Every finding on record at Crystal Care Center of Ashland

Based on record review, observation, staff interview and review of the manufacturer instructions for the facility glucometers, the facility failed to ensure staff maintained proper infection control practices while using glucometers. This affected two (Residents #12 and #41) of two residents blood sugar assessments observed and had the potential to affect an additional seven (Residents #3, #5, #24, #40, #41, #43, #44 and #58) identified by the facility as also receiving blood sugar monitoring via glucometer. The facility census was 58.Findings include:1. Record review for Resident #12 revealed an admission date of 10/29/25. Diagnoses included type two diabetes mellitus with diabetic chronic kidney disease and muscle weakness.Review of the care plan dated 10/29/25 revealed Resident #12 had potential risk for hyper/hypoglycemia due to diagnosis of diabetes. Interventions included obtaining blood sugar levels as ordered.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was mildly cognitively impaired, required assistance with activities of daily living, received hypoglycemic medication (including insulin) and received insulin injections daily. Review of the physician order dated 04/20/26 revealed an order for NovoLog flex pen subcutaneous solution pen injector 100 units per milliliter (ml) inject two units subcutaneously before meals related to type two diabetes mellitus. Hold dose for blood sugar below 70.Observation on 04/22/26 at 8:35 A.M. of Licensed Practical Nurse (LPN) #109 complete a fingerstick blood sugar assessment on Resident #12 prior to insulin administration revealed LPN #109 removed the glucometer from the top drawer of the medication cart. The glucometer was uncovered and lying on top of lancets. No other glucometers were visibly present. LPN #109 entered Resident #109's room, did not clean the glucometer, assessed Resident #109's blood sugar via fingerstick with use of the glucometer then returned to the medication cart. LPN #109 revealed there was one glucometer on her medication cart used for all the residents who received blood sugar finger sticks on her assignment. LPN #109 then revealed she did not clean the glucometer on day shift because night shift cleans them. After being questioned about cleaning the glucometer, LPN #109 then took an alcohol wipe and wiped the front and back of the glucometer off lasting less than five seconds then returned the glucometer back to the medication cart.2. Record review for Resident #41 revealed an admission date of 12/02/22. Diagnoses included diabetes mellitus due to underlying conditions with hyperosmolarity and weakness.Review of the care plan dated 12/03/22 revealed Resident #41 had potential risk for hypo/hyperglycemia related to diagnosis of diabetes. Interventions included obtaining blood sugar levels as ordered.Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #41 was cognitively intact. Resident #41 required assistance with activities of daily living and received insulin injections daily.Review of the physician orders for Resident #41 revealed an order for Humalog Kwik pen subcutaneous solution pen injector 100 units per ml inject six units subcutaneous before meals related to type two diabetes mellitus, hold if blood sugar is less than 100.Observation on 04/22/26 at 11:25 A.M. of LPN #205 complete a fingerstick blood sugar assessment on Resident #41 prior to insulin administration revealed LPN #205 removed the glucometer from the top drawer of the medication cart. The glucometer was uncovered and lying on top of lancets. No other glucometers were visibly present. LPN #205 wiped the glucometer off with an alcohol wipe, entered Resident #41's room and assessed her blood sugar via fingerstick with use of the glucometer. After returning back to the medication cart, LPN #205 wiped the glucometer off with an alcohol wipe for less than seven seconds and wrapped the glucometer with dry tissue. LPN #205 verified the glucometer was used for all residents who received fingerstick blood sugars on that assignment.Interview and observation of medical supplies available on 04/23/36 at 1:08 P.M. with Assistant Director of Nursing (ADON) #155 revealed Super Sani Germicidal Disposable wipes were to be used to clean the facility glucometers.Review of the Manufacturer's instructions for the facility used glucometers revealed, Cleaning and Disinfecting the Assure Prism multi-Blood Glucose Monitoring System revised 03/01/23 revealed to minimize the risk of transmitting blood borne pathogens, the cleaning and disinfecting procedure should be performed as recommended in the instructions. The instructions for use of Super Sani Germicidal Disposable wipes included the meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood borne pathogens. With the use of Super Sani Germicidal Disposable wipes the cleaning procedure included wiping the entire surface of the glucometer three times horizontally and three times vertically using one towelette to clean blood and other body fluids. Dispose the towelette in the trash can. Disinfecting included pulling one new towelette and wiping the entire surface of the glucometer three times horizontally and three times vertically to remove blood-borne pathogens. Dispose the towelette in the trash bin. Allow exterior to remain wet for two minutes then wipe the meter using a dry cloth. The recommended cleaning and disinfectants that were acceptable for use in cleaning the glucometer between resident use did not include use of alcohol wipes.The deficiency was an incidental finding observed during the complaint investigation.

