION NAME], Vitamin K 10 mg IM (intramuscular), Fri (Friday) PT/INR". However, the verbal order was not transcribed. LPN #2's nurse's note, dated 03/02/11 at 3:00 P.M., revealed Resident #46's PT/INR was "critical high". LPN #2 documented the physician ordered Vitamin K (a medication given for the treatment of [REDACTED]. LPN #2's nurse's note, dated 03/03/11 at 2:00 P.M., stated Resident #46 was passing "gross blood" in her stool. Her blood pressure was low at 88/40 (normal range 120/80), her oxygen level on room air was 89% (normal range 95-100%), her pulse was normal at 70, and respirations were normal at 18 per minute. The physician was contacted and gave an order for [REDACTED]. Resident #46 was admitted to the hospital for inpatient treatment. Resident #46 did not return to the facility as of 03/31/11. Interview with LPN #2 on 04/02/11 at 9:00 A.M. revealed on 03/01/11 she worked over onto the afternoon shift and did not find any PT/INR laboratory results for Resident #46. She did not remember what prompted her specifically, but she called the laboratory to make sure the PT/INR was going to be drawn the next day. She verified she administered the [MEDICATION NAME] at 5:00 P.M. on 03/01/11 to Resident #46 without any PT/INR tracking on the medical record, and did not telephone the physician for any additional direction. LPN #2 indicated she received the abnormal PT/INR results on 03/02/11, which were high, and she telephoned the physician and received orders. The [MEDICATION NAME] was not administered on 03/02/11. LPN #2 indicated Resident #46 was not showing any signs of any active bleeding and she put Resident #46 on bedrest to keep her from being bumped or injured, which could cause bleeding. According to the medication administration record (MAR), LPN #2 administered the Vitamin K (IM) on 03/02/11 at 2:30 P.M. On 03/03/11, LPN #2 indicated she was notified by a state tested nursing assistant (STNA #3) that Resident #46 was found with a lot of blood in her stool. LPN #2 said Resident #46 was immediately assessed and found with normal color stool with a moderate amount of bright red blood. Vital signs were taken, the physician was notified and Resident #46 was transported to the hospital by ambulance at 2:20 P.M. Interview with STNA #3 on 04/02/11 at 10:55 A.M. revealed she immediately reported the blood in Resident #46's stool to LPN #2 on 03/02/11. STNA #3 indicated Resident #46 had some bleeding from her nose sometime before 10:00 A.M. STNA #3 said when she saw Resident #46, there was some dried, crusted blood on the outside of her nose and she could see some blood on the inside of her nose. STNA #3 used tissues to dab the blood from Resident #46's nose. STNA #3 thought the bleeding was from the use of oxygen, but reported it to the LPN #2. STNA #3 did not know if LPN #2 assessed Resident #46 at that time. LPN #2 was re-interviewed on 04/02/11 at 11:10 A.M. and she did not recall Resident #46 having any bleeding from her nose. The facility's policy for "Anticoagulant Therapy," effective 06/11/09, indicated the facility would use the following procedure for the treatment/management of residents receiving anticoagulant therapy: ? The charge nurse will notify the physician of the resident's admission and obtain orders pertinent labs to monitor anticoagulant therapy. ? The charge nurse will place the anticoagulation medication on a separate medication administration record (MAR) and in the event there are changes with the dosage, all changes will be made on this separate anticoagulation MAR. ? The charge nurse will place a red sheet of paper with "Resident on Anticoagulant" in plastic with the resident's MAR. ? The charge nurse is responsible to monitor the results of the PT and INR. ? The charge nurse will document the results on the "PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flow Sheet" which will be kept with the anticoagulant MAR and should document the date of the last lab results, the current [MEDICATION NAME] dose, that the physician was notified of results, if there was any dosage change, the date of the next lab test, and the nurse's signature. ? The charge nurse is to review the PT/INR/[MEDICATION NAME] Flow sheet along with the narcotic count for each shift. ? The oncoming nurse should review with the off going nurse and verify the last lab on the chart matches the last lab on the "PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flowsheet." The charge nurse will compare the current physician order with the flow sheet and the anticoagulant MAR, and the charge nurse will check that the dose of anticoagulant ordered matches the dose of the medication on the cart to assure the proper dose is given. Interview with the corporate regional RN on 03/31/11 at 4:25 P.M. verified the facility's nurses did not follow this policy and procedure. Review of Laboratory Diagnostic Tests with Nursing Implications, 5th Edition, pages 369-372, [MEDICATION NAME] is an oral anticoagulant to decrease the clotting process. The major use of the PT is to monitor oral anticoagulant therapy. The INR was devised to improve the PT monitoring process. When PT is above 40 seconds, bleeding may occur. 2. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The "Short Term Problems Need List" and plan of care initiated on 03/03/11 indicated the resident was at risk for abnormal bleeding relative to [MEDICATION NAME]. Interventions included monitoring lab results, administering [MEDICATION NAME] as ordered, and notifying the physician as needed. Admission physician orders included [MEDICATION NAME] 3 mg to be given every day and for PT/INR testing to be completed every Monday and Thursday. Resident #31's medical record revealed there was no laboratory report dated Monday 03/07/11 for the PT/INR. However, LPN #3's nurse's note dated 03/07/11 at 4:10 P.M. revealed a PT level of 118.4 and an INR greater than 10. LPN #3 documented the physician was notified and gave orders to administer Vitamin K 10 mg (IM); hold the administration of [MEDICATION NAME]; repeat the PT/INR level on Wednesday 03/09/11; and send the resident to the hospital if any signs or symptoms of bleeding were identified. Review of Resident #31's laboratory report dated 03/09/11 revealed the PT/INR levels decreased to a PT of 13.7 (normal PT range 9.7-11.9 seconds) and an INR of 1.3 (normal INR range 2.0-3.0). There were no nurse's notes or any other documentation to indicate the physician was notified of the 03/09/11 lab results until 03/10/11. On 03/10/11 physician orders were documented on the 03/09/11 lab report to administer 6 mgs. of [MEDICATION NAME] on 03/10/11, then decrease [MEDICATION NAME] to 3 mgs daily afterward and to check a PT/INR on Friday 03/11/11. Review of Resident #31's laboratory report dated Friday 03/11/11 revealed a PT level of 12.3 (normal PT range 9.7-11.9 seconds) and an INR of 1.2 (normal INR range 2.0-3.0). The physician was contacted and ordered [MEDICATION NAME] 6 mgs to be given for two days, then administer [MEDICATION NAME] 3 mgs a day and repeat a PT/INR on Monday 03/14/11. The PT/INR was not completed on Monday 03/14/11 as ordered because Resident #31 refused the lab draw. The physician was not notified that the lab draw was not completed. Review of Resident #31's laboratory report dated Tuesday 03/15/11 revealed a PT level of 25.4 (normal PT range 9.7-11.9 seconds) and an INR level of 2.5 (normal INR range 2.0-3.0). There was no documentation found on the lab report nor any other documentation in the medical record that the physician was notified of the Tuesday 03/15/11 PT/INR results. On Thursday 03/17/11, the physician faxed new orders based on the results of the Tuesday 03/15/11, PT/INR lab report to continue [MEDICATION NAME] at 3 mgs daily. There were no additional orders given at this time for further PT/INR laboratory testing, and no documentation in the nurse's notes of any follow up with the physician. Resident #31 had the next PT/INR drawn on Monday 03/21/11, which was six days after the results from 03/15/11. Review of the PT/INR results for Monday 03/21/11 were a PT level of 17.1 (normal PT range 9.7-11.9 seconds) and an INR level of 1.6 (normal INR range 2.0-3.0). There was no documentation on the lab report, nurse's notes or on the "PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" to indicate the Monday 03/21/11, PT/INR results were forwarded to the physician. There were no physician orders related to this low INR, and there was no evidence of any additional PT/INR testing completed as of 03/31/11. Resident #31's medical record and these identified concerns were reviewed and verified with the corporate regional RN, the DON, the administrator, and LPN #1 on 03/31/11 at 5:30 P.M. 3. Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A plan of care dated 12/03/10 indicated Resident #42 was at risk for bleeding relative to receiving [MEDICATION NAME] and interventions included to assess for negative outcome of [MEDICATION NAME] use; assess for signs and symptoms of bleeding, epistaxis, hematuria, petechiae, [MEDICAL CONDITION]; educate resident and family on risks and benefits of anticoagulant use; provide medication as ordered by the physician; and assess labs and make recommendations for changes to the physician. Resident #42's printed monthly physician orders for February and March 2011 included orders for a monthly PT/INR level, and for [MEDICATION NAME] 5.5 mgs to be given every evening. Review of Resident #42's PT/INR results completed on 02/14/11 revealed a PT level of 18.2 (normal PT range: 9.7-11.9 seconds) and an INR level of 1.8 (normal INR range: 2.0-3.0). Documentation