Every finding on record at Crystal Care Center of Franklin Furnace

Based on medical record review, interviews and facility policy review, the facility failed to ensure residents were permitted to be served or consume tubular meats (various encased meats that are shaped into a tubular form) whole. This affected one resident (#13) of two residents reviewed for choices. The facility census was 24. Findings Include:Review of the medical record for Resident #13 revealed an initial admission date of 09/23/24 with a readmission date of 02/24/26. Diagnoses included cirrhosis of the liver, hypomagnesemia, pruritus, cyst of pancreas, ventral hernia, COPD, respiratory failure, esophageal varices, ESBL resistance, dysphagia, major depressive disorder, hypothyroidism, rheumatoid arthritis with rheumatoid factor, neuropathy, morbid obesity, heart failure and hepatic encephalopathy. Review of the care plan dated 10/01/24 revealed the resident was at risk for nutrition/hydration problems related to obesity status, diuretic medication use, poor dental status, inadequate intakes at times, cirrhosis of liver, hypomagnesemia, cyst of pancreas, obesity, heart failure, hypertension, hepatic encephalopathy and resident desires to loose weight. Interventions include allow the resident to make choices/preferences of food as able and observe resident for coughing, choking, chewing problems, pocketing food, drooling and/or holding food in mouth and provide diet as ordered. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required supervision or touch assistance with eating. The resident received a therapeutic diet and had no swallowing issues. Review of the resident's monthly physician orders for April 2026 identified orders dated for No added salt, regular texture, regular consistency. On 04/27/26 at 1:40 P.M., an interview with Resident #13 revealed she was not allowed to have hot dogs unless they were cut up. She said they chop them up and put them in a bun to eat due to another resident choking in a facility up north and now they were punished for it. On 04/29/26 at 12:12 P.M., an interview with Dietary Manager (DM) #139 revealed a resident choked in a facility up north and now the company banned them from serving any meat that are tubular, like hot dogs, sausage links and smoke sausage. Dietary Manager (DM) #139 revealed the facility is now permitted to serve hot dogs however they must be cut up. [NAME] #126 revealed the hot dogs are cut in quarter pieces. On 04/29/26 at 2:17 P.M., an interview with the Licensed Nursing Home Administrator (LNHA) verified the facility does not serve tubular meats and hot dogs must be cut up. Review of the facility policy titled, Resident Rights, last revised 12/16 revealed employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to self-determination and exercise his or her rights as a resident of the facility. Review of the facility policy titled, Safe Preparation and Serving of Tubular Meats, undated revealed the facility will ensure that tubular meats (hot dogs, sausages, kielbasa) are prepared and served in a manner that minimizes choking risk and promotes resident safety. The facility defined tubular meats as cylindrical shaped processed meats that pose a high choking risk due to their size, shape and texture, especially for individuals with dysphagia or impaired chewing/swallowing ability. Residents will be assessed for swallowing ability and dietary needs by Speech Therapy and/or nursing as indicated. Diet orders must be followed as prescribed.

Based on observation, medical record review, interview and facility policy review, the facility failed to ensure resident representatives were notified of changes in condition. This affected one resident (#25) of 15 sampled residents. The facility census was 24. Findings Include:Review of the medical record for Resident #25 revealed an admission date of 06/07/23. Diagnoses included hypertension, hyperlipidemia, anxiety disorder, history of MRSA, legal blindness, adult failure to thrive, chronic conjunctivitis, osteoarthritis, congestive heart failure, Vitamin D deficiency, adjustment disorder with depressed mood, major depressive disorder, dysphagia, age related nuclear cataract and diabetes mellitus. Review of the care plan dated 06/20/23 revealed the resident was at risk for skin breakdown related to decreased mobility, diabetes mellitus, incontinence, picking at her skin intermittent, moisture associated skin damage (MASD) and has current treatment for MASD with treatment in place. Interventions included administer medication as ordered, refuses treatment at times, encourage resident to comply and explain risks and benefits, apply lotion to day skin as needed, apply treatment as ordered, assist resident to the bathroom as needed, provide, provide peri care after each incontinence episode, apply barrier cream after incontinence care, pressure redistribution mattress to bed, and wheelchair cushion as ordered. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was at risk for skin breakdown and had no skin issues. Review of the initial weekly non-pressure skin gird dated 03/15/26 revealed the resident was found to have shearing to her left buttock measuring 0.5 cm by 0.5 cm. The assessment had no description of the wound, however, did document the wound was blanchable. Review of the medical record revealed no documented evidence the resident's representative was notified of the skin impairment, MASD. Review of the weekly non-pressure skin grid revealed the skin tear to the resident's face measured 2.0 cm by 1.0 cm. The resident was observed picking her face causing the skin tear. Review of the medical record revealed no documented evidence the resident's representative was notified of the new skin impairment. On 04/29/26 1:55 P.M., an interview with the Director of Nursing (DON) verified the facility had no documented evidence the resident's representative was notified of the new skin impairments. Review of the facility policy titled, Change In Condition and Physician Notification Policy, last revised in 09/19 revealed the facility was to promptly identify, respond to and report changes in condition in resident condition to the resident's physician, Nurse Practitioner (NP), Physician Assistant (PA), resident and/or representative. The nurse will document timely regarding the change in resident's condition, interventions and notifications.

Based on observation, medical record review, interview and facility policy review, the facility failed to ensure comprehensive wound assessments were conducted and failed to monitor burns for worsening skin impairment and signs/symptoms of infection. The facility also failed to ensure physician orders were implemented as ordered. This affected two residents (#25 and #26) of three residents reviewed for wounds and one resident (#27) of five residents reviewed for unecessary medications. The facility census was 24. Findings Include:1. Review of the medical record for Resident #25 revealed an admission date of 06/07/23. Diagnoses included hypertension, hyperlipidemia, anxiety disorder, legal blindness, adult failure to thrive, chronic conjunctivitis, osteoarthritis, congestive heart failure, Vitamin D deficiency, adjustment disorder with depressed mood, major depressive disorder, dysphagia, age related nuclear cataract and diabetes mellitus. Review of the care plan dated 06/20/23 revealed the resident was at risk for skin breakdown related to decreased mobility, diabetes mellitus, incontinence, picking at her skin intermittent, moisture associated skin damage (MASD) and has current treatment for MASD with treatment in place. Interventions included administer medication as ordered, refuses treatment at times, encourage resident to comply and explain risks and benefits, apply lotion to day skin as needed, apply treatment as ordered, assist resident to the bathroom as needed, provide, provide peri care after each incontinence episode, apply barrier cream after incontinence care, pressure redistribution mattress to bed, and wheelchair cushion as ordered. Review of the initial weekly non-pressure skin gird dated 03/15/26 revealed the resident was found to have shearing to her left buttock measuring 0.5 cm by 0.5 cm. The assessment had no description of the wound, exposed tissue type or exudate. The facility implemented the treatment to cleanse the wound, apply triad past and leave open to air. Review of the weekly non-pressure skin grid dated 03/22/26 revealed the shearing wound measured 0.4 cm by 0.4 cm. The assessment had no description of the wound, exposed tissue type or exudate. The facility determined the wound had improved. Review of the resident's monthly physician orders for April 2026 identified orders dated 03/25/26 apply triad paste to left buttocks daily and as needed for wound care and 04/23/26 for monitor scab under left eye until resolved. Review of the weekly non-pressure skin grid dated 03/30/26 revealed the shearing wound measured 0.2 cm by 0.2 cm. The assessment had no description of the wound, exposed tissue type or exudate. The facility determined the wound had improved. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The resident required substantial/maximal assistance with toileting and dependent on staff for bed mobility and transfer. The resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had no skin issues. Review of the weekly non-pressure skin grid dated 04/06/26 revealed the shearing wound measured 0.2 cm by 0.2 cm. The assessment had no description of the wound, exposed tissue type or exudate. The facility determined the wound was unchanged. Review of the weekly non-pressure skin grid dated 04/13/26 revealed the shearing wound measured 0.2 cm by 0.2 cm. The assessment had no description of the wound, exposed tissue type or exudate. The facility determined the wound was unchanged. Review of the weekly non-pressure skin grid dated 04/20/26 revealed the shearing wound measured 0.2 cm by 0.2 cm. The assessment had no description of the wound, exposed tissue type or exudate. The facility determined the wound was unchanged. Review of the Wound Nurse Practitioner (WNP) progress note dated 04/29/26 revealed the WNP was completing the initial evaluation of the wound to the left buttocks. The WNP classified the wound as moisture associated skin damage (MASD) measuring diffuse (when the boundary between the wound and surrounding healthy tissue is not sharp or clearly demarcated. The wound tissue gradually merges with adjacent skin making it difficult to determine exactly where the wound begins and ends.) by diffuse by 0.1 centimeters (cm). The wound was described as 100 percent pink tissue. The WNP implemented the treatment to cleanse the wound with wound cleanser, apply triad paste and leave open to air daily and as needed. On 04/29/26 at 1:55 P.M., an interview with the Director of Nursing (DON) verified the wound assessments lacked a description of the wound, exposed tissue type or exudate. 2. Review of the medical record for Resident #26 revealed an initial admission date 12/11/25 with a readmission date of 04/20/26. Diagnoses included chronic gout, dysphagia, diabetes mellitus, atrial fibrillation, hyperlipidemia, chronic kidney disease, gastro-esophageal reflux disease, hypertension, anxiety disorder, depression, congestive heart failure, otitis media, chronic obstructive pulmonary disease and acute respiratory failure with hypercapnia. Review of the care plan dated 04/09/26 revealed the resident was receiving wound management related to left thigh blister. Interventions included complete treatment as ordered, keep area clean and dry, monitor for signs/symptoms of infection, obtain measurements weekly and as resident will allow, supplements as ordered and will follow with Wound Nurse Practitioner (WNP). Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The resident required supervision or touching assistance with eating. The assessment indicated the resident was at risk for skin breakdown, however had no skin issues. Review of the progress note dated 04/05/26 at 2:19 revealed the resident had spilled ramen noodles on her left leg while sitting in her recliner attempting to eat. The left leg was assessed and found to be pink with no blistering. The nurse applied a cool rag, and the resident stated it helped and she was feeling better. Review of the state tested nursing assistant (STNA) shower assessment sheet dated 04/05/26, authored by the Director of Nursing (DON) revealed the resident had a pink/reddened area to the left thigh measuring 2.0 centimeters (cm) by 2.0 cm. Review of the medical record revealed no monitoring of the burn for worsening skin impairment, pain or signs/symptoms of infection until 04/07/26 when the resident was found to have a blister to her left thigh. Review of the progress note dated 04/07/26 revealed a blister to the left thigh from the incident occurring on 04/05/26. The resident reported discomfort to thigh. The WNP was made aware and a new order for Silvadene cream every shift was obtained. Review of the resident's discontinued physician orders identified an order dated 04/07/26 to monitor left leg for signs and symptoms of infection until resolved, Review of the weekly non-pressure skin grid dated 04/08/26 revealed the burn to the left upper thigh measured 8.9 centimeters (cm) by 3.4 cm and was a fluid filled blister. The assessment contained no description of the blister or surrounding tissue. Review of the initial evaluation WNP progress note dated 04/15/26 revealed the resident was being seen for a burn to the left thigh. The second degree burn to the left anterior mid-thigh measured 1.0 cm by 1.0 cm by 0.2 cm and described as 100% pink tissue and a reddened peri-wound with a scant amount of serous drainage. The WNP also documented the wound was epithelializing with visible cell migration. The WNP gave the order to cleanse with wound cleanser, apply triad past and cover with bordered gauze dressing daily and as needed. The facility was also to monitor for signs/symptoms of infection. Review of the resident's readmission nursing observation dated 04/20/26 revealed the resident was readmitted to the facility with a burn to her left thigh measuring 1.0 cm by 1.0 cm. Further review of the assessment revealed no description of the burn's appearance and surrounding tissue. Review of the wound NP progress note dated 04/22/26 revealed the second degree burn to the left anterior mid-thigh measured 1.0 cm by 1.0 cm by 0.2 cm with 100% pink tissue. The wound had a scant amount of serous exudate, and the peri-wound was reddened. The facility determined the wound was unchanged. The treatment of triad paste and leave open to air daily and as needed was continued. Review of the resident's monthly physician orders for April 2026 revealed no current physician orders for a treatment and monitoring of the second degree burn to the left anterior mid-thigh. On 04/29/26 at 2:53 P.M., an interview with Director of Nursing (DON) verified the ongoing monitoring of the burn should have occurred, had no current treatment in place and monitoring for signs/symptoms of infection as ordered by the WNP. On 04/30/26 at 9:42 A.M., observation of the burn to Resident #26' left mid-thigh with Licensed Practical Nurse (LPN) #121 revealed the wound had light pink-whitish pealing skin with a brownish scabbed area approximately 0.2 cm around to the inner mid-thigh and the outer left mid-thigh had an open wound was approximately the size of a fifty cent piece that was light pink-red in color with a moderate amount of brownish drainage. Review of the facility policy titled, Wound Management Program, undated revealed wound assessment protocol consisted of wound type and location, stage, size, drainage, wound bed, surrounding skin condition and pain level. Document at least weekly and with any notable change, wound measurements, staging, dressing changes, resident response and pain level, interventions in care plan and resident/family education. 3. Review of the medical record for Resident #27 revealed an initial admission date of 04/29/29 with the latest readmission date of 01/28/23. Diagnoses included nicotine dependence, atrial fibrillation, diabetes mellitus, anxiety disorder, seasonal allergic rhinitis, insomnia, gastro-esophageal reflux disease, chronic pulmonary embolism, peripheral vascular disease, dysphagia, hypertensive retinopathy, chronic obstructive pulmonary disease, congestive heart failure, hypertension, major depressive disorder, hyperlipidemia, anemia, sleep anemia, diabetic neuropathy and restless leg syndrome. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the Vitamin D level results dated 03/19/26 revealed a level of 27 nanograms/milliliter (ng/ml) (normal 30-100 ng/ml). The physician typed the order Vitamin D3 5000 units by mouth daily on the lab result.Review of the medical record revealed the physician order for Vitamin D3 5000 units by mouth daily was not implemented.On 04/29/26 at 1:56 P.M., an interview with the Director of Nursing (DON) verified the physician's order for order Vitamin D3 5000 units by mouth daily was not implemented as ordered.Review of the facility policy titled, Physician Orders Policy and Procedure, dated 06/09/22 revealed the physician may send a signed and dated fax medical order.

Based on observations, record review, staff interview, and facility policy review, the facility failed to ensure each resident received food in a form to meet their individual chewing or swallowing needs. This affected three of seven individuals who required food/drinks with altered texture (Residents #14, #15, and #17). The facility census was 28. Findings Include:1.Review of the record for Resident #14 revealed an admission date of 11/17/25, diagnoses including diabetes, hypertension, and chronic obstructive pulmonary disease. A nutrition assessment by the dietician on 11/23/25 stated the resident required a diet of mechanical soft texture with chopped meats.Review of the Minimum Data Set assessment completed 12/18/25 documented a brief interview for mental status (BIMS) score of 13, indicating intact cognition. MDS further documented the resident had no choking or swallowing issues. Review of physician's order on 12/05/25 indicated the resident was to receive a mechanical soft diet with chopped meats. Observations on 12/31/25 at 12:10 P.M. revealed Resident #14 to receive her lunch tray in her room. The card on the tray stated the meat was to be chopped. Observations revealed a regular consistency piece of Salisbury baked steak. The meat had not been chopped up. The resident began to try to eat the meat in regular form.Interview with the Director of Nursing on 12/31/25 at 12:23 P.M. confirmed Resident #14's Salisbury baked steak had not been chopped and should have been.Interview with Dietary Manager #55 on 01/05/26 at 11:00 A.M. revealed when meat is ordered to be chopped it should be cut into pieces that are not bigger than one inch. Further interview on 01/05/26 at 11:10 A.M. the Director of Nursing stated Resident #14's meat was to be chopped as she refuses to wear her dentures. 2. Review of the record for Resident #15 revealed an admission date of 05/05/25, diagnoses including Kufor-Rakeb Syndrome (a neurological disorder causing juvenile-onset parkinsonism) and dysphagia (difficulty swallowing). Review of a hospital discharge summary of 05/05/25 revealed because of a modified barium swallow on 04/10/25, he was to receive honey thickened liquids.Review of Minimum Data Set assessment on 12/16/25 documented he had a BIMS score of 11, indicating moderately impaired cognitive status. He had a physician's order dated 05/15/25 for honey thickened liquids. Observations on 12/31/25 at 12:12 A.M. revealed Resident #15 to receive his lunch tray in the lounge area across from the nursing station. He was observed to receive a cup of water and a cup of Kool-Aid. Interview with Registered Nurse #72 on 12/31/25 at 12:12 A.M. confirmed the liquids were not thickened. She stated she thought the order for thickened liquids had been discontinued. She checked the physician's orders and stated the liquids were to be thickened to honey consistency. She then took the liquids and added thickener to honey consistency. Review of a speech therapy screen on 01/04/26 revealed Resident #15 arrived to the facility with a diet requiring honey thick liquids. This indicates a significant swallowing disorder. An assessment when he first arrived to the facility revealed no clinical signs or symptoms of aspiration. However, he is most likely experiencing silent aspiration. It is recommended that he have a modified barium swallow study to determine if he is safe for a diet upgrade. 3. Review of the record for Resident #17 revealed an admission date of 12/28/25 and diagnoses including dementia and dysphagia (difficulty swallowing). A physician's order on 12/28/25 indicated the resident was to receive a mechanical soft diet with ground meats. The plan of care dated 01/02/26 stated the resident was at risk for swallowing problems related to no teeth. It stated he wears only upper denture. Speech therapy notes dated 01/04/26 stated they were working on compensatory strategies to address swallow dysfunction focused on alternating liquids/solids to increase pharyngeal clearance, liquid delivery using small/controlled sips/intake, modification to bolus sizes and order/method of food/liquid presentation, rate control, and small bites/sips (1/2-1/3 teaspoon). Observations on 12/31/25 at 12:15 P.M. revealed Resident #17 to receive his lunch tray in his room. He received a regular consistency piece of Salisbury baked steak. The meat was not ground. Interview with the Director of Nursing on 12/31/25 at 12:25 P.M. revealed Resident #17's meat was not ground and should have been. Interview with Dietary Manager #55 on 01/05/26 at 11:00 A.M. revealed when meat is ordered to be ground it should be put in the food processor and ground into small pieces with gravy added after grinding. She stated that when meat is ordered to be chopped it should be cut into pieces that are not bigger than one inch. Review of the facility procedure revised January 2019 revealed the following diets are modified in texture to promote ease of chewing and swallowing. No two patients/residents are alike; therefore diets must be individualized based on their chewing/swallowing ability. Mechanical soft: this diet is used for patients/residents with limited chewing ability. The portion units used for any ground recipes have been updated to include the amount of sauce and/or gravy used in the recipe preparation. As a general rule, three ounces of protein, when ground, becomes an eight ounce scoop. This deficiency represents non-compliance investigated under Complaint Numbers 2703787.