Based on record review and interviews, the facility failed to ensure a safe discharge for Resident #62. This affected one (Resident #62) of three residents reviewed for planned discharges. The facility census was 58.Findings include:Closed record review for Resident #62 revealed an admission date of 06/23/25 and a discharge date of 12/05/25. Diagnoses included osteomyelitis, sacral spina bifida, paraplegia, muscle weakness, cauda equina syndrome (roots of nerves form a bundle in the lowest part of the spinal column), chronic myeloproliferative disease (rare blood cancers), chronic kidney disease stage three, peripheral vascular disease, diplegia of upper limbs (a type of cerebral palsy the muscles in the arms and hands are weak or paralyzed making it difficult to perform daily activities), chronic myeloid leukemia, Arnold Chiari Syndrome (structural problem affecting the brain which can affect function and lead to various neurological challenges) with spina bifida, chronic angle closure glaucoma bilateral, type two diabetes mellitus with a foot ulcer, urinary incontinence, anxiety disorder, repeated falls, dependence on wheelchair, and a pressure ulcer. Record review of the care plan dated 06/24/25 revealed Resident #62 required assistance for activities of daily living (ADL) related to osteomyelitis, spina bifida, paraplegia, cauda equina and chronic myeloproliferative disease. The resident was totally dependent and does not participate in putting on and taking off footwear, required set up and clean up assistance for eating, oral hygiene and upper body dressing, supervision or oversight including verbal cues or encouragement for oral hygiene, personal hygiene, putting on taking off footwear, bed mobility, required weight bearing assistance including holding, lifting, or supporting trunk or limbs for lower body dressing, toilet hygiene, shower/bath self, sit-to-stand with one staff, transfer, stand pivot with one staff. Staff will assist as needed with daily hygiene and will assist with showering the resident per facility policy.Review of the care plan dated 06/26/25 revealed Resident #62 had potential for complications related to the use of catheter to urostomy stoma. Interventions included changing the urostomy catheter as needed for plugging or displacement and providing urostomy catheter care per the facility policy and as needed.Review of the care plan dated 06/25/25 revealed Resident #62 had potential for bowel and bladder elimination complications related to colostomy/urostomy. Interventions included to cleaning the stoma site and changing the dressing per orders. Teach/instruct on ostomy care techniques and allow the resident to participate at his own pace.Review of the care plan dated 06/25/25 revealed Resident #62 had actual area of skin impairment related to a pressure ulcer of sacrum. Interventions included initiating wound treatment and continuing the treatment as ordered by the medical doctor (MD). Nursing to observe the wound dressing daily to ensure that the dressing remains intact and that there are no signs or symptoms of infection or increased drainage.Review of the care plan dated 07/15/25 revealed Resident #62 had an actual area of skin impairment related to diabetic ulcer of the right foot.Interventions included initiating wound treatment and continuing the treatment as ordered by the MD. Nursing to observe the wound dressing daily to ensure that the dressing remains intact and that there are no signs or symptoms of infection or increased drainage.Review of the care plan dated 10/09/25 revealed Resident #62 had a need to collect items and refused to discard anything resulting in difficulty moving around safely and causing a potential fire hazard. Interventions included go through the room with the resident quarterly to clean up the clutter and move items out of room for safety reasons.Review of the progress note for Resident #62 dated 10/30/25 at 3:36 P.M. completed by Social Worker Designee (SWD) #153 revealed (Resident #62) and (Department of Developmental Disabilities ([NAME]) Care Manager) met for discharge planning today. The progress note included Resident #62 would continue the Passport Medicaid Waiver non-skilled caregiver services in the home along with services for wound care. No firm discharge date has been established at this time.Review of the progress note for Resident #62 dated 11/04/25 at 8:24 A.M. completed by Licensed Practical Nurse (LPN) #119 revealed on 11/03/25 at 10:00 A.M. Resident #62 was observed sitting on the floor between the bed and the wheelchair (w/c). Resident #62 stated, I tried to get in w/c by myself and slid off bed. Resident #62 was educated on importance of assistance with transfers. Review of the progress note for Resident #62 dated 11/24/25 at 1:19 P.M. completed by SWD #153 revealed the referral was made to Mobile Wound Care and planned to discharge home on [DATE].Review of the discharge return not anticipated Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 was cognitively intact. He had an indwelling catheter and an ostomy. Resident #62 required set up or clean up assistance with eating, oral hygiene, personal hygiene, partial/moderate assistance with toileting hygiene, lower body dressing, sit to stand, chair/bed to chair transfer, substantial maximal assistance with shower/bath, used a manual wheelchair and was independent for wheelchair mobility.Record review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for Resident #62 for December 2025 revealed:- An order initiated 06/24/25 for Aquaphor (a thick, petroleum-based skin protectant) to the right foot every day shift was completed by the nursing staff on 12/01/25, 12/02/25, 12/03/25 and 12/05/25. The area provided for documentation on 12/04/25 was left blank.- An order initiated 10/02/25 to change the colostomy set every three days and as needed was completed by the nursing staff on 12/01/25 and 12/04/25.- An order initiated 12/03/25 to cleanse the area to the top of the left foot second toe with normal saline/wound cleanser, pat dry, apply betadine solution (antiseptic) and leave open to air every day sift was documented as completed on 12/03/25 and 12/05/25. The area provided for documentation on 12/04/25 was left blank.- An order initiated 12/03/25 to cleanse the area to the top of the right foot with normal saline/wound cleanser, pat dry, apply betadine-soaked gauze, cover with abdominal (ABD) pad and wrap with Kerlix and secure with tape every day was documented as completed on 12/03/25 and 12/05/25. The area provided for documentation on 12/04/25 was left blank.- An order dated 11/21/25 to cleanse area to sacrum with normal saline, pat dry, apply normal saline moistened collagen sheet cover with silicone super absorbent dressing every day and night shift was completed by the nursing staff on 12/01/25, 12/02/25, 12/03/25 and 12/05/25 twice a day. The area provided for documentation on 12/04/25 from 6:00 A.M. to 6:00 P.M. was left blank.- An order dated 10/02/25 for colostomy care for every shift was documented every shift from 12/01/25 to 12/05/25 at 6:00A.M. to 6:00 P.M. as completed.- An order dated 10/02/25 for Foley catheter care every shift was documented every shift from 12/01/25 to 12/05/25 at 6:00A.M. to 6:00 P.M. as completed.- An order dated 11/21/25 for left buttocks cleanse with normal saline, apply collogen sheet followed by calcium alginate rope and cover with silicone super absorbent dressing to be done every shift (two 12-hour shifts) was documented as completed on 12/03/25 to 12/05/25 day shift. The area provided for documentation on 12/04/25 day shift was left blank.- An order dated 11/21/25 for right buttocks cleanse with normal saline, apply collogen sheet followed by calcium alginate rope and cover with silicone super absorbent dressing to be done every shift (two 12-hour shifts) was documented as completed on 12/03/25 to 12/05/25 day shift. The area provided for documentation on 12/04/25 day shift was left blank.- An order dated 10/02/25 for ostomy catheter care every shift was documented every shift from 12/01/25 to 12/05/25 at 6:00A.M. to 6:00 P.M. as completed.- An order dated 10/07/25 for transfer status stand pivot with one assist every shift was documented every shift from 12/01/25 to 12/05/25 at 6:00A.M. to 6:00 P.M. as completed.- An order dated 10/30/25 for sterile wet dressing to suprapubic site every shift was documented as completed on 12/03/25 to 12/05/25 day shift. The area provided for documentation on 12/04/25 day shift was left blank.Review of the Discharge Summary for Resident #62 dated 12/05/25 at 5:53 P.M. completed by Registered Nurse (RN) #177 revealed medications were reviewed and reconciled with the resident and his mother; discharged to home in the family car.Review of the progress note for Resident #62 dated 12/08/25 at 1:03 P.M. completed by SWD #153 revealed a telephone call from (Resident #62's) home care provider noting that there were concerns with his personal care and medication management. Further review of the closed medical record for Resident #62 revealed no documented evidence that the resident was educated on ostomy management prior to discharge, and there was no documentation to include how Resident #62's ADL needs would be met at home.Telephone interview on 04/22/26 at 4:33 P.M. with Resident #62's wife (with Caregiver #210 present) confirmed the resident was discharged home from the facility. Resident #62's wife stated, He was discharged home; it was just me; I am disabled too. Resident #62's wife revealed she and Resident #62 had a Medicaid waiver for care and services. Upon returning home from the nursing home, Resident #62 no longer had the waiver, so there was no one to help with his daily care needs. The caregiver for Resident #62's wife (Caregiver #210) revealed she was the independent provider through Medicaid Waiver for Resident #62's wife. She used to also be the caregiver for Resident #62 until he went to the nursing home and lost the waiver program. She revealed he had wound care every day at the nursing home, he went home, and the wound care nurse came once a week. The wounds became infected, and he had to go back to the hospital. The wife was blind, he gets poop on the floor, on himself, he's not able to do it, his wife is developmentally disabled, and they keep sending him home. Caregiver #210 revealed his colostomy bag kept coming off, and he got stool all over himself; she was no longer allowed to assist him because of the lost waiver, but she tells him he needs to try to wash up, and he would just throw his arms up in the air and continued sitting in the chair with stool on himself. Resident #62 was unable to bath/shower without assistance, and no one was there to assist him.Telephone interview on 04/22/26 at 512 P.M. with Resident #62's Power of Attorney (Sister) revealed Resident #62 would be safe to live at home if he had the extra help with bathing/showers and wound care. When he left the nursing home, they set up home health. They sent him home for placenta treatment for the wound. The nursing home set it up with the agency, but the wound became infected and he went back to the hospital. He wanted to go home; he did not want to be in a nursing home, but he could not shower. He had a hard time meeting his needs with colostomy care and wound care, bathing, and home health would not come daily. She stated that she did not know who was helping with the waiver, and it was not a safe discharge from the nursing home. The hospital and nursing homes send him home because he is strong willed and insists. Resident #62's Power of Attorney revealed she has been caring for grandchildren who live with her now and also cares for her [AGE] year-old mother and had not been able to go to check on Resident #62.Interview on 04/22/26 at 5:28 P.M. with SWD #153 revealed she set up home health care for Resident #62 for therapy and nursing. He elected to go with a company who provided wound care seven days a week. He had a waiver, but he lost it. His wife had the same worker coming in the home from the waiver he used to have, so, she felt it was a safe discharge. Interview on 04/23/26 at 11:00 A.M. with the Administrator confirmed Resident #62 did not have the level one waiver available when he discharged home.Interview on 04/23/26 at 11:37 A.M. with SWD #153 revealed on 10/30/26, she did believe Resident #62 still had his waiver, it was learned later, before discharge, the waiver was lost. The support person was to reapply for the waiver with him. SWD #153 revealed his mom would have been able to take care of him. SWD #153 was informed that his mom was [AGE] years old, and Resident #62's sister (Power of Attorney) also cared for his mom.Review of the email dated 04/23/26 at 11:38 A.M. from the Home Health Company that was set up to be initiated upon discharge by SWD #153 for Resident #62 (sent to the facility Administrator) revealed they did a start of care for Resident #62 on 10/09/25. They provided skilled nursing two times a week to monitor the foot ulcer with dressing change. Resident #62 had a third party wound specialist that managed the buttocks wound. The Home Health Company did not provide a home health aide. The Home Health referral orders were for skilled nursing/physical therapy/occupational therapy. The resident was readmitted to the hospital on [DATE]. The resident's wife was the primary caregiver and was able to care for the wounds, diabetes management, etc.Interview on 04/23/26 at 12:43 P.M. with LPN #137 confirmed she remembered Resident #62 stating, he would do a lot, but as far as being able to bathe or clean up, he needed help, and he needed help with his ostomies. He was a picker, he kept messing with the bags and ostomies, so we had to change them multiple times a day for him. LPN #137 revealed she never provided education or observed Resident #62 provide any care for himself prior to discharge.Interview on 04/23/26 at 12:53 P.M. with LPN #118 revealed Resident #62 was at risk for falls and required assistance with transfers due to his falls. LPN #118 revealed she never educated Resident #62 on any care or medications. She would cut the shapes for both his ostomies, and he would apply them. The nurses always administered his medications and provided his care. He needed help with bathing transfers, meal set up, and cleaning himself up.Interview on 04/23/26 at 1:03 P.M. with Certified Nursing Assistant (CNA) #165 revealed she cared for Resident #62 when he resided at the facility. Resident #62 required assistance with transfers; she would stand and pivot him to the chair. He needed help to get washed up; he needed a lot of help to get bathe. The nurses did the dressing changes to his wounds and administered his medications, and he needed someone to set up his meals.This deficiency represents non-compliance investigated under Complaint Number 2679689.

Based on record review, observation, interviews, facility policy review, and review of the 2025 International Pressure Injury Guidelines, the facility did not follow appropriate infection control practices during wound care and failed to provide or offer an appropriate pressure reducing mattress to support healing of a pressure ulcer. This failure affected one resident (Resident #26) of three residents reviewed for wound care. The facility census was 58.Findings include: Record review for Resident #26 showed admission on [DATE], discharge on [DATE], readmission on [DATE], discharge on [DATE], and readmission on [DATE]. Diagnoses included a Stage IV pressure ulcer and muscle weakness. A Stage IV ulcer involves full thickness tissue loss with exposed bone, tendon, or muscle, and may include slough, undermining, or tunneling.Review of the care plan dated 07/25/25 indicated an actual skin impairment to the sacrum related to pressure. Interventions included initiating wound treatment, continuing treatment as ordered, and providing a pressure reducing mattress.Review of the Discharge Return Anticipated MDS 3.0 (03/10/26) documented that Resident #26 had intact memory, was independent with cognitive decision making, and had one Stage IV pressure ulcer that was present upon admission.Physician orders dated 04/11/26 directed daily wound care to the sacrum: cleanse with wound cleanser, pat dry, lightly pack with normal saline-moistened collagen, and cover with a silicone super absorbent dressing.The Weekly Skin Grid Pressure report dated 04/21/26 at 4:47 P.M. documented a sacral Stage IV ulcer first identified on 07/18/25. The wound exhibited full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar in portions of the wound bed; and scant light pink drainage. The ulcer had not healed.Observation on 04/22/26 at 2:15 P.M. of Registered Nurse (RN)/Wound Care Nurse #127 providing wound care with Assistant Director of Nursing (ADON) #155 present. Resident #26 requested care while standing with a walker for support. The resident was observed on a standard facility mattress with a visible indentation where the resident's buttocks rested. RN/Wound Care Nurse #127 removed the old dressing, cleansed the wound with cleanser and 4x4 gauze, packed the wound with saline moistened collagen, and applied a new dressing. At no point during the procedure did she wash her hands or use hand sanitizer. Although she changed gloves, she did not perform hand hygiene between steps.During an interview at the time of the observation, both RN/Wound Care Nurse #127 and ADON #155 confirmed that Resident #26 did not have an appropriate pressure reducing mattress, such as a low air loss mattress, which is indicated for a Stage IV pressure injury. They acknowledged the visible indentation in the mattress and could not explain why a low air loss mattress had not been offered. ADON #155 stated she would obtain one. In addition, Resident #26 reported discomfort from sinking into the mattress and stated he had never been offered a low air loss mattress.The 2025 International Pressure Injury Guideline (NPIAP/EPUAP/PPPIA, 4th Edition) identifies low air loss mattresses as a reactive support surface recommended for Stage IV pressure injuries. These surfaces provide pressure redistribution and microclimate management and are recognized as integral components of pressure injury management. Evidence, including a 2023 systematic review, indicates that air based support surfaces improve healing conditions by offloading pressure, reducing friction and shear, managing moisture and heat, and supporting an optimal healing microenvironment.The facility's Clean Dressing Change policy (dated 06/01/24) requires staff to remove the existing dressing, remove gloves, perform hand hygiene, don clean gloves, cleanse and dry the wound, then again perform hand hygiene and don new clean gloves before applying the ordered dressing. RN/Wound Care Nurse #127 did not follow these hand hygiene steps.This deficiency represents non-compliance investigated under Complaint Number 2646034.

