Every finding on record at Elizabeth Scott Community

Based on review of infection control logs, staff interview and review of the facility policy, the facility failed to maintain an adequate infection surveillance program. This had the potential to affect all residents residing in the facility. The facility census was 54.Findings include:Review of the facility's infection control surveillance logs for December 2025, January 2026, February 2026, March 2026, April 2026, and May 2026 revealed the pathogen associated with infections was not identified. Interview on 06/11/26 at 1:55 P.M. with Assistant Director of Nursing (ADON) #162, who also served as the facility's Infection Preventionist (IP), confirmed there was no tracking of the pathogen associated with the infections identified for December 2025, January 2026, February 2026, March 2026, April 2026, and May 2026. Furthermore, ADON #162 could not answer how the facility kept track of trends and patterns other than mapping.Review of the facility policy titled, Surveillance for Infections, dated September 2017, revealed the IP personnel was responsible for gathering and interpreting surveillance data. In addition to collecting data on the incidence of infections, the surveillance system was designated to capture certain epidemiologically important data that may influence how the overall surveillance data was interpreted. The pathogen must be identified in order to determine if the resident met the criteria for the definition of infections.

Based on medical record review, staff interview and review of facility policy, the facility failed to adequately monitor residents for effectiveness, adverse reactions and side effects of psychotropic medication use. This affected five (#5, #10, #20, #29, and #49) of five residents reviewed for unnecessary medications. Additionally, the facility failed to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. This affected one (#10) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #10 was admitted on [DATE]. Diagnoses included age related osteoporosis without current pathological fracture, and unspecified dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 04/10/26, revealed the resident was severely cognitively impaired and the resident received antipsychotic and antidepressant medications. Review of the care plan, updated 02/10/26 and 02/18/26, revealed Resident #10 used antidepressant and antipsychotic medications. Interventions included to give medications ordered by the physician, monitor/document side effects and effectiveness and to monitor/document/report to the medical doctor as needed ongoing signs and symptoms. The interventions did not include where findings were documented. Review of the physician orders revealed Resident #10 had an order dated 03/10/26 for sertraline hydrochloride (antidepressant) oral tablet 50 milligrams (mg), give 50 mg by mouth at bedtime for depression. Further review revealed an order dated 05/07/26 for quetiapine fumarate (antipsychotic) oral tablet 25 mg, with instructions to give one tablet in the morning and one tablet at bedtime for depression. Review of the physician progress note, dated 05/21/26, revealed Resident #10 had a diagnosis of dementia with behavior disturbances/anxiety/insomnia and advanced, progressive-labile behaviors. The resident's family refused a psychiatric consult to evaluate and treat. Review of the Medication Administration Record (MAR) and Treatment Administration Record for June 2026 revealed no documentation for monitoring the effectiveness of, or adverse reactions/side effects to, sertraline hydrochloride or quetiapine fumarate. Further review of the medical record revealed no evidence Resident #10 was monitored for the effectiveness of, or adverse reactions/side effects to, sertraline hydrochloride or quetiapine fumarate. Interview on 06/10/26 at 8:51 A.M. with the Director of Nursing (DON) verified Resident #10 did not have medical diagnoses to support the use of antidepressant or antipsychotic medications. A follow-up interview on 06/10/26 at 12:10 P.M. with the DON verified there was no evidence Resident #10 was routinely monitored for the effectiveness of, or adverse reactions and side effects to, psychotropic medications. 