Every finding on record at Eagle Creek Nursing Center

Based on observations, interviews, and review of facility policy, the facility failed to ensure the kitchen was maintained in a clean, sanitary manner. This had the potential to affect all residents residing in the facility as the facility identified no residents who did not receive food prepared in the kitchen. The facility census was 70. Findings include:Observation on 06/22/26 at 8:55 A.M. revealed a pipe located underneath the 3-sink compartment across from the steam table was leaking water into a metal pan placed underneath it. The tiles behind the metal pan were loose and a black mildew-like substance was located on the tiles and floor beneath them. Two ceiling tiles located above the steam table were covered with a black mildew-like substance and were saturated with water. One of the ceiling tiles was bulging down in the center due to being saturated with water and was dripping water onto the steam table located below it. Several of the small white tiles located at the threshold between the food preparation area and the dish washing area were missing or broken creating a gash in the floor which had debris caked into it. Interview with Food Services Director #225 at the time of the observations confirmed the air condition had been freezing up causing condensation on the pipes above the ceiling tiles to saturate some of the tiles with water. Food Services Director #225 confirmed the pipe located under the 3-sink compartment across from the steam table was leaking and staff had placed a metal pan underneath it to collect the water which sometimes spilled over onto the floor. Food Services Director #225 confirmed several small white tiles were missing or broken creating a gash in the floor which was caked with debris. Observation on 06/23/26 at 12:20 P.M. revealed the two ceiling tiles located above the steam table appeared to have been replaced since the previous day but had new water stains on them. The pipe under the 3-sink compartment across from the steam table continued to leak water into a metal pan placed underneath it. The tiles behind the metal pan were loose and a black mildew-like substance was located on the tiles and floor beneath them. Several small white tiles located at the threshold between the food preparation area and the dish washing area were missing or broken creating a gash in the floor which had debris caked into it. Interview with Regional Dietitian #515 at the time of the observation confirmed all findings. Review of the facility policy titled Kitchen Sanitation and Cleaning Schedule Policy, last reviewed/revised on 02/12/26, revealed food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.

Based on observations, interviews, and review of facility policy, the facility failed to ensure resident rooms were maintained in a clean and sanitary manner. This affected two residents (#55 and #69) whose room was observed during the annual and complaint survey. The facility census was 70. Findings include:Observation on 06/22/26 at 8:15 A.M. revealed a strong urine odor was present in the room of Resident #55 and Resident #69 which could be smelled from the hallway. Observation on 06/22/26 at 12:03 P.M. revealed Resident #55 and Resident #69 were sitting in their room consuming their lunch meals. The urine odor continued to be present in the room. Housekeeper #401 entered the room to clean and mop. Observation on 06/22/26 at 4:15 P.M. revealed Resident #69 was lying in the bed. The sheets contained a rust-colored, circular stain on them located near the residents grab bar. Light brown stains were located on the sheets around where the residents feet were lying. Cobwebs and dust were present on the walls and ceiling between the residents sink and window, and debris was present underneath Resident #55 and Resident #69's beds and on the floor underneath the nightstand which was located under the residents television. The corner of the residents nightstand, which was located below the residents television, was broken and had been taped. The tape contained brown and pink stains and appeared to be old. The odor of urine remained present in the room. Observation on 06/23/26 at 9:45 A.M. revealed Resident #69's sheets continued to have a rust-colored, circular stain present near the residents grab bar with light brown stains located on the sheets near the foot of the residents bed. The cobwebs and dust remained on the ceiling and walls between the residents sink and window. Debris continued to be present under the beds of both Resident #55 and Resident #69 and under the nightstand located beneath the television. The odor of urine remained present in the room. Observation on 06/24/26 at 3:05 P.M. revealed Resident #69's sheets continued to have a rust-colored, circular stain present near the residents grab bar with light brown stains located on the sheets near the foot of the residents bed. The cobwebs and dust remained on the ceiling and walls between the residents sink and window. Debris continued to be present under the beds of both Resident #55 and Resident #69 and under the nightstand located beneath the television. The odor of urine remained present in the room. Interview with Certified Nursing Assistant (CNA) #710 and CNA #718 at the time of the observation confirmed there were cobwebs and dust present on the walls and ceiling between the residents sink and window, confirmed there was debris under the beds of both residents and the nightstand located under the television, and confirmed Resident #69's sheets had a rust-colored, circular stain located near the residents grab bar and also light brown stains near the foot of the residents bed. They confirmed residents bed sheets were to be changed on their shower days and Resident #69 was scheduled to receive a shower on day shift that same day. They confirmed there was a strong urine odor present in the room likely related to Resident #55 being incontinent of urine in large amounts which may saturate through her incontinence briefs into the mattress. Observation on 06/25/26 at 12:10 P.M. revealed Resident #69's sheets continued to have a rust-colored, circular stain present near the residents grab bar with light brown stains located on the sheets near the foot of the residents bed. The cobwebs and dust remained on the ceiling and walls between the residents sink and window. Debris continued to be present under the beds of both Resident #55 and Resident #69 and under the nightstand located beneath the television. The corner of the residents nightstand under the television continued to have a broken corner which had dirty tape holding the broken corner in place. The odor of urine remained present in the room. Interview with Licensed Practical Nurse (LPN) #603 at the time of the observation confirmed all observations. LPN #603 confirmed Resident #69's sheets needed to be changed immediately following the observation, confirmed the nightstand needed repaired or replaced, confirmed the room needed to be cleaned, and confirmed there was a urine odor present which may be related to a resident located in the room next to Resident #55 and Resident #69 who was incontinent and non-compliant with care. Review of the facility policy titled Occupied Standard Room Cleaning Procedure, last reviewed/revised 04/16/26, revealed proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. Cleaning referes to the removal of visible soil from surfaces through the physical action of scrubbing with detergents/surfactants and rinsing with water. Occupied resident rooms will be cleaned daily to maintain a sanitary environment. This deficiency represents non-compliance identified during the investigation of Complaint Number 2986097.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents received mechanically altered diets as ordered by the physician. This affected one resident (#69) out of the five residents reviewed for nutrition during the annual and complaint survey. The facility census was 70. Findings include:Record review for Resident #69 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included cerebral infarct, muscle weakness, and dysphagia (difficulty swallowing). Review of the admission Minimum Data Set (MDS) assessment, dated 04/19/26, revealed the resident had impaired cognition. The resident was assessed to receive a mechanically altered diet. Review of the care plan, last reviewed/revised on 06/23/26, revealed the resident had increased nutrition/hydration risk. Interventions included to provide diet as ordered. Review of the active physicians order, dated 04/15/26, revealed the resident was to receive a pureed texture diet with nectar thick liquids. Review of the facility recipe for pureed egg omelet baked, not dated, revealed refer to regular recipe instructions, then measure the desired number of servings into the food processor. Blend until smooth. Add milk if product needs thinning. Add commercial thickener if product needs thickening. Observation on 06/23/26 at 8:50 A.M. revealed Resident #69 was sitting up in her wheelchair in her room eating her breakfast meal. No staff were present in the room. The meal ticket on the residents tray indicated the resident was to receive a pureed baked omelet. The residents breakfast plate had scrambled eggs which were lumpy in texture present on it which the resident was consuming. Observation and interview with Registered Nurse (RN) #300 on 06/23/26 at 8:55 A.M. of Resident #69's breakfast tray confirmed there were scrambled eggs present on the residents plate and no pureed omelet despite the residents meal ticket indicating the resident was to receive a pureed omelet. RN #300 confirmed she would take the plate back to the kitchen and correct the food to meet the residents physician ordered diet. Review of the facility policy titled Puree Food Preparation Guidance, not dated, revealed the puree product is to be maintained between a pudding-like or mashed potato equivalent thickness. This deficiency represents non-compliance identified during the investigation of Complaint Number 2986097.