Based on record review, observation, interview and review of the insulin pen instruction manual, the facility failed to administer insulin to Resident #12 per the physician order. This affected one (Resident #12) of two residents observed for insulin administration. The facility census was 58.Findings include:Record review for Resident #12 revealed an admission date of 10/29/25. Diagnoses included type two diabetes mellitus with diabetic chronic kidney disease and muscle weakness. Review of the care plan dated 10/29/25 revealed Resident #12 had potential risk for hyper/hypoglycemia due to diagnosis of diabetes. Interventions included administering medications per physician's order.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was mildly cognitively impaired, required assistance with activities of daily living, and received hypoglycemic medication (including insulin) and insulin injections daily. Review of the physician order dated 04/20/26 revealed an order for NovoLog flex pen subcutaneous solution pen injector 100 units (u) per milliliter (ml) inject two u subcutaneously before meals related to type two diabetes mellitus. Hold dose for blood sugar below 70.Observation on 04/22/26 at 8:35 A.M. during medication administration for Resident #12 revealed Licensed Practical Nurse (LPN) #109 removed Resident #12's NovoLog flex pen from the medication cart and applied the needle. She then dialed the flex pen to two units; LPN #109 did not prime the flex pen. Upon entering the room, Resident #12 was sitting up in bed. The staff had already removed Resident #12's breakfast tray. LPN #109 stated Resident #12 finished her breakfast at around 8:30 A.M. Resident #12 stated she ate 100% of her breakfast. LPN #109 administered the two units of insulin to Resident #12 subcutaneously and returned to the medication cart. She confirmed Resident #12's insulin was administered after breakfast and confirmed she did not prime the insulin pen and stated, I only prime the insulin pens when they are new, I broke too many pens trying to prime them. LPN #109 revealed she would dial the pen forward then when she forced the dial back to zero to prime it, the pen would break, so she stopped priming them. Interview with the Director of Nursing (DON) on 04/22/26 at 2:57 P.M. revealed insulin pens were to be primed before each use.Review of the progress note for Resident #12 dated 04/22/26 at 3:43 P.M. completed by Assistant Director of Nursing (ADON) #155 revealed Resident #12's lunch blood sugar was 198 with a re-check of 202. Review of the Medication Administration Record (MAR) revealed routine blood sugar results were not documented.Review of the undated insulin pen instruction manual titled, Instruction for use for NovoLog insulin pens for use guidance revealed to attach a new needle to the pen. Always do a safety test (Priming) before each injection to check your pen and the needle to make sure they are working properly and to make sure you get the correct insulin dose. Select two units by turning the dose selector until the dose pointer is at the two mark, press the injection button all the way in, when insulin is coming out of the needle tip, your pen is working correctly. If no insulin appears, you may need to repeat this step up to three times before seeing insulin. If no insulin comes out after the third time the needle may be blocked. If this happens change the needle and repeat the safety check. After the safety check is complete, select the dose to administer.This deficiency represents non-compliance investigated under Complaint Number 2646034.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, closed medical record review, facility policy review, review of an Emergency Medical Services (EMS) run report, and hospital records, the facility failed to ensure Resident #60 was transferred and weighed in a manner consistent with his plan of care. This resulted in Actual Harm on [DATE] at approximately 9:00 A.M. when Resident #60 was weighed while using a Hoyer (mechanical) lift by Certified Nursing Assistants (CNA) #150 and #152. Resident #60 raised himself up in his electric lift chair, stood up with the assistance of his front wheeled walker, and a Hoyer lift sling was placed underneath him. Resident #60 was then raised into the air by two staff members in the Hoyer lift, where Resident #60 weighed 438 pounds. After the weight was obtained, Resident #60's lift chair was stuck in an upright position, so a decision was made by the two CNAs to place Resident #60 in bed. CNA #152 removed Resident #60's supplemental oxygen nasal cannula so the oxygen tubing would not become tangled as the CNAs turned Resident #60 while he remained suspended in the Hoyer lift. After the oxygen was removed, Resident #60 began to panic and flailed his arms, and the Hoyer lift tipped. Resident #60 fell approximately three feet, hit his head, and landed on his back on the floor. Resident #60 was unhooked from the Hoyer lift, was determined to be blue and not breathing. A code was called, staff began cardiopulmonary resuscitation, and Emergency Medical Services (EMS) was summoned. Resident #60 was subsequently transferred to a local hospital and admitted for further care. This affected one resident (#60) of three residents reviewed for accidents. The facility census was 52. Findings include:Review of the closed medical record for Resident #60 revealed an admission date of [DATE]. Medical diagnoses included chronic combined systolic and diastolic congestive heart failure (CHF), atrial fibrillation, severe morbid obesity with alveolar hypoventilation, cardiomyopathy, chronic respiratory failure with hypoxia, and the presence of an implanted cardiac pacemaker. Review of Resident #60's physician's orders dated [DATE] revealed the resident had an order for supplemental oxygen at three (3) liters (L) per minute via nasal cannula to be worn continuously. Resident #60 had no orders to be transferred via a Hoyer lift and had no order for routine weight monitoring. Review of Resident #60's plan of care dated [DATE] revealed the resident had the potential for falls due to medical diagnoses of CHF, lymphedema, chronic pain, morbid obesity, disorder of the lungs, and a history of falls. Listed interventions included to assist Resident #60 with transfers as needed, and to encourage the use of assistive devices for transfers/ambulation. An additional intervention was added on [DATE] to utilize assistance of three staff members with Hoyer lift while getting the resident's weight. Continued review of Resident #60's plan of care dated [DATE] revealed Resident #60 required assistance with activities of daily living (ADL). A listed intervention noted Resident #60 required supervision or oversight, including verbal cues or encouragement for transfers and when moving from a seated to a standing position with the use of his front wheeled walker. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #60 had a brief interview for mental status (BIMS) score of 15, indicting intact cognition. Resident #60 had no recorded behaviors or rejection of care. His height was listed as 70 inches, and his weight was 430 pounds. Resident #60 was not coded to have utilized a mechanical lift. Review of Resident #60's physical therapy discharge summary note dated [DATE] revealed the resident received physical therapy (PT) in the facility from [DATE] until [DATE]. The reason for discharge was listed as the highest practical level was achieved. Resident #60's functional skill assessment noted the resident required supervision or touching assistance with sit to stand and chair/bed-to-chair transfers. Resident #60 was noted as able to walk ten (10) feet with supervision or touching assistance. Review of a Nurse Practitioner (NP) progress note dated [DATE] revealed Resident #60 was seen at the facility for increased edema and oozing to his bilateral legs. Resident #60 had recent laboratory testing with no acute findings. The report noted Resident #60 had a history of CHF, lymphedema, and the note referenced his BNP level (used to assess heart function and diagnose conditions such as heart failure) was slightly elevated. The note reflected that the NP had ordered Lasix (a diuretic) 20 milligrams (mg) orally for five days and for weights to be monitored daily for 3 days. Review of a local Emergency Medical Services (EMS) run report dated [DATE] at 9:05 A.M. revealed they were called to the facility for a medical trauma. Staff reported Resident #60 had been dropped from a Hoyer lift with the cardiac arrest following. The report noted the collapse was witnessed and cardiopulmonary resuscitation (CPR) was initiated by staff approximately two minutes after the collapse. Resident #60 appeared unresponsive, was apneic (not breathing), and without a pulse, with CPR in progress by facility staff. Resident #60 was noted to be pale and cyanotic. EMS applied an electrocardiogram (ECG) and obtained a rhythm that was unable to be shocked by an automatic electronic defibrillator (AED). Review of a nursing progress note dated [DATE] at 9:43 A.M. revealed at approximately 8:50 A.M., Agency Licensed Practical Nurse (LPN) #151 heard a loud sound accompanied by verbalization from another staff member stating, I need a nurse! Agency LPN #151 followed an unnamed staff member into Resident #60's room where the resident was observed unconscious on the floor. The Hoyer lift was observed tipped over with Resident #60 still attached. Agency LPN #151 responded quickly and noted Resident #60 to be cyanotic (a bluish or purplish discoloration of the skin and mucous membranes due to a lack of oxygen in the blood) in his face and lips. Resident #60 was quickly removed from the Hoyer straps, and the scene was cleared of obstacles. Cardiopulmonary Resuscitation (CPR) was immediately initiated while another staff member called nine-one-one (911). Resident #60's code status was verified as a full code. Resident #60 continued to receive high-quality CPR and was ventilated by an artificial manual breathing unit (AMBU) bag while awaiting emergency medical services (EMS) arrival to the facility. EMS arrived at the facility at approximately 9:00 A.M. and CPR continued. EMS established an artificial airway and intravenous (IV) access. Resident #60's pulse was re-established at approximately 9:34 A.M. and he was transported to a local hospital at 9:35 A.M. by EMS. Resident #60's family and physician were both notified. Review of an interdisciplinary team (IDT) progress note dated [DATE] at 11:09 A.M. revealed Resident #60's incident involving the Hoyer lift was reviewed, and a new intervention was implemented to use three staff members while obtaining Resident #60's weight via the Hoyer lift. Review of the fall investigation dated [DATE] revealed Resident #60 had a fall while using the mechanical lift. Post-fall, Resident #60 required CPR and subsequent hospitalization. Resident #60 was noted to be a long-term resident in the facility. Resident #60 was being weighed by CNAs #150 and #152. Resident #60 was placed in the Hoyer sling and attached appropriately to the lift. Resident #60 was raised up into the Hoyer lift and his weight was obtained. Resident #60 began having sudden and uncontrolled movements while suspended in the lift and began to swing while in the Hoyer. The two CNAs attempted to move Resident #60 to his bed when the Hoyer lift flipped forward, and Resident #60 fell to the ground. Resident #60 was observed non-responsive and found to have an absence of both pulse and respirations. CPR was initiated and EMS was notified. EMS responded, aided in resuscitative efforts, and transported the resident to a local hospital where he was admitted . Review of a hospital emergency physician note dated [DATE] at 3:07 P.M. revealed Resident #60 was seen in the emergency department as a trauma transfer from another hospital. Resident #60 sustained a fall from a Hoyer lift from approximately 4 feet with a subsequent cardiac arrest. Imaging completed in the emergency department indicated Resident #60 had multiple rib fractures which were presumed to have been caused by chest compressions during CPR. Resident #60 was admitted to the hospital's intensive care unit (ICU). Review of a hospital physician's history and physical dated [DATE] at 3:15 P.M. revealed Resident #60 presented to a local hospital with diagnoses including nonischemic cardiomyopathy, obstructive sleep apnea, restrictive lung disease, type two diabetes mellitus, and lymphedema. The note referenced Resident #60 was at his nursing facility where staff were utilizing a Hoyer lift when Resident #60 fell approximately three feet onto the floor. Per staff, Resident #60 went into immediate cardiac arrest. EMS arrived at the facility and advanced cardiac life support (ACLS) [a set of clinical guidelines established for the urgent and emergent treatment of cardiopulmonary arrest and cardiovascular emergencies] was provided by EMS. Return of spontaneous circulation (ROSC) was obtained after approximately 20 minutes. Interview on [DATE] at 8:45 A.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #210 revealed Resident #60 was placed in a Hoyer lift with two staff members who were obtaining the resident's weight. Resident #60 became anxious and flailed his arms, and the Hoyer lift tipped. Resident #60 fell to the ground, was not breathing and had no pulse. CPR was initiated, EMS arrived at the facility, aided in resuscitative efforts, and Resident #60 was transported to a local hospital and admitted into the ICU. The DON reported she had completed a full investigation into the event. Interview on [DATE] at 10:50 A.M. with CNA #150 revealed she was a CNA and worked as a receptionist and assisted in medical records. On [DATE], she was working as the receptionist when CNA #152 asked her to assist in using the Hoyer lift to obtain Resident #60's weight. She entered Resident #60's room at approximately 8:55 A.M. CNA #150 stated Resident #60 slept in his electric recliner per his preference. Resident #60 assisted and raised the electric recliner to the elevated position. He stood using his walker to steady himself and was wearing his supplemental oxygen per nasal cannula. As Resident #60 stood, CNA #152 placed the Hoyer lift sling on the seat of his recliner underneath him. Resident #60 sat down and attempted to lower the electric recliner down from a raised to a seated position. The electric recliner would not move and was stuck in an upright, raised position. The two CNAs obtained Resident #60's weight, and due to the chair being stuck in the upright position, decided to transfer Resident #60 into his bed. CNA #150 reported to avoid tangling the oxygen tubing and fear of knocking over equipment, CNA #152 removed the resident's nasal cannula. Resident #60 was suspended in the Hoyer lift and was being rotated to align with the bed. Resident #60 began to flail his arms, and the Hoyer lift fell over. Resident #60 landed on his back on the floor, and the open legs of the Hoyer lift were entrapped on the bed. The CNAs summoned additional help, Resident #60 was removed from the Hoyer and sling, and staff came in to aid in resuscitative efforts. Interview with CNA #152 on [DATE] at 11:17 A.M. revealed she asked CNA #150 to help her use the Hoyer lift to obtain a weight on Resident #60. The legs of the lift were open, and the wheels were locked. His oxygen nasal cannula was applied. He was educated to keep his hands on his chest or lap. Resident #60 was connected to the lift and was raised. His weight was obtained at 438 pounds. CNA #152 reported the resident's recliner was stuck in the upright position, so the two CNAs were going to place Resident #60 in his bed. In preparation to move and rotate Resident #60 while up in the lift, CNA #152 removed Resident #60's oxygen nasal cannula so it would not become tangled. Resident #60 began to panic and flailed his arms. CNA #152 recalled re-educating the resident to relax and to place his hands on his chest or in his lap without success. The entire Hoyer lift flipped, and Resident #60 landed on his back on the floor. CNA #152 immediately called for help and noted the resident had started turning blue. CNA #152 stated she did not get a chance to reapply his oxygen after removal, as the whole event happened so quickly. Additional staff immediately responded, and a code was started. CNA #152 reported Resident #60's head hit the wall, and when disconnecting him from the lift he had to be pulled away from the wall. EMS arrived shortly after the additional staff responded and Resident #60 left with EMS. Interview on [DATE] at 12:53 P.M. with Wound Nurse #205 revealed she was doing wound treatments on the 100-hall and came by the nurse's station. She ran down to Resident #60's room when she heard other staff members yelling for help. When she entered the room, Resident #60 was on the floor and his face was blue. Resident #60 was on his back, under the Hoyer lift, and had to be pulled away from the wall as he was scrunched on the wall. Resident #60 was quickly freed from the lift and CPR was started by facility staff. EMS arrived and continued CPR. EMS attempted additional interventions including intubation but was unsuccessful. Intravenous access was established by EMS and EMS personnel administered resuscitative medications. Staff and EMS were rotating performing CPR compressions. After approximately 30 minutes of resuscitative efforts, Resident #60 was observed to have a pulse. EMS transported the resident to a local hospital. Interviews conducted on [DATE] between 8:45 A.M. and 11:32 A.M. with CNA #114, CNA #115, CNA #133, and CNA #145 confirmed Resident #60 did not require the use of the Hoyer lift. Interviewed staff consistently reported Resident #60 was able to stand and pivot from his recliner to the bedside commode near his chair. Interview on [DATE] at 12:13 P.M. with the Administrator and DON confirmed Resident #60 did not require the Hoyer lift for transfers but on [DATE] opted for the Hoyer lift to be used to obtain his weight instead of the seated facility chair scale. The Administrator and DON reported Resident #60 had shared the seated chair scale was uncomfortable. Both confirmed the resident had previously used a Hoyer lift in prior facility stays, but at the time of the incident confirmed he was able to stand and pivot and did not require the use of the Hoyer lift for mobility. Review of the policy Fall Prevention and Management dated [DATE] revealed the policy defined falls as an event in which an individual unintentionally comes to rest on the ground, floor, or other level. Individualized interventions will be implemented based on assessment and risk factors. Interventions will be monitored for effectiveness. The plan of care will be revised as needed. The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: On [DATE], at approximately 9:30 A.M., the Hoyer lift involved in Resident #60's fall was removed from service. On [DATE], the Hoyer lift involved in Resident #17's fall was inspected by the DON and Maintenance Director #308. The manufacturers' guidelines were reviewed. The lift was determined to be in good working order with no concerns noted. On [DATE], Maintenance Director #308 inspected all in-house lifts and slings. The facility identified five (5) lifts and 12 slings. All were found to be in good working order with no concerns noted. On [DATE], the DON completed an audit for all current residents who used a Hoyer lift for transfers. The facility identified 15 in-house residents (#7, #13, #20, #24, #27, #32, #38, #39, #40, #42, #44, #45, #46, #47, and #53) required the use of a Hoyer lift for transfers and/or to obtain ordered weights. There were no adverse findings. On [DATE], the DON initiated re-education for all nursing staff (including CNAs, licensed nurses, and clinical managers) on transfers, including mechanical (Hoyer) lifts, the facility's weight policy (including refusal, notification, and documentation) and emergency response procedures. A post-education quiz was utilized to verify staff's knowledge. On [DATE] at 3:00 P.M., an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the interdisciplinary team to discuss Resident #60's Hoyer-involved fall. The facility's Medical Director attended via phone. The corrective action plan was reviewed with no additional recommendations received. On [DATE], the DON initiated competencies for all CNAs on operation of a Hoyer lift transfer. This training was completed on [DATE]. All CNAs demonstrated appropriate knowledge and skills for use of the Hoyer lift. Beginning on [DATE], the DON or designee will conduct randomized observational audits of mechanical Hoyer lift transfers on at least five (5) residents weekly for a duration of four weeks. Results will be reported to the Administrator and QAPI committee for any modification of intervention or adjustments as needed. Beginning on [DATE], the Maintenance Director or designee will conduct randomized audits of mechanical lifts and mechanical lift sling/pads at least twice weekly for a duration of four weeks. Results will be reported to the Administrator and QAPI committee for any modification of intervention or adjustments as needed. Beginning on [DATE], the DON or designee will conduct randomized interviews with nursing staff on Hoyer procedures and safety on at least five staff members weekly for a duration of six weeks. Results will be reported to the Administrator and QAPI committee for any modification of intervention or adjustments as needed. Beginning on [DATE], the DON or designee will conduct randomized audits of weights to ensure weights are completed timely and accurately and are appropriately documented twice weekly for a duration of four (4) weeks. Results will be reported to the Administrator and QAPI committee for any modification of intervention or adjustments as needed. Beginning on [DATE], the DON or designee will conduct a code blue drill weekly for four weeks. Results will be reported to the Administrator and QAPI committee for any modification of intervention or adjustments as needed. This deficiency represents non-compliance investigated under Complaint Number 2569777.

