Every finding on record at Eliza at Chagrin Falls

Based on observation and staff interview, the facility failed to appropriately label and date food for storage. This had the potential to affect 21 of 22 residents who received meals from the facility kitchen. The facility identified one resident (Resident #1) who received no food by mouth. The facility census was 22.Findings include: Observations on 01/20/26 at 9:52 A.M. with Dietary Manager #239 during the initial main kitchen tour revealed the following:In dry storage there was a bag of tortilla chips open to air and not labeled or dated.In the refrigerator there was an almost full pan of orange gelatin left uncovered, unlabeled and undated, a bag of diced carrots left open, unlabeled and undated, and a bag of cheddar cheese left open, unlabeled and undated.In the freezer there was a bag of French fries open to air not labeled and dated and a bag of fried chicken open to air, not labeled or dated.Interview at the time of the observation with Dietary Manager #239 verified the above findings during the initial kitchen tour.

Based on record review, interview and review of facility policy, the facility failed to provide showers/bathing per resident preference and schedule. This affected six residents (#10, #11, #14, #25, #34 and #37) out of 22 residents reviewed for showers. The facility census was 22.Findings include:1. Review of the medical record for Resident #25 revealed an admission date of 06/15/24 with diagnoses of metabolic encephalopathy, acute cystitis (bladder infection), dementia, heart failure, anxiety disorder, delirium, and malignant neoplasm of trachea. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive decline. The resident required moderate assistance for all activities of daily living (ADL) including grooming, hygiene, and toileting needs. Resident #25 was dependent on staff for all mobility and transfer needs and utilized a wheelchair. The resident was always incontinent of bowel and bladder. Review of Resident #25's physician orders effective January 2026 revealed Resident #25 was to receive showers and skin checks twice weekly every Wednesday and Saturday per resident preference. Interview on 01/20/26 at 9:40 A.M. with Resident #25 revealed she had not received scheduled showers twice weekly per her preference. The resident stated it had been a while since she had a shower and would like them to restart. Resident #25 could not recall the last time she received a shower/bed bath. Interview with Certified Nursing Assistant (CNA) #208 on 01/22/25 at 7:25 A.M. revealed showers were scheduled twice weekly or more per resident preference. All showers were documented on a shower sheet for each resident and given to the Director of Nursing (DON) upon completion. Both the CNA and nurse sign off on all shower sheets and include documentation of skin checks for that resident. CNA #208 revealed if a resident refused a shower, the CNAs attempted again later that day and notified the nurse who provided re-education to the resident regarding the importance of showers/bed baths. CNA #208 stated that any refusals for showers/bed baths by a resident were documented in the progress notes and in the CNA tasks in the electronic medical record (EMR). Review of shower sheets for the last two months (December 2025 to January 2026) for Resident #25 revealed only two showers were documented, 12/31/25 and 01/07/26. Review of progress notes for Resident #25 revealed one documented shower refusal on 01/18/26. Review of CNA tasks in Resident #25's EMR revealed only one shower was documented on 12/26/25 from December 2025 to January 2026. Interview with the DON on 01/22/26 at 11:45 A.M. verified the missed showers for Resident #25 including the lack of shower/bathing documentation. 2. Review of the medical record for Resident #10 revealed an admission date of 01/05/26 with diagnoses including quadriplegia, malignant neoplasm of the spinal cord, and muscle wasting. Review of January 2026 physician orders revealed Resident #10 had an order dated 01/07/26 to schedule and complete skin checks twice weekly on bath/shower days in the morning every Wednesday and Sunday. Review of the care plan dated 01/05/26 revealed Resident #10 had an ADL functional performance deficit being dependent on staff for assistance. Interventions included for staff to provide assistance to maintain hygiene, adjust clothing, roll from lying on the back to left and right, transfers to bed to chair, and for dressing. Review of the five-day MDS assessment dated [DATE] revealed Resident #10 had intact cognition. He was dependent on staff assistance for showers/bathing, rolling left and right and transfers. Review of facility Shower Sheets revealed Resident #10 had a shower on 01/07/26 and on 01/18/26. The shower sheet dated 01/18/26 indicated Resident #10's wife assisted him with his shower. Interview on 01/20/26 at 11:48 A.M. with Resident #10 revealed he did not feel there was enough staff as he had been at the facility for three weeks and only had two showers. He was scheduled for and preferred to have a shower twice a week on Wednesday and Sunday. He had to have his wife come in and give him a shower on 01/17/26, since the facility had missed the previous two scheduled showers on 01/11/26 and 01/14/26. Staff had stated they were unable to give him a shower on those days as they did not have time. Interview on 01/22/26 at 9:30 A.M. with Agency CNA #231 revealed she came to the facility approximately six times a month and was unable to get all her scheduled showers/baths completed as there were too many assigned to be able to get done. Interview on 01/22/26 at 11:44 A.M. with Interim DON revealed Resident #10 was to receive a shower twice a week as scheduled as well as per his preference. She verified Resident #10 had received only two showers since admission on [DATE]. She also verified the shower sheet completed on 01/18/26 should have been dated 01/17/26 (Saturday) as she had assisted Resident #10 to his shower chair so Resident #10's wife could give him a shower. She verified Resident #10 did not receive a shower or bath from 01/08/26 to 01/16/26 (nine days) including on his scheduled shower days, 01/11/26 (Sunday) and 01/14/26 (Wednesday). She revealed there had been a problem with showers getting completed and had not found a solution yet. She stated she was going to go over the issue at the next staff meeting. 3. Review of the medical record for Resident #34 revealed an admission date of 01/13/26. On 01/22/26, the resident was sent to the hospital emergency room (ER). His diagnoses included malignant neoplasm to his prostate, diabetes, and hypertension. Review of January 2026 physician orders revealed Resident #34 had an order dated 01/16/26 to schedule and complete skin checks twice weekly on bath/showers days every night shift on Monday and Friday. Review of baseline care plan dated 01/15/26 revealed Resident #34 was cognitively intact and under the shower and bathing section he was not assessed for his ability. He required partial to moderate assistance with transfers. Review of facility Shower Sheets revealed one shower sheet since Resident #34's admission that was dated 01/16/26 at 9:00 P.M., completed by CNA #208. The sheet revealed he was offered a shower and Resident #34 had refused as he stated he was tired. Interview at the time of the review with the Administrator verified the sheet was filled out on 01/22/26. Interview on 01/20/26 at 9:27 A.M. with Resident #34 and Resident #34's wife revealed the biggest concern they had with the facility was not receiving a bed bath since he was admitted to the facility. Resident #34 stated the staff had not washed him since he was admitted and he felt dirty. Interview on 01/21/26 at 3:07 P.M. with the Administrator verified there were no shower/bath sheets for Resident #34 from the date Resident #34 was admitted on [DATE] until 01/21/26 (nine days). Interview on 01/22/26 at 8:45 A.M. with the Administrator revealed he interviewed staff that had provided care for Resident #34 to find out why there were no shower/bath sheets and found CNA #208 had offered Resident #34 a shower/bed bath on 01/16/26 but he had refused. CNA #208 had not filled out a shower/bath sheet until today, 01/22/26. Interview on 01/22/26 at 9:30 A.M. with Agency CNA #231 revealed she came to the facility approximately six times a month and was unable to get all her showers/baths completed as scheduled as there were too many assigned to be able to get done. Interview on 01/22/26 at 11:44 A.M. with Interim DON revealed Resident #34 was scheduled to receive a shower and/or bath twice a week. The only shower/bath sheet was dated 01/16/26 (that was filled out on 01/22/26). She verified she had no documentation Resident #34 was offered or given a shower/bath from 01/17/26 to 01/22/26 (six days) including on 01/19/26, his scheduled shower/bath day. She stated there had been a problem with showers getting completed and had not found a solution yet. She was going to go over the issue at the next staff meeting. 4. Review of the closed medical record for Resident #37 revealed an admission date of 08/01/25 and discharge to home on [DATE]. His diagnoses included fracture of right arm, hypertension, unsteadiness on feet, muscle weakness and history of falling. Review of August 2025 physician orders for Resident #37 revealed an order dated 08/01/25 to schedule and complete skin checks twice weekly on bath/shower days every nightshift on Tuesday and Saturday, and an order dated 08/19/25 to schedule and complete skin checks twice weekly on bath/shower days every dayshift on Tuesday and Saturday. Review of the five-day MDS assessment dated [DATE] revealed Resident #37 had impaired cognition. He required substantial to maximum staff assistance with lower body dressing and transfers. He was dependent on staff for rolling left and right in bed. The assessment indicated showers/bathing were not attempted due to medical condition and/or safety concerns. Review of facility Shower Sheets revealed Resident #37 had a bed bath on 08/12/25 and 08/26/25. Review of the care plan dated 08/16/25 revealed Resident #37 had an ADL functional performance deficit being dependent on staff for assistance. Interventions included for staff to provide assistance with hygiene, adjusting clothes, rolling left and right in bed, and substantial to maximum assistance with transfers. Interview on 01/22/26 at 9:30 A.M. with Agency CNA #231 revealed she came to the facility approximately six times a month and stated she was unable to get all her showers/baths completed as scheduled as there were too many assigned to be able to get done. Interview on 01/22/26 at 11:44 A.M. with Interim DON revealed Resident #37 was scheduled to receive a shower and/or bath twice a week and there was no medical reason why Resident #37 could not at least receive a bed bath during his stay. She verified the facility only had two shower sheets for Resident #37 during his stay, on 08/12/25 and 08/26/25, and there was no evidence Resident #37 received a shower from 08/01/25 to 08/11/25 (11 days) and from 08/13/25 to 08/25/25 (13 days). She stated there had been a problem with showers getting completed and had not found a solution yet. She was going to go over the issue at the next staff meeting. 5. Review of the medical record for Resident #11 revealed an admission date of 08/23/24. Diagnoses included macular degeneration, Crohn's disease, osteoarthritis, and a history of falling. Review of the quarterly MDS assessment dated [DATE] revealed Resident #11 had intact cognition. The resident used a wheelchair for mobility and required partial/moderate assistance for showers/baths, sit to stand, and transfers. Review of physician orders effective January 2026 revealed Resident #11 was to receive showers and skin checks twice weekly on Wednesdays and Saturdays. Review of the shower sheets for the last two months (December 2025 to January 2026) revealed Resident #11 received a shower on 12/06/25 and 12/10/25. Thereafter, there was a ten-day gap before a shower was received on 12/20/25. The resident then had a shower on 12/24/25 and refused a shower on 12/27/25. Afterwards, the resident did not receive another shower until 01/10/26 which was 14 days from the previous shower. Ten days after that Resident #11 received a shower on 01/17/26. Interview on 01/20/26 at 11:32 A.M. with Resident #11 stated she didn't get her showers when she was supposed to. Interview on 01/21/26 at 3:07 P.M. with the Administrator verified there were no additional shower/bath sheets for Resident #11. Interview on 01/22/26 with CNA #208 revealed Resident #11 required total care, could assist and was able to stand and pivot. The resident did not refuse care. Interview on 01/22/26 at 9:30 A.M. with Agency (CNA) #231 revealed she came to the facility approximately six times a month and stated she was unable to get all her scheduled showers/baths completed as there were too many assigned to be able to get done. Interview on 01/22/26 at 11:44 A.M. with Interim DON revealed Resident #11 was to receive a shower twice a week as scheduled as well as per preference. She verified that those were all the shower sheets available for Resident #11. She stated there had been a problem with showers getting completed and had not found a solution yet. She was going to go over the issue at the next staff meeting. 6. Review of the medical record for Resident #14 revealed an admission date of 01/02/26. Diagnoses included displaced intertrochanteric fracture, diabetes, congestive heart failure, and a history of falling, Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had intact cognition. The resident was one-person physical assistance with showers/bathing. Review of physician orders effective January 2026 revealed Resident #14 was to have showers and skin checks twice weekly on Mondays and Thursdays. Review of the shower sheets from admission for Resident #14 revealed the resident received a bed bath on 01/20/26. There were no other shower sheets. Interview on 01/20/26 at 1:50 P.M. with Resident #14 stated she didn't get enough showers. Interview on 01/21/26 at 3:07 P.M. with the Administrator verified there were no additional shower/bath sheets for Resident #14. Interview on 01/22/26 at 9:30 A.M. with Agency (CNA) #231 revealed she came to the facility approximately six times a month and stated she was unable to get all her scheduled showers/baths completed as there were too many assigned to be able to get done. Interview on 01/22/26 at 11:44 A.M. with Interim DON revealed Resident #14 was to receive a shower twice a week as scheduled as well as per preference. She verified that those were all the shower sheets available for Resident #14. She stated there had been a problem with showers getting completed and had not found a solution yet. She was going to go over the issue at the next staff meeting. Review of facility policy labeled, Hygiene, Bathing, and Showering Policy, revised 2023 revealed the facility provided assistance with personal hygiene, bathing, and showering to maintain residents' comfort, dignity, health, and quality of life. Hygiene and bathing services were provided in accordance with the residents' needs and preferences. This deficiency represents non-compliance investigated under Complaint Number 2599654.