Based on record review, staff interview, and review of the facility policy the facility failed to ensure the physician provided a response to consultant pharmacist recommendations. This affected one (Resident #4) of five residents reviewed for unnecessary medications. The facility census was 28. Findings include: Review of the medical record for Resident #4 revealed an admitted [DATE] with diagnoses including dementia, anxiety, depression and unspecified psychosis. Review of the physician orders for Resident #4 dated March 2024 revealed the resident was ordered Seroquel (antipsychotic) 50 milligrams (mg) by mouth for agitation. Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 12/14/23 revealed resident had moderate cognitive impairment. Review of the consultant pharmacist's recommendation for Resident #4 dated 01/30/24 revealed the resident was receiving Seroquel for a diagnosis of agitation and it was recommended to consider changing to an appropriate diagnosis or titration off the medication. The physician signed the recommendation on 02/17/24 but did not document acceptance or denial of the pharmacy recommendation. Interview on 03/05/24 at 12:42 P.M. with the Director of Nursing (DON) confirmed the physician did not document a response to the pharmacy recommendation for Resident #4 dated 01/30/24. Review of the facility policy titled Pharmacy Recommendations revised January 202 revealed the consultant pharmacist performed a comprehensive review of each resident's medication regiment routinely as required by regulations. The DON or the Assistant Director of Nursing (ADON) would review the recommendations with the physician and Medical Director as soon as practical but no later than 30 days. Any urgent recommendations must be addressed immediately. The DON would track the recommendations and ensure any changes were implemented into the medical record.

Based on medical record review, staff interviews, and observation, the facility failed to ensure development and implementation of comprehensive resident care plans. This affected three (Residents #3, #12, #129) of 15 residents reviewed for care plans. The facility census was 29. Findings include: 1. Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including heart failure, dementia, and presence of cardiac pacemaker. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #3 dated 01/10/24 revealed this resident was moderately cognitively impaired. Review for the care plan for Resident #3 initiated 09/06/05 revealed it did not include care and monitoring of the resident's pacemaker. Interview on 03/06/24 at 2:45 P.M. with the Director of Nursing (DON) confirmed Resident #3 had a pacemaker in place but was unsure how often pacemaker checks were to be conducted. The DON further confirmed Resident #3's care plan did not outline the care and services the facility was to provide for the resident's pacemaker. 2. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses including bipolar disorder, paranoid schizophrenia, schizoaffective disorder, and psychotic disorder with delusions. Review of the quarterly MDS assessment for Resident #12 dated 12/28/23 revealed the resident was mildly cognitively impaired. Review of the physicians' orders for Resident #12 revealed an order dated 03/06/24 for Tagamet 400 milligrams (mg) to be administered daily for sexual behaviors. Review for the care plan for Resident #12 initiated 06/06/19 revealed it did not include the resident's sexual behaviors and/or use of Tagamet for sexual behaviors. Interview on 03/06/24 at 2:45 P.M. with the DON confirmed Resident #12 exhibited negative sexual behaviors which were being managed with the medication, Tagamet. The DON further confirmed Resident #12's care plan did not include the resident's sexual behaviors and the care and services the facility was to provide regarding management of the negative sexual behaviors. 34299 3. Review of the medical record for Resident #129 revealed an admitted [DATE] with diagnoses including diabetes mellitus type two, hypertension, non-Hodgkin's lymphoma with metastasis to the bones and fracture of the shaft of the right humerus. Review of the plan of care for Resident #129 initiated 02/22/24 revealed it did not include care and treatment regarding the cast to the resident's right arm. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for Resident #129 dated February 2024 and March 2024 revealed they did not include care related to the resident's cast to the right arm, circulation checks or skin checks. Review of the MDS for Resident #129 dated 02/25/24 revealed the resident was cognitively impaired and required assistance from staff for activities of daily living (ADLs.) Review of the nurse progress note for Resident #19 dated 02/29/24 timed at 11:50 A.M. revealed the resident returned from the orthopedic physician appointment with no new orders. The note did not include monitoring of Resident #129 skin, circulation or edema to right hand. Observations on 03/04/24 at 9:16 A.M. and on 03/06/24 at 11:33 A.M. of Resident #129 revealed the resident's lower right arm was in a cast with edema noted to the resident's fingers on the right hand. Interview on 03/06/24 at 3:12 A.M. with Licensed Practical Nurse (LPN) #140 confirmed Resident #129 was admitted with a cast to lower right arm and the resident's fingers were swollen. LPN #140 confirmed there were no orders to monitor the circulation, skin or edema to the resident's right hand. Interview on 03/06/24 at 3:25 P.M. with the DON confirmed Resident #129's care plan did not include interventions related to the resident's cast care or circulation and skin check for the right hand.

Based on medical record review, observation, and staff interview the facility failed to ensure care and services were provided to residents with casts to the extremities. This affected one (Resident #129) of one residents with a cast and 13 sampled residents. The facility census was 28. Findings include: Review of the medical record for Resident #129 revealed an admitted [DATE] with diagnoses including diabetes mellitus type two, hypertension, non-Hodgkin's lymphoma with metastasis to the bones and fracture of the shaft of the right humerus. Review of the plan of care for Resident #129 initiated 02/22/24 revealed it did not include care and treatment regarding the cast to the resident's right arm. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for Resident #129 dated February 2024 and March 2024 revealed they did not include care related to the resident's cast to the right arm, circulation checks or skin checks. Review of the MDS for Resident #129 dated 02/25/24 revealed the resident was cognitively impaired and required assistance from staff for activities of daily living (ADLs.) Review of the nurse progress note for Resident #19 dated 02/29/24 timed at 11:50 A.M. revealed the resident returned from the orthopedic physician appointment with no new orders. The note did not include monitoring of Resident #129 skin, circulation or edema to right hand. Observations on 03/04/24 at 9:16 A.M. and on 03/06/24 at 11:33 A.M. of Resident #129 revealed the resident's lower right arm was in a cast with edema noted to the resident's fingers on the right hand. Interview on 03/06/24 at 3:12 A.M. with Licensed Practical Nurse (LPN) #140 confirmed Resident #129 was admitted with a cast to lower right arm and the resident's fingers were swollen. LPN #140 confirmed there were no orders to monitor the circulation, skin or edema to the resident's right hand. Interview on 03/06/24 at 3:25 P.M. with the DON confirmed Resident #129's care plan did include interventions related to the resident's cast care or circulation and skin check for the right hand.

Based on observation, interview, record review and facility policy, the facility failed to ensure physician's orders were in place for wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 23. Findings Include: Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had moderate cognitive impairment. Resident #18 required limited assistance of one staff person for activities of daily living. Resident #18 did not have any pressure areas but did require a non surgical dressing with or without topical medication other than to his feet. Review of the physician orders for 04/22 revealed there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) for 04/22 revealed no documentation of treatment. However, the weekly skin assessment last completed on 04/23/22 by the Director of Nursing indicated the resident had a wound to his scalp measuring two centimeters (cm) by three cm from a surgical incision. The area had a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes from 01/22 through 04/22 was silent on wound care and treatment. Review of the plan of care for at risk for impaired skin integrity/an open skin cancer lesion to head dated 05/21/20, revealed treatments per order and skin assessment as ordered. An observation of Resident #18 on 04/19/22 at 10:57 A.M., 04/20/22 at 9:19 A.M. and 1:40 P.M. revealed a Band-Aid in place to the top of his head. An interview on 04/20/22 at 11:10 A.M. with Registered Nurse (RN) #211 revealed the resident had a treatment to the top of his head. It was completed daily. An observation on 04/20/22 at 11:48 A.M. of wound care for Resident #18 revealed RN #211 washed hands, put on her gloves and removed the old Band-Aid from residents scalp. The wound was not bleeding. She placed the Band-Aid in her gloves, removed and washed her hands. RN #211 then put on her gloves, had the honey gel in a medicine cup and a large Band-Aid on the over the bed table on a paper towel. RN #211 cleansed the area with wound cleanser, patted dry. The area had no drainage, redness or odor noted. RN#211 removed gloves, washed hands, put on new gloves and used a sterile swab to apply the honey gel to the wound. She then covered the wound with the large Band-Aid that was dated and initialed. RN #211 placed the trash in the can, removed gloves and washed hands. An interview on 04/20/22 at 2:55 P.M. with the Director of Nursing (DON) revealed the DON completed the weekly skin/wound assessment which included the measurements and treatment. The DON confirmed there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said the wound was treated, but did not have documentation. Review of the facility policy titled Wound Care, dated 12/20 revealed wounds would be evaluated when observed and weekly until resolved. Wounds will be monitored for location, size (measure width, length, and depth), undermining, tunneling, exudates, necrotic tissue and presence or absence of granulation tissue and epitheliazation.

Based on record reviews and staff interviews, the facility failed to ensure residents pain medications were available for administration and failed to ensure ordered pain medication was administered as ordered. This affected one resident (#21) out of the two residents reviewed for pain management. The facility census was 23. Findings include: Record review for Resident #21 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 03/06/22, revealed this resident had mildly impaired cognition. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. This resident was assessed to have occasional pain and to have received scheduled pain medication. Review of the care plan, dated 03/14/22, revealed this resident was at risk for pain. Interventions included to administer medication as ordered. Review of the physicians order, dated 02/24/22, revealed an order to administer one [MEDICATION(S)] 10-325 milligram (mg) tablet every four hours for pain. Review of the Controlled Drug Use Record for Resident #21's [MEDICATION(S)] 10-325 mg tablets revealed the last tablet was removed from a card for administration on 04/09/22 at 8:00 P.M. There was no documentation of the medication being available for administration from any other sources until 04/12/22 at 7:00 A.M. Review of the Controlled Drug Use Record for [MEDICATION(S)] 5-325 mg tablets revealed the record contained a label containing Resident #21's name with a filled date of 04/11/22. The directions indicated to administer one tablet of [MEDICATION(S)] 5-325 mg tablet every four hours for pain. The record contained hand written writing at the top of the sheet which read 2 tabs. Documentation on the record revealed two tablets had been pulled from the card every four hours from 04/12/22 at 7:00 A.M. through 04/14/22 at 8:00 P.M. to be administered to the resident. Review of the Medication Administration Record (MAR) for 04/2022 revealed on 04/11/22 at 4:00 P.M. and on 04/12/22 at 4:00 A.M. the residents [MEDICATION(S)] 10-325 mg dose was documented as not being administered. All other scheduled doses of [MEDICATION(S)] 10/325 mg were documented as being administered as ordered every four hours from 12:00 A.M. on 04/10/22 through 04/14/22 at 8:00 P.M. Interview with Resident #21 on 04/18/22 at 8:26 P.M. revealed the facility had run out of the residents ordered [MEDICATION(S)] 10-325 mg tablets and the resident had not received the medication for approximately two days. Interview with Licensed Practical Nurse (LPN) #217 on 04/20/22 at 10:57 A.M. verified there was no record of the [MEDICATION(S)] 10-325 mg tablets being available for administration to Resident #21 from 04/09/22 at 8:00 P.M. through 04/12/22 at 7:00 A.M. Interview with the Regional Director of Clinical Services (RCDS) #300 on 04/20/22 at 1:12 P.M. verified the order for Resident #21 was for the resident to receive one tablet of [MEDICATION(S)] 10-325 mg every four hours and the resident had received two tablets of [MEDICATION(S)] 5-325 mg instead from 7:00 A.M. on 04/12/22 through 8:00 P.M. on 04/14/22. Interview with Registered Nurse (RN) #211 on 04/21/22 at 8:30 A.M. verified Resident #21 had not been administered scheduled [MEDICATION(S)] 10-325 mg tablets for two days as the medication was unavailable. RN #211 verified the MAR contained inaccurate documentation of the administration of the [MEDICATION(S)] 10-325 mg tablets on 04/10/22 and 04/11/22 as RN #211 had documented them as being administered in error. RN #211 verified RN #211 had hand-written 2 tabs on the top of the Controlled Drug Use Record for the residents [MEDICATION(S)] 5-325 mg tablets which resulted in the resident receiving double the amount of ordered acetaminophen every four hours from 04/12/22 at 7:00 A.M. through 04/14/22 at 8:00 P.M. RN #211 verified the label on the Controlled Drug Use Record for the residents [MEDICATION(S)] 5-325 mg tablet read to administer one every four hours. Review of the facility policy titled Medication Administration-General Guidelines, revised 11/2018, revealed medications were to be administered in accordance with the written orders of the prescribed. If a dose of regularly scheduled medication was not available, it was to be documented on the MAR along with an explanatory note.

Based on record review and interviews the facility failed to provide an appropriate diagnosis for the use of an antipsychotic. This affected one resident (Resident #17) out of five residents reviewed for unnecessary medications. The facility census was 33. Findings include: Record Review of Resident #17 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: [CONDITION(S)], [CONDITION(S)], dementia, nicotine dependence, coronary angioplasty, COVID-19, mood disorder, benign prostatic hyperplagia, pain, diabetes mellitis, anxiety, depression, hypertension, gastro-[CONDITION(S)] reflux disease, urine retention, [CONDITION(S)], and nutritional deficiencies. Review of the Minimum Data Set (MDS) assessment completed on 02/09/22 revealed this resident had moderate to severe cognitive impairments. Review of Physician Orders revealed this resident is receiving the following medications: [MEDICATION(S)] 25 milligrams (mg) 1 tablet by mouth daily for unspecified dementia with behavioral disturbances and [MEDICATION(S)] 25 mg 1 tablet by mouth daily at bedtime for unspecified dementia with behavioral disturbances. Interview with Regional Clinician #300 on 04/20/22 at 02:35 P.M. verified Unspecified Dementia with Behavioral Disturbance is not an acceptable diagnosis for the use of [MEDICATION(S)]. Also verified the resident takes this medication on a daily basis.

Based on record review and interview the facility failed to timely complete a significant change Minimum Data Set (MDS) 3.0 assessment for Resident #3 following the initiation of Hospice services. This affected one resident (#3) reviewed for hospice services. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hospice level of care, dated 07/06/21 revealed Resident #3 elected to receive Hospice services effective 07/16/21. Review of the significant change MDS 3.0 assessment, dated 08/11/21 revealed this assessment was completed 26 days after Resident #3 was admitted to Hospice services. Interview with MDS Coordinator #905 on 11/16/21 at 1:25 PM verified the significant change MDS assessment for Resident #3 had been completed on 08/11/21. Interview with Regional Director of Clinical Services (RDCS) #845 on 11/16/21 at 1:50 P.M. verified the significant change assessment for Resident #3 should have been completed within 14 days of the time the resident began Hospice services.

Based on observation, record review and interview the facility failed to ensure fall safety interventions were in place as care planned for Resident #14, who was at risk for falls and had a history of falls. This affected one resident (#14) of nine residents reviewed for falls. Findings include: Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] disease, paranoid [CONDITION(S)], hearing loss, malignant neoplasm of brain, history of [CONDITION(S)] ([CONDITION(S)]), muscle weakness and need for assistance with personal care. Review of the plan of care, initiated 03/02/20 revealed Resident #14 was at risk for falls and potential injury due to impaired balance, unsteady gait and history of falls. Interventions included ensure resident wearing footwear properly, or non-skid socks, non-skid strips to floor at bedside, encourage to stand from seated position using arms of the chair, apply shoes before ambulating and therapy ordered as needed. Record review revealed Resident #14 sustained a fall of 08/08/21 in his room at the bedside resulting in a right knee abrasion. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/01/21 revealed Resident #14 had moderately impaired cognition and required limited assistance from staff for bed mobility, transfers, walking, toileting, eating and hygiene. Review of the fall risk assessment, dated 11/06/21 revealed Resident #14 was at moderate risk for falls and had multiple falls in the past six months. Symptoms included jerking when turning and noted the resident was unbalanced when standing. Review of a physician's order, dated 11/15/21 revealed to ensure proper footwear when ambulating, ensure resident wore threaded footwear when up , must sit in chair when smoking not at picnic table, non-skid socks, occupational therapy to evaluate and treat three to five times weekly for neuro- muscular reeducation and the anti-psychotic medication, [MEDICATION(S)] 0.5 milligrams one time a day and 5 milligrams at bedtime for behaviors. On 11/15/21 at 3:43 P.M. Resident #14 was observed ambulating and was noted to be unsteady on his feet when exiting from his room. On 11/15/21 at 3:45 P.M. observation of Resident #14's room revealed no non-skid floor strips near the resident's bed. On 11/16/21 at 3:30 P.M. interview with Regional Operations Nurse (RN) #845 verified Resident #14 did not have non-skid floor strips in place. RN #845 revealed the non-skid floor strip intervention, initiated on 03/02/20, was discontinued on 11/16/21 because the resident didn't need it any longer. During the interview, RN #845 revealed new flooring had been installed last week in Resident #14's room and the non-skid floor strips were not replaced on the floor at that time. On 11/17/21 at 9:03 A.M. interview with Maintenance Director #156 revealed the non-skid floor strips in Resident #14's room had not been replaced since the new flooring had been installed. Review of the facility policy titled Fall Policy, dated 10/01/18 revealed the facility was to complete a review of resident falls and implement interventions to attempt to prevent or reduce falls and injuries related to falls.

Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) assessments for Resident #3 were accurately completed. This affected one resident (#3) of three residents reviewed for hospice services and/or pressure ulcers. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. Review of the Hospice level of care, dated 07/06/21 revealed Resident #3 elected to receive Hospice services effective 07/16/21. Review of Section O of the significant change MDS 3.0 assessment, dated 08/11/21 revealed Resident #3 was not identified to have received Hospice services. Review of Section O of the quarterly MDS 3.0 assessment, dated 11/11/21 revealed Resident #3 was not identified to have received hospice services. b. Review of the weekly skin assessments, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section M of the significant change MDS 3.0 assessment, dated 08/11/21 revealed Resident #3 was assessed to have an unhealed Stage II pressure ulcer. Interview with MDS Coordinator #905 on 11/16/21 at 1:25 P.M. verified the MDS 3.0 assessments for Resident #3, dated 08/11/21 and 11/11/21, had not been completed accurately as the resident had been receiving Hospice services at the time of the assessments. MDS Coordinator #905 revealed she would immediately complete a modification for both assessments to correct the errors. Interview with Licensed Practical Nurse (LPN) #311 on 11/16/21 at 1:40 P.M. revealed Resident #3 had treatment orders in place for self inflicted scratches to his buttocks but had never had any areas of pressure. Interview with Chief Clinical Officer (CCO) #921 on 11/16/21 at 2:55 P.M. verified Section M of the significant change MDS 3.0 assessment, dated 08/11/21, contained inaccurate documentation of an unhealed Stage II pressure ulcer for Resident #3.