Based on medical record review, resident interview, staff interview, Nurse Practitioner (NP) interview, review of hospital records, and review of facility policy, the facility failed to adequately monitor Resident #271's cellulitis (potentially serious bacterial skin infection), failed to timely identify a change in condition, and further failed to notify the physician of the resident's decline. This resulted in actual harm for Resident #271 on 03/29/25 when the facility failed to adequately monitor the resident's right lower extremity cellulitis to identify a worsening of the condition and, therefore, did not notify the physician of the decline. Resident #271's family member intervened and requested the facility transfer the resident to the hospital for further evaluation and treatment. Subsequently, Resident #271 was admitted to the hospital and treated with intravenous (IV) antibiotics due to a deterioration of the condition. Additionally, the facility failed to provide interventions for constipation for Resident #16 and further failed to implement heel protection devices per physician order for Resident #323 that placed the residents at potential for more than minimal harm that was not harm. This affected three (#271, #16 and #323) of three resident reviewed for quality of care and treatment. The facility census was 59. Findings include: 1. Review of Resident #271's closed medical record revealed an admitted [DATE]. Diagnoses included fracture of the right tibia, atrial fibrillation, chronic obstructive pulmonary disease (COPD), and cellulitis. The resident transferred to the hospital on 03/29/25 and discharged from the facility on 03/30/25. Review of the Minimum Data Set (MDS) assessment, dated 01/21/25, revealed Resident #271 required substantial staff assistance with all activities of daily living (ADLs). Review of the care plan, initiated 01/20/25, revealed Resident #271 had a potential for alteration in skin integrity. Review of the Certified Nurse Practitioner (CNP) progress note, dated 03/28/25, revealed Resident #271 was seen for a follow up visit by CNP #710 due to right leg redness due to a skin tear found the previous day. Per staff, the skin tear was observed on 03/27/25 and was cleaned and covered. Staff stated on 03/28/25, the resident's right lower leg was red, and that was a new finding. The resident complained of some pain with palpitation of the lower right leg but denied any chest pain or shortness of breath. Per nursing, vital signs were stable and no other concerns or findings were reported. Further review revealed CNP #710's assessment included a diagnosis of cellulitis with new redness to the lower right leg from the ankle to the knee. There was mild warmth and pain present with palpation. The resident did not have a fever and no additional changes were noted. Doxycycline (antibiotic) 100 milligrams (mg) was ordered. Additional orders included monitoring the skin and the resident's progress and call the CNP or medical physician if fever increased, redness with streaking, increased pain, or changes in vital signs were observed. Review of a health status note, dated 03/29/25, revealed the nurse spoke to Resident #271's daughter and informed her of the cellulitis and skin tear. The resident's daughter was very upset that she was not informed about the resident's worsening skin condition. Further review of Resident #271's medical record revealed no evidence the resident's skin condition was monitored until 03/29/25 at 7:30 P.M. when the resident's daughter brought her concerns to the attention of staff and the resident was subsequently transported to the hospital per family request. Review of Resident #271's nursing observations dated 03/29/25 revealed the resident's daughter visited at approximately 7:30 P.M. and asked the nurse to send the resident to the hospital to be evaluated properly. At the time, Resident #271 was on antibiotic therapy for right lower leg cellulitis. Review of the hospital notes, dated 03/29/25, revealed Resident #271 was brought to the emergency room (ER) due to an infection of the right lower extremity. Symptoms began on 03/27/25 and the resident was started on Doxycycline on 03/28/25. The daughter went to visit the resident and she was concerned because the dressing on the right lower extremity was too tight and the infection was spreading up to the proximal (area from the hip to the knee) leg. There were photos of the right leg in the system. There was cellulitis involving the anterior tibia (front, outer area of the leg) and also the medial aspect (inner part, located between the hip and the knee) of the thigh and across the buttocks, which appeared to be erythematous (abnormal redness) rash concerning for cellulitis as well. The resident had a previous history of stroke and a right hip fracture per the daughter. The daughter did not want the resident to return to the facility she came from. Further review of the hospital notes revealed Resident #271's lower right leg was tender with 2+ pitting edema (indicating a moderate amount of fluid buildup in the tissue) present. The leg had erythema (redness) present. The resident had diffuse edema of the right lower extremity with diffuse patchy areas of erythema with mild increase in temperature. There was also an area of erythema on the medial thigh. The resident had a lot of tenderness with palpation of the right lower extremity. The resident was admitted to the hospital and started on IV antibiotics. Additional review of the hospital records revealed photographs were taken on 03/29/25, upon arrival to the ER, and revealed the cellulitis had migrated up the resident's inner thigh and onto her buttocks. Interview with Licensed Practical Nurse (LPN) #913 on 04/30/25 at 4:40 P.M. revealed she cared for Resident #271 on 03/29/25. LPN #913 stated she informed the Infection Control Nurse (ICN) that the resident's cellulitis was weeping fluids. At that time, a mesh sleeve was applied by both nurses, with no other intervention or notification made to the physician. LPN #913 stated that at approximately 12:00 P.M., Resident #271's daughter arrived at the facility and was extremely upset because staff had failed to inform her of the resident's worsening cellulitis. Resident #271's daughter left and returned later in the day and requested the resident be transferred to the hospital for evaluation. Interview with CNP #710 on 05/01/25 at 10:55 A.M. verified she had not been notified of Resident #271's worsening cellulitis until the resident was transferred to the hospital by request of the family. CNP #710 reviewed the photographs taken at the time of Resident #271's admission to the hospital of the worsening cellulitis and stated that had the resident been in that condition when she saw her on 03/28/25, she would have sent her to the hospital immediately. Review of the facility policy titled, Notification of Changes, revised 01/01/25, revealed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Further review revealed circumstances requiring notification included significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include life-threatening conditions or clinical complications. 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, chronic pain syndrome, and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/17/24, revealed Resident #16 was cognitively intact. The resident was always continent of urine and occasionally incontinent of bowel. Review of the physician orders revealed Resident #16 had an order dated 04/19/25 for lactulose oral solution, give 30 milliliters (ml) by mouth every 24 hours as needed for constipation. Review of the plan of care dated 04/21/25 revealed Resident #16 was at risk for alteration in bowel elimination and constipation. Interventions included administering laxatives, stool softeners, or other bowel medications as ordered. Additionally, if no bowel movement (BM) within three days, begin bowel evacuation protocol per facility policy. Review of Resident #16's bowel tracking log from 04/10/25 through 04/30/25 revealed no documented BMs between 04/25/25 through 04/28/25. Review of the Medication Administration Record (MAR) from 04/19/25 through 04/30/25 revealed the lactulose was not administered to the resident during this time period. Interview on 05/01/25 at 3:04 P.M. with the Administrator verified the bowel tracking log log indicated Resident #16 did not have a BM from 04/25/25 through 04/28/25 and further confirmed there was no evidence interventions for constipation were offered or administered to the resident. Review of the facility policy titled, Routine Bowel Regimen, dated August 2018, revealed the BMs of residents were monitored. The policy stated that if a resident did not have a BM for three days, a nurse would assess and notify the physician if any issues were identified. Residents who were determined to have a typical bowel movement schedule other than three days, would implement the bowel movement protocol relevant to their personal routine. Unless the physician had given a different order, a laxative would be administered. 3. Review of the medical record revealed Resident #323 was admitted to the facility on [DATE]. Diagnoses included atherosclerosis of native arteries of extremities with gangrene, hypertension, end stage renal disease, type II diabetes mellitus, and hyperkalemia. Review of the admission MDS assessment, dated 04/09/25, revealed Resident #323 was cognitively intact. Review of the hospital discharge records, dated 04/09/25, revealed Resident #323's discharge instructions included Prevalon boots (heel protectors) on when in bed. Review of the physician orders revealed an order dated 04/14/25 for Resident #323 to have Prevalon boots on while in bed. Observation on 04/28/25 at 10:30 A.M. revealed Resident #323 was in bed and was not wearing Prevalon boots. Interview on 04/28/25 at 11:28 A.M. with Certified Nursing Assistant (CNA) #610 verified Resident #323 did not have Prevalon boots or any type of heal protectors on while in bed. CNA #610 reported the resident never had Prevalon boots since admitting to the facility. Observation on 04/29/25 at approximately 4:15 P.M. revealed Resident #323 was in bed and did not have Prevalon boots on. Interview on 04/29/25 at approximately 4:17 P.M. with Resident #323 revealed he never had Prevalon boots or any type of heel protector since admitting to the facility. Resident #323 reported he would wear them if he had them. Observation on 04/30/25 at 9:30 A.M. revealed Resident #323 was in bed and did not have Prevalon boots on. This deficiency represents non-compliance investigated under Complaint Numbers OH00164819 and OH00164408.