Based on observation, interview, record review, review of Centers for Medicare & Medicaid Services memorandum and review of facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were in place or implemented when indicated and the facility failed to ensure the catheter valve/port on Resident #33's indwelling catheter (a flexible tube used to drain urine from the bladder) drainage bag (a bag that collects urine) was not on the floor. This affected four Residents (#1, #14, #33, #36) out of ten residents reviewed for EBP and/or catheter use. This had the potential to affect 14 residents (#1, #6, #10, #12, #14, #19, #21, #22, #25, #27, #28, #33, #34 and #36) identified with EBP and seven residents (#6, #10, #14, #19, #22, #25 and #33) identified by the facility with urinary catheters. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 01/14/26 and his diagnoses included aftercare following surgery of genitourinary system, acute cystitis and malignant neoplasm of the bladder. Review of the undated Baseline Care Plan for Resident #36 revealed Resident #36 had bilateral nephrostomy tubes (a thin catheter that drains urine directly from the kidney). There was nothing on his care plan regarding EBP to be utilized. Review of January 2026 physician orders for Resident #36 revealed an order dated 01/17/26 for EBP including gown and glove during high contact resident care activities due to bilateral nephrostomy tubes. Observation on 01/21/26 at 7:58 A.M. revealed an aide came and reported to Agency Registered Nurse (RN) #238 that Resident #36 had blood in his right nephrostomy tube and bag. Agency RN #238 went to check Resident #36's nephrotomy tube and upon entrance to his room there was no signage indicating Resident #36 was on EBP. Agency RN #238 proceeded to apply gloves but no gown as she bent over Resident #36 and assessed including turning him to his side. During her assessment Agency RN #238's uniform came in direct contact with Resident #36. Agency RN #238 contacted Physician Assistant (PA) #235 of the blood in his nephrostomy tube. Interview on 01/21/26 at 8:05 A.M. with Interim Director of Nursing (DON) who was walking by Resident #36's room verified there was no signage that indicated Resident #36 was on EBP. She verified Resident #36 was to be on EBP due to his bilateral nephrostomy tubes. Observation on 01/21/26 at 8:12 A.M. revealed Agency RN #238 re-entered Resident #36's room as PA #235 asked her to get a set of vitals. PA #235 was in his room with gloves on but no gown and evaluated Resident #36 including leaning over Resident #36 as she conducted a head-to-toe assessment. During PA #235's assessment her white lab coat came in direct contact with Resident #36. Agency RN #238 then obtained his blood pressure, heart rate, and oxygen saturation without gloves and/or a gown in place. Interview on 01/21/26 at 8:20 A.M. with PA #235 verified Resident #36 was on EBP. She stated she was not even thinking and went in and assessed Resident #36. She verified she did not utilize a gown. Interview on 01/21/26 at 10:00 A.M. with Agency RN #238 revealed she was from agency and did not see a sign indicating Resident #36 was on EBP. She verified she did not wear a gown as she assessed Resident #36 and when she took Resident #36's vitals she did not have gloves and/or a gown on. Interview on 01/21/26 at 12:06 P.M. with Interim DON verified Agency RN #238 and PA #235 should have worn EBP including gloves and gown during Resident #36's assessment and taking vitals as they were in direct contact. 2. Review of the medical record for Resident #33 revealed an admission date of 01/19/26 and his diagnoses included benign prostatic hyperplasia (enlargement of the prostate causing urinary issues) with lower urinary tract symptoms, chronic kidney disease, and diabetes. Review of January 2026 physician orders revealed Resident #33 had an order for an indwelling urinary catheter and catheter care to be provided every shift. There was no order for EBP. He also had an order for cephalexin (antibiotic) 500 milligrams (mg) one capsule by mouth every six hours for four days as he had a urinary tract infection (UTI). Review of the care plan dated 01/20/26 revealed Resident #33 required EBP as he was at risk for developing a MRDO (multidrug resistant organism) infection as he had a wound. Interventions included posting signage on the door or wall outside of the resident room indicating precautions and required personal protective equipment of gown and gloves. Observation on 01/20/26 at 9:16 A.M. revealed Resident #33 was lying in a low bed with his indwelling urinary catheter drainage bag on the side of his bed with part of the bag laying on the floor. The valve/port to the drainage bag was in direct contact with the floor as the drainage bag was not in a dignity pouch. Interview on 01/20/26 at 9:18 A.M. with Licensed Practical Nurse (LPN) #222 verified Resident #33's indwelling urinary catheter drainage bag valve/port was in direct contact with the floor and part of the bag was also lying on the floor. She also verified there was no signage on the outside of Resident #33's door indicating he was on EBP. She verified he should be on EBP as he had an indwelling urinary catheter and wounds. She also verified he had a current UTI and was on antibiotic therapy. Review of the Baseline Care Plan dated 01/21/26 revealed Resident #33 had an indwelling urinary catheter and was dependent on staff for his toileting hygiene. There was nothing in the baseline care plan regarding care of his urinary catheter including keeping the drainage bag especially the valve/port off the floor and EBP. Interview on 01/21/26 at 12:06 P.M. with Interim DON verified Resident #33's indwelling catheter bag should not be on the floor and Resident #33 did not have an order for EBP. She verified he should have had a physician order for EBP as he had wounds and an indwelling urinary catheter. She revealed when a resident was admitted at times there was a delay in getting the signage up and a physician order for EBP. She revealed it was not on the admitting nurse checklist to implement and that she had planned to add that so at times the signage did not get hung or the physician order obtained until she came in and reviewed the admission. She verified it could be a day or two after a resident was admitted until she was on duty to hang up the sign and obtain a physician order for EBP. 3. Review of the medical record for Resident #1 revealed an admission date of 12/31/25 and his diagnoses included acute and chronic respiratory failure, hypertension, malignant neoplasm of tongue and presence of gastrostomy tube (g-tube) (a tube inserted through the abdomen into the stomach to provide nutrition, fluids, and/ or medications). Review of January 2026 physician orders revealed Resident #1 had an order for EBP including wearing gown and gloves during high-contact resident care activities due to presence of a g-tube. Review of the care plan dated 01/02/26 revealed Resident #1 required EBP as he was at risk for developing a MRDO (multidrug resistant organism) infection as he had a wound and an indwelling medical device (g-tube). Interventions included posting signage on the door or wall outside of the resident room indicating precautions, personal protective equipment (PPE) of gown and gloves, and providing education to the resident, visitors and caregivers. Review of the five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had intact cognition and had a g-tube. Observation on 01/21/26 at 9:17 A.M. revealed LPN #222 applied gloves and gown prior to entering Resident #1's room to administer his medications through his g-tube. Resident #1 and Resident #1's wife, who was present in the room immediately questioned LPN #222 why the nurse had a gown on. LPN #222 explained that Resident #1 was on EBP due to his g-tube and staff needed to wear gloves and gown when in direct contact with Resident #1. Resident #1 and Resident #1's wife became upset stating he had been at the facility several weeks and never had seen any staff including LPN #222 wear a gown during the administration of his g-tube medications and/or other direct care needs. LPN #222 shrugged her shoulders when Resident #1 and Resident #1's wife questioned again why it was the first time staff had worn a gown. Interview on 01/21/26 at 9:29 A.M. with Resident #1's wife revealed she was upset as she was at the facility every day and had seen Resident #1 multiple times receive his medications through his g-tube and the nurse had never had a gown on until today, 01/21/26. Interview on 01/21/26 at 12:06 P.M. with Interim DON verified Resident #1 was on EBP as he had a g-tube and that staff were to wear a gown and gloves especially during high contact care activities including the administration of medications through his g-tube. 4. Review of the medical record for Resident #14 revealed an admission date of 01/02/26. Diagnoses included displaced intertrochanteric fracture, diabetes, congestive heart failure, and a history of falling. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required one-person physical assistance with showers/bathing. Review of January 2026 physician orders for Resident #14 revealed an order for Enhanced Barrier Precautions: gown and glove use during high-contact resident care activities due to a surgical wound. Review of the care plan dated 01/18/26 revealed Resident #14 required EBP for being at risk for developing a MRDO (multidrug resistant organism) infection because of a wound. Interventions included posting signage on the door or wall outside of the resident room indicating precautions and required personal protective equipment of gown and gloves. Observation on 01/21/26 at 7:56 A.M. of Resident #14 revealed the resident in bed asleep. There was signage on the door indicating Enhanced Barrier Precautions (EBP) and there was no Personal Protective Equipment (PPE) on or near the door to the resident's room. Interview on 01/21/26 at 8:02 A.M. with LPN #222 confirmed PPE for EBP was not in place. Review of facility policy labeled, Indwelling Catheter Justification and Removal, dated 2023 revealed there was nothing in the policy regarding ensuring the catheter drainage bag was not on the floor. Review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, by the Centers for Medicare & Medicaid Services, Department of Health & Human Services revealed enhanced barrier precautions are indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. The effective date for implementation of enhanced barrier precautions under the guidelines was 04/01/24. Review of the undated facility policy labeled, Enhanced Barrier Precautions (EBP), revealed the purpose of the policy was to prevent the spread of MDRO and other transmissible pathogens through consistent application of EBP. Facilities were to implement EBP for residents who are colonized or infected with MDRO, are at risk for MDRO including ventilator-dependent residents, residents with indwelling medical devices and residents with wounds. EBP expands standard precautions by requiring a gown and gloves during high-contact resident care activities. The policy revealed a standardized sign would be posted outside the resident room indicating EBP required.