Based on observation, record review, facility fall investigation review, review of hospital records and interview the facility failed to ensure adequate assistance and/or fall safety interventions were provided to prevent falls for Resident #16 and Resident #76. Actual Harm occurred on 10/01/20 when Resident #16, who required two staff assistance for activities of daily living including transfers and toilet use sustained a fall with injury while being assisted by one State tested Nursing Assistant (STNA) to the bed side commode. The resident was assessed to have a laceration to her face, over her left eye measuring 4.5 centimeters long by 0.2 centimeters wide which required seven sutures. This affected two residents (#16 and #76) of two residents reviewed for falls. Findings Include: 1. Review of Resident #16's medical record revealed an admitted on 08/03/20 with diagnoses including unspecified [CONDITION(S)] disease, arthropathy (disease of the joints), low back pain, muscle weakness, unspecified abnormalities of gait and mobility, Type II diabetes mellitus with diabetic chronic kidney disease, vitamin D deficiency and [CONDITION(S)]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/10/20 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 which revealed she was cognitively intact. The assessment revealed the resident required extensive assistance from two staff for bed mobility, transfers and toileting. The assessment also revealed the resident was unsteady and required staff assistance to stabilize when she moved from a sitting to a standing position, moved on and off the toilet, and completed a surface-to-surface transfer, for example transferred from her bed to a chair or wheelchair. A plan of care, originally initiated on 08/03/20 revealed Resident #16 was at risk for falls due to decreased mobility. Interventions included to keep call light within reach, keep the resident's bed in the lowest position (except during care), gripper socks when up and therapy screen. On 08/17/20 non-skid strips to the floor next to the resident's bed and in the bathroom were added to the care plan. On 08/22/20 the care plan was updated to include assistance from staff with transfers as needed, address pain as needed, and non-skid strips to the floor in the bathroom. On 09/28/20 a Dycem (non-skid mat) was placed in the recliner and a personal alarm to the resident's bed and recliner were added per the resident's power of attorney's (POA) request. Review of the physician's orders for 09/2020 and 10/2020 revealed treatment orders for non-slip socks to be used when the resident was not in bed and a mat on the floor at the resident's bedside. Record review revealed Resident #16 had a history of falls following her admission. The resident sustained falls on 08/22/20, 08/30/20, 09/27/20, 09/28/20 and 10/01/20. On 08/22/20 Resident #16 fell while transferring unassisted. The resident sustained a dislocation to her shoulder as a result of the fall and her right arm was in a sling. The care plan was updated on this date to include assistance from staff with transfers as needed. Review of Physical Therapy notes for Resident #16, dated 08/27/20 revealed the resident required maximum assistance with bed mobility and transfers and required moderate assistance from one to two staff with skilled instruction for proper hand and foot placement and cues for left side neglect and posture. The notes did not provide guidance as to when the resident would require one assistance versus two for these tasks. On 08/30/20 at 11:52 A.M. Resident #16 fell while being assisted by an STNA to the bathroom. The resident fell forward and landed on her right shoulder. The resident expressed pain in her right shoulder and was sent out to the hospital for evaluation but upon returning to the facility, no further injury to the resident's shoulder had occurred. There was no evidence the resident's care plan was updated with any new interventions following this incident. A Post Fall Investigation completed following Resident #16's fall on 08/30/20 revealed a new intervention was noted on the investigation report for the resident to have two person staff assistance while ambulating. On 09/27/20 the resident fell while trying to reach a snack on her table. The fall was not witnessed and no staff were involved in the incident. On 09/28/20 the resident slid out of her recliner chair onto the floor. The resident had blood coming from the bridge of her nose and a noticeable raised area on her forehead above her right eye. The resident's injuries were assessed and treated in the facility. On 10/01/20 at 2:00 P.M. Resident #16 fell face first on the floor while getting on the bedside commode. The resident gashed her forehead open and complained of pain to her head but did not lose consciousness after the fall. The Director of Nursing (DON), resident's family and nurse practitioner (NP) were notified. The resident was transferred to the emergency room at 2:30 P.M. On 10/01/20 at 10:35 P.M. the resident returned to the facility from the hospital. The resident had a laceration over her left eye measuring 4.5 centimeters long by 0.2 centimeters wide with no depth noted. The resident required seven sutures to the area. Review of the Fall Investigation for the fall that occurred on 10/01/20 at 2:00 P.M. revealed Resident #16 fell face first on the floor while getting on the bedside commode. The resident was being assisted by one STNA (STNA #153) at the time of the incident. The resident complained of pain to her head and was transferred to the hospital. A statement from STNA #153's revealed she was in the room with the resident when the incident occurred. Resident #16 needed to use the bed side commode and she was helping her. The resident turned to sit down, her foot slipped and she fell . There was no indication as to whether the resident had non-skid socks on at the time of the incident. The fall investigation revealed the resident required two person assistance with a gait belt for all transfers. The report was completed by the facility Former Director of Nursing (FDON). A fall risk assessment, dated 10/01/20 at 2:20 P.M. revealed Resident #16 was high risk for falls. The resident had multiple falls in the last six months. The resident took diuretics, antihypertensives, non-steroidal anti-[CONDITION(S)] and [CONDITION(S)] medications more than three times a week. The resident's gait analysis indicated the resident was unable to independently come to a standing position, exhibited a loss of balance while standing, strayed off the straight path of walking, required hands-on assistance to move from place to place, changed gait pattern when walking through doorways, exhibited jerking or instability when making turns, and used an assistive device. Review of the hospital records for Resident #16, dated 10/01/20 at 2:51 P.M. revealed an emergency department triage assessment was completed at 2:56 P.M. The resident had a fall with head laceration that was estimated at one inch to her forehead. The fall risk assessment conducted at the hospital indicated the resident was at high risk for falls and high fall risk interventions should be initiated. The hospital records revealed the resident had been up to go to the bathroom and fell . Nursing home staff were present. Laceration to the resident's forehead and possible deformity to nose and small abrased areas on the resident's face were noted. On 10/01/20 at 6:23 P.M. laceration set up with suture tray started. Discharge instructions included the resident was to be observed for any evidence of head injury and return to the hospital immediately for any signs of head injury, sutures must be cleansed daily and can be removed in five days. Review of the Activities of Daily Living (ADL) Look Back Reports for Resident #16 dated 08/16/20 to 10/01/20 revealed staff documented the resident required two person assistance with transfers daily from 09/01/20 through 09/14/20, 09/16/20 through 09/18/21 and 09/21/20 through 10/01/20. Review of the Activities of Daily Living (ADL) Index Report for Resident #16 from 08/01/20 through 10/31/20 revealed the resident's ADL score increased (showing a decline in functional status) from a three on 08/05/20 to a twelve (showing the need for assistance from two staff to complete ADL's). The resident remained at a score of twelve daily from 08/25/20 through 10/31/20. On 05/05/21 at 4:45 P.M. and 05/06/21 at 2:03 P.M. interview with Clinical Chief Officer (CCO) #154 regarding Resident #16's fall on 10/01/20 confirmed there was only one STNA assisting the resident at the time of the fall. CCO #154 revealed the resident was a one to two-person assist depending on her ability from day to day. However, there was no evidence what criteria staff should use to determine how much assistance the resident needed at any given time. In addition, CCO #154 confirmed the staff documentation on the ADL records and progress notes indicated the resident required two person assistance with transfers daily from September to October 2020 including when the fall occurred. On 05/10/21 at 10:00 A.M. interview with Chief Clinical Officer (CCO) #154 confirmed the ADL score would reflect a six if the resident was assisted by one person and a 12 if two people were required to assist the resident. Attempted interviews with LPN #155, STNA #156 and STNA #153 during the survey were unsuccessful as none of these staff currently worked at the facility at the time of the survey. In addition, current fall risk safety interventions for Resident #16 included non-skid strips to the floor in front of the resident's chair which was added 10/01/20. On 11/01/20 the care plan was updated to educate resident to pull the call light for assistance, medication review, and a visual reminder of Call Don't Fall in room. The care plan was updated on 11/09/20 to place a mat on the floor in front of the recliner when the resident was up in the chair. On 03/01/21 remove wheelchair from room when not actively using it and use the resident's recliner instead when the resident wants to sit in the room. On 05/05/21 at 10:17 A.M. and 4:20 P.M. observation of Resident #16 and her room revealed the resident did not have all fall interventions in place as per the current care plan. The resident did not have any non-skid strips on the floor in the bathroom or in front of her recliner chair, there was no visual reminder to Call Don't Fall in the resident's room, there was no personal alarm being used on the resident's bed or on her recliner chair, and there was a wheelchair still in the resident's room while the resident was sitting in her recliner chair. On 05/05/21 at 4:35 P.M. observation with CCO #154 and Acting Director of Nursing (DON) #109 of Resident #16's room confirmed the above listed fall interventions were not in place as care planned. Review of the facility policy titled Fall Response Policy and Procedure, dated 08/01/18 revealed in response to falls, to implement an intervention to guard against a fall of the same type, add the intervention to the care plan and communicate it to the direct care staff. 2. Review of Resident #76's medical record revealed an admitted [DATE] with admitting diagnoses including intracranial injury, [CONDITION(S)], right above the knee amputation, left above the knee amputation, [CONDITION(S)] of skin, constipation, [CONDITION(S)] and aftercare following surgical amputation. Review of the acute care hospital discharge summary, dated 04/19/21 revealed an Occupational Therapy (OT) note from 04/15/21 which identified Resident #76 had poor trunk control and sitting balance with impaired safety. Review of the fall risk assessment, dated 04/23/21 revealed a score of 17 indicating the resident was at high risk for falls. Review of the plan of care, dated 04/24/21 revealed Resident #76 was at risk for falls related to decreased/impaired mobility, medications and impaired balance related to recent bilateral above the knee amputation. Interventions included to keep bed in lowest position except for care, keep call light within reach, staff to anticipate resident needs and therapy screen as needed. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/30/21 revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 14. The resident required extensive assistance of two staff for bed mobility, transfers and toileting. Review of the resident's monthly physician's orders for May 2021 revealed an order for physical therapy (PT) three to five times a week for four weeks for therapeutic exercises, therapeutic activities, wheelchair mobility and training. Resident #76 sustained a fall on 05/10/21. The post fall investigation, dated 05/10/21 revealed Laundry Assistant (LA) #114 was pushing the resident outside the side door to smoke while the State tested Nursing Assistant (STNA) held the door open. When LA #114 pushed the resident across the threshold he forcefully convulsed causing LA #114 to loose her grip on the chair. This caused the chair to flip backwards resulting in the resident landing on the ground (blacktop). On 05/10/21 at 11:19 A.M. observation of the resident revealed he was laying on the blacktop/gravel on his back with his wheelchair tipped over backwards outside the door. The resident appeared to be trunk heavy as he was a recent bilateral above the knee amputation. At the time of the observation, staff were assessing the resident and had called 911. The resident was subsequently transferred to the hospital for an evaluation. The resident was treated for low back pain as a result of the fall with no significant injury noted. On 05/10/21 at 3:30 P.M. interview with the DON revealed the facility had no evidence Laundry Assistant #114 had training to provide assistance to Resident #76 with wheelchair mobility. In addition, there was no evidence the wheelchair being used for the resident appropriate for mobility based on the resident's recent bilateral above the knee amputations and positioning needs. Review of the facility policy titled Fall Response Policy & Procedure, dated 08/01/18 revealed it was the policy of the facility to ensure to the best of it's ability the safety and well-being of residents who were at risk for falls.

Based on record review, review of hospital records, review of a fall investigation, facility policy review and interview the facility failed to provide timely effective pain management for Resident #16 following a fall on 08/22/20 at 12:28 P.M. that resulted in a dislocation of the resident's right shoulder. Actual Harm occurred when the resident was not provided effective pain relief until being transferred to the hospital on 08/22/20 at 9:47 P.M. (over nine hours after the fall occurred) at which time the resident complained of sharp constant pain rated a 10 on a scale of one to 10 with 10 being the worst pain. This affected one resident (#16) of two residents reviewed for pain management. Findings Include: Review of Resident #16's medical record revealed an admitted on 08/03/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's care plan, dated 08/03/20 and revised on 08/10/20 revealed the resident was at risk for pain. The plan revealed the resident was generally able to advise staff when she was in pain and would also use non-verbal cues and gestures that indicated pain. The resident had scheduled pain medication as well as as needed (PRN) pain medication for breakthrough pain. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident should be assessed at medication pass, meal times, and as needed. Attempt non-pharmacological interventions including repositioning, distraction with activity of the resident's choice, and one to one visits from staff. Staff should notify the physician as needed. Staff should observe for any side effects of pain medication, observe for signs and symptoms of nonverbal pain, and provide therapy services as ordered by the physician. Review of physician's orders for Resident #16, dated from 08/2020 revealed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/10/20, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 which reflected her cognition was intact. The assessment revealed the resident required extensive assistance from two staff to complete tasks including bed mobility, transfers and toileting. The resident required limited assistance from one staff for walking in her room. The resident was assessed to be unsteady and required staff assistance to stabilize when she moved from a sitting to a standing position, moved on and off the toilet, and completed a surface-to-surface transfer, for example transferred from her bed to a chair or wheelchair. Review of Resident #16's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. which was documented as being effective. There was no additional pain medication administered to the resident on 08/22/20. Review of Resident #16's nursing progress notes revealed on 08/22/20 at 12:28 P.M. the resident had a fall while attempting to ambulate to the restroom without assistance. A head to toe assessment was completed by Registered Nurse (RN) #150 with no redness, discoloration or injury noted. However, the resident reported hitting her right shoulder and indicated she had right shoulder pain. The physician, Director of Nursing (DON) and family were notified of the fall. On 08/22/20 at 2:13 P.M. Resident #16 continued to report pain to her right shoulder. The progress note revealed no deformities were noted but the resident exhibited limited range of motion (ROM) at that time. An x-ray was ordered. However, there was no evidence the resident's pain was comprehensively assessed or treated at that time even though she reported pain and had limited range of motion. Record review revealed no evidence the resident's pain level was addressed until 08/22/20 at 9:05 P.M. At that time, Licensed Practical Nurse (LPN) #151 noted the resident fell during day shift. Upon an evening assessment, the resident's right shoulder appeared deformed, was tender to touch and the resident had limited ROM. Mobile-X took an x-ray of her right shoulder but the results had not been received. At that time, LPN #151 notified the physician of her assessment of Resident #16 and the physician suggested the resident be sent out to the hospital. The resident's Power of Attorney (POA) was notified and also requested the resident be sent to the hospital. An ambulance service was contact to pick up the resident. On 08/22/20 at 9:47 P.M. Resident #16 was transferred to the hospital. The resident's pulse was elevated at 90 beats per minute at the time of transfer with other vital signs within normal limit. The resident returned to the facility on [DATE] at 3:01 A.M. Review of hospital information revealed the resident was administered [MEDICATION(S)] two mg for pain relief and [MEDICATION(S)] 60 mg at the hospital for conscious sedation to manipulate her shoulder back into place. The resident's right arm was placed in a sling. Review of Resident #16's fall investigation, completed by RN #150, dated 08/22/20 at 12:30 P.M. revealed the resident was found on the floor by a State-tested Nursing Assistant (STNA). The resident appeared not to have any injuries, redness, discoloration, or open areas. The resident reported right shoulder pain at that time. Orders were received for an x-ray of the right shoulder and a referral to physical therapy and/or occupational therapy. The resident was not taken to the hospital. The resident was alert and oriented. The resident stated at the time of the incident she was experiencing some pain in her right shoulder. The resident also reported her fingers were numb. Mobile X-ray arrived and completed x-rays of the right shoulder where a dislocation was found. The resident was to be assisted with any transfer, pain was to be addressed and therapy consulted for possible treatment. Review of Resident #16's Pain Assessment, completed on 08/22/20 at 2:48 P.M. revealed the resident had frequent pain in the last five days which made it hard for her to sleep at night. The resident reported five out ten pain on a numeric rating scale from zero to ten. The verbal descriptor scale was not completed that would indicate whether the pain was mild, moderate, severe, or very severe. The indicators of pain or possible pain section of the assessment was not completed which would indicate any non-verbal indications of pain such as crying, moaning, facial expressions of pain, protective body movements or postures such as rubbing, massaging, clutching, or holding a body part. The frequency of indicator of pain or possible pain section was not completed. There was no indication that any scheduled pain medication had been received. The nurse noted the resident requests [MEDICATION(S)] one to two times daily for generalized pain and the resident was repositioned. There no additional pain assessments completed or documentation of the resident's pain level. Review of Resident #16's x-ray report dictated on 08/22/20 at 9:10 P.M. revealed the findings included an interior dislocation of the right humeral head and anterior dislocation of the right humeral head. Review of Resident #16's hospital transfer report, dated 08/23/20 at 2:05 A.M. revealed a pain assessment conducted in the emergency roiagnom on [DATE] at 10:43 P.M. indicated the resident rated her pain a level 10 on a numeric scale of zero to 10, with 10 being the worst pain, in her right shoulder. The resident reported the pain as sharp and constant. The resident received an injection of [MEDICATION(S)] Sulfate 2 mg for severe pain on 08/22/20 at 10:43 P.M. The resident received an injection of [MEDICATION(S)] 50 mg intravenous once on 08/22/20 at 10:43 P.M. and then [MEDICATION(S)] 60 mg intravenously once at 12:21 A.M. to place the resident under conscious sedation. A right shoulder reduction was performed. The resident remained under conscious sedation until 1:31 A.M. The resident was discharged with a sling to her right arm with instructions to wear the sling 24 hours until her follow up appointment with an orthopedic specialist. Attempted interviews with RN #150, STNA #152 and STNA #153 during the survey were unsuccessful. None of the staff involved in the incident were employed at the facility at the time of the survey. On 05/05/21 at 4:45 P.M. and 05/06/21 at 2:03 P.M. interview with Chief Clinical Officer (CCO) #154 confirmed Resident #16 was administered a dose of [MEDICATION(S)] 500 mg at 10:00 A.M. on 08/22/20 (which was before the fall occurred) with no additional pain medication being administered until the resident (who complained of pain) arrived at the emergency roiagnom on [DATE] at 10:43 P.M. CCO #154 confirmed according to the documentation, Resident #16 was only repositioned one time during this time period. CCO #154 confirmed a pain assessment after the fall occurred indicated the nurse assessed the resident's pain at the time of the fall but did not complete the documentation until two hours later. CCO #154 confirmed there was no additional documentation between 2:30 P.M. and 9:05 P.M. that indicated the resident's status was monitored or her pain level had been assessed. Review of the facility policy, titled Pain Assessment and Management, revised 03/2015 revealed facility staff should conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Furthermore, during the comprehensive pain assessment gather the following information as indicated from the resident or representative: history of pain and its treatment, characteristics of pain, intensity of pain, descriptors of pain, pattern of pain, location and [CONDITION(S)] of pain and frequency, timing and duration of pain, the impact of pain on quality of life, factors that precipitate or exacerbate pain, factors and strategies that reduce pain, and symptoms that accompany pain. Re-assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated.