Based on medical record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR) were completed and updated to reflect a new qualifying diagnosis. This affected one (#51) of two residents reviewed for PASARR accuracy. The facility census was 70. Record review for Resident #51 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, dysphagia, contractures, COVID-19, muscle weakness, hypertension, depression, cerebrovascular disease, hemiplegia and hemiparesis, constipation, lack of coordination, and malaise. Review of an updated diagnosis list revealed a new diagnosis of Bipolar Disorder was added on 02/21/25. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had moderately impaired cognition.Review of the most recent PASARR documentation provided by the facility for Resident #51 revealed it was completed prior to admission on [DATE], with no further documentation which reflected the addition of the new diagnosis.Review of the most recent PASARR review provided by the facility revealed this was most recently completed on 04/19/18. The diagnosis of Bipolar Disorder was not captured on this review. Interview with the Director of Nursing on 06/23/2026 at 3:50 P.M. verified no other PASARR reviews had been completed following addition of the new mental health diagnosis of Bipolar Disorder on 02/21/25. She reported a new screening was completed on 06/23/26 following surveyor intervention.

Based on observations and staff interview, the facility failed to store foods and maintain kitchen equipment under sanitary conditions. This affected all 71 residents who received food from the kitchen. The facility census was 71. Findings include: During initial kitchen tour on 12/16/24 at 8:47 A.M., the was a large unlabeled and undated food bin containing a white substance under the food preparation counter. There was soy sauce, Worcestershire sauce, mayonnaise and opened bag of cheese with no expiration date or use by date in the walk-in refrigerator. Further observations of the stove ventilation revealed the hood had brown fuzzy debris of a quarter of inch in length hanging from the bottom rack. The debris was over the cooking surface of the stove, which contained open pans of cooking food. Interview on 12/016/24 at 8:50 A.M. the Dietary Manager, (DM) #280 verified there was no use by dates for open foods of soy sauce, Worcestershire sauce, mayonnaise and bag of cheese. DM #280 verified the stove hood was dirty and there was no evidence of stove hood cleaning provided. DM #280 stated there were no facility policies for labeling, and storage of foods and there was no facility policies provided of equipment cleaning. The facility confirmed all 71 residents receive their meals from the kitchen.

Based on medical record review, review of recipes, observations, staff interviews and policy review, the facility failed to provide special dietary foods as ordered by the physician. This affected three (#14, #15 and #37) of five residents reviewed for special dietary foods. The facility census was 71. Findings include: 1. Record review of Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dysphagia, weight loss history and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition and required assistance with eating. Further review of Resident #14's medical record revealed the resident had a diet order for fortified foods at each meal. 2. Record review of Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstruction pulmonary disease, nausea and history of weight loss. Review of the MDS assessment dated [DATE] revealed Resident #15 had intact cognition and required assistance with eating. Further review of Resident #15's medical record revealed the resident had a diet order for fortified foods at each meal. 3. Record review of Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia, heart disease and history of weight loss. Review of the MDS assessment dated [DATE] revealed Resident #37 had severely impaired cognition and required assistance with eating. Further review of Resident #37 medical record revealed the resident had a diet order for fortified foods at each meal. Review of fortified foods recipe for fortified oatmeal included sugar, butter, dry milk and evaporated milk. The fortified potato recipe revealed use of half and half cream and butter. Observation on 12/17/24 at 12:24 P.M. of Resident #14, #15, and #37 had served ravioli, green beans, bread and sherbert. There were no fortified foods served at the lunch meal. Interview on 12/17/24 at 11:18 A.M. the [NAME] #250 revealed she did not follow fortified food recipes, including oatmeal and potatoes for Resident #14, #15 and #37. [NAME] #250 stated the recipes included more ingredients to increase the calories in the foods. [NAME] #250 verified she had not prepared any fortified foods for the lunch meal Interview on 12/18/24 at 1:14 P.M. the Dietary Manager, (DM) #280 revealed the cooks have not prepared fortified foods by following the by fortified food recipes, which included high caloric ingredients. The fortified foods are planned for the residents as assessed by the Registered Dietitian, (RD) #140. Review of the facility policy tilted, Diet Orders Policy dated 03/18/24 revealed the facility will ensure residents are provided meals as ordered by their healthcare provider.

Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan for a resident on an anticoagulant. This affected one (#41) of three residents reviewed for hospitalization . The facility census was 71. Findings include: Record review of Resident #41 revealed a most recent admitted [DATE]. Diagnoses include acute and chronic respiratory failure with hypoxia, tracheostomy status, hemiplegia, unspecified affecting left nondominant side, chronic obstructive pulmonary disease, convulsions, heart failure, type two diabetes mellitus without complications, long term use of antithrombotics/antiplatelets and abnormal uterine and vaginal bleeding 12/12/24. Review of the 11/04/24 admission Minimum Data Set (MDS) assessment revealed Resident #41 is moderately cognitively impaired and was coded as taking an anticoagulant and an antiplatelets. Review of a physician order dated 10/31/24 revealed Resident #41 had an order for Eliquis (apixaban, an anticoagulant) five milligrams every 12 hours. Review of the medical record on 12/17/24 revealed there was not a care plan addressing the use of anticoagulant bleeding risk for Resident #41. Interview with the Director of Nursing (DON) on 12/19/24 at 9:14 A.M. verified there was not a care plan addressing Resident #41 uses of an anticoagulant and risk for bleeding.