Based on observation, interview, record review and review of facility policy, the facility failed to appropriately cover an indwelling urinary catheter drainage bag with a dignity/privacy pouch. This affected one resident (#33) out of three residents reviewed for urinary catheters and had the potential to affect seven residents (#6, #10, #14, #19, #22, #25 and #33) identified by the facility with urinary catheters. The facility census was 22.Findings include: Review of the medical record for Resident #33 revealed an admission date of 01/19/26 and his diagnoses included benign prostatic hyperplasia (enlargement of the prostate causing urinary issues) with lower urinary tract symptoms, chronic kidney disease, and diabetes. Review of January 2026 physician orders revealed Resident #33 had an order for an indwelling urinary catheter and catheter care was to be provided every shift. Observation on 01/20/26 at 9:16 A.M. revealed Resident #33 was lying in a bed with his indwelling urinary catheter drainage bag on the side of his bed with part of the bag laying on the floor. From the hallway, yellow urine of approximately 100 cubic centimeters (cc) was seen as there was no dignity/privacy pouch covering the catheter drainage bag. Interview on 01/20/26 at 9:16 A.M. with Resident #33 revealed he was pleasantly confused regarding the privacy of his catheter. Interview on 01/20/26 at 9:18 A.M. with Licensed Practical Nurse (LPN) #222 verified Resident #33's indwelling urinary catheter drainage bag was not covered with a dignity/privacy pouch and from the hallway, urine was seen inside his drainage bag. Review of Baseline Care Plan dated 01/21/26 revealed Resident #33 had an indwelling catheter and was dependent on staff for his toileting hygiene. There was nothing in the care plan about providing a dignity pouch to cover his urinary catheter drainage bag.Review of facility policy labeled, Resident Rights, dated 11/28/16 revealed all residents had the right to be treated with dignity and respect. There was nothing in the policy regarding ensuring privacy/dignity in relation to covering an indwelling catheter drainage bag. This deficiency represents non-compliance investigated under Complaint Number 2599654.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents were free of significant medication errors. This affected two residents (#1 and #25) out of five residents reviewed for medication administration. The facility census was 22.Findings include:1. Review of the medical record for Resident #25 revealed an admission date of 06/15/24 with diagnoses of metabolic encephalopathy, acute cystitis (bladder infection), dementia, heart failure, anxiety disorder, delirium, and malignant neoplasm of trachea. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive decline. Resident #25 required moderate assistance for all activities of daily living including grooming, hygiene, and toileting needs, and was dependent on staff for mobility and transfers utilizing a wheelchair. Review of the care plan dated 12/26/25 revealed Resident #25 had congestive heart failure Interventions included to administer cardiac medications as ordered and to monitor any signs and symptoms of congestive heart failure including orthopnea (difficulty breathing while lying down), weakness and/or fatigue, increased heart rate, lethargy (drowsiness) and disorientation. Review of physician orders revealed Resident #25 had an order dated 12/29/25 for amlodipine besylate 5 milligrams (mg) once daily for hypertension with a parameter to hold the medication for systolic blood pressure (SBP) less than 130. Review of the Medication Administration Record (MAR) for December 2025 and January 2026 revealed Resident #25 was erroneously administered amlodipine on multiple days when the ordered parameters indicated the medication was to be held. Resident #25 received amlodipine on 01/05/26 with a SBP of 116, on 01/07/26 with a SBP of 127, on 01/08/26 with a SBP of 122, on 01/10/26 with a SBP of 121, on 01/11/26 with a SBP of 113, on 01/12/26 with a SBP of 104, on 01/17/26 with a SBP of 108, and on 01/18/26 with a SBP of 118. Interview on 01/21/25 at 5:15 P.M. with Director of Nursing (DON) verified the multiple significant medication errors and stated nursing staff should not have administered the amlodipine as the blood pressure levels were outside of the parameters to be given. 2. Review of the medical record for Resident #1 revealed an admission date of 12/31/25 and diagnoses included dysphagia (difficulty swallowing), acute and chronic respiratory failure with hypoxia (low levels of oxygen in body tissues), malignant neoplasm of the tongue, and gastrostomy status (g-tube) (a tube inserted through the abdomen into the stomach to provide nutrition, fluids, and/or medications). Review of December 2025 and January 2026 physician orders revealed Resident #1 had the following orders: aspirin 81 mg chewable tablet per g-tube due to heart disease, atorvastatin calcium (cholesterol medication) 40 mg tablet per g-tube in the morning, and brensocatib 25 mg tablet per g-tube in the morning due to bronchiectasis (a lung condition that causes cough, sputum production with recurrent lung infections). He had an order dated 12/31/25 that medications may be crushed as appropriate and placed in a food item or given with liquid. There was no order indicating the medications could be crushed together and administered through his g-tube. Review of the care plan dated 01/06/26 revealed Resident #1 had a nutritional problem related to dysphagia, hypertension, chronic kidney disease, underweight and enteral nutrition related to nothing by mouth status (NPO). Interventions included providing enteral nutrition and flushes as ordered, and the dietician to evaluate. There was nothing in the care plan regarding administration of medications including crushing it through the g-tube. Review of the five-day MDS assessment dated [DATE] revealed Resident #1 had intact cognition and had a g-tube. Review of the care plan dated 01/19/26 revealed Resident #1 required tube feeding. Interventions included he needed the head of bed elevated 45 degrees during the tube feed, to check the tube placement and gastric contents per facility policy, provide care to the tube site as ordered, and to monitor, document and report any abnormal signs and symptoms. There was nothing in the care plan regarding the administration of medications including crushing it through the g-tube. Observation on 01/21/26 at 9:17 A.M. revealed Licensed Practical Nurse (LPN) #222 prepared the following medications at the medication cart: aspirin 81mg chewable tablet, atorvastatin calcium 40 mg tablet, and brensocatib 25mg tablet. She then took all the medications and crushed the medications together. She proceeded to enter Resident #1's room and after checking for placement and flushing Resident #1's g-tube with water, administered all the combined crushed medications. She administered a water flush after the combined crushed medications. Interview on 01/21/26 at 10:04 A.M. with LPN #222 verified she crushed the following medications together: aspirin 81mg chewable tablet, atorvastatin calcium 40 mg tablet, and brensocatib 25 mg tablet and then administered it through Resident #1's g-tube. She verified Resident #1 did not have an order to crush all his medications together and administer all at once. She stated she always had crushed the medications together and did not know they needed to be crushed separately unless there was a physician order. She was not aware of whether a physician and/or pharmacist had reviewed if the above medications were safe to crush together and if there was a potential for an interaction if they were crushed and administered together. Interview on 01/21/25 at 10:32 A.M. with Consultant Pharmacist #500 revealed she had not reviewed Resident #1's medications to ensure they were able to be crushed together and administered safely through his g-tube especially the brensocatib since it was a new medication that she was not familiar with. She revealed she would have to research if it was safe. Interview on 01/21/26 at 12:09 P.M. with Interim Director of Nursing (DON) revealed the nurse should not have crushed the medications together and administered the medications through Resident #1's g-tube. She verified there was no evidence that the physician and/or pharmacist had reviewed Resident #1's medications to ensure it was safe to crush the medications together and whether there were known drug interactions if they were crushed together. Review of the facility policy labeled, Enteral Feeding, dated 2023 revealed the purpose of the policy was to provide adequate nutrition and hydration. Prior to flushing, and administration of medication per feeding tube the nurse needed to ensure proper placement. There was nothing in the policy regarding crushing of medications. Review of the facility policy labeled, Medication Administration Policy, dated 2023 revealed all medications would be administered safely, accurately, and in accordance with the resident's plan of care and prescribed orders. Medication administration standards revealed the licensed nurse shall follow the rights of medication administration including right resident, right medication, right dose, right route, right time, right documentation, right reason and right response. There was nothing in the policy regarding crushing medications including through a g-tube.