2. Review of the medical record revealed Resident #49 was admitted on [DATE]. Diagnoses include dementia in other diseases classified elsewhere with unspecified severity and other behavioral disturbances, bipolar II disorder, Alzheimer's disease, unspecified dementia moderate with other behavioral disturbances, anxiety disorder, type II diabetes without complications, and major depressive disorder. Review of the MDS assessment, dated 05/11/26, revealed the resident was severely cognitively impaired. The resident received antipsychotic, antidepressant, antiplatelet, hypoglycemic, and anticonvulsant medications. Review of the physician orders revealed Resident #49 had an order dated 11/14/24 for escitalopram oxalate (antidepressant) tablet 20 mg, one tablet by mouth in the morning for depression and monitor for side effects and document negative findings in the nurses' notes. Further review revealed an order dated 04/21/26 for Seroquel (antipsychotic) oral tablet 25 mg, with instructions to give 0.5 tablet by mouth two times a day for dementia. Review of the care plan, updated 05/25/26, revealed Resident #49 used antidepressant and antipsychotic medication. Interventions included to give medications ordered by the physician, monitor/document side effects and effectiveness, monitor/document/report to medical doctor as needed ongoing signs and symptoms, and offer non-pharmacological interventions. The interventions did not include where findings were documented. Review of the MAR and TAR for June 2026, revealed no documentation for monitoring the effectiveness of, or adverse reactions/side effects to, psychotropic medications. Further review of the medical record revealed no evidence Resident #49 was monitored for the effectiveness of, or adverse reactions/side effects to, escitalopram oxalate or Seroquel. Interview on 06/10/26 at 12:10 P.M. with the DON verified there was no evidence Resident #49 was routinely monitored for the effectiveness of, or adverse reactions and side effects to, psychotropic medications. 3. Review of the medical record for Resident #5 revealed an admission date of 06/17/25. Diagnoses included dementia, major depressive disorder, mental disorder, and anxiety disorder. Review of the quarterly MDS dated [DATE] revealed Resident #5 had severe cognitive impairment. The resident received anti-anxiety and anti-depressant medications. Review of the physicians orders revealed Resident #5 had the following orders: an order dated 12/09/25 for buspirone 15 mg, give one tablet by mouth three times a day for anxiety; an order dated 03/25/26 for Zoloft (antidepressant) 50 mg, give one tablet by mouth at bedtime for depression combined with 25mg tablet to total 75 mg; and an order dated 04/10/26 for Ativan 0.5 mg, give one tablet by mouth two times a day for anxiety/agitation. Review of the care plan dated 05/29/26 revealed Resident #5 used anti-anxiety and antidepressant medications. Interventions included to give medications ordered by the physician, monitor/document side effects and effectiveness and to monitor/document/report to medical doctor as needed ongoing signs and symptoms. The interventions did not include where findings were documented. Further review of the medical record revealed no evidence Resident #5 was monitored for the effectiveness of, or adverse reactions/side effects to, buspirone, Zoloft, or Ativan. Interview on 06/10/26 at 12:10 P.M. with the DON verified there was no evidence Resident #5 was routinely monitored for the effectiveness of, or adverse reactions and side effects to, psychotropic medications. 4. Review of the medical record for Resident #20 revealed an admission date of 12/21/25. Diagnoses included Alzheimer's, dementia, major depressive disorder, and insomnia. Review of the quarterly MDS dated [DATE] revealed Resident #20 was cognitively impaired. Further review of the MDS revealed Resident #20 received anti-psychotic and anti-anxiety medications. Review of the physician orders revealed Resident #20 had the following orders: an order dated 04/10/26 for lorazepam 0.5 mg, give one tablet by mouth at bedtime for anxiety and an order dated 06/10/26 for Seroquel 100 mg, give one tablet by mouth at bedtime for dementia with agitation; and an order dated 06/10/26 for Seroquel 50 mg, give on tablet by mouth for dementia with agitation. Review of the care plan dated 04/30/26 revealed Resident #20 used anti-anxiety and antipsychotic medications. Interventions included to give medications ordered by the physician, monitor/document side effects and effectiveness and to monitor/document/report to medical doctor as needed ongoing signs and symptoms. The interventions did not include where findings were documented. Further review of the medical record revealed no evidence Resident #20 was monitored for the effectiveness of, or adverse reactions/side effects to, lorazepam or Seroquel. Interview on 06/10/26 at 12:10 P.M. with the DON verified there was no evidence Resident #20 was routinely monitored for the effectiveness of, or adverse reactions and side effects to, psychotropic medications. 