Based on observation, staff interview and review of the facility policy, the facility failed to maintain a clean and sanitary kitchen and further failed to ensure food items were not stored directly on the floor. This had the potential to affect all 59 residents who received meals from the facility kitchen. The facility census was 59. Findings include: Observations on 04/28/25, beginning at approximately 8:15 A.M., revealed the following: The dry storage area, located in the main kitchen, revealed there were three crates of onions stacked and stored directly on the floor. The wall behind the dishwashing machine had an unknown black substance, which went from mid-wall down to the floor. There was buildup and debris under a metal table located in the kitchen. There was buildup and debris located against a wall and behind a refrigerator in the kitchen. A concurrent interview with Dietary Manager #750 verified the above findings. DM #750 reported the black substance behind the dishwashing machine was mold. Review of the facility policy titled, Food Safety Requirements, dated 01/01/25, revealed food would be stored in accordance with professional standards for food service safety. Food items located in dry storage areas would be kept off of the floor. This deficiency represents non-compliance investigated under Complaint Number OH00165111.

Based on resident interview, staff interview, review of the Facility Assessment (FA) and review of staffing reports, the facility failed to have sufficient staff to meet resident needs as identified in the FA. This had the potential to affect all 59 residents of the facility. The facility census was 59. Findings include: Interview with Resident #30 on 04/28/25 at 9:34 A.M. revealed the facility was extremely short staffed and her call light went unanswered on multiple occasions, which resulted in her urinating on herself in bed. Resident #30 revealed call lights were often unanswered within 30 minutes on second and third shifts. Interview with Resident #35 on 04/28/25 at 10:04 A.M. revealed Certified Nursing Assistants (CNAs) took a long time to answer call lights. Resident #35 stated staff instruct her to stay in bed until assistance arrived, but no one comes. Interview with Resident #269 on 04/28/25 at 10:36 A.M. revealed care was not provided timely and she had taken herself to the bathroom, even though she was directed to wait for staff assistance. Interview with Resident #18 on 04/28/25 at 10:43 A.M. revealed she had frequently wait for over 30 minutes for staff assistance after pressing her call light. Interview with Resident #28 on 04/28/25 at 3:24 P.M. revealed there were not enough CNAs, resulting in her incontinence brief not being changed timely. Interview with Licensed Practical Nurse (LPN) #913 on 04/30/25 at 4:40 P.M. verified the facility was short on staff, especially on second and third shift. While there were a sufficient number of nurses to complete their tasks, LPN #913 stated the CNAs could not handle the workload and respond to call lights timely to assist residents. Review of the FA, dated 07/29/24, revealed the facility identified second shift required six CNAs and the night shift required four CNAs for the entire shift to meet resident needs. Review of the Staffing Tool, dated 03/29/25, revealed the facility census was 66. Review of the facility staff clock in and out reports for 03/29/25 revealed on second shift (2:00 P.M. to 10:00 P.M.) four CNAs (#315, #475, #740, #820) worked the full shift. One CNA (#840) worked from 2:00 P.M. to 5:45 P.M. Two CNAs (#515 and #525) worked from 2:00 P.M. to 6:45 P.M. This revealed seven CNAs worked from 2:00 P.M. to 5:45 P.M., six CNA's from 2:00 P.M. to 6:45 P.M. and four CNAs cared for 66 residents from 6:45 P.M. to 10:00 P.M., resulting in only four CNAs from 6:45 P.M. until 10:00 P.M. when the FA identified six were needed. Further review of the facility clock in and out reports for 03/29/25 revealed on third shift (10:00 P.M. to 6:00 A.M. on 03/30/25), two CNAs (#685 and #655) worked the full shift. CNA #440 worked from 1:45 A.M. to 6:45 A.M. One CNA (#315) worked from 10:00 P.M. to 2:15 A.M. and Medication Technician (MT) #540 worked from 10:00 P.M. to 2:45 A.M. This revealed that after 2:45 A.M., there were only three CNAs working when the FA identified four CNAs were needed for the entire shift. Interview on 05/01/25 at 9:15 A.M. with the Administrator, with concurrent review of the staff clock in and out reports, verified the facility had insufficient CNA staffing on 03/29/25 for both the second and third shift, based on the CNA staffing need identified in the facility in the FA. This deficiency represents non-compliance investigated under Complaint Number OH00164408.