Based on record review and interview the facility failed to ensure performance reviews for nursing assistants were completed timely as required. This had the potential to affect all 11 residents residing in the facility. Findings include: Review of the personnel file for State tested Nursing Assistant (STNA) #789 revealed a hire date of 10/03/22. There was not a 90-day evaluation completed as required. Review of the personnel file for STNA #791 revealed a hire date of 05/31/22. There was not a 90-day evaluation completed as required. Review of the personnel file for STNA #798 revealed a hire date of 07/19/21. There was not a 90-day or annual evaluation completed as required. Interviews completed on 05/31/23 at 4:30 P.M. with the [NAME] President of Human Resource Services (VPHRS) #834, and Human Resource Specialist (HRS) #835 revealed they confirmed the performance evaluations were not completed at required.

Based on observation and interview the facility failed to ensure all medications were stored appropriately in medication carts. This had the potential to affect all 11 residents residing in the facility. Findings include: Observation of the medication carts completed on 05/30/23 at 9:15 A.M. revealed there were a total of 23 loose medications observed. There were 13 loose medications observed in the Cherry Hill medication cart, as well as 10 loose medications and a yellow powder spilled throughout the top drawer of the Maple Lane medication cart. The facility had a total of two medication carts. Interview on 05/30/23 at 9:30 A.M. with Registered Nurse (RN) #801 revealed she confirmed there were 13 loose medications observed in the Cherry Hill medication cart, as well as 10 loose medications and a yellow powder spilled throughout the top drawer of the Maple Lane medication cart.

Based on observation and interview, the facility failed to maintain the overhead hood vents, fire suppression nozzles, and backsplash behind the stove in a clean, sanitary, and safe manner. This had the potential to affect ten of the eleven residents residing in the facility. Resident #76 did not receive food from the facility kitchen. The facility census was 11. Findings include: A tour of the kitchen on 05/30/23 from 9:15 A.M. through 9:44 A.M. with Dietary Manager #821 revealed the overhead vents and the fire suppression nozzles were greasy and had accumulated dust. The backsplash behind the stovetop was greasy. Dietary Manager #821 verified the condition of the hood, nozzles, and back splash at the time of the observation.

Based on record review and interview, the facility failed to complete a comprehensive assessment for Resident #275 within 14 days after admission. This finding affected one resident (#275) of ten residents reviewed for comprehensive assessments. The facility census was 11. Findings include: Review of the medical record for Resident #275 revealed an admitted [DATE]. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of bilateral middle cerebral arteries, celiac disease, Parkinson's disease, and chronic heart failure. Review of Resident #276's Minimum Data Set (MDS) 3.0 assessments revealed an admission assessment was initiated with an assessment reference date (ARD) of 05/19/23 but was not completed as required. Interview with Registered Nurse (RN) #796 on 05/31/23 at 12:50 P.M. confirmed the admission MDS assessment for Resident #275 was opened on 05/19/23 but sections C, D, E, and Q were still in progress, and the assessment was not completed on time. Interview with Licensed Social Worker (LSW) #802 on 05/31/23 at 1:10 P.M. confirmed she assessed sections C, D, E and Q. LSW #802 confirmed sections C, D, E and Q were not completed on time for Resident #275's admission MDS assessment with an ARD of 05/19/23.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for Resident #7 to include anticoagulant use. This affected one resident (#7) of five residents who were reviewed for care plans with high-risk medications. The facility census was 11. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE]. Diagnoses included acute on chronic systolic congestive heart failure, atrial fibrillation, essential primary hypertension, and ischemic cardiomyopathy. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/17/23, revealed Resident #7 had intact cognition. Resident #7 received an anticoagulant seven of the seven days prior to the assessment reference date. Review of Resident #7's physician orders effective May 2023 revealed Eliquis 5 milligrams (mg) twice daily for blood thinner (anticoagulant). Review of Resident #7's comprehensive care plan dated 05/24/23 revealed a focus of activities of daily living, risk for falls, alteration in nutrition status, risk for pain, and risk for skin impairment/breakdown. There was no focus or interventions for anticoagulant use. Interview on 05/31/23 at 3:07 P.M. with Registered Nurse (RN) #796 verified Resident #7's comprehensive care plan dated 05/24/23 did not contain a focus for anticoagulant use. Interview on 06/01/23 at 11:14 A.M. with Administrator indicated the facility had no policy regarding care plans and only used standard requirements.

Based on interview and record review the facility failed to ensure the fall care plan for Resident #76 was updated in a timely and complete manner. This affected one resident (#76) of ten resident care plans reviewed. The facility census was 11. Finding include: Resident #76 was admitted to the facility on [DATE] with diagnoses including intracerebral hemorrhage, gastrostomy status, and abnormal findings on diagnostic imaging of central nervous system. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/15/23, revealed Resident #76 had severely impaired cognition. The resident could sometimes make self understood and sometimes understood others. Resident #76 was totally dependent on two people for transfers. The resident was totally dependent on one person for locomotion and eating. The resident required the extensive assistance of two people for bed mobility, dressing, toilet use, and personal hygiene. The Morse Fall scale reviews completed on 05/10/23, 05/16/23, 05/18/23, 05/21/23, 05/22/23, 05/27/23, and 05/28/23 each revealed Resident #76 to be a high fall risk. Review of the plan of care dated 05/10/23 revealed the resident was at risk for falls. Interventions added on 05/10/23 included: anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs a prompt response to all requests for assistance, bed against wall per family's request, bed bolsters in place to bed, and ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Interventions added on 05/27/23 were for the bed to be kept in the lowest position and mats to floor on both sides of the bed. Interventions added on 05/28/23 were to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Review of the care plan dated 05/28/23 revealed Resident #76 had an actual fall with no injury, related to poor communication/comprehension on 05/28/23. Interventions included: continue interventions on the at-risk plan, determine and address causative factors of the fall, and neuro-checks to be done per facility protocol. There were no interventions added to the care plan after Resident #76's falls on 05/15/23, 05/16/23, 05/17/23, and 05/21/23 even though there were interventions in the nurse's notes and Interdisciplinary Team (IDT) notes. Resident #76's fall from 05/08/23 was reviewed by the IDT on 05/31/23. The resident's fall from 05/16/23 had a fall report done on 05/16/23 but the post fall assessment was not completed until 05/30/23. The IDT review on 05/18/23 for Resident #76's fall on 05/17/23 recommended hourly rounds, but that was added to the care plan. The post fall note completed on 05/24/23 for Resident #76's fall on 05/21/23 had an intervention to place things that were grabbable, such as the resident's tube feed pole, on his left side. That was not added to the fall care plan. The IDT review done on 05/31/23 of Resident #76's fall on 05/27/23 recommended offer to toilet before bed and P.M., but that was not added to the fall care plan. Interview on 06/01/23 at 10:45 A.M. Registered Nurse (RN) #796 verified Resident #76's care plan updates were not timely and all recommended interventions were not included in the care plan.

Based on observation and interview, the facility failed to post nurse staffing data daily as required. This had the potential to affect all 11 residents residing in the facility. Findings include: Observation on 06/01/23 at 9:40 A.M. revealed posted nurse staffing data in a plastic sign holder which was displayed on the receptionist desk at the front entrance of the facility. The posted nurse staffing data was dated 05/30/23. Interview at the time of the observation with Receptionist #819 verified the posted nurse staffing data displayed was dated 05/30/23. Receptionist #819 removed the nurse staffing data from the plastic sign holder which also held nurse staffing data sheets dated for 05/26/23, 05/27/23, 05/28/23 and 05/29/23. There were no nurse staffing data sheets for 05/31/23 and 06/01/23. Receptionist #819 stated the facility scheduler provided the nurse staffing data sheets for posting and was off from work and did not provide the prepared sheets for 05/31/23 and 06/01/23. Observation and interview on 06/01/23 at 10:11 A.M. with Receptionist #819 indicated the nurse staffing data sheets for 05/31/23 and 06/01/23 were now completed and 06/01/23 would be posted. Observation at the time of the interview revealed the completed nurse staffing data sheets for 05/31/23 and 06/01/23.