Based on observation, staff interview and facility policy review the facility failed to properly store and date opened food items, take food temperatures without committing cross-contamination and prepare and serve meals in a sanitary manner. The had the potential to affect all 26 residents residing in the facility. Findings Include: 1. On 05/03/21 from 12:10 P.M. to 1:21 P.M. an initial tour of the kitchen revealed a large container of Lite Buttermilk Ranch dressing, dated 04/01/21 and a large container of Creamy Coleslaw dated 02/11/21 were observed in the refrigerator. Both of the containers had been opened and some of the contents were missing at the time of the observations. On 05/03/21 at 12:55 P.M. interview with Former Dietary Manager (FDM) #134 confirmed both items had been opened and dated 04/01/21 and 02/11/21 as noted above. FDM #134 revealed the items had been dated with the dates the items arrived on the delivery truck and were not dated again once the items were opened. FDM #134 could not confirm how long either item had been opened and stored in the refrigerator. FDM #134 removed both items and disposed of them in a covered trash can. Observation of items in the freezer on 05/03/21 at 1:17 P.M. revealed an individual package of frozen waffles were opened and exposed to the cold air and did not have a date on them, a box with a bag of frozen sausage patties were opened and exposed to the cold air and did not have a date on them, and a bag of frozen hamburger patties were opened and exposed to the cold air and did not have a date on them. Interview with FDM #134 on 05/03/21 at 1:19 PM confirmed the individual package of frozen waffles and the bag of frozen sausage patties were open and exposed to the cold air and were not dated. FDM #134 removed both items from the freezer and disposed of them in a covered trash can. Interview with the Administrator on 05/03/21 at 1:21 P.M. confirmed the bag of frozen hamburger patties were opened and exposed to the cold air and were not dated. The Administrator removed the hamburger patties from the freezer and disposed of them in a covered trash can. Review of the facility policy titled Food Receiving and Storage, revised on 10/2017 revealed all foods stored in the refrigerator or freezer would be covered, labeled, and dated. 2. On 05/06/21 at 11:52 A.M. observation of meal preparation for the lunch meal revealed Cook #120 was taking temperatures of the food items before serving the items to the residents. Cook #120 washed her hands and applied/donned clean gloves. She grabbed a thermometer and placed it in a breaded fish fillet. After obtaining a satisfactory temperature, Cook #120 removed the thermometer and placed into a baked potato without first cleaning the thermometer. After a satisfactory temperature was obtained from the baked potato, Cook #120 removed the thermometer and placed it in a dinner roll without first cleaning the thermometer. At this time, FDM #134 observed Cook #120 remove the thermometer from the dinner roll and was getting ready to place it in the vegetables and intervened. FDM #134 handed Cook #120 some alcohol swabs and Cook #120 cleaned the thermometer prior to putting it into the vegetables. Interview with FDM #134 on 05/06/21 at 12:40 P.M. confirmed Cook #120 had obtained temperatures from the fish fillet, baked potato, and dinner roll without properly cleaning the thermometer in between food items. A policy related to properly taking food temperatures was requested but was not provided during the time of the survey. 3. On 05/06/21 from 11:52 A.M. to 12:30 P.M. observation of the kitchen staff during preparation, plating, and serving the lunch meal revealed Cook #123 cooking a hamburger on the stove. The cook had gloves on. Cook #123 touched a knob on the front of the stove to turn the burner off, turned around and grabbed a pair of tongs and placed them in a bowl that was full with dinner rolls. Next, Cook #123 picked up a sandwich that had already been made up from the counter with the same gloves on and wrapped the sandwich with plastic wrap. Then, the cook went back over to the stove and touched the same knob on the front of the stove again. The cook then grabbed the thermometer from a container and placed the thermometer into the hamburger to obtain a satisfactory temperature. Cook #123 had not completed any hand hygiene or changed his gloves during the observation. Continuing with meal preparation, Cook #123 opened an alcohol wipe and cleaned the thermometer off before he placed it back into the container. The cook proceeded to open a bag of hamburger buns, grabbed one bun from the bag, and placed the hamburger onto the bun using a spatula. Next, Cook #123 opened a plastic bag of sliced American cheese, grabbed one slice of cheese from the bag, and placed it on the hamburger with his gloved hand. The cook continued without completing any hand hygiene or changing his gloves. Cook #123 opened a drawer with his gloved hands and rummaged through it to find the appropriate serving scoop for the vegetables. The cook scooped some vegetables and placed them on the plate next to the cheeseburger. At 12:12 P.M., Cook #123 moved to the steam table, still without completing any hand hygiene or changing his gloves and began plating food to be served to the residents. As the cook was placing each item (fish filet, vegetables, baked potato, and dinner roll) on to the plate, he was observed touching each food item with his gloved hands on every plate of food. The container of cooked vegetables was placed behind the container of fish filets on the steam table. Cook #123 was observed plating the cooked vegetables. As the cook scooped the vegetables and broth and brought the scoop over the fish filets, broth from the vegetables was observed dripping into the fish filets. Once all the residents' meals had been plated and placed into the dining carts, Cook #123 removed his gloves and threw them into a covered trash can. At 12:19 P.M., a meal tray was observed on the counter close to the kitchen door. The meal tray had been placed in a clear trash bag that was left opened. Before Cook #123 washed his hands, he grabbed the meal tray in the trash bag with his bare hands, carried the tray to the back of the kitchen and placed it on top of other dishes next to the three compartment sink to be washed. Cook #123 then washed his hands at the sink. Interview with Cook #123 on 05/06/21 at 12:21 P.M. confirmed the meal tray in the clear trash bag had been removed from a resident's room under quarantine/droplet isolation precautions. Interview with FDM #134 on 05/06/21 at 12:40 P.M. confirmed observations of Cook #123 touching several different items in the kitchen, as described above, without the proper completion of hand hygiene or changing gloves until after he carried the meal tray from the isolation room back to the three compartment sink. FDM #134 revealed she had been working with Cook #123 on the importance of proper hand hygiene in the kitchen but he struggled to adhere to her expectations. FDM #134 revealed she would educate the cook again and continue to work on improving hand hygiene in the kitchen to avoid any risk of contamination. A policy regarding meal service preparation and service was requested but no policy was provided during the time of the survey.

Based on record review, staff interview, review of Food and Drug Administration (FDA) information, review of a HealthDay News Study and facility policy review the facility failed to provide adequate justification for the use of antibiotics for those residents who tested positive for the COVID-19 virus. This affected 19 residents (#2, #5, #10, #14, #15, #16, #17, #18 #19, #21, #24, #25, #26, #80, #81, #82, #83, #84 and #85) of 20 residents who had been prescribed antibiotics. The facility census was 26. Findings Include: Review of Resident #2, #5, #10, #14, #15, #16, #17, #18 #19, #21, #24, #25, #26, #80, #81, #82, #83, #84 and #85's medical records, dated 12/01/20 to 01/31/21 revealed each of these residents were prescribed and administered [MEDICATION(S)] (an antibiotic used to treat bacterial infections) when they tested positive for COVID-19 virus. Upon review of these resident's medical records at the time the antibiotic was initially ordered, there was no evidence to support McGeer's criteria had been met indicating an infection was present for the antibiotics to be prescribed and administered. On 05/06/21 at 4:08 P.M. interview with Chief Clinical Operator (CCO) #154 verified the facility medical director (MD) prescribed all residents who tested positive for the COVID-19 virus the antibiotic [MEDICATION(S)]. She said the MD based the decision on the use of the medication in the United [NAME] (UK) indicating the use of the antibiotic would lessen the complications of COVID-19 virus. Review of information on the FDA website (https://www.fda.gov) revealed the following FDA response to the question, Are antibiotics effective in preventing or treating COVID-19? No. Antibiotics do not work against viruses; they only work on bacterial infections. Antibiotics do not prevent or treat COVID-19, because COVID-19 is caused by a virus, not bacteria. Some patients with COVID-19 may also develop a bacterial infection, such as pneumonia. In that case, a health care professional may treat the bacterial infection with an antibiotic. In addition, an article from HealthDay News, dated 08/04/20 revealed the following: Early in the U.S. coronavirus pandemic, many people landing in the hospital may have been given unnecessary antibiotics, a new study suggests. The findings come from one of the hard-hit hospitals in New York City, the initial epicenter of the U.S. pandemic. Researchers there found that of COVID-19 patients admitted between March and May, just over 70% were given antibiotics. That's despite the fact that COVID-19 is caused by a virus, and very few of those patients actually had a coexisting bacterial infection. Antibiotics kill bacteria, but are useless against [CONDITION(S)] infections such as the common cold, the flu and COVID-19. Review of the facility policy titled, Antibiotic Stewardship, last revised 08/2019 revealed the facility committed to improving antibiotic use in the facility. Facility leadership was committed to embracing and executing the Centers for Disease Control and Prevention's (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes. The seven core elements for antimicrobial stewardship included leadership commitment, accountability, drug expertise, action, tracking, reporting and education.

Based on observation, record review, staff interview and facility policy and procedure review the facility failed to ensure comprehensive care plans were developed as required for Resident #3, #20, #76 and #78. This affected four residents (#3, #20, #76 and #78) of 17 residents reviewed for care planning. Findings Include: 1. Review of Resident #3's medical record revealed an original admitted [DATE] with the latest readmission of 11/14/20 and admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had adequate vision, did not utilize glasses, had clear speech, understood others, made herself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 14. Review of the resident's monthly physician's orders for May 2021 revealed an order dated 04/14/21 for CBD (cannabidiol) Rest Gummy 25 milligrams (mg) daily at bedtime and an order dated 04/26/21 to increase the resident's Trazadone to 75 milligrams by mouth daily at bedtime for [CONDITION(S)]. Review of the resident's plan of care revealed no plan of care addressing the resident's [CONDITION(S)]. On 05/06/21 at 11:00 A.M. interview with the Director of Nursing (DON) verified the resident had no plan of care addressing the [CONDITION(S)]. 2. Review of Resident #20's medical record revealed an admitted [DATE] with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly MDS 3.0 assessment, dated 04/09/21 revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a BIMS score of 15. Review of the resident's monthly physician's orders for May 2021 revealed on 04/14/21 the resident was prescribed [MEDICATION(S)] 5 mg by mouth daily at bedtime for [CONDITION(S)]. Further review revealed on 04/27/21 the resident was also prescribed [MEDICATION(S)] 5 milligrams (mg) by mouth daily at bed time for [CONDITION(S)]. Review of the resident's plan of care revealed no plan of care addressing the resident's [CONDITION(S)]. On 05/05/21 at 10:45 A.M. interview with the DON verified the resident had no plan of care addressing the resident's [CONDITION(S)]. 3. Review of Resident #76's medical record revealed and admitted d of 04/23/21 with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's dental/oral examination, dated 04/23/21 revealed staff assessed the resident to be edentulous. Review of the resident's comprehensive MDS 3.0 assessment, dated 04/30/21 revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a BIMS score of 14. The resident required extensive assistance of two staff for personal hygiene. The assessment indicated the resident has no obvious or likely cavity or broken natural teeth. Review of the resident's monthly physician's orders for May 2021 revealed a current order for the resident to see the dentist. On 05/03/21 at 5:01 P.M. observation of the resident revealed he had multiple decayed teeth. Review of the resident's plan of care revealed no plan of care addressing the resident's decayed teeth. On 05/11/21 at 11:15 A.M. interview with the DON verified the resident had decayed teeth and the resident's MDS, admission assessment and oral assessment were inaccurate to reflect the obvious carious teeth. She also verified the resident had no plan of care addressing the resident's decayed teeth. 4. Review of Resident #78's medical record revealed an original admitted [DATE] with the latest readmission of 11/14/20 and admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had adequate vision, did not utilize glasses, had clear speech, understood others, made herself understood and had no cognitive deficit as indicated by a BIMS score of 14. The resident required extensive assistance of two for bed mobility, dependent on two staff for transfers and was non-ambulatory. The assessment indicated the resident had no skin issues. Review of the resident's monthly physician's orders for May 2021 revealed an order initiated 11/15/20 for Aspirin 81 milligrams (mg) by mouth daily for blood thinner, [MEDICATION(S)] 75 mg by mouth daily for blood thinner and [MEDICATION(S)] 2.5 mg by mouth daily for blood thinner. Review of the resident's plan of care revealed the resident had no comprehensive plan of care related to the use of anticoagulant medications. On 05/06/21 at 11:00 A.M. interview with the DON revealed the resident had no plan of care addressing the resident's anticoagulant medication use. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016 revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional was to be developed and implemented for each resident.

Based on observation, record review, interview and facility policy and procedure review the facility failed to develop and implement adequate nutritional interventions to meet the nutritional needs of residents and to prevent weight loss. The facility failed to ensure Resident #21 and Resident #76 received additional food items requested during meals. The facility failed to obtain accurate weights for Resident #8 resulting in inappropriate interventions being implemented and the facility failed to ensure Resident #19 received nectar thickened liquids as ordered by the physician. This affected four residents (#8, #19, #21 and #76) of five residents reviewed for nutrition and/or thickened liquids. Findings Include: 1. Review of Resident #8's medical record revealed an admitted [DATE] with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's acute care hospital discharge summary revealed the resident weighed 58.9 kilograms/129.58 pounds. The assessment indicated the resident was edentulous and received a regular diet. Review of the facility admission nursing observation documentation, dated 02/25/21 revealed no recorded admission weight or height was obtained for the resident. Review of the plan of care, dated 02/26/21 revealed the resident was at risk for nutrition/hydration problems related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to administer medications as ordered, allow resident to make choices, preferences of food as able, dietary consult as needed, observe resident for coughing, choking, chewing problems, pocketing, drooling and/or holding food in mouth, obtain lab work as ordered, obtain weight as ordered, provide diet as ordered, provide supplement as ordered and speech therapy (ST) screen as needed. Review of the resident's monthly physician's orders revealed an order dated 02/25/21 for health shakes three times a day between meals and weekly weights for four weeks then monthly, on 02/26/21 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nutritional assessment, dated 03/08/21 revealed a weight of 249 pounds on 03/04/21 was utilized to configure the resident's caloric intake needs, protein and fluid needs. The resident was assessed to require 2445 calories per day, 102 grams of protein per day and 2445 milliliters (ml) of fluids per day. The Registered Dietician (RD) recommended to continue the regular diet, add 30 ml liquid protein and monitor weights per facility protocol. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had unclear speech, usually understood others, usually made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of five. The resident required extensive assistance of two staff for transfers and bed mobility and required supervision with eating. The assessment indicated the resident's weight was 247 pounds and he had not had a weight loss. Review of the dietary note, dated 04/16/21 at 2:49 P.M. revealed the RD was reviewing the resident due to a weight loss. The note documented the resident's admission weight was erroneous as it was a hospital weight from admission and was charted instead of an actual weight upon admission to the facility. The RD re-figured the resident's caloric needs at 2592 calories per day, 91 grams of protein per day. The resident had further weight loss from 04/02/21 to 04/09/21 and the resident current Body Mass Index (BMI) was below normal parameters for his age. The RD recommended chocolate health shakes three times a day to provide 660 calories and 18 grams of protein and continue weekly weights. Review of the resident's weights revealed on 03/04/21 the resident weighed 249 pounds, 03/12/21 250 pounds, 03/18/21 246.7 pounds, 03/23/21 247.1 pounds, 04/02/21 136 pounds, 04/07/21 133.6 pounds, 04/09/21 133.2 pounds, 04/09/21 136 pounds, 04/14/21 129.4 pounds, 04/20/21 130 pounds, 04/27/21 130.8 pounds on 05/05/21 133.6 pounds. On 05/04/21 at 3:45 P.M. interview with Chief Clinical Officer (CCO) #154 and the Director of Nursing (DON) verified the inaccurate weights and the use of the inaccurate weights to base the resident's caloric intake on. Review of the facility policy titled, Weight Policy, dated 01/21 revealed the facility would attain/maintain a resident's weigh within recommended range as appropriate in relation to their medical and physical status. Weights would be obtained in a timely and accurate manner, documented and responded to appropriately. 2. Review of Resident #76's medical record revealed and admitted [DATE] with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care, dated 04/24/21 revealed the resident was at risk for nutrition/hydration problems related to wound, recent surgery and history of poor intake. Interventions included administer medications as ordered, allow resident to make choices preference of food as able, dietary consult as needed, observe resident for coughing, choking, chewing problems, drooling and/or holding food in mouth, obtain labs as ordered, obtain weight as ordered and provide diet as ordered Speech Therapy (ST) screen as needed. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a BIMS score of 14. The resident required supervision with eating and the resident's weight was recorded at 118 pounds with no known weight loss. Review of the plan of care, dated 04/30/21 revealed the resident was at risk for altered nutrition and hydration related to skin impairment, poor food choices and obesity as evidenced by Stage I pressure ulcer, drinks excessive pop and Body Mass Index (BMI) greater than 30. Interventions included assist with meals as needed, dental consult as needed, fluids as needed, honor food preferences as able, medications as ordered, monitor food preferences as able, monitor for signs/symptoms of dehydration, monitor intake and output as ordered, monitor skin issues and signs/symptoms of wound healing, obtain food preferences, offer alternative fluid options, oral care as needed, provide diet as ordered, RD referral as needed and weight as ordered. Review of the nutritional assessment, dated 04/30/21 revealed the resident received a regular diet. The assessment indicated the resident had good food intake with extra food requests, so no additional need for extra nourishment/supplement. The assessment indicated the resident weighed 117.6 pounds and was 42 inches in height. The resident had no adjusted BMI for the recent bilateral above the knee amputation. The resident also had a Stage I pressure ulcer and surgical incision to right above the knee amputation. The resident's estimated caloric intake was 1336 to 1604 per day, 53 to 64 grams of protein per day and 1604 ml of fluid. Review of the resident's meal percentages from 04/23/21 to 05/09/21 revealed the resident consumed 75 to 100% of his meals. On 05/03/21 at 5:01 P.M. interview with Resident #76 revealed he loved the food and indicated he would like double portions but the facility would not give him the double portions because they often ran out of food at meals. On 05/04/21 at 1:05 P.M. observation of the resident's lunch meal revealed the resident consumed 100% of his meal and asked facility staff for more. The State tested Nursing Assistant (STNA) reported the kitchen was out of food being served. The STNA did not offer the resident a substitute. On 05/11/21 at 11:15 A.M. interview with the Director of Nursing (DON) revealed the resident had not been provided additional food as requested. 3. Review of Resident #21's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/09/21 revealed the resident had intact cognition. The resident required extensive assistance from two staff to complete ADL care. The resident required supervision with set up assistance from staff for eating. The resident did not have any significant weight loss and was on a therapeutic diet. Review of the care plan for Resident #21, revised on 04/09/21 revealed the resident had potential for or an alteration in nutrition and hydration related to advanced age, [CONDITION(S)], [CONDITION(S)], gastro-[CONDITION(S)] reflux disease (GERD), a history of a poor appetite, non-compliance with diet, and diuresis. The resident preferred soft fried eggs for breakfast, broiled fish, dark meat chicken, tomato soup, grilled cheese and a dinner roll or sliced bread. Interventions included a regular diet with one enhanced food item at each meal, double portions, offer substitution if 50% or less of a meal was eaten, supplements as ordered (Ensure three times daily) and weights as ordered. Review of physician's orders for Resident #21 for May 2021 revealed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress notes for Resident #21 from 04/01/21 through 05/05/21 revealed the resident was being followed by a dietitian. On 04/12/21, the resident was noted with an average intake of 50% of her meals with four refusals noted. The resident required supervision following setup help. The resident's body mass index (BMI) was noted to be low for the resident's age at 20. No significant weight changes were noted. A weight gain would be ideal due to the low BMI. The resident had fair oral intake and no new nutritional recommendations were made. On 04/23/21, the resident was reviewed for significant weight gain. The resident had meal intakes of 68% of meals in the last week with seven refusals noted. Gradual weight gain was desirable related to underweight status. On 05/05/21 at 12:27 P.M. interview with Resident #21 revealed the resident enjoyed the lunch meal but had requested a second helping of oven baked potatoes but was informed by the kitchen they had run out of the potatoes and they could not provide the resident with another serving. On 05/05/21 at 12:45 P.M. interview with Former Dietary Manager (FDM) #134 confirmed the kitchen did run out of the oven fried potatoes on this date at lunch. FDM #134 revealed the kitchen staff had prepared only enough potatoes for every resident to receive one serving but could not provide any second helpings even though residents had requested another serving or for residents who had orders for double portions. On 05/05/21 at 5:07 P.M. interview with Executive Director (ED) #113 revealed the kitchen was stocked with additional potatoes which could have been prepared for the residents upon request. ED #113 revealed the staff should have accommodated any requests for a second helping and stated this would be addressed with the kitchen staff immediately because it was unacceptable. A policy was requested related to ensuring enough food was prepared for meals but was not provided at the time of the survey. 4. Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/09/21 revealed the resident had severely impaired cognition. The resident required extensive assistance from two staff to complete activities of daily living (ADLs). The resident did not have any significant weight loss and was on a mechanically altered diet. Review of the care plan for Resident #19, revised on 04/12/21 revealed the resident had a potential nutritional and hydration risk related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included diet as ordered, mechanical soft with chopped meats and nectar thick liquids and thickened liquids as ordered. Review of the physician's orders for May 2021 revealed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/04/21 at 12:20 P.M. Resident #19 was observed eating lunch in his room. Observation revealed the resident had a chicken breast cut up into pieces, french fries, Spanish rice, half of a breadstick and two cups of juice with a [NAME] straw. Both cups of juice were about half full. The two cups of juice were thin in texture and not nectar thick as ordered. On 05/05/21 at 8:16 A.M. Resident #19 was observed eating breakfast in his room. The resident had eaten most of his breakfast which included a waffle and sausage. The resident had a cup of orange juice and coffee on his over the bed table. The cup of juice was approximately 25% full and cup of coffee was about 75% full. The orange juice was not nectar thick in consistency. On 05/05/21 at 12:30 P.M. Resident #19 was observed eating lunch in his room. The resident had a cup of coffee and a nutritional supplement on his lunch tray. The cup of coffee was about 75% full. The cup of coffee was not nectar thick consistency. The nutritional supplement was in a cardboard box and could not be observed for consistency. On 05/05/21 at 12:32 P.M. observation and interview with Licensed Practical Nurse (LPN) #101 of Resident #19 verified the cup of coffee on the resident's meal tray was not nectar thick. The nurse confirmed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nutritional supplement was empty at the time of the observation. A facility policy related to thickened liquids was requested but was not provided during the survey.