Based on medical record review, observation, staff interview and review of a memo from Centers for Medicare and Medicaid Services (CMS), the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when a resident with a chronic diabetic ulcer requiring wound treatments and dressing changes was not timely placed on enhance barrier precautions. This affected one (#60) of two reviewed for infection control. The facility census was 71. Findings include: Record review of Resident #60 revealed an admitted [DATE]. Diagnoses include type two diabetes mellitus with foot ulcer 02/03/24, viral hepatitis B, iron deficiency anemia, vitamin d deficiency, chronic pain syndrome, pleural effusion, fibromyalgia, cirrhosis of the liver, major depressive disorder, encephalopathy, chronic obstructive pulmonary disease, hypertension, benign prostatic hyperplasia, nausea, and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively intact and has a Diabetic foot ulcer. Review of Resident #60's wound clinic report dated 10/07/24 revealed the right medial forefoot abrasion went from abrasion to diabetic ulcer per Wound Certified Nurse Practitioner. Review of Resident #60's physician order dated 10/14/24 revealed an order to cleanse wound to right ball of foot with normal saline apply calcium alginate with silver to wound bed then zinc to peri wound then cover with abdominal pad and kerlix secure with tape for diabetic ulcer once a day. This order was discontinued 11/18/24. Review of Resident #60's physician order dated 11/18/24 revealed an order to cleanse wound to right ball of foot with normal saline apply santyl to wound bed then cover with calcium alginate with silver then zinc to peri wound then cover with abdominal pad and kerlix secure with tape for diabetic ulcer. This order was discontinued on 12/04/24. Review of Resident #60's physician order dated 12/04/24 revealed an order to cleanse wound to right ball of foot with normal saline apply santyl to wound bed then cover with abdominal pad and kerlix secure with tape. change daily and as needed for diabetic ulcer once a day. This order was discontinued on 12/18/24. Observation on 12/16/24 at 3:55 P.M. revealed there was no sign by the room or information showing Resident #60 was on enhanced barrier precautions. Review of a Physician Order dated 12/16/24 revealed Enhanced barrier precautions related to diabetic wound. Further review of the medical record on 12/17/24 revealed Resident #60 had an abrasion to the right medial forefoot on 08/01/24 that was classified as a chronic diabetic ulcer on 10/07/24. The wound required treatments and dressing changes and was not placed on enhanced barrier precautions until 12/16/24. Interview with the Director of Nursing (DON) on 12/19/24 at 1:34 P.M. verified Resident #60 has a chronic diabetic foot ulcer and was not placed on enhanced barrier precautions until 12/16/24. Review of memo from CMS titled QSO-24-08-NH dated 03/20/24 revealed enhanced barrier precautions are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multi-drug resistant organism (MDRO). Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure call lights were in reach per the resident's plan of care. This affected one (#34) of three residents reviewed for call lights. The census was 65. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE] with a diagnosis of dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) for Resident #34 dated 10/29/22 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of the care plan for Resident #34 dated 10/22/20 revealed the resident had an ADL self care performance deficit related to Alzheimer's. Resident #34 required supervision/assistance with bed mobility, transfers, eating and toileting. Declines or fluctuations in ADL's were expected due to diagnosis of Alzheimer's. Interventions included staff should encourage resident to use call bell for assistance. Observation on 01/03/23 at 12:45 P.M. of Resident #34 revealed the resident was in bed, and her call light was clipped to the wall and was outside the resident's reach. Interview on 01/03/23 at 12:45 P.M. with State tested Nursing Assistant (STNA) #150 confirmed Resident #34 was able to use her call light and it should be within reach at all times. STNA #150 confirmed the call light was clipped to the wall and was out of the reach of resident. Interview on 01/04/23 at 9:15 A.M. with the Director of Nursing (DON) confirmed all residents should have their call lights within reach when they are in bed. Review of the facility policy titled Resident Communication System and Call light policy dated 06/30/17 revealed when resident is confined to bed and chair be sure the call light is within easy reach of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00138421.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents with pressure ulcers received proper wound care. This affected one (#34) of three residents reviewed for wound care. The census was 65. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE] with a diagnosis of dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) for Resident #34 dated 10/29/22 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of the care plan for Resident #34 dated 10/26/22 revealed the resident had impaired skin integrity as evidenced by stage IV pressure ulcers to sacrum and to the left hip. Interventions included the following: monitor wound for signs of infection, treatment as ordered, turning and repositioning per facility protocol. Review of the most recent wound assessments for Resident #34 dated 12/30/22 revealed wound to resident's sacrum was classified as a stage IV pressure ulcer and measured 6.9 centimeters (cm) in length by 4.7 cm in width by 1.6 cm in depth and wound to resident's left hip was classified as a stage IV pressure ulcer and measured 1.3 cm in length by 1.5 cm in width by 1.1 cm in depth. Review of the January 2023 monthly physician orders for Resident #34 revealed an order dated 11/19/22 to cleanse pressure ulcer to sacrum with normal saline, gauze with Dakin's solution in the wound, cover with ABD pad once daily and as needed and an order dated 11/26/22 to cleanse pressure ulcer to left hip with normal saline, gauze with Dakin's solution in the wound, cover with ABD pad once daily and as needed. Observation on 01/04/23 at 7:35 A.M. of wound care for Resident #34 per Licensed Practical Nurse (LPN) #300 assisted by State tested Nursing Assistant (STNA) #150 revealed aide and nurse positioned Resident #34 on her left hip (the hip with a stage IV pressure ulcer) and LPN #300 removed the ABD pad and pulled the packing out of the sacral wound bed. STNA #150 positioned Resident #34 on her back with sacral wound uncovered and making direct contact with resident's incontinence brief while nurse removed the ABD pad and pulled the packing out of the left hip wound bed. STNA #150 then positioned Resident #34 on her left side while LPN #300 completed the treatment to resident's sacral wound. The treatment to the sacrum took approximately 15 minutes, and during the sacral treatment the left hip wound was uncovered and was in direct contact with resident's incontinence brief. After completing the sacral wound treatment, the aide positioned Resident #34 on her back. LPN #300 cleansed the left hip wound with normal saline but did not apply an ABD pad to cover the wound as per the physician's order. STNA #150 then fastened Resident #34's incontinence brief over the left hip wound. Interview on 01/04/23 at 8:12 A.M. with LPN #300 confirmed she and aide had positioned resident directly on her left side which had a stage IV pressure ulcer during the sacral dressing treatment. LPN #300 further confirmed she had taken off the wound dressings for both wounds at the start of the treatment leaving the left hip wound uncovered during the treatment to the sacral wound and possibly increasing chance of wound infection. LPN #300 confirmed she had not applied an ABD pad to cover the left hip wound after she packed the wound and confirmed the physician's order read the wound was to be covered with an ABD pad. Interview on 01/04/23 at 9:15 A.M. with the Director of Nursing (DON) confirmed Resident #34 should not be positioned on her left hip during wound care to the sacrum because of the existing pressure ulcer to the left hip. DON confirmed resident should have been positioned on her right side during treatment to the sacrum. DON confirmed nurses should treat one area at a time and should not remove the old dressing to the wound until the time of the treatment. DON confirmed Resident #34's physician's order to the left hip was for wound to be covered with an ABD pad and the wound should not be left uncovered in order to prevent possible wound infection. Review of the facility policy titled Pressure Injury Prevention and Treatment dated 09/18/20 revealed residents would receive necessary treatment and services consistent with professional standards of practice to promote healing and to prevent infection. Further review of the policy revealed treatments should be administered as ordered. This deficiency represents non-compliance investigated under Complaint Numbers OH00138421 and OH00138391.