Based on observation, resident interview, staff interview, and policy review, the facility failed to maintain a comfortable, clean, sanitary, and homelike environment that was in good repair. This affected four (#40, #30, #48 and #22) of four residents reviewed for the environment with the potential to affect and additional 23 residents (#3, #8, #10, #16, #17, #20, #24, #26, #27, #28, #34, #41, #42, #43, #47, #54, #57, #59, #319, #320, #321, #322, #323) residents who resided on the 300-unit. The facility census was 59. Findings include: 1. Observation on 04/28/25 at approximately 10:10 A.M. revealed a door was located at the far end of the 300-hall, past the nursing station. There was a gap between the bottom of the door and the door frame, through which the outside could be seen. Interview on 04/28/25 at approximately 10:15 A.M. with Resident #40 revealed the resident could often feel the elements of the weather because of the gap between the door and the doorframe. Resident #40 reported she could feel the heat and cold air coming in, she worried about insects getting in, and it was especially drafty and uncomfortable in the winter time. Interview on 04/30/25 at approximately 9:13 A.M., Registered Nurse (RN) #585 verified the gap between the bottom of the door and the door frame, allowing the outside elements into the facility. 2. Observation on 04/28/25 at 9:42 A.M. of Resident #30's room revealed the window air conditioning unit was not properly installed, leaving a space open to the outdoors. Coinciding interview with Resident #30 revealed she believed spiders and insects were coming in through her window where the window air conditioning unit was not properly installed and open to the outdoors. Interview on 05/01/25 at 08:37 A.M. with the Director of Maintenance (DM) #880 verified the window air conditioning unit was not properly installed and left a space open to the outdoors. 3. Observation on 05/01/25 at 10:30 A.M. of the shower room located on the 300-unit revealed the following: There were numerous broken tiles surrounding the drain in the shower area. There was a blood-soaked item located on the floor to the right of the toilet. There was a dried red substance on the wall behind the toilet. There were numerous scuffed, scraped, and chipped areas on the door. An interview on 05/01/25 at 10:36 A.M. with Certified Nursing Assistant (CNA) #500 verified the above findings. 4. Observation on 04/28/25 at 11:04 A.M. of Resident #48 and Resident #22's bathroom revealed the baseboard was not attached to the bathroom wall on the side of the toilet and sink. Further observation of the room revealed the wall behind Resident #48's recliner had a large are with the paint scrapped off and food particles scattered on the floor. Interview on 04/29/25 at 10:05 A.M. with Registered Nurse (RN) #345 confirmed the unattached baseboard in Resident #48 and Resident #22's bathroom, the paint scraped off the wall behind Resident #48's recliner, and the food particles scattered on the floor. Review of the facility policy titled, Resident Environmental Quality, dated 11/29/22, revealed the facility should have a sanitary and comfortable environment for residents, staff, and the public. Review of the facility policy titled Resident Rights, dated 06/01/24, revealed residents had the right to a safe, clean, comfortable, and homelike environment. This deficiency represents non-compliance investigated under Master Complaint Number OH00165111 and Complaint Numbers OH00164819 and OH00164408.

Based on medical record review, review of electronic communications (e-mail), staff interview and review of facility policy, the facility failed to ensure a request for medical records was addressed timely. This affected one (#270) of one resident reviewed for medical record requests. The facility census was 59. Findings include: Review of the medical record for Resident #270 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses include altered mental status, psychosis, encephalopathy, anxiety, restlessness and agitation, depression, sepsis, hypertension, and a history of cerebral infarction. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of an e-mail, dated 03/07/25 at 4:08 P.M., revealed Resident #270's family member requested the resident's medical records from the facility. Further review of an e-mail dated 03/14/25 at 2:15 P.M., revealed Resident #270's family member sent another email following up on the previous request for the resident's medical records. There was no response from the facility informing the family member of the process for requesting medical records. Interview on 04/29/25 at 10:36 A.M. with Social Service Designee (SSD) #425 revealed a form must be completed to request medical records and then given to the Administrator. SSD #425 revealed she could not recall receiving a request for medical records for Resident #270. A follow-up interview on 04/29/25 at 3:40 P.M. with SSD #425 confirmed the family of Resident #270 had sent e-mails on 03/07/25 and 03/14/25 requesting medical records. SSD #425 revealed she returned from vacation on 03/17/25 and must have missed the e-mails requesting medical records from Resident #270's family. SSD #425 stated she would follow-up with the family and expedite the request. Interview on 04/30/25 at 7:45 A.M. with the Administrator revealed he had not been notified of a request for medical records for Resident #270. Review of the facility policy titled, Release of Medical Records, dated 06/01/24, revealed requests for records should be referred to the Director of Nursing, Administrator, or another staff member previously designated by the facility. After receiving a request, the facility would notify the requesting party of the cost to obtain the records and would provide the records within two days after receipt of payment for the copies. This deficiency represents non-compliance investigated under Complaint Number OH00164819.

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure physician ordered catheter care was provided. This affected three (#53, #48 and #22) of six residents reviewed for catheter care. The facility census was 59. Findings included: 1. Review of Resident #53's medical record revealed an admitted [DATE]. Diagnoses included lymphedema, chronic kidney disease, and obstructive uropathy. Review of Resident #53's quarterly Minimum Data Set (MDS) assessment, dated 01/14/25, revealed the resident had intact cognition. Additionally, the resident had a suprapubic catheter. Review of Resident #53's care plan revealed he was at risk for complications related to the use of a suprapubic catheter. Resident #53 would have no signs and symptoms of a urinary tract infection (UTI) or complications related to suprapubic catheter use. Interventions included to assist with suprapubic catheter care. Review of the physician orders revealed an order dated 01/14/25 to complete suprapubic catheter care every shift and an order dated 04/04/25 to apply a clean four by four (4 x 4) gauze to the suprapubic site daily. Review of the Treatment Administration Record (TAR) for March 2025 revealed no documentation Resident #53's suprapubic site was cleaned and the gauze was changed on 03/06/25, 03/20/25, 03/22/25, and 03/27/25. Further review of the TAR for April 2025 revealed no evidence the treatment was completed on 04/02/25, 04/06/25, 04/08/25, 04/09/25, 04/14/25, 04/15/25, 04/18/25, 04/19/25, 04/20/25, 04/24/25, 04/28/25, and 04/29/25. Additional review of the TAR revealed no evidence suprapubic catheter care was provided for Resident #53 on the day shift on 04/03/25, 04/06/25, 04/08/25, 04/09/25, 04/14/25, 04/15/25, 04/19/25, 04/20/25, 04/24/25, 04/28/25, and 04/29/25. Further review revealed no documentation care was provided on the night shift on 04/08/25, 04/09/25, and 04/30/25. Interview on 04/30/25 at 11:25 A.M. with Resident #53 revealed staff failed to cleanse and change the dressing to his suprapubic catheter daily. Resident #53 stated there were times when several days would pass between dressing changes. Interview on 05/01/25 at 11:22 A.M. with Infection Control Preventionist (ICP) #310 and MDS Nurse #710 confirmed treatments were not documented as completed for Resident #53's suprapubic catheter care and dressing changes. 51528 2. Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included type II diabetes mellitus and obstructive and reflux uropathy. Review of the quarterly MDS assessment, dated dated 03/31/25, revealed Resident #48 was cognitively intact and had an indwelling urinary catheter. Review of a physician order dated 09/30/24 revealed Resident #48 had an order for indwelling urinary catheter care every shift. Review of the Treatment Administration Record (TAR) for April 2025 revealed Resident #48's catheter care was not documented as provided on the 6:00 A.M. to 6:00 P.M. shift on 04/04/25, 04/06/25, 04/09/25, 04/10/25, 04/19/25, and 04/20/25. Further review revealed no evidence the care was provided on the 6:00 P.M. to 6:00 A.M. on 04/23/25. Interview on 04/30/25 at 9:18 A.M. with Registered Nurse (RN) #345 confirmed catheter care was not documented as completed for Resident #48 on the 6:00 A.M. to 6:00 P.M. shift on 04/04/25, 04/06/25, 04/09/25, 04/10/25, 04/19/25, and 04/20/25 and on the 6:00 P.M. to 6:00 A.M. shift on 04/23/25. 3. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type II, peripheral vascular disease, and congestive heart failure. Review of the quarterly MDS assessment, dated 03/10/24, revealed Resident #22 had mild cognitive impairment and had a suprapubic catheter. Review of a physician order dated 01/14/25 revealed Resident #22 had and order for suprapubic catheter care every day shift. Further review revealed an order dated 03/08/25 for Mupirocin (treats bacterial infections) external ointment two percent (%), apply to surrounding skin of catheter topically two times a day for suprapubic catheter care. Review of the TAR for April 2025 revealed there was no documentation that suprapubic catheter care was provided on 04/19/25 and 04/20/25. Further review revealed there was no documentation that Mupirocin ointment was applied to the skin surrounding the resident's catheter upon rising on 04/19/25, 04/20/25, 04/24/25, and 04/29/25 and on the 6:00 P.M. to 6:00 A.M. shift on 04/23/25. Interview on 04/30/25 at 9:18 A.M. with RN #345 confirmed catheter care was not documented as completed for Resident #48 on the 6:00 A.M. to 6:00 P.M. shift on 04/04/25, 04/06/25, 04/09/25, 04/10/25, 04/19/25, and 04/20/25 and on the 6:00 P.M. to 6:00 A.M. shift on 04/23/25. Further interview with RN #345 verified Resident #22's suprapubic catheter care was not documented as completed on 04/19/25 and 04/20/25 and Mupirocin ointment was not documented as completed upon rising on 04/19/25, 04/20/25, 04/24/25, and 04/29/25 and on the 6:00 P.M. to 6:00 A.M. shift on 04/23/25. Review of the facility policy titled, Catheter Care, dated 06/01/24, revealed catheter care would be performed every shift and as needed by nursing personnel. Review of the facility policy titled, Suprapubic Catheterization, dated 06/01/24, revealed suprapubic catheters would be changed in accordance with current standards of practice to minimize risk for bacterial contamination or failed insertions. The care and maintenance of suprapubic catheters shall be in accordance with physician's orders.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure central lines were cared for in accordance with professional standards of practice. This affected one (#323) of one resident reviewed for intravenous (IV) therapy. The facility census was 59. Findings include: Review of the medical record revealed Resident #323 was admitted to the facility on [DATE]. Diagnoses included atherosclerosis of native arteries of extremities with gangrene, hypertension, end stage renal disease, type II diabetes mellitus, and hyperkalemia. Review of the admission Minimum Data Set (MDS) assessment, dated 04/09/25, revealed Resident #323 was cognitively intact. The resident had a central line. Review of the plan of care dated 04/18/25 revealed Resident #323 had potential for complications related to use of IV medications and/or IV fluids. Interventions included changing the dressing to the IV site as ordered and per facility policy, checking for signs and symptoms of infiltration at the site, and checking the IV site for signs and symptoms of infection. Review of a physician order dated 04/14/25 revealed Resident #323 had an order to flush subclavian IV antibiotic line with 10 milliliters (ml) of normal saline before and after medication administration every shift. There were no orders for monitoring the IV site or for dressing changes, including the type or frequency. Further review of Resident #323's medical record revealed no evidence the central line dressing had been changed. Observation on 04/30/25 at 9:15 A.M. of Resident #323's central line, with Registered Nurse (RN) #585, revealed the resident had a central line to his right chest. There was a transparent dressing, with a date that was illegible. Additionally, the dressing was rolled back and discolored. The resident's central line was completely uncovered and exposed. Concurrent interview with RN #585 verified Resident #323's central line was exposed and needed to be covered. RN #585 also verified the date on the dressing was unable to be read. Interview on 04/30/25 at 10:16 A.M. with Licensed Practical Nurse (LPN) #675 verified Resident #323 should have had a physician order for the central line dressing to be changed, adding staff would otherwise not know to change the dressing. Interview on 05/01/25 at 12:35 P.M. with RN #310 verified there were no orders to monitor Resident #323's central line site or for dressing changes. Further interview with RN #310 confirmed there was no evidence the facility had changed the central line dressing from admission (22 days earlier). Review of the facility policy titled, Central Vascular Access Device (CVAD) and Midline Catheter Dressing Changes, dated, revealed a sterile dressing would be applied and maintained on all midline catheters and CVADs (peripherally inserted central catheters, and accessed implanted ports), to secure the vascular access device, minimize site complications, and to detect and prevent other complications associated with infusion therapy. The policy further stated sterile transparent, semi-permeable membrane dressings were the preferred covering for CVAD and midline insertion sites due to allowed visualization of the insertion site. The policy stated dressings should be changed every five to seven days, when the site was rotated, if the integrity of the dressing was compromised, and/or upon suspected contamination. The CVAD and midline catheter skin sites and surrounding area should be assessed for redness, tenderness, swelling, and drainage upon admission, at least daily, and with dressing changes. The policy further stated documentation in the medical record would include the date and time of dressing changes, the type of dressing used, condition of the site, and the nurse's signature.