Based on observation, review of resident diets, review of dietary spreadsheets, staff interview and facility policy review the facility failed to follow the dietary spreadsheet for residents on a therapeutic diet, resulting in all the residents in the facility receiving a regular diet during the lunch meal on 05/06/21. This had the potential to affect 11 residents (#1, #2, #7, #10, #17, #18, #19, #22, #23, #78, and #175) who were prescribed therapeutic diets. The facility census was 26. Findings Include: Review of a facility document titled Diet Type Report, dated 05/03/21 revealed Resident #10, #18, #19, #22 and #23 were on a mechanical soft diet. Resident #2, #17, #18 and #78 were on a low concentrated sweets diet. Resident #18 and #175 were on a renal diet. Resident #1, #18 and #78 were on a low salt diet. Resident #7, #18, #19, and #22 were to receive chopped or ground meats. Review of the dietary spreadsheet for the lunch meal on 05/06/21 revealed residents on a regular diet were to receive one fish fillet, one cheese topped baked potato, four ounces of a Capri vegetable blend, one roll, one serving of dessert, one margarine, eight fluid ounces of 2% milk, and six fluid ounces of coffee or tea. Residents on a mechanical soft diet should receive two ounces of gravy and ground breaded fish and a cheese topped baked potato without the skin. Residents on a low concentrated sweets diet should receive a plain baked potato and skim milk. Residents on a renal diet should receive four ounces of rice or noodles instead of a baked potato and four fluid ounces of 2% milk. Residents on a low salt diet should receive a plain baked potato and no roll. On 05/06/21 at 11:52 A.M. observation of preparation for the lunch meal revealed the kitchen staff preparing breaded fish fillets, cheese topped baked potatoes, a Capri vegetable blend, roll, and jell-o (later substituted with a cookie due to the jell-o not reaching the appropriate temperature) for the lunch meal. The kitchen staff were observed using a fork to break up the fish fillet into pieces for a couple residents but were not observed grinding or chopping up the fish, nor was there any ground or chopped fish already made on the steam table. During the meal preparation, there was no observation of any ground fish, gravy, baked potatoes without skin or cheese, or rice or noodles as indicated on the dietary spreadsheet to meet the needs of the residents on a mechanical soft, low concentrated sweets, simple renal, or low salt therapeutic diet. On 05/06/21 at 12:33 P.M. and 12:40 P.M. interview with Former Dietary Manager (FDM) #134 revealed the kitchen staff did not reference the dietary spreadsheet prior to making the meal and did not prepare any of the above items listed for the therapeutic diets. FDM #134 revealed she was not aware she needed to follow the spreadsheets for diets and confirmed all the residents had received a regular diet for the meal served. Review of the facility policy titled Therapeutic Diets, revised on 10/2017 revealed therapeutic diets were prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Furthermore, a therapeutic diet was considered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: diabetic or calorie controlled diet, low sodium diet, cardiac diet, or altered consistency diet. A facility policy that addressed following dietary spreadsheets for meal preparation was requested but was not provided during the survey.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memos, Nursing Home Guidance from the Centers for Disease Control (CDC), observation, record review, review of facility policies including the COVID-19 Infection Control and Prevention policy and guidelines, the COVID-19 Prevention and Management policy, the Donning and Removing of Personal Protective Equipment (PPE) policy, Isolation Precautions policy, Infection Control Measures during Infectious Disease Threat policy and interviews with staff the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 in the facility. This resulted in Immediate Jeopardy affecting all 25 residents when the facility failed to ensure PPE was readily available and properly used by staff, failed to ensure the proper use and storage of N95 masks, failed to ensure all staff were properly screened for COVID-19 upon entering the facility, failed to properly utilize a quarantine unit and failed to ensure dedicated housekeeping supplies were used only on the facility COVID-19 unit to prevent the spread of COVID-19 in the facility. Between 12/16/20 and 12/30/20 the facility identified 23 residents, Resident #3, #7, #21, #24, #25, #26, #27, #1, #2, #8, #9, #10, #11, #12, #13, #14, #16, #18, #19, #23, #6, #15 and #17 who tested positive for COVID-19. One resident, Resident #14 required hospitalization in an intensive care unit due to COVID-19. The facility's lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 25 residents at risk for the likelihood of harm, complications and/or death. On 12/28/20 at 4:30 P.M. the Director of Nursing (DON), Executive Director (ED), and Regional Director of Clinical Services, Registered Nurse (RN) #112 were notified Immediate Jeopardy began on 12/28/20 when observation revealed a lack of available PPE to care for residents on the facility quarantine unit, a storage area for N95 masks reuse was not being utilized and the DON reported staff were taking N95 masks home with them to store. Additional observations revealed the area designated for staff to apply (don) and remove (doff) PPE between the COVID-19 unit and quarantine unit lacked available PPE, hand sanitizer and a trash receptacle. Staff were observed entering the quarantine unit from the COVID-19 unit without first cleansing their eye protection. Hand sanitizer and cleaning material for eye protection was not available in the don and doff area of the COVID-19 unit. Physical Therapist Assistant (PTA) #118 was observed entering the facility without completing the COVID-19 screening tool. The housekeeping cart was being utilized on both the COVID-19 unit and the quarantine unit without being sanitized between units. Staff were observed moving between resident rooms on the quarantine unit without cleaning their eye protection or covering their N95 mask with a surgical mask and removing the surgical mask and were not changing their isolation gowns. The facility's failure to effectively implement infection control practices likely contributed to the COVID-19 outbreak that spread through out the facility infecting 23 of 25 residents. The Immediate Jeopardy was removed on 12/31/20, when the facility implemented the following corrective actions: · On 12/28/20 by 7:00 P.M. the DON/Designee had all eight staff members (the ED, RNs #105 and #112, Licensed Practical Nurse (LPN) #120, State tested Nursing Assistants (STNAs) #108, #109, #122, and #124 working in the facility discard their N95 mask currently in use and replaced it with a new N95 mask. These staff members were instructed and observed to sanitize their eye protection at this time. The facility instructed staff to discard and apply a new N95 mask after each use and instructed staff on the proper procedure for eye protection sanitation. The DON/designee also conducted an audit to ensure each staff member had washed their hands properly. · On 12/28/20 by 7:00 P.M. the DON/designee placed a housekeeping cart for use solely on the COVID-19 negative unit. · On 12/28/20 by 11:00 P.M. the DON/designee assessed all 25 current facility residents for signs/symptoms of COVID-19 with no new concerns identified. · On 12/28/20 by 11:00 P.M. the DON/designee ensured all eight staff members (the ED, RNs #105 and #112, LPN #120, STNAs #108, #109, #122, and #124) currently working in the facility had been properly screened for COVID-19. · On 12/28/20 by 11:00 P.M. the DON/designee ensured PPE including gloves, gowns, N95 masks, face shields, and hand sanitizer were readily available for staff use. PPE was placed at the facility entry, the non- COVID-19 unit entry, the COVID-19 unit entry, and on the COVID-19 unit. · On 12/28/20 by 11:00 P.M. DON/designee educated all 28 of 28 facility staff on the facility hand hygiene policy, the COVID-19 prevention and management policy including training on proper screening procedures prior to any staff member, contracted staff member, visitor of vendor entering the facility. Education was provided to all 28 staff on the proper donning and doffing of PPE when leaving COVID-19 positive unit, proper disposal of N95 mask after each single use and utilizing separate housekeeping carts for COVID-19 positive and COVID-19 negative units. · On 12/28/20 by 11:00 P.M. the DON/designee developed a par level of PPE to ensure adequate levels of PPE (gowns, gloves, eye protection, N95 masks and hand sanitizer) were available at all times. · On 12/28/20 by 11:00 P.M. the Regional Director of Clinical Services educated the DON and all 28 facility staff related to ensuring an adequate supply of PPE (gowns, gloves, eye protection, N95 masks and hand sanitizer) was readily available at all times. · On 12/28/20 a plan for the DON/Designee to observe the screening process at the facility entrance five times daily for 30 days to ensure proper screening occurs before staff or visitors enter facility was implemented. After 30 days additional audits would be completed at the discretion of the facility Quality Assurance (QA) committee. · On 12/28/20 a plan for the DON/designee to conduct rounds in the facility to observe that PPE (gowns, gloves, eye protection, N95 masks and hand sanitizer) was readily available five times daily was implemented. After 30 days additional audits would be completed at the discretion of the facility QA committee. · On 12/28/20 a plan for the DON/designee to observe hand hygiene of direct care staff five times daily for 30 days to ensure proper hand hygiene was implemented. After 30 days additional audits would be completed at the discretion of the facility QA committee. · On 12/28/20 a plan for the DON/designee to observe three staff members doffing PPE daily for 30 days to ensure proper disposal of N95 mask after each single use and proper disposal or sanitation of eyewear was implemented. After 30 days additional audits would be completed at the discretion of the facility QA committee. · On 12/29/20 a plan for the DON/designee to observe COVID-19 negative units and the COVID-19 positive unit daily for 30 days to ensure separate carts were used on COVID-19 positive and COVID-19 negative units was implemented. After 30 days additional audits would be completed at the discretion of the facility QA committee. · On 12/30/20 at 1:00 P.M. the DON/designee provided staff education to all 28 facility staff related to wearing a surgical mask over an N95 mask and disposing of the surgical mask between quarantined rooms and sanitizing eye protection between quarantined rooms. · On 12/30/20 a plan for the DON/designee to observe three staff members doffing PPE from quarantined rooms daily for 30 days to ensure proper application and discarding of surgical mask worn over N95 mask was implemented. After 30 days additional audits would be completed at the discretion of the facility QA committee. · On 12/30/20 a plan for the DON/designee to observe three staff members doffing PPE from quarantined rooms daily for 30 days to ensure proper sanitation of eye protection was implemented. After 30 days additional audits would be completed at the discretion of the facility QA committee. Although the Immediate Jeopardy was removed on 12/31/20, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of completing /conducting audits to ensure the effectiveness of the staff training and the new processes developed. Findings include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) memo QSO 20-20-ALL dated 03/20/20 revealed the Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of the CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of the Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations We expect facilities to use this new process, in conjunction with the latest guidance from CDC to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80 (a)(2)(i) and (ii)). Review of the facility COVID-19 tracking log revealed the following: On 11/16/20 the facility was notified their Chief Clinical Officer RN #113 had tested positive for COVID-19. The facility did not provide information as to when this employee had last been in the facility but indicated she was responsible for oversight at this facility as well as other facilities in the corporation. Contract tracing was completed and the facility determined there was no risk to the facility at that time. On 12/07/20, Licensed Practical Nurse (LPN) #123 tested positive for COVID-19 and the facility determined this LPN had not been with any residents for the previous 72 hours. The DON reported she notified the Local Health Department with each positive staff test and was informed they did not feel residents were at increased risk due to staff not having contact with residents within 72 hours of their positive test. In addition, the facility with communication from the local health department indicated no staff who had contact with these employees were required to quarantine as staff were wearing N95 masks at work. On 12/14/20 LPN #121 and STNAs #107, #108 and #141 tested positive for COVID-19. On 12/16/20 STNA #117 and STNA #143 tested positive for COVID-19. The DON reported the local health department was informed of each positive test and assisted with contact tracing. The DON revealed on 12/14/20 all facility residents were placed in quarantine and any resident or staff who had symptoms of COVID-19 were administered a rapid test. Residents with a positive COVID-19 tests were immediately moved to the COVID-19 unit. On 12/16/20 seven residents, Resident #3, #7, #21, #24, #25, #26 and #27 tested positive for COVID-19. On 12/21/20 13 residents, Resident #1, #2, #8, #9, #10, #11, #12, #13, #14, #16, #18, #19 and #23 tested positive for COVID-19. On 12/30/20 three residents, Resident #6, #15 and #17 tested positive for COVID-19 for a total of 23 of the facility 25 residents testing positive for COVID-19. As of 12/30/20 Resident #5 had refused COVID-19 testing and Resident #20 was negative for COVID-19. Of the residents who tested positive for COVID-19, Resident #14 required hospitalization and was admitted to the intensive care unit. As of 12/28/20 the facility was unable to provide any information as to how they believed the spread of COVID-19 occurred to the residents of the facility. The following infection control concerns were identified and verified during the COVID-19 Focused Infection Control Survey: 1. On 12/28/20 beginning at 9:36 A.M. a tour of the facility quarantine unit revealed four residents, Resident #6, #15, #17 and #20 were observed residing on the unit. Each resident had a physician order for [REDACTED]. A don/doff area located between the quarantine unit and the facility COVID-19 unit revealed there was no PPE, hand sanitizer, or trash receptacle available in this area. Interview with the DON at the time of the observation verified the above findings. At the time of the observation, the DON revealed an isolation cart with PPE had been in the don/doff area and she was not sure why it had been moved. The DON stated PPE should be available at the outside entry door to the unit for staff entering the unit and for staff working on the unit in addition to PPE being available on the unit itself for staff providing care to residents. The DON had no explanation why the PPE supplies were not available. On 12/28/20 at 10:45 A.M. STNA #122 was observed entering the facility quarantine unit from the COVID-19 unit through an area created by using two plastic walls from ceiling to floor. Upon entrance to the quarantine unit, STNA #122 was observed to change her isolation gown. However, she did not cleanse her goggles before entering the quarantine unit. In addition, there was no hand sanitizer available for the STNA to use after discarding the gown and gloves which she had worn on the COVID-19 unit before applying a clean gown and gloves on the quarantine unit. At the time of the observation, interview with STNA #122 confirmed her goggles were not cleansed and there was no means to sanitize her hands before entering the quarantine unit. Review of the facility policy titled Infection Control Measures During Infectious Disease Threat, dated 03/2020 revealed the facility would follow strict adherence to transmission-based precautions. Review of the facility policy titled Covid-19 Prevention and Management, dated 11/30/20 revealed adequate supply of PPE would be available to all staff and applicable to their duties and responsibilities. 2. On 12/28/20 beginning at 9:36 A.M. a tour of the facility quarantine unit revealed an area designated for the storage of staff N95 masks. However, this area was not currently being utilized for N95 storage. An interview with the DON at the time of the observation revealed on 12/21/20 the facility had to enlarge their COVID-19 unit and the area where the masks had been stored became part of the quarantine unit so staff were no longer leaving their masks in the storage area. The DON revealed at that time the facility did not provide an area where staff could properly store their N95 mask at the end of their shift. The DON revealed staff were taking their N95 masks home and would bring them back to work. During the interview the DON revealed the facility did not have a system in place to monitor how often the N95 mask was used by each staff member, how it was being stored or if it was being utilized outside of the facility. In addition, the DON was unable to provide information to ensure the appropriate rest times between usage or to ensure the N95 mask was not being used for more than five donning and doffing. On 12/28/20 at 11:20 A.M. interview with Kitchen Staff #127 revealed she took her N95 mask and goggles home with her at the end of her shift. Kitchen Staff #127 indicated she would take the mask and goggles off when in her car and leave them there until the next day she worked. Kitchen Staff #127 reported she would normally wear the same N95 and goggles for four to five days, unless they became visibly soiled and then she would obtain new supplies. On 12/28/20 at 11:25 A.M. during a follow up interview with the DON, the DON revealed some staff re-use their N95 masks and others do not. At the time of the interview, the DON revealed she was not aware how many staff took their N95 masks home, if the mask was stored in a paper bag, not worn for at least 72 hours between use or discarded after five uses. On 12/28/20 at 12:54 P.M. Business Office Manager (BOM) #115 was observed entering the facility with an N95 mask on. BOM #115 completed the self screening COVID-19 questionnaire and continued to her office without donning a new N95. Interview with BOM #115 revealed she had been to another facility and had the N95 from there and just continued to wear the same N95 mask at all the facilities she went to. On 12/29/20 at 5:58 A.M. interview with LPN #120 revealed she placed her N95 mask in a paper bag and took it home after her shift due to the facility not having a storage area for staff to properly store their N95 masks in the facility. When asked about N95 use, LPN #120 reported she did not let the N95 mask rest for at least 72 hours before re-using it. On 12/30/20 at 8:07 A.M. observation of the facility quarantine unit revealed no N95 masks were available for staff to use. At the time of the observation, the DON confirmed no N95 masks were in the box located at the entry to the quarantine unit. The DON reported she did not realize she had delivered an empty box of N95 masks when she delivered the PPE the earlier that morning. Review of the facility policy titled COVID-19 Prevention and Management, dated 11/30/20, revealed adequate supply of PPE would be available to all staff and applicable to their duties and responsibilities. Review of the CDC's Implementing Filtering Facepiece Respirator (FFR) Reuse, Including Reuse after Decontamination, When There Are Known Shortages of N95 respirators guidelines revealed NIOSH-certified N95 FFRs were designed to filter 95% of particles when appropriately filtered to the wearer's face. This means that an N95 that was not properly fit to the face would likely give the wearer less protection. N95 FFRs were designed to be single-use devices but may be used multiple times under crisis capacity strategies. N95 FFR performance would decrease as the number of hours and number of donning and doffing's increased. The number of times that an FFR could be reused would likely be limited by its fit because the tethering straps could become weaker or stretched after each donning. Each time an N95 FFR was donned or doffed, the integrity of the straps may be impacted. Repeated donning and doffing would result in the straps no longer being able to generate enough force to create a tight seal with the face. The resulting poor seal would allow unfiltered air to enter the N95 FFR and into the wearer's breathing zone. The CDC recommended limiting the number of donning for an N95 FFR to no more than five per device. If manufacturer guidance on how many times a particular FFR could be donned was not available, the CDC recommended limiting the number of uses to no more than five per device based on published data on changes in FFR fit from a limited number of FFR models over multiple donning. One strategy to reduce the risk of contact transfer of pathogens from the FFR to the wearer during FFR reuse was to issue five N95 FFRs to each healthcare staff member who cared for patients with suspected or confirmed COVID-19. The healthcare staff member could wear one N95 FFR each day and store it in a breathable paper bag at the end of each shift with a minimum of five days between each N95 FFR use, rotating the use each day between N95 FFRs. This would provide some time for pathogens on it to die off during storage. This strategy required a minimum of five N95 FFRs per staff member, if healthcare personnel don, doff, and store them properly each day. 3. On 12/28/20 at 11:30 A.M. the ED was observed leaving the COVID-19 unit through a donning/doffing area created with the use of two plastic barriers from ceiling to floor. The ED was observed exiting the COVID-19 unit, removed her gown and gloves in the doff area and then proceeded outside the donning/doffing area, touching the plastic, to obtain hand sanitizer to wash her hands. The ED then proceeded to the DON's office to obtain wipes to clean her face shield. On 12/28/20 at 11:31 A.M. interview with the ED verified hand sanitizer and sanitizing wipes for cleaning of eye protection were not readily available to be utilized inside the donning/doffing area by staff leaving the COVID-19 unit. On 12/28/20 at 11:55 A.M. Chief Clinical Officer, RN #113 confirmed no PPE or hand sanitizer was located at the entry of the COVID-19 unit for staff use. Review of the facility policy titled COVID-19 Prevention and Management, dated 11/30/20 revealed adequate supply of PPE would be available to all staff and applicable to their duties and responsibilities. Review of the facility undated policy titled Donning and Removing of PPE revealed staff would wash their hands with soap and water or alcohol based hand sanitizer immediately after removing all PPE. 4. On 12/28/20 at 12:00 P.M. interview with RN #105 revealed she exited outdoors from the COVID-19 unit, discarded her PPE, entered the quarantine unit from outdoors, obtained new PPE and provided care to the residents on the unit. RN #105 revealed she had just administered noon medications to residents on the quarantine unit. RN #105 stated she passed medication and completed treatments for residents on the quarantine unit and the COVID-19 unit. RN #105 stated she was able to administer morning medications to the quarantine residents before the COVID-19 positive residents, however she had obtained report from the night nurse on the COVID-19 unit. RN #105 stated she made at least five entries to the quarantine unit from the COVID-19 unit daily and was back and forth between the units throughout the day. On 12/28/20 at 12:03 P.M. interview with STNA #124 revealed she only used the side door to enter and exit the COVID-19 unit during her shift and disposed of her PPE when leaving the COVID-19 unit. However, there was no trash receptacle readily available for staff to dispose of soiled PPE in that area. On 12/28/20 at 12:03 P.M. interview with RN #113 and RN #105 revealed there was no trash receptacle or hand sanitizer available for staff to use when they removed PPE when exiting to the outside from the COVID-19 unit and no PPE or hand sanitizer available to apply when entering the unit. RN #113 confirmed no trash receptacle or hand sanitizer was available at the exit of the unit and was unsure where staff were discarding PPE when leaving the unit. RN #113 then obtained a trash can from Resident #25's room and stated it would be replaced shortly and obtained hand sanitizer from the nurse's station to place at the exit . On 12/28/20 at 1:45 P.M. during a follow up interview with RN #105, the RN revealed she now entered the COVID-19 unit using the main entry after leaving the non-COVID-19 unit. RN #105 was observed donning an isolation gown and sanitizing her hands. RN #105 reported the N95 mask and goggles were the same PPE she had on while on the COVID-19 unit and the quarantine unit. RN #105 reported she did not utilize a surgical mask over her N95 mask while caring for residents on the quarantine unit. RN #105 also indicated she did not clean her goggles during her shift but disposed of both her goggles and N95 mask at the end of her shift. On 12/28/20 at 1:47 P.M. during an interview with RN #113, the RN reported any staff member entering the quarantine unit should use a new N95 mask and new goggles/face shield or properly sanitize their existing goggles/face shield. On 12/30/20 at 8:13 A.M. interview with STNA #125 revealed she was working on the facility quarantine unit. During the interview, STNA #125 reported she cleaned her goggles at the end of her shift and discarded the N95 at that time. STNA #125 reported she did not wear a surgical mask over the N95 mask and did not clean her goggles between residents on the quarantine unit. On 12/30/20 at 8:20 A.M. interview with the DON revealed eye protection (goggles or face shields) should be cleaned between residents on the quarantine unit and a disposable mask should be worn over the N95 to protect residents on the quarantine unit from possible exposure to COVID-19. The surgical mask should be changed between residents. Review of the facility policy titled Isolation Precautions, dated 08/2019 revealed the facility would provide appropriate containers for placement of linens and trash and Isolation carts should be kept full of needed PPE. Review of the facility policy titled Hand Hygiene, dated 08/2019 revealed the sequence for putting on and taking off PPE included that staff should wash their hands on a regular basis, before and after the use of gloves, and when donning and doffing PPE. 5. On 12/28/20 at 12:27 P.M. Physical Therapy Assistant (PTA) #118 was observed entering the facility. Observation revealed PTA #118 did not complete the facility COVID-19 self screening process. PTA #118 was observed asking RN #112 where the location of the therapy room was because she had not worked at the facility for a long time. RN #112 did not inquire if PTA #118 had completed the COVID-19 screening and escorted PTA #118 to the therapy area and then returned to the DON office. On 12/28/20 at 12:41 P.M. RN# 113 was observed instructing PTA #118 to deliver therapy services to the residents on the quarantine unit first and then to the residents on the COVID-19 unit. Interview with PTA #118 at that time revealed she was getting ready to start therapy with residents. The PTA was asked if she had completed COVID-19 screening upon entry to the facility. PTA #118 replied she had not. RN #113 then confirmed PTA #118 was not included on the COVID-19 screening log for staff. Review of the facility policy titled COVID-19 Prevention and Management, dated 11/30/20, revealed all staff who enter the facility would complete the COVID-19 staff sign in and respiratory assessment. Review of CDC Preparing for COVID-19 in Nursing Homes, dated 11/20/20 revealed all health care providers should be screened at the beginning of their shift for any signs/symptoms, including fever, of COVID-19. 6. On 12/28/20 between 10:00 A.M. and 12:30 P.M. observations of the facility COVID-19 unit revealed Housekeeping Staff (HSK) #126 was cleaning on the COVID-19 unit utilizing supplies from a housekeeping cart. On 12/28/20 at 12:57 P.M. interview with HSK #126 revealed she normally would clean the COVID-19 unit and then go through the plastic area between the units and clean the facility quarantine unit. HSK #126 stated she had one cleaning cart which she used on both units and the cart was stored on the COVID-19 unit. On 12/28/20 at 12:59 P.M. interview with RN #113 revealed cleaning should occur on the quarantine unit first and then proceed to the COVID-19 unit. RN #113 confirmed cleaning supplies should not be shared between the two units and staff were always to move from a clean area to a dirty area. On 12/30/20 at 8:15 A.M. Housekeeper (HSK) #126 was observed exiting Resident #17's room. HSK #126 then moved cleaning supplies to Resident #15's room, put on clean gloves and entered the room to start cleaning. At the time of the observation, interview with HSK #126 confirmed she did not change her isolation gown, clean her goggles or put a surgical mask over her N95 mask. HSK #126 reported had been inserviced on hand washing and changing PPE when leaving the unit, however she stated she had not been trained on changing gowns, cleaning goggles or applying a surgical mask over an N95 mask while working between rooms on the facility quarantine unit. On 12/30/20 at 8:20 A.M. interview with the DON revealed eye protection (goggles or face shields) should be cleaned between residents on the quarantine unit and a disposable mask should be worn over the N95 mask to protect residents on the quarantine unit from possible exposure to COVID-19. The DON stated gowns were to be changed between each resident room entered on the quarantine unit. Review of the CDC guidelines Sparkling Surfaces: Stop COVID-19's Spread indicated [MEDICAL CONDITION] that causes COVID-19 can be spread by indirect contact with contaminated surfaces. Surfaces that are touched frequently increase the chance that germs could be spread to residents and staff. Surfaces which look clean could have pathogens present. The coronavirus causing COVID-19 has been shown to survive on surfaces from several hours to days. 7. On 12/30/20 at 7:55 A.M. STNA #121 was observed inside the facility without wearing any type of mask. STNA #121 was observed entering the kitchen hallway, returned to the entry area and gave a paper to the DON. STNA #121 was then observed talking with staff who were completing their COVID-19 screening and obtaining PPE. On 12/30/20 at 7:58 A.M. during an interview with the DON, she reported STNA #121 had worked night shift and was leaving to go home. The DON confirmed STNA #121 did not have a mask on while inside the facility. Review of the facility policy titled COVID-19 Prevention and Management, dated 11/30/20 indicated employees would don a face mask before entering the facility and wear a face mask while they are in the facility. Review of the CDC Guidelines Preparing for COVID-19 in Nursing Homes, dated 11/20/20 revealed all health care providers would be screened upon entry to the facility.