Based on observation, interview, and policy review, the facility failed to store foods, discard expired foods and maintain food equipment in sanitary condition. This had the potential to affect 54 residents who received food from the kitchen. The facility census was 54. Findings include: Observation on [DATE] at 9:37 A.M. revealed following sanitation violations in the main kitchen: 1. Two open orange juice containers in reach-in refrigerator with no open date. 2. One thickened water container in reach-in refrigerator with no open date. 3. Two cranberry juice containers in reach-in refrigerator with no open date. 4. One unlabeled and undated container of a white substance on storage shelf. 5. One bag of opened and unsealed shredded cheese in walk in refrigerator. 6. A tray of 12 individual bowls of cereal unlabeled and undated in the dry storage area. 7. One box of opened cream of wheat cereal with expired date of [DATE]. In the dining area, the ice machine had ice scoops stored in containers that did not permit drainage. The containers were on top of the ice machine and the ice scoops were stored horizontally in the ice scoop containers. In the dining room, the observation of the resident refrigerator revealed the following sanitation violations: 1. Two pizza boxes containing pizza dated [DATE] and no identified resident. 2. Two containers of tomatoes dated [DATE]. 3. One opened loaf of bread undated. 4. Two containers of whole milk dated [DATE]. In the dishwashing area, the floor had an area of 36 inches by 6 inches of missing and cracked tiles with noted food debris. In the kitchen cooking area, the hood vents above the stove and grill area, had visible grey dust directly over the cooking surface. Throughout the kitchen area and dish washing area, the ceiling was soiled with food debris and visible dust. Interview on [DATE] at 9:37 A.M. the Diet Manger, (DM), #181 verified the foods in the reach in refrigerator and in the resident refrigerator should have open dates, had labels and the expired foods should have been discarded. DM #181 verified opened perishable foods are to be discarded after seven days. The DM #181 verified the dishwasher floor tile needed repaired. DM #181 verified the hood vents had dust over the cooking area and the ice machine scoops should be stored vertically. Interview on [DATE] at 9:00 A.M. with Maintenance Director, (MD) # 186 and DM #181 verified the hood vents had dust above the cooking surface and needed cleaned. The MD #186 stated although the hood cleaning contract company cleaned and inspected the hood in [DATE], and scheduled to return [DATE], the vents should be cleaned between visits of the contract company. The MD #186 verified the cracked and missing tiles in dishwashing area needed replaced and the ceiling needed cleaned. Review of facility policy, Storage of Refrigerated Foods Policy dated [DATE], and Hood and Filter Cleaning Instructions, undated, revealed refrigerator items must have a label, and a date the food should be consumed or discarded. Hood filters will be cleaned as needed.

Based on observation ,interview, and policy review, the facility failed to maintain food equipment in good repair. This had the potential to affect 54 residents who received food from the kitchen. The facility census was 54. Findings include: Observation on 08/22/22 at 9:37 A.M. revealed the walk-in freezer had six inches by 24 inch area of ice buildup under the condenser at the back of the freezer. There was noted ice particles on top of and below food boxes stored below the condenser. Interview on 08/22/22 at 9:37 A.M. the Diet Manger, (DM) #181 verified the walk-in freezer had ice built up under the condenser and had not been working properly for several months. The DM #181 verified there was ice above and below boxes of frozen foods which did not permit proper air circulation. Interview on 08/25/22 at 9:00 A.M. with Maintenance Director, (MD) # 186 verified the walk-in freezer had ice built up under the condenser, had been occurring for a month and had not been removed or repaired. He verified a freezer condenser would not normally have an ice buildup. He verified the ice buildup would reduce air circulation in the freezer. Review of facility policy, Storage of Refrigerated Foods Policy dated 02/19/19 revealed all foods should be stored to allow air circulation.

Based on observation, interviews, and record review, the facility failed to timely implement a behavioral care plan. This affected one resident (#7) out of the three residents reviewed for mood and behavior. The facility census was 54. Findings include: Record review for Resident #7 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge Minimum Data Set (MDS) assessment, dated 06/28/22, revealed this resident had exhibited physical and verbal behaviors directed at others one to three days during the lookback period. Review of the progress note, dated 06/28/22, revealed this resident had been aggressive with another resident and was seen hitting the other resident with her cane. The resident was placed on 15 minute checks and was to be sent to another facility for behavioral management and medication review. Review of the facility census timeline for this resident revealed the resident was transferred out of the facility on 06/28/22 and returned to the facility on [DATE]. Review of the active care plans for this resident revealed a care plan addressing behaviors and providing interventions for behavior management was not implemented until 08/23/22. Observation on 08/22/22 from 10:55 A.M. through 11:10 A.M. revealed Resident #7 was extremely agitated and was being argumentative with staff. The resident was observed to stand in the doorway of Resident #6's room and tell the resident to shut up as he was talking and then walk back to her room. Interview with Registered Nurse (RN) #104 on 08/24/22 at 2:30 P.M. verified Resident #7 had behavioral problems and a care plan had not been implemented addressing the behavioral problems until 08/23/22.

Based on staff interview, and record review the facility failed to accurately assess a resident status and submit the discharge assessment when the resident was discharged to the hospital. This affected one (Resident #1) of one reviewed for resident assessment. The facility census was 54. Findings include: Record review of Resident #1 revealed an admitted [DATE]. The resident had pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 02/27/22 quarterly Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired and required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. The resident required total dependence for bathing and used a wheelchair and walker to aid in mobility. Review of progress notes dated 4/14/22 at 1:57 P.M. revealed Resident out of facility at hospital. Review of progress notes dated 04/14/22 at 2:37 P.M. revealed call received from hospital, nurse states that resident will be going inpatient hospice at another facility. Review of the electronic medical record on 08/24/22 revealed the last completed MDS assessment was a quarterly done on 02/27/22. There was no documented evidence of a discharge MDS assessment being completed. Interview with Regional Director of Clinical Services #250 on 08/25/22 at 10:26 A.M. verified Resident #1 was discharged to the hospital on 04/14/22 and there was not a completed discharge Minimum Data Set assessment.