5. Review of the medical record for Resident #29 revealed an admission date of 05/22/26. Diagnoses included dementia, Alzheimer's disease, anxiety, and depression. Review of the MDS assessment dated [DATE] revealed Resident #29 had severe cognitive impairment and received antipsychotic and antidepressant medications. Review of the physician orders dated 05/22/26 revealed Resident #29 had an order for sertraline 50 mg, give one tablet by mouth at bedtime for depression. Further review revealed an order dated 06/10/26 for Seroquel 25 mg, give a half of a tablet by mouth at bedtime related to dementia in other diseases classified elsewhere, severe with anxiety. Review of the care plan dated 05/30/26 revealed Resident #29 used anti-depressant and anti-psychotic medications. Interventions included to give medications ordered by the physician, monitor/document side effects and effectiveness and monitor/document/report to medical doctor as needed ongoing signs and symptoms. The interventions did not include where findings were documented. Further review of the medical record revealed no evidence Resident #29 was monitored for the effectiveness of, or adverse reactions/side effects to, sertraline or Seroquel. Interview on 06/10/26 at 12:10 P.M. with the DON verified there was no evidence Resident #29 was routinely monitored for the effectiveness of, or adverse reactions and side effects to, psychotropic medications. Review of the facility policy titled, Psychotropic Medication Assessment and Monitoring, dated 02/26/25, revealed the purpose was to administer and monitor the effects of psychotropic medications. Residents receiving psychoactive medication would be monitored by the Registered Nurse (RN)/Licensed Practical Nurse (LPN). The behavior of residents receiving psychoactive medication would be monitored by the RN/LPN at appropriate intervals, looking at intentional and unintentional changes in behaviors.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure residents were treated for constipation. This affected one (#6) of one resident reviewed for bowel movements. The facility census was 52. Findings include: Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses of dementia, heart disease, and heart failure. Review of the comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had impaired cognition and was occasionally incontinent of stool and was dependent for toileting hygiene. Review of the current care plan revealed Resident #6 was frequently incontinent of bowel and bladder. Interventions included documenting bowel movements. Further review revealed Resident #6 was at risk for developing pressure ulcers related to bowel and bladder incontinence. Interventions included providing assistance with toilet use and incontinence care to keep skin clean and dry. Review of Resident #6's medical record revealed no documented bowel movement between 07/02/24 and 07/06/24 and between 07/21/24 and 07/25/24. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2024 revealed Resident #6 received one treatment for constipation on 07/17/24. Interview on 09/12/24 at 8:40 A.M. with Unit Manager (UM) #505 confirmed Resident #6 had no documented bowel movement for five days between 07/02/24 and 07/06/24, and for five days between 07/21/24 and 07/25/24. UM #505 further confirmed Resident #6 received no treatment for constipation for either occurrence. Continued interview with UM #505 revealed nurses should receive alerts through the electronic medical record system when a resident has no bowel movement for 72 hours and nurses have authority to implement physician orders for constipation. UM #505 further confirmed Resident #6 should have received an intervention for constipation on 07/05/24 and on 07/24/24. Review of the policy, Bowel Program, revised 04/07/15, revealed standing physician orders should be implemented when residents do not have a bowel movement in 72 hours. Additionally, standing laxative orders could include Milk of Magnesia, Dulcolax suppository and/or Fleets enema.