Based on observation, record review, resident and staff interview and facility policy and procedure review the facility failed to implement an effective and individualized pain management program to manage Resident #20's right knee pain. This affected one resident (#20) of three residents reviewed for pain. Actual Harm occurred on 10/19/20 when staff failed to administer two routine doses of Resident #20's scheduled [MEDICATION NAME] (a narcotic [MEDICATION NAME] used to control pain) resulting in the resident experiencing excruciating pain affecting his activities of daily living including consuming his lunch meal due to the significant amount of pain he was experiencing. Findings Include: Review of Resident #20's medical record revealed an admission date of [DATE] with the admitting [DIAGNOSES REDACTED]. Review of Resident #20's plan of care, dated 07/24/20 revealed the resident was at risk for pain related to right knee total arthroplasty revision (knee replacement). Interventions included to administer medications as ordered and ask the resident if he was having pain. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/09/20 revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The MDS assessment revealed the resident received, scheduled, as needed pain medications and non-pharmacological interventions for pain. The resident reported he had pain frequently and rated the pain an eight out of ten on a pain scale of one to ten with ten being the worst pain, but the pain had not interfered with sleep or his day to day activities. Review of the pain assessment, dated 10/14/20 revealed Resident #20 had pain frequently in the past five days. The resident rated the pain a three out of 10 on the standard pain scale. The assessment revealed the resident received [MEDICATION NAME] 10 milligrams (mg) by mouth every four hours around the clock (scheduled) for the pain. On 10/19/20 at 1:00 P.M. during an interview with Resident #20, the resident voiced concerns that he had not yet received his morning medications (8:00 A.M.), which included a dose of pain medication. The resident proceeded to then share that he had actually missed the last two doses of his scheduled pain medication (8:00 A.M. and 12:00 P.M.) and was in excruciating pain which had prevented him from eating his lunch because he was in so much pain. The resident then asked the surveyor for assistance with getting his pain medication and again said he couldn't eat lunch because his pain was so bad. On 10/19/20 at 1:15 P.M. interview with Registered Nurse (RN) #134 verified Resident #20 had not yet received his 8:00 A.M. or 12:00 P.M. medications on this date, including his scheduled [MEDICATION NAME] 10 mg. RN #134 verified the pain medication was ordered every four hours and had been scheduled for 8:00 A.M. and 12:00 P.M. On 10/19/20 at 1:35 P.M. RN #134 was observed administering Resident #20's scheduled 8:00 A.M. medications. At the time of the administration, Resident #20 reported his pain was rated an eight out of a 10 on the standard pain scale. State tested Nursing Assistant (STNA) #111 entered the resident's room while the nurse was preparing the resident's medication outside the resident's door to collect his lunch tray. The resident had not eaten his lunch. The STNA asked the resident if he was going to eat and he stated, no, I hurt to bad. The STNA offered the resident an alternate meal but the resident declined stating I am just in too much pain. Further observation revealed the resident's 8:00 A.M. [MEDICATION NAME] had not been signed out as given and the narcotic count was correct. At the time of the observation RN #134 documented she administered the [MEDICATION NAME] at 12:00 P.M. instead of 1:35 P.M. the actual time of the administration and to match the narcotic count sheet. On 10/19/20 at 1:40 P.M. RN #134 was observed completing the documentation of the above medication administration. The RN documented administration of the morning medications and recorded the resident's pain level at 8:00 A.M. as zero (0) no pain. The nurse left the 8:00 A.M. [MEDICATION NAME] medication administration section blank and signed her initials to the 12:00 P.M. [MEDICATION NAME] administration. On 10/19/20 at 1:42 P.M. interview with RN #134 verified she had not given the resident his morning pain medication, [MEDICATION NAME] at 8:00 A.M. or assessed the resident for pain at 8:00 A.M. She also verified she had not given his 12:00 P.M. dose of [MEDICATION NAME] until 1:35 P.M. which fell outside of the allotted hour before and hour after timeframe the medication must be administered. On 10/19/20 at 1:50 P.M. interview with RN Supervisor #117 revealed she had been unaware that RN #134 was administering medications due at 8:00 A.M. at 1:35 P.M. and unaware Resident #20 had not received his 8:00 A.M. or 12:00 P.M. scheduled pain medication of [MEDICATION NAME] 10 mg. Review of Resident #20's progress note, dated 10/19/20 at 3:25 P.M. and authored by Corporate Registered Nurse (CRN) #135 revealed the resident had unrelieved right knee pain. The Nurse Practitioner was notified, and a new order was obtained for [MEDICATION NAME] as needed. The entry documented the resident was given a dose of the as needed [MEDICATION NAME]. Review of the facility Medication Administration policy and procedure, dated 01/2018 revealed medications were to be administered as prescribed in accordance with good nursing principles and practices. Medications were to be administered within 60 minutes of the scheduled time. This deficiency substantiates Complaint Number OH 091.

Based on medical record review, observations, and staff interview, the facility failed to ensure one resident (Resident #9) with a pressure ulcer received the necessary treatment and services to promote healing. This affected one of two residents identified with pressure ulcers. This resulted in actual harm to Resident #9 when a suspected deep tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to the left heel declined to an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). In addition Resident #9 developed a new suspected deep tissue injury on the right heel. Findings include: Review of the medical record for Resident #9 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a Minimum Data Set 3.0 assessment completed 09/20/18 revealed the resident had memory problems, was totally dependent upon staff for bed mobility, transfer, locomotion, toileting, and personal hygiene, and had two unstageable pressure ulcers that were suspected deep tissue injuries. Review of the admission skin assessment on 09/17/18 revealed the resident had pressure ulcers present on admission. It stated there was a blister on the left heel which had no measurements or description but was staged as a suspected deep tissue injury. It also stated there was a pressure ulcer on the left heel which had no measurements or description but was staged as a suspected deep tissue injury. Review of the plan of care revealed Resident #9 was at risk for impaired skin integrity related to fragile skin, impaired mobility, incontinence, poor nutrition, resisting care, and behaviors of picking at skin. It stated the resident had an unstageable pressure ulcer of the left heel. Interventions included elevate heels as tolerated, pressure reduction devices if ordered, and turn and reposition as ordered. (There was no evidence in the nurses progress notes the resident resisted any care related to the pressure ulcers). A skin grid completed on 09/19/18 indicated Resident #9 had a clear, fluid filled blister on the left heel measuring 3.0 centimeters (cm) long by 3.5 cm wide which was staged as a suspected deep tissue injury. A second skin grid indicated the resident had a pressure ulcer on the left heel measuring 3.0 cm long by 3.0 cm wide which was a dark purple, suspected deep tissue injury. There was no evidence of any treatment implemented for the pressure ulcers until 09/19/18 (2 days after admission) at which time physician's orders were obtained for skin prep to both heels twice per day, turn and reposition every two hours, and elevate heels in bed. Review of a skin grid dated 09/25/18 revealed Resident #9 had a 3.0 cm long by 3.5 cm wide ruptured blister with skin flap over blister on the left heel. The color was white/pink and it was staged as a suspected deep tissue injury. There was no further skin grid or measurements for the second area on the left heel previously identified on 09/19/18. On 09/25/18 physician's orders were obtained to discontinue the skin prep for the left heel. The left heel was to be cleansed with wound cleanser, pat dry, apply calcium alginate, and cover with a dressing daily. Review of a skin grid dated 10/02/18, but signed by Licensed Practical Nurse (LPN) #52 on 10/10/18, revealed Resident #9 had a 3.0 cm long by 3.5 cm wide ruptured blister with skin flap over blister on the left heel. The color was white/pink and it was staged as a suspected deep tissue injury. There was no further skin grid or measurements for the second area on the left heel previously identified on 09/19/18. On 10/08/18 a physician's order was obtained to discontinue the calcium alginate treatment to the left heel. The new order was to cleanse with normal saline, cover with duoderm and change every seven days. Interview with LPN #52 on 10/11/18 at 12:15 P.M. revealed he did not know if he looked at Resident #9's pressure ulcer on 10/02/18 but confirmed he signed the skin grid on 10/10/18. He stated on 10/10/18 the resident only had one area on the left heel. Observations on 10/09/18 at 12:44 P.M. revealed Resident #9 was in bed and staff was feeding her lunch. The resident's heels were resting on a pillow (heels not floated). On 10/09/18 at 2:53 P.M. the resident was again observed in bed with her heels resting on a pillow (heels not floated). On 10/10/18 at 4:55 P.M. the resident was observed up in a reclined geri chair in the lounge. The resident had socks on her feet and both heels were resting on the foot rest of the chair. On 10/10/18 at 5:30 P.M. the resident was up in a reclined geri chair in the dining room. Staff were feeding her supper. The resident had socks on her feet and both heels were resting on the foot rest of the chair. Observations on 10/11/18 at 9:40 A.M. revealed Resident #9 had a 0.5 cm in diameter light brown scabbed area on the right heel. The left heel was observed to have a 7.0 cm long by 6.5 cm wide open area on the heel. The open area had a red wound bed and had loose, black, necrotic skin partially covering the open area. The ulcer also had some intact black necrotic skin at the base of the open wound. The observations were confirmed by the Director of Nursing (DON) at that time. She further confirmed the pressure ulcer on the left heel was now an unstageable pressure ulcer. Review of a skin grid completed by the DON on 10/11/18 revealed Resident #9 had a 6.5 cm long by 7.0 cm wide ruptured blister on the left heel with a skin flap over the blister, moderate amounts of serous drainage, reddish purple in color. It indicated the wound was unchanged. A second weekly skin assessment completed by the DON on 10/11/18 indicated Resident #9 had an unstageable area to the left heel and a new suspected deep tissue injury at the right heel (no measurement was included). Interview with the DON on 10/11/18 at 9:30 A.M. and 10:50 A.M. confirmed Resident #9's pressure ulcers on the left heel were not measured upon admission and there were no physician's orders obtained to treat the areas until 09/19/18. The DON further stated the facility had been tossing around the idea of getting some type of heel elevator boots for the resident as it was difficult to keep her heels elevated. At 11:15 A.M. the DON confirmed there was no evidence Resident #9 had a pressure area on the right heel prior to 10/11/18. On 10/11/18 at 12:15 P.M. the DON confirmed that, although the resident was observed to have black, necrotic tissue on the left heel, the skin grid she completed on 10/11/18 did not indicate that. This deficiency substantiates Master Complaint Number OH 452.