Based on observation, interview, and record review, the facility failed to timely revise fall care plan interventions. This affected one resident (#35) out of the three residents reviewed for falls. The facility census was 54. Findings include: Record review for Resident #35 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/12/22, revealed this resident had moderately impaired cognition and was assessed to require supervision for bed mobility and extensive assistance from one staff member for transfers and toileting. Review of the care plan, dated 11/02/18, revealed this resident was at risk for falls. Interventions included non-skid strips in front of chair, non-skid strips to floor beside bed, and reminder sign to ask for assistance with transfers and ambulation. Observation on 08/24/22 at 4:05 P.M. revealed Resident #35 was sitting in her recliner in her room. There were no non-skid strips present by the bed, in front of the chair, or anywhere else in the room. There was not a sign present in the room to remind the resident to ask for assistance with transfers and ambulation. Verified with Registered Nurse (RN) #210 at the time of the observation. Interview with the Director of Nursing (DON) on 08/24/22 at 4:15 P.M. revealed Resident #35 had recently had a room change at which time the Interdisciplinary Team had met and reviewed the residents fall interventions. The DON stated interventions including non-skid strips to the side of the bed and in front of the chair and the reminder sign to call for assistance had been agreed upon to be discontinued. The DON verified the interventions on the residents fall care plan had not been updated as agreed upon by the Interdisciplinary Team.