Based on observation, interview, record review and policy review, the facility failed to appropriately store medications in two of two medication carts, and in one of one medication room refrigerator. This had the potential to affect all 19 residents residing in the facility. Findings include: Observation on 04/27/21 at 11:08 A.M. with Registered Nurse (RN) #250 during medication administration from the medication cart labeled cherry revealed a vial of [MEDICATION(S)] U-100 insulin stored in the top drawer of the medication cart. The [MEDICATION(S)] insulin vial was opened, not dated, not labeled, and was not in a labeled storage box or container. Interview with RN #250 at the time of the observation confirmed the above finding. Observation on 04/27/21 at 11:26 A.M. with RN #251 of medication storage room revealed three [MEDICATION(S)] 5 [MEDICATION(S)] units per 0.1 milliliter vials (used to diagnose tuberculosis) stored in the refrigerator. Each of the three [MEDICATION(S)] vials were opened and undated. Interview with RN #251 at the time of the observation confirmed the above finding. Observation on 04/27/21 at 11:44 A.M. with RN #252 of medication cart storage revealed an injectable pen of [MEDICATION(S)] (anti-diabetic medication) 2.5 milligrams per 1.5 milliliter stored in the top drawer of the medication cart labeled maple. The [MEDICATION(S)] injectable pen was observed to be previously used, was not dated, was not labeled, and was not in a labeled storage box or container. Review of the facility policy titled Storage of Medication/Nutritional Supplements, reviewed February 2021, revealed medications/nutritional supplements shall be stored in the packaging, containers or other dispensing systems in which they are received, and medication containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Review of the facility policy titled Insulin Storage, reviewed March 2021, revealed opened insulin will be dated the day it is opened. Review of the facility policy titled Medication Administration, dated 09/14/20, revealed prepare medications according to orders and standard of practice/ensuring to check package open dates/expiration dates.

Based on observation, interview, record review and policy review the facility failed to ensure transmission based precautions were initiated upon admission for Resident #70, the facility failed to ensure staff and visitors followed appropriate transmission based precautions guidelines for Resident #70, and the facility failed to ensure soiled laundry was handled appropriately for Resident #119. This affected two Residents (#70 and #119) of three residents reviewed for infection control, and had the potential to affect all 19 residents residing in the facility. Findings include: 1. Record review revealed Resident #70 was admitted on [DATE] from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition, required limited one staff assistance for bed mobility and toileting, limited two staff assistance for transfers, and was always continent of urine and bowel. The assessment did not indicate isolation or quarantine. Review of Resident #70's medical record revealed no documented immunization information for COVID-19. Review of the physician's orders dated 04/16/21 revealed quarantine 14 days, transmission based respiratory droplet and contact precautions every shift until 04/27/21. Review of the progress notes dated 04/16/21 revealed transmission based precautions (TBP) were in place. There was no documentation of TBP prior to 04/16/21. Interview on 04/29/21 at 1:36 P.M. with RN #251 confirmed TBP were not ordered until 04/16/21, three days after Resident #70's admission from the hospital on 04/13/21, and there was no documentation TBP were initiated prior to 04/16/21. Registered Nurse (RN) #251 indicated TBP were required for COVID-19 because the resident had a hospital stay and there was no documentation of COVID-19 vaccination. Observation on 04/27/21 at 8:44 A.M. with RN #252 during medication administration revealed on the door of Resident #70's room two posted signs, Droplet Precautions and Contact Precautions. Review of the facility TBP sign, Contact Precautions, undated, revealed everyone must clean their hands, including before entering and when leaving the room. Further review of Contact Precautions sign indicated the source was the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Review of the facility TBP sign, Droplet Precautions, undated, revealed everyone must clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry, and remove face protection before room exit. Further review of Droplet Precautions sign revealed pictures to indicate use of face shield or goggles for face protection, and indicated the source was the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention 2. Observation on 04/27/21 at 8:46 A.M. with RN #252 during medication administration revealed RN #252, who was wearing an N95 (respirator) mask and face shield, donned a gown and gloves, and enter Resident #70's room. Observed standing next to Resident #70's bed was a visitor wearing no personal protective equipment (PPE). RN #252 requested the visitor put on a surgical mask, which the visitor complied, and did not request the visitor wear any additional PPE including a face shield or goggles, gloves or a gown. The visitor then left Resident #70's room indicating a need to obtain a cup for the resident. Upon exiting the room, the visitor did not perform handwashing and walked to the common dining area, obtained a Styrofoam cup and re-entered Resident #70's room still wearing a surgical mask. Upon entry, the visitor did not perform handwashing and did not put on any additional PPE including a face shield or goggles, gloves or a gown. RN #252 then exited Resident #70's room after removing the gown, gloves and performing handwashing. RN #252 did not change the N95 mask which was unprotected by a surgical mask, and did not disinfect the face shield or change the face shield. Interview with RN #252 at the time of the observation confirmed the above findings and indicated an understanding that visitors only had to wear surgical masks including residents on TBP. Interview on 04/27/21 at 9:57 A.M. with Unit Clerk #300 verified visitors were pre-scheduled and educated with guidelines for wearing a surgical mask with visits. Unit Clerk #300 indicated no one visited when on TBP unless approved by management. Review of the visit schedule titled Rehab Pavilion, dated 04/27/21, revealed a visitor scheduled for Resident #70 at 10:30 A.M. Resident #70 was not identified on the list with a requirement for TBP. Interview on 04/27/21 at 11:36 A.M. with RN #251 confirmed visitors for residents in TBP were educated to wear a gown, face shield and an N95, and to perform handwashing before and after leaving the resident's room. RN #251 indicated activity staff monitored visitors and helped ensure guidelines were followed. Interview on 04/27/21 at 12:50 P.M. with Activities #302 verified visits were pre-scheduled and the information was provided to nursing staff. Activities #302 confirmed visitors for residents in TBP were to wear a mask and gown, and Unit Clerk #300 would use the schedule to know which residents were on TBP to educate visitors as they arrived or nursing staff would do the same as needed. Interview on 04/27/21 at 1:20 P.M. with Housekeeping #303 confirmed with residents in TBP, the N95 mask had to be covered with a surgical mask upon entry or the N95 mask changed upon exit of the room, and the face shield or goggles disinfected upon exit of the room. Interview on 04/27/21 at 2:12 P.M. with RN #251 verified when exiting resident rooms with TBP, the face shield or goggles had to be disinfected or changed. Interview on 04/27/21 at 2:23 P.M. with Infection Preventionist (IP) #304 confirmed residents admitted and not vaccinated for COVID-19 are placed on TBP for 14 days. IP #304 verified visitors for residents on TBP were required to wear a surgical mask, face shield, and gown, and use handwashing prior to entering and when exiting the room. Interview on 04/28/21 at 9:23 A.M. with Unit Clerk #300 verified the visitation schedule dated 04/27/21 did not have residents identified with TBP including Resident #70, and confirmed when Resident #70's visitor arrived on 04/27/21, the visitor was not educated on TBP as required. Review of the facility policy titled COVID-19: PPE Use During Pandemic, dated 02/10/20, all staff will wear a face shield in all patient care areas when in Yellow (staff working in a designated space where no active, suspected or isolation cases of COVID-19 are noted) and Red (staff working in a designated space with confirmed cases of COVID-19 on the unit/facility) zones. The face shield will be disinfected at the beginning of the work day, after every patient care encounter and at the end of the work day with a facility approved disinfectant per CDC (Centers for Disease Control) disinfection guidelines. Review of the facility policy titled COVID-19: Visitation and Communal Activities, dated 01/25/21, revealed residents who are on transmission-based precautions for COVID-19 should only receive visits that are virtual, through windows, or in-person for compassionate care situations, with adherence to transmission-based precautions. 3. Record review revealed Resident #119 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan dated 04/24/21 revealed the resident had a self-care performance deficit with activities of daily living. Interventions included to provide one staff assistance with bed mobility, toileting, transfers, dressing and bathing, and encourage the resident to participate to the fullest extent possible. Observation on 04/27/21 at 11:07 A.M. with RN #250 during medication administration revealed soiled linen on Resident #119's bathroom floor adjacent to the sink, soiled towels on Resident #119's bathroom shower floor, and soiled clothing on Resident #119's bathroom floor adjacent to the bathroom door. Interview with RN #250 at the time of the observation confirmed the above findings and indicated soiled laundry should be bagged and placed in the soiled laundry area and not left on a resident's floor. Review of the facility education of policy titled Soiled Linen, dated 04/27/21 to 04/28/21, revealed make sure the soiled linen is properly handled from the point of collection to the laundry, and treat all soiled linen as potentially infectious. 4. Resident #9 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders revealed and order dated 04/15/21 for quarantine for 14 days, Transition Based, Respiratory Droplet and Contact Precautions. Review of the immunization record for the resident was negative for any COVID-19 vaccine. The care plan dated 04/15/21 revealed a care area for at risk of respiratory illness, COVID-19 with an intervention of Institute isolation precautions as individually appropriate. Observation of and interview with State tested Nurse Aide (STNA) #205 on 04/28/21 9:01 A.M. revealed the STNA exited Resident #9's room wearing a face shield and face mask but no gown. The door to the room had isolation signs prominently displayed and personal protection equipment (PPE) including surgical masks, gowns and gloves hanging on the door. The STNA verified she should have donned a gown and wiped her face shield. Interviews on 04/27/21 at 2:12 P.M. with RN #251 verified staff need to wipe or change their face shield when exiting isolation rooms. Review of the COVID-19: PPE Use During Pandemic policy dated 02/10/20 revealed : all staff will wear a face shield in all patient care areas when in Yellow (staff working in a designated space where no active, suspected or isolation cases of COVID-19 are noted) and Red (staff working in a designated space with confirmed cases of COVID-19 on the unit/facility) zones. The face shield will be disinfected at the beginning of the work day, after every patient care encounter and at the end of the work day with a facility approved disinfectant per CDC. 5. Resident #126 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders revealed an order of 04/23/21 for quarantine for 14 days, transmission based respiratory droplet and contact precautions every shift until 05/06/21. Review of the immunization record for the resident was negative for any COVID-19 vaccine. The care plan dated 04/21/21 revealed care areas included impaired immunity related to [CONDITION(S)] with recent [CONDITION(S)] with a risk for contracting infections due to impaired immune status and an intervention to keep the environment clean and people with infection away. The care plan revealed a second care area was for risk of COVID-19 with an intervention to institute isolation precautions as individually appropriate. Interview on 04/27/21 at 11:36 A.M. with RN #251 revealed visitors for residents on isolation are educated to wear a gown and face shield and an N95 and to wash hands before and after leaving the room. Activities staff monitor the visitors and the visits are pre-scheduled and monitored by them, and they go over the guidelines with them. Observation on 04/27/21 at 4:15 P.M. revealed Resident #126's daughter was visiting in his room, wearing a surgical mask and no face shield or goggles and no personal protective gown. The door to the room had isolation signs prominently displayed and PPE including surgical masks, gowns and gloves hanging on the door. She was momentarily joined by Resident #126's son who was wearing a surgical mask. Interview on 04/27/21 at 4:18 P.M. with Resident #126's daughter and son revealed no staff had informed them they needed to wear a face shield and gown when visiting their father. The son reported he was not screened by anyone when he entered the building and proceeded back to his father's room with no instructions on PPE. Interview on 04/29/21 with RN #251 revealed she could find no documentation that transmission based precautions were ordered for Resident #126 upon his admission on 04/21/21, only the order of 04/23/21. Review of the schedule for visitors for 04/27/21 did not contain any visits for Resident #126. Review of the undated facility transmission-based precautions sign, Droplet Precautions revealed everyone must clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry, and remove face protection before room exit. Further review of the Droplet Precautions sign revealed pictures to indicate use of face shield or goggles for face protection, and indicated was the source of the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