Based on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure resident pain was effectively managed. This affected one (#269) of one resident reviewed for pain management. The facility census was 59. Findings include: Review of the medical record for Resident #269 revealed an admitted [DATE]. Diagnoses included fracture of the left lower leg, chronic pain, and anxiety. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #269 was cognitively intact. Review of physician orders dated 04/25/25 revealed Resident #269 had orders for Tylenol 325 milligrams (mg) by mouth every four hours as needed for pain and oxycodone-acetaminophen 5-325 mg, give one tablet by mouth every six hours as needed for pain. Review of the Medication Administration Record (MAR) for April 2025 , dated 04/2025 revealed on 04/26/25 at 3:00 A.M., Licensed Practical Nurse (LPN) #360 administered Tylenol 650 mg to Resident #269 for a pain level of two. Further review of the MAR revealed the first dose of oxycodone-acetaminophen was not administered until 04/26/25 at 4:52 P.M. for a pain level of three. Interview on 04/28/25 at 10:40 A.M. with Resident #269 revealed she was only given Tylenol for pain when she was first admitted to the facility due to oxycodone-acetaminophen being unavailable. On a scale of one to 10, with 10 being the worst, Resident #269 stated her pain was a ten during the time the oxycodone acetaminophen was unavailable. Resident #269 stated the Tylenol brought her pain level down to around an eight; however, it did not last long before she was in severe pain, causing her to vomit. A telephone interview on 04/30/25 at 1:58 P.M. with LPN #490 revealed she was the nurse who entered Resident #269's admission medication orders. LPN #490 stated the facility's corporate office could not get a resident identification number for the resident so the medications could not be filled through the pharmacy. LPN #490 communicated with administration through a group chat letting the Administrator know the issues with the admission and medications. During this time, LPN #490 stated Resident #269 was in pain, quoting Resident #269 stated it hurts really bad, around a three. LPN #490 stated she told Resident #269 that she would pull the oxycodone-acetaminophen from the control box when the pharmacy verified it. A telephone interview on 04/30/25 at 2:16 P.M. with LPN #360 revealed she was the night shift nurse for Resident #269 on 04/25/25 through 04/26/25. LPN #360 stated LPN #490 contacted the Director of Nursing (DON) and the Administrator regarding Resident #269's medication being unavailable. LPN #360 stated the pharmacy had denied the authorization to pull oxycodone-acetaminophen because they could not verify the resident number. LPN #360 stated the facility was finally able to get Resident #269 in the computer system at 2:00 A.M. on 04/26/25. LPN #360 verified that when Resident #269 requested pain medication on 04/26/25 at 3:00 A.M., she could have pulled the oxycodone-acetaminophen from the control box but did not because the pharmacy said they would be sending it in the delivery tote. LPN #360 confirmed oxycodone-acetaminophen was available for administration on 04/26/25 at 3:00 A.M. when the resident requested it and further verified she inaccurately documented in Resident #269's TAR that the resident's pain level was a two out of 10, but the resident actually reported a pain level of six out of 10. Review of the facility policy titled, Pain Management, dated 08/22/22, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, and the resident's preferences.

Based on medical record review, review of pharmacy recommendations, staff interview and review of facility policy, the facility failed to ensure pharmacy recommendations were reviewed by the physician timely. This affected one (#3) of five residents reviewed for unnecessary medications. The facility census was 59. Findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included asthma, type II diabetes mellitus, schizoaffective disorder, depression, anxiety disorder, schizophrenia, and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/30/25, revealed Resident #3 was cognitively intact. The resident received antipsychotic and antidepressant medication. Review of Resident #3's physician orders revealed an order dated 01/30/24 for Famotidine (acid reducer) 40 milligram (mg) oral tablet, give one tablet by mouth at bedtime for ulcer. The resident also had an order dated 01/13/25 through 04/05/25 for Hydroxyzine (antihistamine) oral tablet 25 mg every eight hours as needed for anxiety. Review of the pharmacy recommendation, dated 03/23/25, revealed the pharmacist recommended to decrease Resident #3's Famotidine from 40 mg to 20 mg to ensure the lowest effective dose. The recommendation was not reviewed and signed by the physician until 04/26/24, which was 34 days after the recommendation was made. Review of the pharmacy recommendation, dated 02/28/25, revealed the pharmacist reported long-term care facility regulations stated all as-needed psychoactive medications must be limited to 14 days in duration. The recommendation further stated the provider must then reassess the resident to continue the as-needed order and must document clinical rationale for extended use and duration of treatment if the medication was to be continued. The recommendation was not reviewed and signed by the physician until 03/31/25, which was 31 days after the recommendation was made. At that time, the physician discontinued the medication. Interview on 05/01/25 at 3:18 P.M. with Licensed Practical Nurse (LPN) #710 verified the facility's policy was for the physician to review recommendations within 30 days. Review of the facility policy titled, Consulting Pharmacist Monthly Drug Review, dated 2016, revealed the consultant pharmacist would conduct monthly medication regime reviews, which would be reviewed by the medical provider within 30 days.

Based on observation, medical record review, staff interview and review of the facility policy, the facility failed to properly store medications in a safe manner. This affected one (#21) of one resident reviewed for for medication storage. The facility census was 59. Findings include: Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included neuromuscular dysfunction of the bladder, benign prostatic hyperplasia, and unspecified pain. Review of the quarterly Minimum Data Set (MDS) assessment, dated, revealed Resident #21 was cognitively intact. Review of the physician orders revealed an order dated for Xtampza ER (extended release oxycodone) 12 hour 18 milligram (mg), give one capsule by mouth two times a day for pain. Further review revealed no physician order for Resident #21 to self-administer medications or for medications to be left at the bedside. Observation on 05/01/25 at 7:47 A.M. revealed Resident #21 sitting in his wheelchair, reclined back with his eyes closed. Further observation revealed a medication cup with one unknown pill in it on Resident #21's bedside table. Concurrent interview with Resident #21 revealed the medication was given to him by the night shift nurse, and he had fallen asleep and forgot to take it. Interview on 05/01/25 at 7:48 A.M. with Licensed Practical Nurse (LPN) #675 confirmed the unattended medication on Resident #21's bedside table. LPN #675 stated the medication had been left by the night shift nurse and verified medications were not to be left unattended with Resident #21. A telephone interview on 05/01/25 at 12:16 P.M. with LPN #490 verified she left the medication, Xtampza, unattended on Resident #21's bedside table. Furthermore, LPN #490 confirmed Resident #21 did not have orders to leave medications at the bedside. Review of the facility policy titled, Medication Administration, dated 08/22/22, revealed to maintain compliance with medication administration, the nurse should observe the resident's consumption of medication.

Based on observation, staff interview, medical record review, review of the Centers for Disease Control and Prevention (CDC) guidance and review of facility policy, the facility failed to ensure receptacles for contaminated personal protective equipment (PPE) were appropriately placed to prevent the transmission of pathogens. This affected one (#320) reviewed for urinary tract infections and medication administration. The facility census was 59. Findings included: Review of Resident #320's medical record revealed an admitted [DATE]. Diagnoses included methicillin susceptible Staphylococcus aureus (MSSA - infection caused by staph bacteria) infection of the left hip joint, alcoholism, and hepatitis C. Review of Resident #320's care plan revealed she required isolation/quarantine due to MSSA of a wound. Interventions included isolation/quarantine precautions would be maintained by staff during acute infection period. Review of Resident #320's physician orders revealed an order dated 04/11/25 for Cefazolin (antibiotic) two milligrams (mg) per 100 milliliters (ml) over 30 minutes intravenously (IV) every eight hours for left hip wound dehiscence/MSSA infection. Further review revealed an order dated 04/14/25 for contact isolation (measures taken to prevent the spread of infections that can be transmitted through direct or indirect contact with a resident or their environment) related to MSSA of the wound. Observation of medication administration on 04/29/25 at 1:57 P.M. with Licensed Practical Nurse (LPN) #370, revealed Resident #320's room door had contact precaution signs posted. LPN #370 and the surveyor donned a gown, gloves, and mask to enter the room. The IV medication was administered. The surveyor and LPN #370 stepped out in the hall and doffed the PPE and found there was no place to dispose of the contaminated PPE. Further observation revealed LPN #370 was required to walk back through Resident #320's room and place the contaminated PPE into a 32 gallon container with a red bag, which was placed near the window on the opposite side of the room from the door. Interview with LPN #370 on 04/29/25 at 2:05 P.M. verified the bin for contaminated PPE was placed on the opposite side of the resident's room and further stated it was set up that way for convenience since the room was quite small and the receptacle failed to fit by the exit door. Interview on 04/30/25 at 3:10 PM with Infection Control Preventionist (ICP) #310 confirmed the bin for contaminated PPE was located across the room from the door to Resident #320's room and staff had to walk back through the room to dispose of contaminated PPE. Review of the CDC guidance for contact precautions, located at https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html, revealed proper discarding of PPE before exiting the patient room is done to contain pathogens.