Based on observation, interview, and record review, the facility failed to ensure ordered medications was available and administered as ordered by the physician. This affected one resident (#36) out of the four residents observed for medication administration. The facility census was 54. Findings include: Record review for Resident #36 revealed this resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/12/22, revealed this resident had mildly impaired cognition and was assessed to require extensive assistance from two staff members for bed mobility, limited assistance from one staff member for transfers, and extensive assistance from one staff member for toileting. Review of the physicians order, dated 10/20/21, revealed an order to administer one capsule of Aspirin 162.5 milligram 24 hour Extended Release medication every day. Review of the active, discontinued, completed, and struck out physicians orders for this resident revealed there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/24/22 at 9:45 A.M. during medication administration revealed the medication Aspirin 162.5 milligram 24 hour Extended Release capsule was not available on the medication cart or in the facility emergency medication supply for administration to Resident #36. There were two cards of the medication [MEDICATION(S)] 40 milligram Delayed Release Capsules on the cart which had multiple doses missing. Interview with Registered Nurse (RN) #210 on 08/24/22 at 9:45 A.M. verified the medication Aspirin 162.5 milligram 24 hour Extended Release capsule was not available in the facility for administration to the resident. RN #210 also verified there were two prescription cards of 40 milligram [MEDICATION(S)] labeled with Resident #35's name present on the medication cart with multiple doses missing although there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN #104 on 08/24/22 at 2:30 P.M. verified the facility did not have the medication Aspirin 162.5 milligram 24 hour Extended Release capsules available for administration and did not have evidence of the facility ever having the medication available for administration to Resident #36. RN #104 stated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #36 had been sent to the facility pharmacy by an outside physician the resident had seen but the order had never been transcribed to the residents Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to ensure accurate daily staffing postings were displayed. This affected all 54 residents residing in the facility. Findings include: Observation on 08/22/22 at 10:30 A.M. revealed the daily staffing postings were displayed in a box located by the nursing station. The postings contained the date and resident census number, but did not contain any information regarding the nursing hours present in the facility. The postings were dated 08/11/22, 08/12/22, 08/13/22, 08/17/22, 08/18/22, and 08/22/22. Interview with Licensed Practical Nurse (LPN) #184 on 08/22/22 at 10:35 A.M. revealed the night shift nursing staff were to fill out the daily staffing postings and place them in box hanging on the wall by the nurses station. LPN #184 verified the postings hanging in the box on the wall by the nurses station contained the dates and resident census number, but did not contain the nurse staffing hours they were supposed to.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, staff interviews, review of the Emergency Medical Services (EMS) run report, review of the facility investigation, review of the facility policy for Cardio-Pulmonary Resuscitation (CPR), and review of the recommended technique for providing CPR, the facility failed to initiate CPR or contact EMS timely for Resident #59 who was found unresponsive, without a pulse or respirations, and who was identified as a Full Code status. This resulted in Immediate Jeopardy when Resident #59 did not receive CPR for six minutes after he was discovered with no vital signs. EMS was not contacted for assistance until six minutes after the resident was discovered. This affected one (Resident #59) of three residents reviewed for Full Code status. The facility identified 33 residents designated as Full Code status. The facility census was 58. On [DATE] at 3:09 P.M., Administrator #100, the Director of Nursing (DON) and Regional Clinical Nurse #500 were notified Immediate Jeopardy began on [DATE] at 9:00 A.M when Resident #59, who was a Full Code status, was found by Licensed Practical Nurse (LPN) #75 unresponsive and without a pulse or respirations. LPN #75 left the resident ' s room, went to the nursing station, and paged overhead for a State tested Nursing Assistant (STNA) and Assistant Director of Nursing (ADON) to come to the floor. LPN #75 called the doctor and reviewed the medical record for the code status. LPN #75 then paged overhead, calling a Code Blue stat. At 9:04 A.M., STNA #02 came to the unit and went to get more assistance. At 9:06 A.M., STNA #01 called 911 and CPR was initiated by Administrator #100. At 9:13 A.M., EMS arrived at the facility and took over life-saving measures. Resident #59 was pronounced deceased by EMS at 9:33 A.M. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 10:00 A.M., the DON and Regional Clinical Nurse #500 initiated an investigation and requested statements from the staff involved. · On [DATE] at 10:00 A.M., Social Service Designee #41 completed a whole house audit on the code status for residents to ensure that code statuses were current and correct. There were a total of 33 residents identified as having a Full Code status. · On [DATE] at 11:00 A.M., the DON started education with all staff in person or via phone on the CPR policy and performing a code with emphasis on what their role would be during a code. All newly hired staff will be educated on the process during orientation. · On [DATE] at 11:00 A.M., Human Resource Staff #06 audited all licensed nurses to verify they had current CPR cards. · On [DATE] at 11:00 A.M., LPN #75 was suspended pending investigation and then terminated on [DATE] for not following the facility ' s CPR policy. · On [DATE] at 12:30 P.M., the DON and Administrator #100 completed a mock Code Blue with staff. All staff responded quickly to the Code Blue announcement and performed CPR skills per the facility CPR policy. · On [DATE] at 12:30 P.