Based on observation, interview, record review and policy review, the facility failed to ensure oxygen tubing was dated per acceptable standards of nursing practice for Residents #119 and #123, and the facility did not ensure oxygen administration orders were in place for Resident #123. This affected two Residents (#119 and #123) of two residents reviewed for respiratory care. The facility reported two residents on oxygen therapy. The facility census was 19. Findings include: 1. Record review revealed Resident #119 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders dated 04/23/21 revealed continuous oxygen via nasal cannula at two liters per minute (LPM), and check oxygen saturation and respiratory rate every shift. Observation on 04/26/21 at 1:27 P.M. revealed Resident #119 sitting up in a wheelchair with oxygen nasal cannula in place, oxygen setting at two LPM, and the oxygen tubing was not dated. Observation on 04/27/21 at 7:50 A.M. revealed Resident #119 was in bed with oxygen nasal cannula in place, oxygen setting at two LPM, and the oxygen tubing was not dated. Observation on 04/27/21 at 11:18 A.M. with Registered Nurse (RN) #250 of Resident #119 confirmed the oxygen nasal cannula was in place, oxygen was set at two LPM, and the oxygen tubing was not dated. 2. Record review revealed Resident #123 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #123 had impaired cognition, required extensive one staff assistance for bed mobility and toileting, required extensive two staff assistance for transfers, was dependent on one staff assistance for bathing, was always incontinent of urine and bowel, and received oxygen. Review of physician's orders for Resident #123 for April 2021 revealed no oxygen administration orders. Review of Resident #123's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/26/21 at 1:29 P.M. revealed Resident #123 in bed with oxygen nasal cannula in place, oxygen setting was at two LPM, and the oxygen tubing was not dated. Observation on 04/27/21 at 7:54 A.M. revealed Resident #123 was sitting up in a chair with oxygen nasal cannula in place, oxygen setting was at two LPM, and the oxygen tubing was not dated. Observation on 04/27/21 at 11:24 A.M. with RN #250 of Resident #123 confirmed the oxygen nasal cannula was in place, oxygen was set at two LPM, and the oxygen tubing was not dated. RN #250 indicated oxygen tubing required dating for weekly replacement. Interview on 04/29/21 at 12:36 P.M. with RN #251 confirmed there were no physician orders for oxygen administration, and verified the nurses should document administering oxygen in the MAR. Review of the facility policy titled Respiratory Therapy and Care of Equipment, revised September 2017, revealed oxygen tubing and the delivery device (nasal cannula or mask) will be changed routinely once a week, equipment will be dated when changed by both the nursing staff and the oxygen company. Review of the facility education of policy titled Oxygen Administration Process, dated 04/27/21 to 04/28/21, revealed oxygen tubing will be labeled with the patients name and date, and verify that there is a physician's order.

Based on interview, observation, record review and policy review, the facility did not ensure Resident #16, who was re-admitted on [DATE] with an indwelling Foley catheter (a small flexible tube inserted into the bladder to allow urine to drain), was assessed for the removal of the indwelling catheter or had a clinical condition demonstrating the catheter was necessary. This affected one resident (Resident #16) of three residents (Resident #3, #6 and #16) reviewed for indwelling Foley catheters. This had the potential to affect four residents (Residents #3, #6, #15 and #16) with indwelling Foley catheters. The facility census was 15. Findings include: Review of the closed medical record for Resident #16 revealed an admission date of [DATE] and a discharge date of [DATE]. She was discharged to the assisted living on 12/10/20 but returned to the skilled nursing home on 12/23/20. She was discharged to the hospital on [DATE] and returned on 01/08/21, and again on 01/26/21 she was discharged to the hospital and returned on 01/28/21. She remained at the facility from 01/28/21 to 03/04/21. Her [DIAGNOSES REDACTED]. Review of the assessment labeled, Bowel and Bladder Evaluation, dated 11/04/20, revealed Resident #16 had occasional bladder incontinence with no hematuria (blood in the urine). She did not have an indwelling catheter. There was no apparent pattern to her incontinence. There was no documented evidence of voiding issues. Review of the assessment labeled, Bowel and Bladder Evaluation, dated 11/29/20, revealed Resident #16 had frequent bladder incontinence with no hematuria. She did not have an indwelling catheter. There was no apparent pattern to her incontinence. There was no documented evidence of voiding issues. Review of the care plan for Resident #16 dated 01/09/21 revealed she had a indwelling Foley catheter, and interventions included monitor urine for color, clarity, and output, position the catheter bag and tubing below the level of the bladder and away from the entrance to the door, and utilize a privacy bag over the catheter bag. The care plan did not include any documentation that Resident #16 was assessed to have the catheter removed or any documentation regarding the medical necessity of the catheter. Review of the assessment labeled, Bowel and Bladder Evaluation, dated 01/09/21, revealed Resident #16 had an indwelling Foley catheter and had no hematuria. There was nothing documented per the assessment regarding the medical necessity for the indwelling Foley catheter or any documentation of assessing the resident to remove the indwelling Foley catheter if no medical necessity. Review of the nursing notes dated 01/09/21 to 03/04/21 revealed Resident #16 continued to have an indwelling Foley catheter, and there was no documented evidence regarding the medical necessity for the catheter or any documentation of assessing the resident for removal of the indwelling Foley catheter. Review of the Medicare five-day Minimum Data Set (MDS) 3.0 assessment, dated 01/11/21, for revealed she had impaired cognition and required extensive assist of one person with toileting. She had an indwelling Foley catheter. Review of the assessment labeled, Bowel and Bladder Evaluation, dated 01/29/21, revealed Resident #16 was readmitted from the hospital and continued to have an indwelling Foley catheter. There was no documented evidence regarding the medical necessity for the indwelling Foley catheter or any documentation of assessing the resident to remove the indwelling Foley catheter if there was no medical necessity. Review of the physician's order per Primary Care Physician #900, dated 01/29/21, revealed Resident #16 had an order for [REDACTED]. Observation of catheter care on 03/15/21 at 12:05 P.M. completed by Licensed Practical Nurse (LPN) #600 for Resident #3 revealed no concerns. Interview on 03/16/21 at 9:02 A.M. with Physician Assistant #606 for Resident #16 revealed she was not aware of any medical necessity [DIAGNOSES REDACTED]. Interview on 03/16/21 at 10:45 A.M. with the Interim Director of Nursing verified she reviewed Resident #16's medical record and they do not have a [DIAGNOSES REDACTED]. She verified bowel and bladder evaluations were completed on 01/09/21 and on 01/29/21, but the evaluation only listed that the resident had an indwelling Foley catheter. The evaluation did not list the medical necessity to have the catheter or an assessment for the removal of the catheter. She verified Resident #16 had the indwelling Foley catheter from 01/08/21 through her discharge on 03/04/21. Review of the facility policy labeled, Indwelling Catheter, dated December 2017, revealed the facility did not ensure they implemented their policy as the policy revealed the use of indwelling urinary catheters was reserved for residents with special medical needs. The policy revealed indwelling urinary catheters may be used based on the following criteria: [MEDICAL CONDITION] as a result of [MEDICAL CONDITION] bladder, urinary obstruction as a result of [MEDICAL CONDITION], and for significant skin breakdown (stage three or stage four ulcer) in an area affected by the incontinence. The policy revealed catheters would not be used to treat simple incontinence or for staff convenience. The policy revealed residents with indwelling catheters must be assessed periodically to determine whether a voiding trial or bladder retraining might be effective. This deficiency substantiates Master Complaint Number OH 675 and Complaint Number OH 573.