on the lab report indicated it was faxed to the physician on 02/14/11. There was no documentation in the nurse's notes or on the "PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" related to these lab results or any physician order changes from the initial order for monthly PT/INR. Resident #42 had another PT/INR test drawn on 02/25/11 (eleven days after the 02/14/11 PT/INR draw even though the physician's order stated monthly). There was no evidence in the medical record of a physician's order change. The results were a PT level of 19.3 (normal PT range: 9.7-11.9 seconds) and an INR level of 1.9 (normal INR range: 2.0-3.0). These lab results were documented on the "PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flowsheet," along with a "Y" (or yes) in the column indicating the physician was notified. The documentation on the "PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" was incomplete, as there was no signature of the nurse who completed this documentation, as well as no documentation regarding any [MEDICATION NAME] dosage change, and no date for the next PT/INR testing. There was no evidence in the medical record of the physician's response to this lab report. Review of Resident #42's physician orders revealed a telephone order dated 03/23/11 for staff to obtain a "PT/INR x 1, then weekly." There was no evidence in the medical record that a PT/INR test was done on 03/23/11. The next PT/INR level was drawn on 03/31/11 (8 days after the order was received on 03/23/11), with the results of a PT level of 18.2 (normal PT range: 9.7-11.9 seconds) and an INR level of 1.8 (normal INR range: 2.0-3.0). These results were faxed to the physician on 03/31/11. According to the nurse's notes written by LPN #1 on 03/31/11 at 1:15 P.M., the physician was notified of these results and the physician changed Resident #42's orders from monthly to weekly PT/INR levels. These findings were reviewed and verified with the corporate regional RN on 03/31/11 at 5:55 P.M. 4. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The "Short Term Problems Need List" and plan of care initiated on 02/09/11 indicated the resident was at risk of adverse reactions related to the use of [MEDICATION NAME]. Interventions included administering [MEDICATION NAME] as ordered; completing lab testing as ordered; monitoring for bleeding; and notifying the physician of any abnormal bleeding and labs. Admitting physician orders included PT/INR lab tests to be done every Monday and Thursday and to administer [MEDICATION NAME] 6 mgs every day. The PT/INR test ordered for Resident #6 on Thursday 02/17/11 was not done until Friday 02/18/11, and there was no documentation to explain the delay in completing this test. The PT/INR results from 02/18/11 was a PT of 46.9 "HI" (normal range: 9.7 - 11.9 seconds) and an INR of 4.6 "VH" (very high) (normal range: 2.0-3.0). The physician was contacted on 02/18/11 and orders were received to hold the [MEDICATION NAME] for 02/18/11; complete PT/INR test every day until the INR was under 3.0; and then resume the [MEDICATION NAME] at 3 mgs every day. The next PT/INR was done on 02/19/11 with results of a PT of 47.3 "HI" (normal range: 9.7 - 11.9 seconds) and an INR of 4.7 "VH" (normal range: 2.0-3.0). Documentation by LPN #2 on the "PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flowsheet" identified the PT (47.3) and the INR (4.7), and noted the current dose of [MEDICATION NAME] was "on hold until INR below 3." However, review of the medication administration record (MAR) revealed this nurse initialed that [MEDICATION NAME] 3 mgs was administered on 02/19/11 at 5:00 P.M. Review of Resident #6's PT/INR results dated 03/21/11 (Monday) revealed the PT was 34.3 (normal range: 9.7 - 11.9 seconds) and the INR was 3.4 (normal range: 2.0-3.0), and the results were faxed to the physician. On 03/22/11 the physician ordered the PT/INR to be done every day for three days (03/23/11, 03/24/11 and 03/25/11) and the [MEDICATION NAME] to be held until the INR was less than 3, and then resume [MEDICATION NAME] at 4 mgs every day. There was no PT/INR test done as ordered on [DATE], and the [MEDICATION NAME] was not given. The PT/INR result of 03/24/11 was 20.7 (normal range: 9.7 - 11.9 seconds) and the INR was 2.0 (normal range: 2.0-3.0). According to the current physician's order of 03/22/11, with the INR below 3.0, [MEDICATION NAME] 4 mgs should have been administered on 03/24/11. However, the MAR revealed the [MEDICATION NAME] was held on 03/24/11. Further record review revealed the PT/INR ordered for 03/25/11 was not completed. These findings were reviewed and verified with the corporate regional RN, the administrator, the DON, and LPN #1 on 03/31/11 at 6:30 P.M. This deficiency is an incidental finding discovered during this complaint investigation.