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held with the Medical Director in attendance via phone, to review action plans of code status audits. Ongoing process changes included the DON will review new admission and readmissions code status five times weekly ongoing to ensure code status accuracy. The DON/Designee will conduct two mock Code Blue drills weekly for four weeks, then monthly to ensure staff respond appropriately to a Code Blue situation. Education will be provided as needed with each mock code. · The results of the audit will be forwarded to the QAPI committee meeting monthly. · Review of the staff education sign-in-sheets, dated [DATE], and documentation of phone calls with times revealed all nurses and STNA's were educated regarding the emergency response procedures as of [DATE]. The sign-in-sheet includes a roster of all nurses and STNA's working in the facility. · Review of the mock Code Blue drills and sign-in-sheets with all staff conducted on [DATE], [DATE], and [DATE] revealed all staff performed a Code Blue simulation with good response. · Review of new admission audits for code status for the weeks of [DATE] through [DATE] and [DATE] through [DATE] revealed all new admissions were reviewed for code status and verified with physician orders. · On [DATE], interviews with LPN #35 and LPN #39 revealed they were in-serviced on the emergency response policy. · On [DATE], interviews with STNA #07, #60 and #69 and LPN #29 revealed they were in-serviced on the emergency response policy. Findings include: Review of Resident #59 ' s medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order, dated [DATE], revealed Resident #59 was a Full Code resuscitation status. Review of a nursing progress note dated [DATE] at 9:00 A.M revealed LPN #75 entered Resident #59 ' s room to do his morning tube feeding and give his medications. LPN #75 called out the resident ' s name and he failed to respond. Resident #59 ' s skin was cool to touch on his extremities and torso with no response to physical stimuli. No pulses could be felt, and no respirations were noted. LPN #75 left the resident ' s room to check the code status and used the facility ' s paging system to call for assistance from an STNA and the ADON. LPN #75 called a second time for STAT assistance (a request for immediate assistance). CPR was started by Administrator #100 and multiple staff members responded. Emergency 911 was called. EMS was on scene and took over CPR. Time of death was documented at 9:32 A.M. The physician and family were notified. Review of LPN #75 ' s statement documented she was checking Resident #59 ' s code status at the nursing station in the computer chart and calling the physician to notify the resident was unresponsive. After reviewing the resident ' s information, she determined Resident #59 was a Full Code resuscitative status and told Administrator #100. Administrator #100 entered the resident ' s room and began CPR. LPN #75 went to the resident ' s room and began assisting Administrator #100 with CPR within minutes of finding the resident unresponsive. Review of Administrator #100 ' s statement, dated [DATE], documented sometime between 9:02 A.M. and 9:04 A.M., STNA #42 alerted the department heads, who were in a meeting, that Resident #59 was not breathing. Administrator #100 ran for assistance and directed Receptionist #07 to call 911. Administrator #100 arrived at the resident ' s room at 9:06 A.M. and started CPR, as staff had reported he was a Full Code. EMS arrived at 9:13 A.M. and took over the CPR. Review of STNA #42 ' s statement, dated [DATE] revealed during rounds at 7:00 A.M , Resident #59 appeared to be sleeping. At 9:04 A.M., after hearing a page to come to the unit from LPN #75, she went to the resident ' s unit. LPN #75 was at the nursing station on the computer and said she was calling the physician of Resident #59, who had expired. STNA #42 ran from the unit to notify department heads of the need for assistance. Review of the EMS run report, dated [DATE], revealed EMS received the call on [DATE] at 9:09 A.M. EMS arrived at the facility at 9:12 A.M. and was with the Resident at 9:14 A.M. Upon arrival, the report indicated facility staff were performing CPR. Resident #59 was pronounced deceased in the facility at 9:39 A.M. During an interview on [DATE] at 11:03 A.M., the DON stated LPN #75 left the room to determine the resident ' s code status and to contact the physician, as LPN #75 had assessed Resident #59 as unresponsive. The DON stated the time between LPN #75 finding Resident #59 unresponsive and initiating CPR was about six minutes. During an interview via telephone on [DATE] at 10:02 A.M., LPN #75 stated she entered Resident #59 ' s room on [DATE] at 9:00 A.M. He was not breathing, pale, mottled left heel, was cold to the touch, had no nail bed color and stated he had been gone for a while. She stated she left the resident, went to the nursing station to check his code status in the computer chart and called the physician. She was aware she was the only staff member on the unit of seven residents. She called for the STNA and ADON to come to the unit. After two minutes, she called STAT for the STNA and ADON to come to the unit. When STNA #42 arrived on the unit at 9:04 A.M., LPN #75 told her she needed assistance with answering call lights because she was calling the physician for Resident #59. LPN #75 stated she told the physician Resident #59 had been gone awhile and he was a Full Code. LPN #75 stated the physician gave an order to release the body. LPN #75 revealed at the time she was on the phone with the physician, Administrator #100 arrived at 9:06 A.M. and started CPR. When she completed the physician call, she assisted Administrator #100 with CPR. During a telephone interview on [DATE] at 10:42 A.M., Administrator #100 stated on [DATE] at 9:04 A.M., she responded to STNA #42 ' s alert of Resident #59 not breathing. She ran to the unit, providing direction to call 911, and obtained the crash cart. At that time, Social Service Designee #41 stated the resident was a Full Code. Administrator #100 arrived at Resident #59 ' s room at 9:06 A.M. and immediately began CPR with board in place and staff assisting with an Ambu bag. Upon entry to unit, LPN #75 stated she was on the phone with the physician. Resident #59 was non-responsive, no pulse, pale, and cold to touch. EMS arrived in five minutes or less and took over CPR. Immediately after the pronouncement of death at 9:32 A.M., the resident ' s family was notified. Administrator #100 stated LPN #75 was suspended and all staff present were educated regarding the facility ' s CPR procedure. All non-working nursing staff were educated within one hour of the incident. A mock Code Blue drill was performed on [DATE] at 12:15 P.M. During a telephone interview on [DATE] at 10:50 A.M., Physician #300 stated he received a phone call on [DATE] at 9:00 A.M. from LPN #75. LPN #75 stated Resident #59 was a full code and had expired. Physician #300 asked LPN #75 if EMS had been called. LPN #75 stated EMS had not been called and CPR had not been started. Physician #300 directed LPN #75 to call EMS and begin CPR, as LPN #75 needed verification of Resident #59 ' s status. Physician #300 verified he received a call 30 minutes later from LPN #75 who reported CPR had been started, EMS had performed CPR and pronounced Resident #59 ' s death. Review of the facility policy titled Cardiopulmonary Resuscitation (CPR), dated [DATE], revealed CPR will be provided to all residents who experience cardiopulmonary arrest. CPR is initiated unless one of the three following conditions is present: 1) a valid Do Not Resuscitate (DNR) order is in place; 2) documented verbal wishes by the resident or decision maker indicating the desire to be DNR but physician order is pending or 3) in the presence of signs of clinical death (e.g., rigor mortis, decapitation, transection, or decomposition). Equipment needed to perform CPR indicated use an Automatic External Defibrillator (AED). As soon as possible. If no AED is available, continue cycle of compressions. Emergency response guidelines included: Activate the emergency response team, do not leave patient alone; if you are alone with the victim, call out for help; if someone is nearby, instruct them to dial 911; in the event help is not available, call 911 and retrieve emergency cart prior to starting CPR, return as soon as possible. This deficiency substantiates Complaint Number OH 013.