Based on interview, record review and policy review, the facility did not ensure weights were obtained and monitored per physician's order for Resident #16. This affected one resident (Resident #16) of four residents reviewed for weight loss. The facility census was 15. Findings include: Review of the closed medical record for Resident #16 revealed an admission date of [DATE] and a discharge date of [DATE]. She was discharged to the assisted living on 12/10/20 but returned to the skilled nursing home on 12/23/20. She was discharged to the hospital on [DATE] and returned on 01/08/21, and again on 01/26/21 she was discharged to the hospital and returned on 01/28/21. She remained at the facility from 01/28/21 to 03/04/21. Her [DIAGNOSES REDACTED]. Review of the care plan for Resident #16, dated 11/04/20, revealed she had the potential for nutritional weight issues related to acute kidney injury, moderate protein calorie malnutrition, and dementia. Interventions included diet as ordered, weights twice weekly, and supplements as ordered. Review of the weights per electronic medical record revealed Resident #16 had the following weights recorded: on 12/01/20 her weight was 151.8 pounds, on 12/07/21 her weight was 146.2 pounds, on 12/28/20 her weight was 142.8 pounds, and on 02/15/21 her weight was 135.8 pounds. Review of the Medicare five-day Minimum Data Set (MDS) 3.0 assessment, dated 01/11/21, revealed she had impaired cognition and required supervision with set-up help with eating. She had a weight of 143 pounds and had no weight loss. Review of the Nutritional Progress Note, dated 02/15/21 at 11:07 P.M., per Dietitian Technician #602 revealed a plan of care meeting was held with Resident #16's daughter. Resident #16's private caregiver confirmed Resident #16's oral intakes at meals were often fair to good. They discussed Resident #16's weight on 02/15/21 which was 135.8 pounds. Resident #16 liked the taste of the higher calorie boost she was trialing; therefore, Dietitian Technician #602 changed her supplement order to Boost VHC, and she also changed the frequency of weights to be obtained twice weekly, every Tuesday and Friday, to closely monitor for weight changes. Review of the physician's order per Primary Care Physician #900, dated 02/16/21, revealed Resident #16 was to be weighed twice weekly every Tuesday and Friday. Review of the Nutritional Progress Note, dated 02/19/21, per Dietitian Technician #602 revealed Resident #16 was getting a supplement, and she had a new weight order in place to obtain weights twice per week to monitor more closely for weight changes. Review of the February 2021 Treatment Administration Record (TAR) for Resident #16 revealed she had a physician's order dated 02/16/21 to obtain her weight weekly every Tuesday and Friday. The TAR was blank for 02/19/21, 02/23/21, and 02/26/21 as no weights were recorded. Review of the March 2021 TAR for Resident #16 revealed on 03/02/21 Resident #16 refused to have her weight completed. No other weights were obtained prior to discharge on 03/04/21 per the medical record. Review of the Nutritional Progress Note, dated 03/01/21, per Dietitian Technician #602 revealed she was requesting a weight as the last weight recorded was on 02/15/21 and was 135.8 pounds which reflected a seven-pound weight loss (4.9 percent weight loss in two months) as her previous weight was 142.8 pounds. Interview on 03/15/21 at 2:17 P.M. with Dietitian Technician #602 verified Resident #16's weights were not obtained per the physician's order. She verified Resident #16 had a weight loss of seven pounds on 02/15/21, and she recommended Resident #16 have a weight completed twice a week to monitor her weight loss closely. She verified she should have had a weight obtained on 02/19/21, 02/23/21, and on 02/26/21 and verified the documentation per the TAR was blank for these days, as well as the weight per the electronic record and nursing notes did not have documented evidence of a weight or why the weights were not obtained. She revealed on 03/01/21 it was documented Resident #16 refused to have a weight completed. Review of facility policy labeled, Weight Monitoring, dated December 2017, revealed the facility did not ensure they implemented their policy as resident weights were to be obtained upon admission and monthly or more often as indicated by the resident's condition and/or the physician's orders. This deficiency substantiates Master Complaint Number OH 675 and Complaint Number OH 573.

Based on interview, record review and policy review, the facility did not ensure pharmacy recommendations for Resident #16 were addressed by the physician. This affected one resident (Resident #16) of three residents reviewed for unnecessary medication. This had the potential to affect all 15 residents residing at the facility. Findings include: Review of the closed medical record for Resident #16 revealed an admission date of [DATE] and a discharge date of [DATE]. She was discharged to the assisted living on 12/10/20 but returned to the skilled nursing home on 12/23/20. She was discharged to the hospital on [DATE] and returned on 01/08/21, and again on 01/26/21 she was discharged to the hospital and returned on 01/28/21. She remained at the facility from 01/28/21 to 03/04/21. Her [DIAGNOSES REDACTED]. Review of the care plan dated 11/20/20 revealed Resident #16 was at risk for adverse reaction related to polypharmacy (use of multiple medications). Interventions included: the facility would review pharmacy consultation recommendations and follow-up as indicated, and review resident's medications with the physician for duplicate medications, proper dosing, timing and frequency of medications, adverse effects and supporting diagnoses. Review of the Pharmacy Consultation Report, dated 12/02/20, completed by Pharmacist #902 revealed Resident #16 received oyster shell calcium with vitamin D supplement, magnesium-oxide supplement, and [MEDICATION NAME] sulfate (iron supplement). Pharmacist #902 recommended to administer the [MEDICATION NAME] sulfate two hours before and after the oyster shell calcium vitamin D supplement and the magnesium-oxide supplement. The rationale for the recommendation revealed for proper absorption they must be administered separately. The report was blank and had no physician response. Review of the Pharmacy Consultation Report, dated 12/30/20, completed by Pharmacist #902 revealed Resident #16 received [MEDICATION NAME] (antibiotic), oyster Shell calcium with vitamin D supplement and iron supplement concomitantly (at the same time). Pharmacist #902 recommended to separate all medications by two hours. The rationale for the recommendation revealed the [MEDICATION NAME] absorption and effectiveness was significantly decreased when administered concurrently. Pharmacist #902 recommended if the medication was to continue, have the physician document the risk versus benefit. The report was blank and had no physician response. Review of the Pharmacy Consultation Report, dated 02/17/21, completed by Pharmacist #902 revealed Resident #16 received oyster shell calcium with vitamin D twice a day, magnesium- oxide four times a day and [MEDICATION NAME] sulfate twice a day. Pharmacist #902 recommended to decrease drug interaction and potentially unnecessary medications have the physician consider reviewing the need for magnesium, calcium, and iron supplements at the current doses, and if the physician wanted the medications to continue to have the [MEDICATION NAME] sulfate administered two hours before the calcium and magnesium oxide. Pharmacist #902 revealed the rationale for the recommendation was for proper absorption the medications must be administered separately. The report was blank and had no physician response. Review of the Pharmacy Consultation Report, dated 02/17/21, completed by Pharmacist #902 revealed Resident #16 received [MEDICATION NAME] twice a day, oyster shell calcium with Vitamin D twice a day and [MEDICATION NAME] twice a day concomitantly. Pharmacist #902 recommended to decrease drug interactions and unnecessary medications have the physician consider reviewing the need for calcium and iron supplements at the current doses, and consider separating the medications by two hours. Pharmacist #902 revealed the [MEDICATION NAME] absorption and effectiveness were significantly decreased when administered concurrently. Pharmacist #902 recommended if the medication therapy was to continue, she recommended the physician document an assessment of the risk versus benefit of the medication therapy. The report was blank and had no physician response. Review of the March 2021 Medication Administration Record [REDACTED].M. and 8:00 P.M., she received her [MEDICATION NAME] at 8:00 A.M. and 8:00 P.M., she received her [MEDICATION NAME] sulfate supplement at 9:00 A.M. and 5:00 P.M., and she received her magnesium oxide at 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M. Interview on 03/16/21 at 9:59 A.M. with Interim Director of Nursing #609 verified the pharmacy recommendations for 12/02/20, 12/30/21 and 02/17/21 were not reviewed and addressed with Resident #16's Primary Care Physician #900. She verified she went through the MAR's from December 2020 to March 2021 and verified Resident #16's medication times for her [MEDICATION NAME] sulfate supplement, [MEDICATION NAME], calcium with vitamin D supplement, and magnesium oxide were not changed per the pharmacist recommendations, and there was no documentation of risks versus benefits to the medications being given concurrently. Review of the facility policy labeled, Pharmacy Consultation Services, dated January 2012, revealed the facility policy did not include how the facility would report to the physician that the pharmacy reported an irregularity per the pharmacy recommendations and how the facility would address the irregularity and recommendations. This deficiency substantiates Master Complaint Number OH 675 and Complaint Number OH 573.