Based on observation, resident interview, staff interview, medical record review and review of facility policy, the facility failed to ensure wound care recommendations for an alternating air/low air loss mattress were implemented to prevent the development of pressure ulcers. This affected on (#53) of three residents reviewed for pressure ulcers. The facility census was 59. Findings included: Review of Resident #53's medical record revealed an admitted [DATE]. Diagnoses included lymphedema, chronic kidney disease, and obstructive uropathy. Review of Resident #53's quarterly Minimum Data Set (MDS) assessment, dated 01/14/25, revealed the resident had an intact cognition. The resident required substantial/maximal staff assistance to roll left and right in bed and had impairments on both sides of his lower extremities. Review of Resident #53's care plan revealed he was at risk for alteration in skin integrity. Interventions included a pressure reducing mattress on his bed to promote comfort and prevent skin breakdown. Review of Resident #53's Braden Scale (assessment to determine pressure ulcer risk), dated 03/17/25, revealed he was at a low risk for the development of pressure ulcers. Review of Resident #53's wound care progress notes dated 03/11/25 revealed the resident was seen for incontinence associated dermatitis of the sacrum and a skin tear to the lower leg. The resident was noted to have a history of a chronic wound and pressure ulcer. Further review revealed Resident #53 was to be on an alternating pressure/low air loss mattress for pressure redistribution and ensure settings were maintained at an appropriate level based on the resident's needs and body habitus. Resident #53 was noted to be at high risk for pressure ulcer formation related to decreased mobility, incontinence of urine and stool, and declining turning and repositioning. Review of a wound care progress note dated 04/01/25 revealed the incontinence associated dermatitis of the sacrum was healed. Resident #53 was noted to have a history of a chronic wound and pressure ulcer. Further review revealed Resident #53 was to be on an alternating pressure/low air loss mattress for pressure redistribution and ensure settings were maintained at an appropriate level based on the resident's needs and body habitus. Resident #53 was noted to be at high risk for pressure ulcer formation related to decreased mobility, incontinence of urine and stool, and declining turning and repositioning. Observation on 04/28/25 at 11:00 A.M. revealed Resident #53 was in bed. The resident did not have an alternating pressure/low air loss mattress. Concurrent interview with Resident #53 revealed he did not get out of bed very often. The resident stated he did not have a special mattress (alternating pressure/low air loss mattress). Interview on 04/28/25 at 11:21 A.M. with Certified Nursing Assistant (CNA) #820 and Licensed Practical Nurse (LPN) #370 verified Resident #53 did not have an alternating pressure/low air loss mattress in place as recommended by wound care. Review of the facility policy titled, Pressure Injury Prevention and Management, revised 01/08/25, revealed the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to to provide treatment and services to heal the pressure ulcer/injury Additionally, to facility was committed to prevent infection and the development of additional pressure ulcers/injuries. The unit manager, or designee, will review skin assessments, progression towards healing, and compliance at least weekly and document a summary of findings in the medical record.

Based on medical record review, observation, staff interview, visitor interview, and review of facility policies, the facility failed to obtain physician orders to ensure a percutaneous endoscopic gastrostomy (PEG) tube was monitored and cared for appropriately. This affected one (#28) of one resident reviewed fur tube feedings. The facility census was 59. Findings include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included dysphagia, muscle weakness, anemia, ileus, and hypertension. Review of the admission Minimum Data Set (MDS) assessment, dated 01/23/25, revealed Resident #28 was severely cognitively impaired and had a feeding tube. Review of the plan of care, dated 01/21/25, revealed Resident #28 had the potential for alteration in skin integrity. Interventions included cleansing the area around the PEG tube site as ordered and as needed, apply dressing, inspect the skin around the PEG tube daily for redness/drainage/breakdown, and observe the PEG tube site for signs and/or symptoms of infection and obtain vital signs to check for temperature elevations. Review of the physician orders for April 2025 revealed Resident #28 had no orders to cleanse, inspect, or observe the area around the resident's PEG tube or to apply a dressing. There was a previous order dated 01/18/25 to cleanse PEG tube with normal saline and apply clean dry dressing daily and as needed every day and night shift. The previous order did not indicate what type of dressing was needed. Review of the Treatment Administration Record (TAR) for April 2025 revealed no documentation related to staff inspecting or observing the resident's PEG tube site. There was also no documentation staff had been cleansing the resident's PEG tube site or that a dressing had been applied or in place from 04/10/25 through 04/29/25. Interview on 04/28/25 at 3:00 P.M. with Resident #28's visitor, who reported visiting the resident daily Monday through Friday, revealed the visitor observed Resident #28's PEG tube with dried blood around it on the previous Thursday (04/24/25). The visitor reported they informed a staff member, who never returned to clean it. The visitor also reported there had been no dressing on the PEG tube site. Observation on 04/29/25 at 9:57 A.M. with Licensed Practical Nurse (LPN) #370 revealed Resident #28's PEG tube site had a split gauze dressing dated 04/29/25. Interview on 04/29/25 at 10:40 A.M. with LPN #370 verified there were no physician orders for the care of Resident #28's PEG tube, including dressings, observing, inspecting, or cleansing the site. LPN #370 stated without physician orders, there was no way to document when PEG tube care was provided, or whether it was provided. LPN #370 verified there should have been physician orders in place and documentation verifying PEG tube care was provided. LPN #370 stated the PEG tube site should be checked at least daily and the dressing should be changed at least daily. Review of the facility policy titled, Care and Treatment of Feeding Tubes, dated 01/01/25, revealed devices would be checked daily to assure the surrounding skin was intact. The policy also stated the facility would involve the physician or designated practitioner in evaluating and managing care to address complications and risk factors. Review of the facility policy titled, Clean Dressing Change, dated 06/01/24, revealed physician orders would specify the type of dressing and frequency of changes.

Based on record review and staff interview, the facility failed to ensure physician's orders were followed timely to change the resident's Foley catheter. This affected one (#60) of three residents reviewed for Foley catheter. The facility census was 65. Findings include: Review of the medical record for Resident #60 revealed an admitted [DATE], with diagnoses including absence of left leg below the knee, diabetes mellitus, and obstructive with reflux uropathy (disorder where urine can't flow normally through the urinary tract due to an obstruction). Review of the written physician's progress note and written order dated 12/06/23, from Resident #60's urologist, revealed she had the same Foley in place from November 2023, when she was hospitalized . He had ordered for the facility staff to exchange the catheter on 12/06/23. Review of the Treatment Administration Record (TAR) for Resident #60 for December 2023 and January 2024, revealed nursing staff had not changed her catheter out as ordered on 12/06/23 until 01/02/24. Review of Resident #60's physician's order dated 01/03/24, revealed an order for Foley catheter change as needed, last changed on 01/02/24. Interview on 01/09/24 at 9:21 A.M., with Resident #60 revealed staff had not changed her Foley catheter per the physician's order. She stated she had seen her urologist on 12/06/23 and he had ordered the nursing staff to exchange her Foley catheter. Resident #60 stated nursing staff had changed her Foley catheter the first week of January 2024. Interview on 01/10/24 at 8:27 A.M., with the Director of Nursing (DON) verified Resident #60's Foley catheter was not changed per the physician's orders dated 12/06/23 until 01/02/24. This deficiency represents non-compliance investigated under Complaint Number OH00149442.

Based on medical record review, observation, staff interview, review of the county positivity rate, review of the Centers for Disease Control (CDC) online resources, and policy review, the facility failed to ensure staff sanitized their eye protection upon leaving the room of residents identified to be on transmission-based precautions. This had the potential to affect all residents residing in the facility. The facility census was 57. Findings include: 1. Observation on 09/06/22 at 4:30 P.M. of the designated COVID-19 unit entrance, revealed a set of double-doors with signage instructing those entering to see the nurse prior to entering. Additional signage was posted regarding donning and doffing procedures for personal protective equipment (PPE). One three-drawer cart was located near the entrance, which contained blue disposable gowns, gloves, medical-surgical masks, and hand sanitizer. No disinfectant wipes or spray was located on or near the cart. Interview on 09/06/22 at 4:35 P.M., with Licensed Practical Nurse (LPN) #483 revealed LPN #483 was the nurse assigned to the COVID-19 unit, as well as resident rooms which were not on the COVID-19 unit for the day shift on 09/06/22. LPN #483 reported staff were required to don a blue disposable gown and gloves in addition to their N95 mask and eye protection, prior to entering the COVID-19 unit. LPN #483 reported staff were not required to change their mask, wear an additional mask, or disinfect their eye protection upon exiting the COVID-19 unit. LPN #483 asked the surveyor if she would need disinfectant wipes upon exiting the COVID-19 unit, and subsequently obtained disinfectant wipes and placed them on the three-drawer cart located near the double-doors leading into the COVID-19 unit. 2. Review of Resident #155's medical record revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #155's admission assessment dated [DATE] revealed the resident had impaired cognition and required the assistance of one staff for a majority of the activities of daily living. Reveal of Resident #155's evaluation for COVID-19 dated 09/09/22 revealed isolation precautions were in place for the resident. Observation on 09/12/22 at 8:58 A.M. revealed signage posted on the door of Resident #155's room directing those entering to see the nurse prior to entering. A three-drawer cart containing PPE was also located next to the door. State tested Nurse Aide (STNA) #427 donned a blue disposable gown and gloves and entered the room. STNA #427 doffed the blue disposable gown and gloves prior to exiting the room and sanitized her hands after exiting the room. STNA #427 then proceeded down the hallway. During the observation, Resident #155's family asked if Resident #155 could be taken off of transmission-based precautions since he was fully vaccinated. STNA #427 reported she would check on this. Interview on 09/12/22 at 9:01 A.M. with STNA #427 verified Resident #155 was on transmission-based precautions as a precaution for COVID-19 due to being newly admitted to the facility. STNA #427 verified she did not sanitize her eye protection prior to or after exiting Resident #155's room and should have. Interview on 09/12/22 at 10:34 A.M. with the Assistant Director of Nursing (ADON) revealed Resident #155 was discovered to have been fully vaccinated and was in the process of being taken off of transmission-based precautions. Review of facility county positivity rates for COVID-19, dated 08/08/22, 08/15/22, 08/22/22, and 09/06/22, revealed the facility was in red, indicating a high communal positivity rate. Review of facility policy titled Staff Mask and Eye Wear Use, not dated, revealed to ensure source control as possible with the use of a facemask to prevent the spread of respiratory symptoms. In substantial or high community transmission - All staff members will be required to wear eyewear (face shield/goggles) at all times when in resident care areas. This includes hallways, Nurse's station, and resident rooms. Eyewear should be disinfected with an approved cleaning solution in between patient care areas for quarantine/suspect and COVID positive rooms per current CDC guidelines. Review of the CDC online resources at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html revealed In healthcare settings, eye protection is used by the health care provider (HCP) to protect their eyes from exposure to splashes, sprays, splatter, and respiratory secretions. Disposable eye protection should be removed and discarded after use. Reusable eye protection should cleaned and disinfected after each patient encounter.