Based on record review, and staff interview the facility failed to ensure one employee was quarantined ten days prior to returning to work as required by The Centers for Disease Control and Prevention, (CDC). This had the potential to affect 22 residents. The facility census was 65. Findings include: Review of the employee timeline log of employees testing positive for COVID -19 revealed on 02/08/21, State tested Nursing Assistant (STNA) #78 tested positive for COVID-19. Review of STNA #78's time card revealed she worked on 02/07/21 and returned to work on 02/14/21. During interview on 08/02/21 at 3:30 P.M., the Director of Nursing verified STNA #78 returned to work prior to completing the ten quarantine days as per CDC guidelines. STNA #78 provided care for 22 residents. Those residents were tested on [DATE] and all tested negative for COVID-19. The Centers for Disease Control and Prevention notification titled Return to Work Guidance for Employees (COVID-19) stated a health care provider who were asymptomatic throughout their infection and are not severely immunocompromised are to be off work at least 10 days have passed since the date of their first positive [CONDITION(S)] diagnostic test. This deficiency substantiates Complaint Number OH 424.

Based on review of an antibiotic tracking log, medical record review, staff interview, review of Food and Drug Administration (FDA) information, review of a HealthDay News Study and policy review, the facility failed to provide adequate justification for the use of antibiotics as a preventative measure for Coronavirus Disease (COVID-19). This affected six (#25, #70, #66, #46, #6 and #32) of 27 residents reviewed who were prescribed antibiotics. Facility census was 62. Findings include: Review of antibiotic use tracking log dated January 2021 revealed Resident #66, #6, and #32 were prescribed [MEDICATION NAME] 250 milligrams (mg) for five days beginning on 01/16/21 for cough and shortness of breath (SOB). Resident #46 was prescribed [MEDICATION NAME] 250 mg for five days beginning on 01/18/21 for cough and SOB Resident #25 was prescribed [MEDICATION NAME] 250 mg beginning on 02/15/21 through 02/21/21 for positive COVID-19 swab. Resident #70 was prescribed [MEDICATION NAME] 250 mg for five days with no start date for dry cough and stuffy nose. Further review revealed there was no documentation or evidence to support McGeer's criteria or other assessment were utilized to determine if an antibiotic should be prescribed and administered as a treatment for [REDACTED]. Review of the Facility Infection Surveillance Tool dated 01/16/21 revealed Resident #6 had decreased oxygen, cough, SOB and hoarseness with the organism marked as COVID-19 with an antibiotic order for [MEDICATION NAME] 250 mg for five days. Review of x-[MEDICAL CONDITION] (x-ray) results dated 01/15/21 for Resident #6 revealed no pneumonia and lungs were clear. Review of telephone order dated 01/15/21 for Resident #6 revealed an order [MEDICATION NAME] 500 mg one time for COVID-19 with respiratory symptoms and then [MEDICATION NAME] 250 mg for four days. Review of the Facility Infection Surveillance Tool, undated, revealed Resident #25 had abnormal breath sounds with the organism marked as COVID-19, no x-ray was obtained and an antibiotic was ordered for [MEDICATION NAME] 250 mg beginning on 02/15/21 through 02/21/21. Review of telephone order dated 02/12/21 for Resident #25 revealed an order for [REDACTED]. Review of the Facility Infection Surveillance Tool dated 01/16/21 revealed Resident #32 had congestion, cough, and runny nose with the organism marked as COVID-19. No x-ray was obtained, and with an antibiotic order for [MEDICATION NAME] mg for five days. Review of telephone order dated 01/15/21 for Resident #32 revealed an order for [REDACTED]. Review of the Facility Infection Surveillance Tool dated 02/19/21 revealed Resident #70 had COVID-19, dry cough, and stuffy nose with the organism marked as COVID-19. No x-ray was obtained and with an antibiotic order for [MEDICATION NAME] 250 mg for five days. Review of telephone order dated 01/15/21 for Resident #70 revealed an order [MEDICATION NAME] 500 mg one time for COVID-19 with respiratory symptoms and then [MEDICATION NAME] 250 mg for four days. Review of the Facility Infection Surveillance Tool dated 01/19/21 revealed Resident #46 had decreased oxygen levels, sore throat, cough, and runny nose with the organism marked as COVID-19, and an antibiotic was ordered for [MEDICATION NAME] 250 mg for five days beginning on 01/18/21. Review of Resident #46's x-ray results dated 01/05/21 and 01/10/20, revealed no infiltrates or pneumonia and lungs were clear. Review of telephone order dated 01/18/21 for Resident #46 revealed an order for [REDACTED]. Review of the Facility Infection Surveillance Tool dated 01/16/21 revealed Resident #66 had decreased oxygen levels, cough, and runny nose with the organism marked as COVID-19 and an antibiotic was ordered for [MEDICATION NAME] 250 mg for five days beginning on 01/18/21. Review of Resident #66's x-ray results dated 01/15/21 revealed no acute findings and similar to prior. Review of telephone order dated 01/15/21 for Resident #66 revealed an order [MEDICATION NAME] 500 mg one time for COVID-19 with respiratory symptoms and then [MEDICATION NAME] 250 mg for four days. On 03/16/21 at 4:00 P.M. an interview with the Administrator and Director of Nursing (DON), confirmed the antibiotics were prescribed by the facility doctor and/or nurse practitioner as a COVID-19 treatment for [REDACTED]. The DON stated that the antibiotics were administered to Resident #25, #70, #66, #46, #6 and #32 per the providers' orders even though a bacterial infection was not confirmed. Review of the information on the FDA website at https://www.fda.gov revealed the following FDA response to the questions regarding COVID-19: Are antibiotics effective in preventing or treating COVID-19? The answer is No. Antibiotics do not work [MEDICAL CONDITION]; they only work on bacterial infections. Antibiotics do not prevent or treat COVID-19, because COVID-19 is caused by [MEDICAL CONDITION], 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. Additionally, an article from HealthDay News, titled Many COVID-19 Patients Given Useless Antibiotics: Study 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 [MEDICAL CONDITION], and very few of those patients actually had a coexisting bacterial infection. Antibiotics kill bacteria but are useless against [MEDICAL CONDITION] infections such as the common cold, the flu and COVID-19. Review of the facility undated Antibiotic Stewardship policy, dated 08/19/20 documented the following: As a component of the monthly Infection Prevention and Control Committee (IPCC) meeting the facility's use of antibiotics will be reviewed to include: monitoring/tracking of antibiotic prescribing, use, and resistance in order to promote a culture of optimal antibiotic use within the facility. Antibiotic Stewardship will focus on improving antibiotic use by avoiding unnecessary or inappropriate antibiotics.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, staff interview, and review of the Broda Chair Instruction manual (a positioning wheelchair), the facility failed to ensure a resident was properly transported in a Broda wheelchair utilizing foot pedals. This resulted in actual harm for one resident (#05) when staff pushed the resident in the wheelchair without foot pedals and the resident placed her feet down to the floor and the wheelchair was pushed over the resident's foot resulting in a fracture to her right ankle. This affected one (#05) of three residents reviewed for accidents. The facility census was 92. Findings include: Review of Resident #05's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #05's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was alert to name only and a Brief Interview of Mental Status (BIMS) score was unable to be obtained as the resident was rarely/never understood. The resident was totally dependent on staff for mobility with one-person assistance and with the use of a wheelchair as a device. Review of Resident #05's Nursing Notes dated 12/31/18 revealed at approximately 7:45 A.M., Licensed Practical Nurse (LPN) #34 was called to the dining room to assess the right foot of Resident #05. State tested Nursing Assistant (STNA) #20 reported that while she was pushing the resident in her wheelchair into the dining room, the resident put her foot on the ground while the wheelchair was moving, causing the foot to bend. Upon assessment, evidence of pain was noted to the Right Lower Extremity (RLE) with non-verbal signs noted, at a pain level of three out of 10. There was no documented evidence foot pedals were being used at the time of the incident. Review of Resident #05's x-ray report revealed it was obtained on 12/31/18 with the results sent to the facility on [DATE] at 5:58 P.M. Findings included a [MEDICAL CONDITION] tibia and fibula. The family and physician were notified of the x-ray results and the findings of a fracture to the right ankle. Physician notification indicated the physician would be in the next day to brace the ankle until an orthopedic appointment could be made. Staff were to continue to monitor the site for pain, redness and tenderness. Review of Resident #05's Nursing notes dated 01/03/19 at 8:35 A.M. revealed the physician was in the facility and put a splint on the resident's right ankle. The physician indicated the resident was to follow-up with the orthopedic physician when he came into the facility. Staff could remove the splint to check the RLE whenever necessary. Further review of Resident #05's medical record on 01/15/19 revealed the resident had not been seen by an orthopedic physician as of this date. Observation of Resident #05 on 01/14/19 at 8:55 A.M. revealed the resident was in bed and provided no verbalizations when questions were asked. Resident #05 was observed to have a brace to her right foot, with bilateral foot pedals sitting on the seat of her Broda wheelchair. Interview with STNA #07 on 01/14/19 at 1:15 P.M. revealed Resident #05 had been able to propel herself in her Broda wheelchair most of the time, but she always used foot pedals when she was pushing the resident in the chair. Interview with STNA #66 on 01/14/18 at 2:20 P.M. revealed she always pushed the resident in her wheelchair (Broda), and that the resident does not self-propel as far as she could remember. She stated that staff always have to provide assistance for locomotion at all times. She could not remember if the resident had ever used foot pedals prior to 12/31/18. Telephone interview with LPN #34 on 01/14/19 at 3:10 P.M. revealed she was the nurse on duty on 12/31/18 for Resident #05. LPN #34 confirmed that an aide was taking the resident to the dining room at the time of the incident. The nurse stated it was reported to her by the aide that the right foot of Resident #05 had gotten caught under the wheelchair as she had been taking the resident to the dining room. She stated the resident would sometimes hold her feet up off the floor but would also try and stop by using her feet prior to this incident. Interview with LPN #59 on 01/15/19 at 8:15 A.M. revealed that she would expect anyone assisting a resident with ambulation in a wheelchair to have bilateral foot pedals in place for safety. The nurse verified that the pedals should be used whenever a resident was being pushed by staff. Interview with STNA #20 on 01/15/19 at 11:00 A.M. verified she was pushing Resident #05 to the dining room on 12/31/18. She stated as she was pushing her, the resident lowered her foot to the ground fast and her right foot went under the wheelchair, and the resident stated, ouch. She verified that she did not use foot pedals while she was pushing the resident to the dining room and verified that the foot pedals should have been used. The STNA stated that Resident #05 had a history of [REDACTED]. During an interview on 01/15/19 at 11:33 A.M. with the Director of Nursing (DON) and the Administrator they both verified they would expect staff to use foot pedals for any resident that was being pushed in a wheelchair, at any time. The Administrator verified Resident #05 was improperly pushed in a wheelchair by facility staff on 12/31/18 resulting in a fracture to the right ankle. Review of the Operating Manual for the Broda chair revealed the manual was issued on 10/23/15 and remained current for the chair. Review of Section 2.5.5, Item #4, indicated that all resident and caregiver's bodies should be clear of all pinch points to prevent injury. As a result, the facility implemented the following actions to correct the deficiency on 01/07/19: · On 12/31/19, Resident #05 was assessed at the time of the incident. The physician and responsible party were notified, and an x-ray was obtained, an order for [REDACTED]. · On 01/01/19, the physician and responsible party were notified of the x-ray results. · On 01/02/19, therapy evaluated the resident and recommended foot pedals be implemented. · On 01/03/19, the physician applied a splint to the resident's ankle. · On 01/03/19, the DON and Assistant Director of Nursing (ADON) completed an audit of other current residents who utilize wheelchairs to determine if leg rests were indicated for use. Any identified during audits were corrected as indicated. · On 01/03/19 and 01/04/19, the DON and/or designee completed staff education on the use of foot pedals when transporting residents. · On 01/03/19, 01/07/19, and 01/14/19, the DON and/or designee conducted audits to ensure foot pedals were in place on wheelchairs as indicated. · Audits will be completed by the DON and/or designee ongoing weekly for two additional months. The results of the audits will be submitted to the Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. · Interviews on 01/15/18 with LPN #38 and STNA #20 verified they were in-serviced on transporting residents while in wheelchairs with foot pedals. This deficiency substantiates Complaint Number #OH 930.