Based on interview, record review and policy review the facility failed to ensure adequate interventions were implemented to prevent the development and deterioration of pressure ulcers. Actual Harm occurred on 01/10/21 when Resident #23, who was determined at risk for pressure ulcers on the admission assessment dated [DATE] and required two-person assist with bed mobility and transfers, did not have interventions to prevent the development of pressure ulcers or to prevent the deterioration of current pressure ulcers. The pressure ulcer to the coccyx deteriorated from a stage II (partial-thickness loss of skin with exposed dermis. The wound bed is visible, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) 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 it is obscured by slough or eschar. If slough or eschar is removed, a stage III or stage IV pressure ulcer will be revealed). In addition, he developed a new pressure ulcer to the right heel which was not staged but was described as a darkened blister. There was no documented evidence the physician was notified regarding the new pressure ulcer to the right heel or the deterioration of the pressure ulcer to the coccyx area. This affected one resident (Resident #23) of four residents reviewed for pressure ulcers. The facility census was 21. Findings include: Review of the medical record for Resident #23 revealed an admission date of [DATE] and a discharge date of [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #23's physician's orders [REDACTED]. He also had a physician's orders [REDACTED]. Additional physician's orders [REDACTED]. Resident #23 did not have any other preventative measures such as pressure reducing devices to bed or chair or turn and reposition. In addition, there was no treatment order for the right heel pressure ulcer after it was discovered on 01/10/21. Review of admission Braden Scale assessment for predicting pressure ulcer risk dated 01/07/21 revealed Resident #23 was at risk for pressure ulcers because he was occasionally moist, he was slightly limited with mobility, and he had a potential problem with friction and shear. Review of undated baseline care plan for Resident #23 completed by Registered Nurse (RN) #672 revealed the area for skin was blank. There was no indication on the baseline care plan Resident #23 was at risk for pressure ulcers, had pressure ulcers or listed any interventions to prevent the worsening or development of pressure ulcers. Review of comprehensive care plan last revised 01/12/21 for Resident #23 had no indication Resident #23 was at risk for pressure ulcers, had current pressure ulcers, and had no interventions to prevent new or the worsening pressure ulcers. Review of form labeled Skin Tool completed on admission on 01/07/21 by RN #672 revealed Resident #23 was admitted with a pressure ulcer to his coccyx measuring 3.0 centimeters (cm) in length by 3.5 cm in width with a depth of 0.1 cm. The pressure ulcer to his coccyx was a stage II. He had a left heel pressure ulcer measuring 2.5 cm in length by 2.5 cm in width with a depth of 0.1 cm. The pressure ulcer to the left heel was classified as a stage II as the area was opened and was pink with granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) present. Resident #23's right heel was pink, intact and blanchable (meaning the pinkness would go away when pressed on). Review of form labeled Skin Tool completed on 01/10/21 by Licensed Practical Nurse (LPN) #671 revealed Resident #23 continued to have a coccyx pressure ulcer that deteriorated to unstageable (a pressure ulcer that has tissue loss with unknown depth as the actual depth of the ulcer was obscured by slough (dead skin that usually is yellow, tan or brown) and/ or eschar (dead skin that was usually black) in the wound bed). The pressure ulcer measured 3.0 cm in length by 2.0 cm in width with a depth of 1.0 cm. The coccyx had a black center and black edges measuring 0.5 cm surrounding the wound. He continued to have a left heel pressure ulcer measuring 3.0 cm in length by 3.0 cm in width. The depth and stage were left blank on the form. The left heel pressure ulcer was described as moist and pink. He had a new pressure ulcer to the right heel measuring 3.2 cm in length by 2.3 cm in width. The depth and stage of the right heel pressure ulcer was left blank. The right heel pressure ulcer was described as an intact darkened blister. The skin tool also noted several dry blackened areas to the left outer aspect of Resident #23's foot. Review of the nursing notes dated 01/10/21 to 01/15/21 revealed no documented evidence Physician #674 or Physician's Assistant #673 were notified of Resident #23's new pressure ulcer to the right heel as documented on the Skin Tool on 01/10/21. There was no documented evidence that a treatment was ordered or provided for the right heel pressure ulcer. In addition, there was no documented evidence in the nurse's notes that Physician #674 or Physician's Assistant #673 were notified of the deterioration of Resident #23's coccyx pressure ulcer from stage II on 01/07/21 to unstageable on 01/10/21. There was no documented evidence the Power of Attorney for Resident #23 was notified of the new pressure ulcer to the right heel or the deterioration of the pressure ulcer to the coccyx. Review of Physician #674's progress note dated 01/10/21 at 11:30 A.M. revealed no documentation related to Resident #23's new pressure ulcer to the right heel or documentation of the deterioration of the pressure ulcer to the coccyx. Review of Physician Assistant #673's progress notes dated 01/12/21, 01/13/21 and 01/15/21 revealed no documentation related to Resident #23's new pressure ulcer to the right heel or documentation of the deterioration of the pressure ulcer to the coccyx. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #23 revealed he was cognitively impaired. He required extensive assistance of two staff for bed mobility, transfers, dressing and toileting. He was unable to ambulate and was at risk for pressure ulcers. He was admitted with two stage II pressure ulcers. Interview on 03/01/21 at 11:15 A.M. with the Administrator and Interim Director of Nursing #619 verified Resident #23 was admitted to the facility on [DATE] and was assessed at risk for developing pressure ulcers, and he had one stage II pressure ulcer to his coccyx and one stage II pressure ulcer to his left heel. They verified on 01/10/21 it was documented on the skin assessment that Resident #23's pressure ulcer to his coccyx deteriorated from a stage II to unstageable with a black center and black surrounding edges, and he also had a new pressure ulcer to his right heel that was a darkened blister. They verified the pressure ulcer to his right heel was not staged per the skin assessment. They verified there was no documented evidence in the medical record the physician or responsible party were notified of the new pressure ulcer to his right heel or the deterioration of his coccyx pressure ulcer. In addition, they verified there was no treatment order for Resident #23's right heel pressure ulcer from the time it was noted on 01/10/21 through the time of discharge on 01/15/21. Review of facility policy labeled treatment of [REDACTED]. The policy did not include ensuring appropriate interventions were implemented and care planned for the prevention of new or the deterioration of pressure ulcers. Review of facility policy labeled Care Planning Process, dated December 2017, revealed the facility did not implement their policy as the facility was to develop an initial care plan within 48 hours of the resident's admission and the care plan was to be based on assessment and may include physician orders [REDACTED]. This deficiency substantiates Complaint Number OH 302.

Based on observation, interview, record review and policy review the facility failed to ensure proper personal protective equipment (PPE) was donned and doffed prior to entering and exiting Resident #6 and Resident #22's rooms who were on respiratory droplet precautions to prevent the potential spread of COVID-19 as they were new admissions. This had the potential to affect all 21 residents residing at the facility. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#22 did not have a physician order [REDACTED]. Review of the care plan, last revised on 02/23/21, revealed no care plan for transmission-based precautions (respiratory droplet precautions) for Resident #22. Observation on 02/25/21 at 7:57 A.M. revealed Registered Nurse (RN) #607 was in Resident #22's room administering his medications, and she adjusted the resident's bed to assist with positioning. She had on a N95 mask and face shield but had no gloves or gown. Observation of Resident #22's door revealed signage stating Resident #22 was on respiratory droplet precautions, and there was a white container with PPE by the door to enter. Upon exiting Resident #22's room, she performed hand hygiene but did not clean her face shield upon exiting. Interview on 02/25/21 at 8:05 A.M. with RN #607 verified Resident #22 was on respiratory droplet precautions as he was a new admission, and they maintain any resident who was a new admission on respiratory droplet precautions for 14 days as precaution to prevent the potential spread of COVID-19. She verified she did not have a gown or gloves on when she was in Resident #22's room, and she verified if a resident was on respiratory droplet precautions staff were to wear a N95 mask, face shield, gown and gloves into the room. She verified she did not cleanse her face shield upon exiting Resident #22's room. She stated she was never trained she needed to cleanse her face shield when she came out of a room on respiratory droplet isolation. 2. Review of the medical record for Resident #6 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#6 did not have a physician order [REDACTED]. Review of Resident #6's care plan dated 2/18/21 revealed she had no care plan for transmission-based precautions (respiratory droplet precautions). Observation on 02/25/21 at 9:12 A.M. revealed Housekeeper #609 entered Resident #6's room with gloves, a N95 mask and a face shield. She did not have a gown on. Observation of Resident #6's door revealed signage stating Resident #6 was on respiratory droplet precautions, and there was a white container with PPE by the door to enter. Housekeeper #609 proceeded to clean Resident #6's room and then she exited the room removing her gloves and completing hand hygiene. She continued to wear the same N95 mask and face shield and did not cleanse the face shield and proceeded to move the cart down the hallway. Interview on 02/25/21 at 9:18 A.M. with Housekeeper #609 stated she was not aware Resident #6 was on respiratory droplet isolation. Housekeeper #609 was shown the signage on the door that revealed Resident #6 was on respiratory droplet precautions, and Housekeeper #609 verified she should have had full PPE including gown, face shield, N-95 mask, and gloves when she was cleaning the room. She verified she did not have a gown on when she was in Resident #6's room. She verified she did not cleanse her face shield when she exited Resident #6's room as she was not trained that she needed to do that. During interview with Housekeeper #609, observation on 02/25/21 at 9:19 A.M. revealed Agency State tested Nursing Assistant (STNA) #610 walked into Resident #6's room with only her face shield and N95 mask that she already had on. She did not have gloves or a gown on. Agency STNA #610 walked up to Resident #6 to see if she had completed her meal and asked if she wanted her to remove it. Resident #6 stated no. Agency STNA #610 proceeded to leave the room and used hand sanitizer prior to exiting. She did not cleanse her face shield when she left Resident #6's room. Interview on 02/25/21 at 9:23 AM with Agency STNA #609 revealed she did not feel the signage on the rooms were accurate at the facility as Resident #6's room had the same sign on the door for weeks so she did not feel Resident #6 was on isolation any longer. She verified she did not ask a nurse or any other facility staff if Resident #6 was in respiratory droplet precautions as she assumed the facility just did not update the signage. She verified she did not wear a gown or gloves when she entered Resident #6's room and verified when she exited Resident #6's room she did not cleanse her face shield. She stated she was never trained that she needed to cleanse the face shield upon exiting a room of a resident on respiratory droplet precautions. Interview on 02/25/21 at 9:38 A.M. with the Administrator verified Resident #6 and Resident #22 were both on respiratory droplet precautions as they were new admissions. She revealed per their procedure they maintain on respiratory droplet precautions for 14 days for any new admission or re-admission. She verified both residents had been admitted less than 14 days ago. She verified RN #607, Agency STNA #610, and Housekeeper #609 should have worn full PPE upon entering a room on respiratory droplet precautions including N95 mask, eye protection, gown, and gloves. She verified staff exiting the room should have cleansed their face shields. Interview on 03/01/21 at 12:14 P.M. with Interim Director of Nursing #619 revealed she was unsure how the facility completed the physician orders [REDACTED]. She revealed she had seen some residents with orders for transmission-based precautions and some without on admission. She revealed all residents that were new admissions or re-admissions were to be on respiratory droplet precautions for 14 days. She revealed RN/ Minimum data Set (MDS) Nurse #620 usually took care of the physician orders [REDACTED]. Interview on 03/01/21 at 12;30 P.M. with RN/ MDS Nurse #620 revealed all new admission and re-admission were to have a physician order [REDACTED].#6 and Resident #22 did not have a physician order [REDACTED]. Review of facility policy labeled Coronavirus Plan, dated February 2020, revealed the facility did not implement their policy as infection control precautions for probable and suspected cases of COVID-19 a healthcare worker entering the room should don a gown, N95 respirator, eye protection and gloves. There was nothing in the policy to ensure a physician order [REDACTED]. There also was nothing noted in the policy regarding doffing of personal protective equipment including cleansing the face shield upon exiting a resident room on transmission-based precautions (respiratory droplet precautions) when a facility was utilizing extended use of PPE.