Based on medical record review, observations, and staff interview, the facility failed to ensure a resident who was unable to carry out their own personal hygiene and was incontinent of bowel and bladder received adequate incontinence care to prevent moisture associated skin damage. This affected one of eight sampled residents (Resident #12). This resulted in harm to Resident #12 who developed open areas on the buttocks caused from moisture from being incontinent of bladder and bowel. Findings include: Review of the medical record for Resident #12 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a Minimum Data Set 3.0 (MDS) assessment completed 09/29/18 revealed the resident had memory problems. The MDS indicated the resident required extensive assistance from two staff with bed mobility, transfer, walking, dressing, and personal hygiene. Resident #12 was totally dependent upon two staff for toileting and bathing. The MDS indicated the resident was always incontinent of bowel and bladder. A care plan dated 02/28/16 documented the resident was occasionally incontinent of bowel and bladder. The goal was for Resident #12 to be clean, dry, and odor free. The care plan indicated to provide incontinence care as needed. On 10/09/18 a care plan was added indicating Resident #12 had bowel incontinence. The intervention was to check the resident every two hours, assist with toileting as needed, and provide pericare after each incontinent episode. Review of a weekly skin assessment dated [DATE] revealed Resident #12 was assessed with [REDACTED]. The note indicated preventative skin care and new treatments were ordered. Review of a nurses' progress notes and physician's orders [REDACTED]. Review of a wound care progress note on 08/17/18 revealed Resident #12 was seen by the wound care nurse practitioner who documented the resident had generalized blanchable redness to the coccyx. It was recommended to keep the area clean and dry and apply zinc oxide cream daily and as needed. A physician's orders [REDACTED]. Review of weekly skin assessments dated 09/06/18 and 09/19/18 revealed Resident #12 was assessed with [REDACTED]. Review of a weekly skin assessment dated [DATE] revealed Resident #12 had excoriation noted at bilateral buttocks and blanchable redness. Observations on 10/10/18 at 2:25 P.M. of Resident #12's buttocks revealed he was incontinent of bowel and his incontinence brief was saturated with dark urine. He was observed to have multiple small scattered open areas on the right buttock. He was observed to have a fifty cent piece size open area on the inner right buttock where the top layer of skin was gone. Interview with Registered Nurse (RN) #56, at the time of the observation, revealed the open areas were caused by moisture. RN #56 stated the resident was to be provided with incontinence care every two hours. Interview with State tested Nursing Assistant (STNA) #57 on 10/10/18 at 2:25 P.M., at the time of the observation, revealed Resident #12 had not been provided with incontinence care since 11:30 A.M. (approximately 3 hours earlier). Interview with STNA #59 on 10/10/18 at 2:30 P.M. revealed she did not feel Resident #12 was checked often enough for incontinence. This deficiency substantiates Complaint Number OH 452, OH 435, and OH 288.

Based on observation, medical record review, and staff interview the facility failed to ensure residents who can self-feed and ambulate with limited assistance received the services necessary to maintain their highest level of independence. Actual harm occurred to Resident #24 when no ambulation program was implemented and the resident's ability to ambulate declined from supervision to extensive assistance. In addition, Resident #11 ability to self-feed was not maintained as staff fed the resident. This affected two of two sampled residents reviewed for activities of daily living. The facility census was 24. Findings include: 1. Review of Resident #24's medical record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #24's admission Minimum Data Set ((MDS) dated [DATE] revealed she had short and long-term memory impairment, no recall, and modified independence for decision making. Resident #24 did not reject care and wandered daily. She required limited assistance of one person, to walk in room, corridor, for locomotion on and off the unit, she used a walker and a wheel chair for mobility. A bed and chair alarm was used daily. Resident #24 started on physical therapy on 10/20/17 due to a fall. Review of physical therapy discharge summary dated 11/10/17 revealed the resident required contact guard assistance for ambulation. At the time of discharge the staff were educated to maintain the residents current level of ambulation. Review of Resident #24's plan of care revealed no plan to maintain Resident #24's ambulation at a limited assistance of one staff. Review of Resident #24's quarterly Minimum Data Set ((MDS) dated [DATE] revealed she had short and long-term memory impairment, no recall, and modified independence for decision making. Resident #24 did not reject care and wandered daily. She required extensive assistance of one person, to walk in room and corridor and for locomotion on and off the unit, she required supervision with set up help to eat, she used a walker and a wheel chair for mobility. A trunk restraint was used daily and bed and chair alarm was used daily. Observation of Resident #24 on 01/23/18 at 9:38 A.M. revealed she was seated in a wheel chair with a pressure alarm and a seat belt on. Interview of Registered Nurse (RN) #125 RN on 01/26/18 at 11:13 A.M. revealed Resident #24 had a bed and chair alarm. RN #125 stated the seatbelt was on all the time. RN #125 stated they could not let Resident #24 walk because she went into other residents' room. Interview with Therapy Director # 200 on 01/26/18 at 1:57 P.M. revealed when Resident #24 was discharged from physical therapy on 11/10/17 she was contact guard with walking When therapy picked her up on 01/11/18 Resident #24 required hand-held assistance of two staff to walk. Interview with State tested Nursing Assistant (STNA) #109 on 01/26/18 at 3:10 P.M. revealed she was not aware Resident #24 was supposed to be walked by staff. She stated she did not know about the walk to dine program. Interview with STNA #117 on 01/26/18 at 3:30 P.M. revealed sometimes they walked Resident #24 but it took two aides because one had to hold her hand and use a gait belt and another STNA pushed a wheel chair behind her. We do not always have enough staff to do that. Interview with the DON on 01/29/18 at 1:50 P.M. confirmed no plan to walk Resident #24 was developed. 2. Resident # 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 completed on 11/10/17 indicated Resident #11 had a Brief Interview of Mental Status (BIMS) score of three indicating severe cognitive impairment. Resident #11 was identified as requiring extensive assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. Review of Resident #11's occupational therapy progress notes dated 10/12/17 indicated Resident #11 had a goal of feeding self 50% of meals with moderate/maximum assistance. Review of Resident #11's physician orders [REDACTED]. Review of Resident #11 Plan of Care indicated the resident was to receive assistance as necessary and sandwiches were to be cut in quarters. Observation of Resident #11 on 01/23/18 at 12:28 P.M. revealed STNA # 136 assisting the resident with his meal. Resident #11 was not afforded the opportunity to assist with his meal as the plate was kept out of his reach. On 01/23/18 at 1:06 P.M. STNA # 136 reported Resident #11 could assist with his meals, however she was the only person in the dining room today and she just fed Resident #11 his meal. STNA # 136 reported Resident #11 often sits at another table, however since she decided to feed him today, he was at the half round table. During the evening meal on 01/23/18 at 5:42 P.M. Resident #11 was being fed vegetable soup by STNA # 136. The DON reported on 01/23/18 at 5:52 P.M. Resident #11 was able to feed himself normally with verbal cuing however he does best with finger foods. When asked if Resident #11 was provided finger foods with his meal, she stated no and had no explanation why he did not receive finger foods. The DON stated Resident #11 should have been able to feed himself the noon meal and she had no explanation why he was fed by staff.

Based on observation, medical record review, and staff interview the facility failed to ensure residents were free from the use of a physical restraint; (seat belt) utilized for staff convenience to restrict movement and not required to treat a medical symptom. This affected two of three sampled residents reviewed for restraint use (Residents #24 and #11). The facility identified one resident as using physical restraints. Actual harm occurred to Resident #24 when the ability to ambulate declined related to the resident's restraint use. In addition, Resident #24 displayed increased agitation to the sound of a pressure alarm as evidenced by the resident becoming tearful during the sounding of the alarm. Findings include: 1. Review of Resident #24's medical record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #24's admission Minimum Data Set (MDS) 3.0 dated 10/16/17 revealed she had short and long-term memory impairment, no recall, and modified independence for decision making. Resident #24 had hallucinations, and delusions, physical aggression directed toward others occurred one to three days in the assessment period, verbal behaviors directed toward others that occurred one to three days, and other behaviors not directed toward others occurred daily. Resident #24 did not reject care and wandered daily. Resident #24 required extensive assistance of two person to transfer. She required limited assistance of one person, to walk in room, corridor, for locomotion on and off the unit, and she required supervision with set up help to eat. She used a walker and a wheel chair for mobility. A bed and chair alarm were used daily. Review of Resident #24's plan of care revealed the resident used a seat belt as a restraint. The plan of care called for the device to be reduced every quarter and as needed. Review of progress notes revealed on 10/16/17 a bed and a chair alarm was implemented. On 10/22/17 a pommel cushion was added to Resident #24's wheelchair to prevent her from sliding out of the chair. On 10/26/17 Resident #24 attempted to self-transfer and ambulate. Due to the resident's fall history (two falls without injury) poor gait and balance, and risk for falls with injury a lap tray for the wheel chair was ordered. On 11/07/17 the pommel cushion was discontinued. Physical restraint assessment dated [DATE] revealed the lap tray was added to promote independence and safety while allowing the resident to remain social. Review of physical therapy discharge summary dated 11/10/17 revealed the resident required contact guard assistance with ambulation. Review of progress notes dated 01/22/18 revealed a seat belt to the wheel chair was ordered. Review of the 01/22/18 restraint assessment revealed a seat belt restraint was used due to Alzheimer's and risk of falls with injury. The assessment also stated the seat belt enabled Resident #24 to be social and allow for independent mobility while remaining safe as redirection was unsuccessful. Observation of Resident #24 on 01/23/18 at 9:38 A.M. revealed she was seated in a wheel chair with a pressure alarm and a seat belt on. At 11:33 A.M. the resident was observed in the dining room with the alarm and seat belt on during the lunch meal. Observation on 01/24/18 at 7:20 A.M. revealed she was in the hall in her wheel chair with the seat belt unbuckled and the alarm was beeping. Interview of State tested Nurse Aide (STNA) #120 on 01/24/18 at 7:35 A.M. revealed she did not know why the alarm was beeping. Licensed Practical Nurse (LPN) #123 stated the alarm was beeping due to a low battery. LPN #123 wiggled the alarm box, the alarm sounded; Resident #24 put her hands over her ears and became tearful. STNA #120 confirmed the sounding of the alarm agitated Resident #24. On 01/24/18 at 10:29 A.M. Resident #24 was observed in a common area seated in a wheel chair the seat belt and alarm was applied. Observation of Resident #24 at 2:33 P.M. revealed she was asleep on the sofa in common area, the pressure alarm under bottom and feet. Interview with STNA #124 on 01/24/18 2:34 P.M. revealed Resident #24 beat the alarm box up. STNA #124 stated every time the alarm went off Resident #24 would throw it. On 01/25/18 at 7:45 A.M. Resident #24 was observed in her room, the door was closed, she was seated in a wheel chair, the alarm was applied; however, the seat belt was not applied. Interview with STNA #131 on 01/26/18 at 10:42 A.M. revealed the resident used alarms in bed and in the wheel chair. She stated the resident did not have a restraint. STNA #131 stated the resident would wander in and out of residents' rooms. Interview with Registered Nurse (RN) #125 on 01/26/18 at 11:13 A.M. revealed Resident #24 had a bed and chair alarm. She stated the resident had a seat belt when in the wheel chair. RN #125 stated the resident had the seat belt on all the time. She stated Resident #24 had used a lap tray before the seat belt, but the resident ripped the Velcro off it. RN #125 stated they could not let Resident #24 walk because she went into other resident rooms. Interview with the Director of Nursing (DON) on 01/26/18 at 1:46 P.M. revealed the seat belt was used because Resident #24 destroyed the lap tray. The DON stated the seat belt was a restraint and she used it because it was on the wheel chair. The DON stated the resident had two falls in October, 2017 but she had no more falls because they restrained her. The DON revealed the pommel cushion was discontinued because Resident #24's feet did not touch the floor and she could not move her wheel chair independently. Interview with Therapy Director #200 on 01/26/18 at 1:57 P.M. revealed when Resident #24 was discharged from physical therapy on 11/10/17 she was contact guard assistance with walking. Therapy Director #200 stated when Resident #24 was discharged from therapy staff were educated to walk her to the dining room to maintain her ambulation. When therapy started working with the resident again on 01/11/18 Resident #24 required hand-held assistance of two staff to walk This was confirmed as a decline in function. 2. Record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 completed 11/10/17 indicated Resident #11 had severe cognitive impairment. Resident #11 was identified as requiring extensive assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. Review of the physician orders [REDACTED]. A restraint enable tree assessment completed by the facility on 11/23/17 identified the use of side rails for positioning. On 01/04/18 a restraint enabler decision tree identified the use of a lap buddy to enable resident to be safe and independent in wheelchair while increasing socialization due to inability to control thrusting in chair and loss of safety awareness. No other restraint enabler decision trees were available for review. During an interview on 01/25/18 at 6:18 P.M. the Administrator confirmed Resident #11 had a seat belt on and reported the seat belt was part of the specialized wheelchair for Resident #11. On 01/26/18 at 8:10 A.M. during interview, RN #125 stated Resident #11 had a specialized wheelchair and that was the reason for the seatbelt. RN #125 reported she was not sure if all specialized wheelchairs had seatbelts, however since the belt was present, they always fastened the belt. On 01/26/18 at 9:06 A.M. during an interview with the DON she reported Resident #11 had the self releasing seat belt, however she was unable to provide an assessment of the seatbelt, the resident's ability to release the seatbelt, or a physician order [REDACTED].>

Based on record review and interview, the facility failed to ensure Resident #5 received an ordered narcotic [MEDICATION NAME] for pain as requested. Actual harm occurred when Resident #5 did not receive ordered pain medication resulting in increased pain described by the resident as throbbing to his legs. This affected one resident (Resident #5) of four residents reviewed for pain medication administration. Findings Include: Record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/20/16 revealed the resident was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive development. The MDS revealed Resident #5 was on a scheduled pain medication regimen and received pain medication as needed. Review of the pain assessment, dated 01/20/16 revealed Resident #5 complained of pain stating it was frequent, his day to day activities were affected by his pain and rated his pain as an eight on a scale of one to ten (with 10 being the worst pain). Review of the current physician orders [REDACTED]. On 03/23/16 at 2:38 P.M., interview with Resident #5 revealed he went to the wound clinic for treatment of [REDACTED]. When asked about pain, the resident indicated he did have pain in his legs and required the use of pain medication. When asked if his pain medications were effective in relieving his pain, he stated the medication was working now that he was getting his medication like the doctor ordered. Further interview revealed Resident #5 stated he had noticed his pain was not being relieved as well when one nurse particular nurse was on duty. The resident stated on one particular weekend when he was given his pain medication by this particular nurse (identified as Licensed practical nurse (LPN) #24) he had no relief from his pain at all. Continued interview revealed Resident #5 stated the next time LPN #24 brought his medication on this weekend, he put his glasses on so he could see his pills. Resident #5 stated he normally took a pain pill that was yellow and oblong, [MEDICATION NAME], for pain and the pill LPN #24 gave him was white and round. Resident #5 reported that when he questioned the nurse, she stated it was the same medicine, just a different pill was sent from the pharmacy. The resident stated he didn't believe this because after taking the medication that LPN #24 gave him his legs just kept throbbing. Resident #5 indicated this had occurred on the weekend, not too long ago and that he reported the incident to the director of nursing (DON) on the following Monday. Resident #5 stated he was aware the nurse that gave him the different medication was no longer working at the facility. When asked if Resident #5 could recall when his pain medication did not provide him with relief, he indicated he could not recall the exact date, but indicated the DON would know because it would correlate with the time period he reported it. Review of the Medication Administration Record (MAR) and pain flow sheet for Resident #5 from January through March, 2016 revealed Resident #5 routinely requested his as needed [MEDICATION NAME] 10 mg tablet for complaint of pain to the lower extremities with good results. Review of the MAR for March, 2016 revealed LPN #24 documented she had administered the pain medication one time on 03/03/16, two times on 03/04/16 and four times on 03/05/16. LPN #24 documented on the MAR that the pain medication was effective. During an interview with the Administrator and DON on 03/23/16 at 4:40 P.M., the DON stated the facility was unable to determine what the white pill medication LPN #24 may have given Resident #5 during the day in question. The DON stated that anything further on his part would be pure speculation. The DON stated on 03/07/16 when he arrived at the facility, Resident #5 reported to him his pain medication did not look the same as the medication he had been taking when administered by LPN #24 and he reported he did not have any relief from the medication LPN #24 had given him during the previous weekend. The DON stated Resident #5 stated his legs continued to hurt even when he was in bed and that was the reason he had questioned LPN #24 about the medication as the medication normally was effective in controlling his pain. The DON stated he immediately interviewed LPN #24 and then both LPN #17 and LPN #24 were taken for a drug test/screen. The DON stated LPN # 24 was immediately placed on administrative leave, and the facility began reviewing all residents MAR records and comparing the MAR with the narcotic records. LPN #24 was subsequently terminated on 03/07/16 due to misappropriation of resident ' s medication This deficiency substantiates Self Reported Incident Control Number OH 055.

Based on observation, medical record review, interview with Respiratory Therapist (RT) #30, interview with facility nursing staff and review of the facility respiratory policy and procedure the facility failed to ensure adequate [MEDICAL CONDITION] care and services were provided to one resident, Resident #15, with a newly placed [MEDICAL CONDITION] to ensure a patent airway. The facility also failed to provide staff education on [MEDICAL CONDITION] care, ensure supplies were readily available for use and monitor the resident to prevent the resident from removing her [MEDICAL CONDITION] (trach) tube on two separate occasions. Both occasions required hospitalization . This resulted in Immediate Jeopardy for one (Resident #15) of one resident reviewed for [MEDICAL CONDITION] care and services who sustained actual harm on 11/14/15 when the resident was found with her [MEDICAL CONDITION] pulled out resulting in a decreased oxygen saturation level. The resident was subsequently admitted to the hospital intensive care unit, placed on a ventilator and diagnosed with [REDACTED]. The facility identified Resident #15 as the only resident with a [MEDICAL CONDITION]. On 12/16/15 at 12:15 P.M. Administrator #24, Administrator #29 and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 11/14/15 at approximately 2:15 A.M. when Resident #15 was found with her [MEDICAL CONDITION] pulled out. The resident ' s oxygen saturation level was assessed as 66%. There was no evidence facility staff attempted to maintain the airway or provide supplemental oxygen until emergency medical service (EMS) personnel arrived onsite. EMS intubated Resident #15 and provided mechanical ventilation. The resident was hospitalized from [DATE] through 11/19/15 with the [DIAGNOSES REDACTED]. The Immediate Jeopardy continued on 12/02/15 when the resident was again found with her [MEDICAL CONDITION] out, was transferred to the hospital and remained hospitalized from [DATE] through 12/04/15 with the [DIAGNOSES REDACTED]. The Immediate Jeopardy remained on-going when interviews conducted from 12/14/15 through 12/16/15 with two Registered Nurses (RNs), two Licensed Practical Nurses (LPNs) and six State tested Nursing Assistants (STNAs) revealed a lack of knowledge of how to care for Resident #15 ' s [MEDICAL CONDITION] and where to obtain [MEDICAL CONDITION] and emergency medical supplies. Interview with the DON on 12/14/15 at 2:30 P.M. verified no formal education related to the care of Resident #15 ' s newly placed [MEDICAL CONDITION] had been completed on or after the resident was re-admitted to the facility on [DATE]. Observations made on 12/16/15 revealed the facility did not have adequate supplies or equipment to care for the [MEDICAL CONDITION]. The recommended and expected equipment the facility should have had, per interview with Contracted RT #30 on 12/17/15 at 9:50 A.M. at resident ' s bedside included additional [MEDICAL CONDITION] including a Shiley #4 and Shiley #6, a suction machine, an ambu bag for emergency situations, a 50 PSI air compressor, oxygen concentrator and a cool [MEDICAL CONDITION] circuit. This recommendation differed from the physician orders [REDACTED]. Additionally, although Resident #15 did not have a written physician order [REDACTED]. As of 12/16/15, the resident had not been evaluated at the facility by a respiratory therapist. The Immediate Jeopardy was removed on 12/17/15 when the facility implemented the following corrective actions: · On 12/16/15 at 12:20 P.M., the DON notified the contracted RT of Resident #15 ' [MEDICAL CONDITION] the need for education for the nursing staff. The facility scheduled the education to take place on 12/17/15 at 10:00 A.M. by the contracted RT. · On 12/16/15 at 12:30 P.M., the DON ordered extra oxygen [MEDICAL CONDITION] consisting of two Shiley #6, two Shiley #4, two #4 inner cannulas and an unspecified number [MEDICAL CONDITION] and suction catheters. · On 12/16/15 at 1:48 P.M., the DON made arrangements with a sister facility to transfer Resident #15 to in order to provide care temporarily until the facility was able to complete nursing staff education and obtain the required supplies to care for the resident ' s trach. · On 12/16/15 at 4:30 P.M., Resident #15 was transferred out of the facility to a sister facility. · On 12/17/15 at 10:00 A.M., the facility held a formal education for the nursing staff, conducted by RT #30 covering the following topics: cool [MEDICAL CONDITION] with or without oxygen, how to set up air compressor and concentrator to meet physician's order [REDACTED]. care,[MEDICAL CONDITIONS] and communicating with the resident during the procedures. Training was also provided related to the Respiratory Therapy Policy and Procedure. A sign in sheet for the training revealed four RNs, two LPNs and seven STNAs received the training. Eleven nursing staff, including three LPNs and nine STNAs were not present for the training on 12/17/15. · On 12/17/15 at 11:00 A.M., contracted RT #30 set up the oxygen [MEDICAL CONDITION] in Resident #15 ' s room which consisted of a 50 PSI air compressor, oxygen concentrator, and cool [MEDICAL CONDITION] circuit to be used upon the resident ' s re-admission to the facility. As of 12/17/15 there was no date set as to when Resident #15 would be readmitted . · On 12/17/15 at 11:30 A.M., the facility implemented a new Respiratory Therapy Policy and Procedure Manual that was provided by RT #30 on 12/17/15. This manual was reviewed with nursing staff during the training provided by RT #30. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of implementing on-going monitoring of the corrective measures, implementing an audit system and not all staff had been trained on the care of a [MEDICAL CONDITION] or the new Respiratory Therapy Policy and Procedure. Findings Include: Review of Resident #15's medical record revealed an original admission date of [DATE] with admitting [DIAGNOSES REDACTED]. Record review revealed on 11/12/15 the resident was readmitted to the facility following a hospitalization . The resident was readmitted with a newly placed [MEDICAL CONDITION]. Review of the resident's progress notes revealed during the resident's hospitalized from [DATE] to 11/12/15 a [MEDICAL CONDITION] was placed for chronic [MEDICAL CONDITION]. Review of the five day Minimum data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #15 had unclear speech, usually made her needs known, usually made herself understood, and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 02. The MDS indicated Resident #15 required extensive assistance from staff for all activities of daily living (ADL ' s). The MDS reflected the facility provided the services of oxygen therapy, suctioning and [MEDICAL CONDITION] care. Review of Resident #15's physician's orders [REDACTED]. Physician orders [REDACTED].#6 with cuff. Review of skilled nursing charting dated 11/12/15 and 11/13/15 reflected the resident had a [MEDICAL CONDITION]. However, there were no narrative nursing notes related to the [MEDICAL CONDITION] or respiratory status of the resident. A nursing progress note, written by LPN #25 dated 11/14/15 at 2:47 A.M. as a late entry progress note for 2:15 A.M., revealed upon entering the room Resident #15 had pulled [MEDICAL CONDITION]. The EMS squad was called. Oxygen saturation was 66%. EMS arrived at 2:20 A.M. A report was called to the hospital emergency room and the DON was notified. The nurse ' s note failed to contain any additional information to determine what care was provided to the resident. There was no evidence the nurse attempted to maintain the resident ' s airway, no evidence the resident was assessed, other than her oxygen level and no evidence respiratory interventions were provided while waiting for emergency personnel to arrive. Review of the EMS Prehospital care report revealed the facility requested EMS services on 11/14/15 at 2:05 A.M. EMS arrived at the facility at 2:11 A.M. and initial contact with Resident #15 was made at 2:12 A.M. Per the care report, the resident was found lying in her bed and the facility nurse informed EMS that Resident #15 had pulled [MEDICAL CONDITION]. The resident ' s oxygen level was in the 90 ' s at the time of the arrival but as time passed her oxygen level declined. EMS personnel placed a blind airway where [MEDICAL CONDITION] and began to provide manual ventilation on the way to the hospital. Vital signs obtained by EMS staff included blood pressure 157/120, heart rate 103 and irregular and respiration rate 28 and labored. Review of hospital history and physical documentation revealed the resident was admitted on [DATE] after she removed her own [MEDICAL CONDITION]. EMS staff intubated the resident through her [MEDICAL CONDITION] site and she was ventilated by manual bag ventilation. The resident was placed on a ventilator, was assessed with [REDACTED]. The resident was admitted to the intensive care unit with [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. There were no changes to the resident ' s [MEDICAL CONDITION] orders from the orders obtained on 11/12/15. However, a new order was implemented on 11/19/15 for the resident to have mitts to her hands at all times to prevent her from pulling out her trach. Review of the nursing progress notes from 11/19/15 through 12/01/15 revealed charting reflected the resident had a [MEDICAL CONDITION]. There were no notes related to the status of the [MEDICAL CONDITION] or use of hand mitts for the resident. Review of the nursing progress note, dated 12/02/15 at 6:48 P.M., written by LPN #13 revealed heard resident yelling down in her room . LPN #13 entered the room to observe Resident #15 had pulled out her trachea . The note indicated LPN #13 attempted to re-insert but was unsuccessful and called emergency transport for the resident to be sent to the emergency room . The physician, DON and family were notified. The note indicated the resident was transferred via cot with two staff assist and left the facility at 6:35 P.M. Review of the nursing progress note revealed no evidence the resident ' s respiratory status was assessed, the resident ' s oxygen level or vital signs were assessed or any evidence the resident ' s hand mitts were in place as ordered at the time of this incident. Review of the EMS Prehospital care report revealed the facility requested EMS on 12/02/15 at 6:22 P.M. EMS personnel arrived at the facility at 6:27 P.M. and initial contact with Resident #15 was made at 6:28 P.M. The resident was sitting in bed and the facility nurse informed EMS the resident had pulled [MEDICAL CONDITION]. Resident #15 had [MEDICAL CONDITION] in place with supplemental oxygen on. Resident #15 was then transported to the hospital. Review of the hospital documentation dated 12/02/15 revealed Resident #15 was admitted with a diagnosis [MEDICAL CONDITION] out /trach malfunction. The resident was hospitalized from [DATE] through 12/04/15 at which time she returned to the facility. On 12/17/15 at 9:25 A.M., telephone interview with LPN #13 revealed she was the nurse on duty on 12/02/15 when Resident #15 pulled out her [MEDICAL CONDITION]. LPN #13 said she attempted to re-insert a new Shiley #6 but was unable to get [MEDICAL CONDITION] in. LPN #13 said she put oxygen on the resident and called 911 for transport to the hospital. LPN #13 said she stayed at the resident ' s side to ensure the oxygen stayed in place until EMS arrived and transported her to the hospital. During the interview, there was no mention as to whether Resident #15 ' s bilateral hand mitts were in place prior to the resident being found with [MEDICAL CONDITION] out. LPN #13 also verified the information provided during the interview was not included in her nurse ' s note and verified there was no assessment, including vital signs or oxygen saturation documented for the resident prior to her leaving the facility with EMS staff. On 12/23/15 at 10:29 A.M. interview with the DON revealed she thought Resident #15 did have mitts in place on 12/02/15 at the time she pulled her [MEDICAL CONDITION] out. The DON indicated that even with the mitts in place, she was still able to pull the tube out and wasn't sure that there was any way the facility could keep the resident from pulling it out based on her cognitive impairment. On 12/14/15 at 9:15 A.M., Resident #15 was observed sitting in the activity lounge with the [MEDICAL CONDITION] in place that was connected to a percent oxygen lock venture system (oxygen delivery system) and an oxygen concentrator with a humidifier bottle. Resident #15 was observed with the physician ordered hand mitts on both of her hands at the time of the observation. On 12/14/15 at 12:50 P.M. interview with the DON revealed Resident #15 was a long term resident of the facility. The DON indicated the resident had been hospitalized and returned on 11/12/15 with a [MEDICAL CONDITION], which was new for the resident. The DON verified the resident had removed [MEDICAL CONDITION] on two occasions as noted above which resulted in hospitalization s including a five day stay in the intensive care unit where she was treated for [REDACTED]. On 12/14/15 at 1:35 P.M., observation [MEDICAL CONDITION] for Resident #15 revealed the following: Upon entry into Resident #15's room, the resident was lying in bed, positioned on her back. LPN #11 had [MEDICAL CONDITION] and supplies set up on the resident's bedside table without any type of barrier. The inner tray of [MEDICAL CONDITION] was sitting directly on the bedside table. The white divided tray had normal saline solution (NSS) in one side. LPN #11 applied a clean pair of gloves, removed the [MEDICAL CONDITION] and placed in the trash can. The LPN then removed her gloves and placed them on the bedside table along with [MEDICAL CONDITION] and other supplies. LPN #11 then applied sterile gloves from the [MEDICAL CONDITION] kit, without washing or sanitizing her hands and placed a barrier on the resident's chest. She then placed a disposable Q-tip in the NSS and proceeded to cleanse around the resident's [MEDICAL CONDITION] stoma, LPN #11 placed the soiled Q-tip into the empty side of the divided tray of [MEDICAL CONDITION]. LPN #11 then obtained a 4 X 4 and dipped it into the NSS in the divided tray and cleansed the outer cannula of the trach, then placed the soiled 4 X 4 in the divided tray along with the soiled Q-tip. LPN #11 then placed a clean [MEDICAL CONDITION] dressing under the outer cannula. LPN #11 disposed of all the soiled equipment and washed her hands. On 12/14/15 at 1:40 P.M., interview with LPN #11 verified she did not wash or sanitize her hands after removing the soiled dressing from Resident #15'[MEDICAL CONDITION] apply the sterile gloves. LPN #11 also verified she placed soiled items with the clean items and continued to use the items. On 12/14/15 at 2:30 P.M., interview with the DON verified the facility did not provide the nursing staff with formal education on the care of Resident 15'[MEDICAL CONDITION] consult with a Respiratory Therapist. During the onsite investigation, the following concerns were identified related to staff knowledge of caring for Resident #15 and the availability of [MEDICAL CONDITION] supplies. On 12/14/15 at 1:00 P.M., interview with STNA #15, on 12/14/15 at 1:15 P.M. interview with STNA #16, on 12/14/15 at 1:20 P.M. interview with STNA #17, on 12/14/15 at 3:30 P.M. interview with STNA #20 and on 12/14/15 at 3:35 P.M. interview with STNA #21 revealed although each of the STNAs was knowledgeable of reporting changes to the nurse on duty, none had received any type of formal training related to Resident #15 ' s [MEDICAL CONDITION] and/or their role in caring for the resident related to the [MEDICAL CONDITION]. On 12/15/15 at 1:35 P.M., observation of Resident #15's bedside stand revealed a suction machine sitting on top and a spare Shiley #[MEDICAL CONDITION] in the first drawer of the bedside stand. On 12/15/15 at 1:40 P.M., interview with LPN #11 revealed if Resident #15'[MEDICAL CONDITION] came out she would call the squad and then try and put the [MEDICAL CONDITION] back in. She said an [MEDICAL CONDITION] was kept at the bedside at all ties. LPN #11 said she was uncomfortable with the sterile suctioning. LPN #11 said she was not as familiar with sterile suctioning because the last facility she was employed with had in-line suctioning for the residents with trachs. On 12/16/15 at 5:50 A.M., interview with LPN #26 revealed she had been employed with the facility for the past two years LPN #26 said Resident #15 was the [MEDICAL CONDITION] since her employment at the facility. LPN #26 said she did have [MEDICAL CONDITION] at another place of employment. LPN #26 said if the resident'[MEDICAL CONDITION] out she would attempt to put something back in it. LPN #26 said she could not think of the name of the device she would use. LPN #26 said the facility did not have one for the resident in the facility that she would use to keep the resident'[MEDICAL CONDITION] open. LPN #26 said the facility had one ambu bag (bag to supply mechanical ventilation) which was kept in the medication room. Upon request LPN #26 entered the medication room. LPN #26 was unable to locate an ambu bag. LPN #26 said the facility does not have a crash cart, but kept some stuff with the backboard. Observation of the cart with red mesh with LPN #26 revealed two backboards, a green emergency oxygen tank, various oxygen tubing and a suction machine. No ambu bag was present on the cart as verified by LPN #26 during the time of the observation. LPN #26 requested the surveyor to accompany her to Resident #15's room to ensure the ambu bag was not being stored in the resident's room. Upon inspection of the resident's room by LPN #26, no ambu was located in the resident's room and was verified by LPN #26 at the time of the observation. LPN #26 said she was unsure what she would do if there was an emergency with Resident #15's [MEDICAL CONDITION]. LPN #26 said the facility had provided no education on how to care for the resident's trach. LPN #26 said she spoke with each night shift STNA she worked with about the resident's [MEDICAL CONDITION]. LPN #26 said she instructed the STNAs she worked with of what she wanted notified of immediately, if the resident pulls [MEDICAL CONDITION], has excessive coughing, difficulty breathing or any type of change. On 12/16/15 at 6:10 A.M. interview with STNA #27 and on 12/16/15 at 6:15 A.M. interview with STNA #28 revealed although each of the STNAs was knowledgeable of reporting changes to the nurse on duty, none had received any type of formal training related to Resident #15 ' s [MEDICAL CONDITION] and/or their role in caring for the resident related to the [MEDICAL CONDITION]. On 12/16/15 at 10:45 A.M., interview with the DON revealed she contacted the facility's contracted oxygen company and spoke with RT #30 regarding Resident #15's [MEDICAL CONDITION]. The DON said the facility and RT #30 were arranging for education to be completed for all nursing staff. No date was provided for the anticipated education at this time. She said RT #30 recommended the facility stock a Shiley #4 to keep at bedside in the event the resident'[MEDICAL CONDITION] dislodged or self-removal occurs. On 12/16/15 at 12:25 P.M., the DON provided documentation the facility arranged for an in-service to be conducted by the contracted RT on 12/17/15 at 10:00 A.M. On 12/16/15 at 1:00 P.M., interview with Administrator #29 revealed the Administrator felt the facility could not deliver the care Resident #15 required with regards to [MEDICAL CONDITION] were planning on transferring Resident #15 to a sister facility until they could provide education to the nursing staff and obtain the required supplies needed to care for Resident #15 ' s trach. On 12/17/15 at 9:50 A.M., interview with contracted RT #30 revealed he was unaware of the facility having a resident with a trach. The RT said he would recommend and expect the facility to ensure they had a Shiley #4, Shiley #6, suction machine and an ambu bag at the resident ' s bedside for emergency situations. The RT said he would recommend and expect the facility to utilize on a daily basis for the resident ' s trach, a 50 PSI air compressor, oxygen concentrator and a cool [MEDICAL CONDITION] circuit. Review of the facility's oxygen vendor contract revealed the facility entered into a binding contract on 10/15/15. The coordination, supervision, and evaluation of services between the organization, the patient and the nursing facility would be the responsibility of the Vice President of Respiratory Services of the oxygen provider. The responsibilities included delivery of quality oxygen equipment and supplies to patients of the company, delivered 24 hours a day, seven days a week and on call for holidays, oxygen equipment and supplies needed from the nursing facility and to maintain compliance with current standards set by the Accreditation Commission for Health Care as applicable. Review of the facility ' s [MEDICAL CONDITION] Care policy and procedure dated 01/04/10, [MEDICAL CONDITION] should be performed, ideally once per day or as often as required to maintain patency of the airway and minimize the risks of infection. The nurse or RT will perform the following steps when [MEDICAL CONDITION]: standard precautions obtain [MEDICAL CONDITION], suction the patient if needed, [MEDICAL CONDITION], with sterile swap and hydrogen peroxide, cleanse the area immediately adjacent to the stoma and base of [MEDICAL CONDITION]. Take extra precautions not to allow solution to actually enter the stoma, with a 4 X 4 soaked in sterile water, rinse the area just cleansed. Observe for signs of discoloration and irritation and enter observations in patients care notes, replace the drain sponge behind [MEDICAL CONDITION], replace oxygen delivery device, and change [MEDICAL CONDITION] collar. This deficiency substantiates Complaint Number OH 848.