Based on observations, staff interview, and review of facility policy, the facility failed to ensure used bed pans were cleaned after use. This affected one resident (#210) reviewed for use of bedpans. The facility identified four residents that use bedpans (#13, #42, #206, and #209). The facility census was 52. Findings include: Review of the medical record for Resident #210 revealed an admitted [DATE] with diagnosis of infection and inflammatory reaction to right knee prosthesis. Review of the Minimum Data Set (MDS) dated [DATE] for Resident #210 revealed she was cognitively intact. Observation on 09/09/24 at 11:00 A.M. revealed a used, uncovered bedpan sitting on top of the toilet riser in the bathroom for Resident #210. Observation on 09/09/24 at 5:02 P.M. revealed a used, uncovered bedpan remained sitting on top of the toilet riser in the bathroom for Resident #210. Interview with Resident #210 at the time of the observation stated she had used the bedpan throughout the day. Interview on 09/09/24 at 5:05 P.M. with Licensed Practical Nurse (LPN) #554 verified the used bedpan was sitting on top of the toilet riser and not covered in bag and verified stool on toilet riser. Interview on 09/12/24 at 3:00 P.M. with the Director of Nursing identified four other residents (#13, #42, #206, and #209) that used bedpans. Review of the facility policy titled, Infection Prevention and Control Program, dated 11/16 revealed the facility will maintain infection control program for preventing, identifying, and controlling infections.

Based on medical record review, review of immunization records, staff interview, review of policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents received or were offered the influenza and pneumococcal vaccinations per CDC recommendations. This affected two (#5 and #26) of five residents reviewed for influenza and pneumococcal vaccination. The facility census was 52. Findings include: 1. Review of the medical record revealed Resident #5 was admitted on [DATE]. Diagnoses included cerebral atherosclerosis, chronic kidney disease stage 2, hyperkalemia, essential (primary) hypertension, type two diabetes mellitus without complications, hyperlipidemia, and unspecified dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is rarely understood and a mental status was not conducted. Vaccines influenza and pneumococcal were documented as offered and declined. Review of the social service progress notes dated 11/03/23 revealed Resident #5's Power of Attorney (POA) gave consent for the flu vaccine. Review of the immunization report revealed Resident #5 last received the influenza vaccine on 09/20/22. Interview on 09/12/24 at 8:12 A.M. with Licensed Practical Nurse (LPN) #504 verified Resident #5's POA provided consent for the vaccine on 11/03/23 and there is no record the vaccine was provided. Review of facility policy Seasonal/Annual influenza vaccine, dated January 2022, verified long-term residents are prone to developing serious complications if they contract influenza all residents will be offered the season/annual influenza vaccination each year. Review of CDC guidance titled, Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, dated 08/29/24, revealed the CDC recommended routine annual influenza vaccine with some exceptions. Adults aged 65 and older preferentially receive a higher dose or adjuvanted influenza vaccines. 2. Review of the medical record revealed Resident #26 was admitted on [DATE]. Diagnoses included encephalopathy, essential hypertension, type two diabetes mellitus without complication, dysphagia oropharyngeal phase, other acute kidney failure, and acute respiratory failure with hypoxia. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact and the pneumococcal vaccine was offered and declined. Further review of the medical record revealed no declination of the pneumococcal vaccine. Interview on 09/12/24 at 8:15 A.M. with Licensed Practical Nurse (LPN) #504 verified there was no declination of the pneumococcal vaccine. Review of policy, Pneumococcal Vaccine Administration dated March 2015 verified the residents will be offered the pneumococcal vaccine unless the resident has had one or more of the following documented an allergy to the pneumococcal vaccine, an order from the primary care physician or medical director stating the pneumococcal vaccine is medical-contraindicated or the resident personally refuses administration. Review of CDC guidance titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, reviewed 06/27/24 revealed the CDC recommended pneumococcal vaccination for all adults over 65. For adults over 65 who had not previously received any pneumococcal vaccine, the CDC recommended one dose of PCV15 or PCV20. If PCV15 was used, follow up with one dose of PPSV23 at least one year later.

Based on observation and staff interview, the facility failed to ensure fecal matter was cleaned off the toilet riser following use. This affected one resident (#210) reviewed for clean environment. The facility census was 52. Findings include: Review of the medical record for Resident #210 revealed an admitted [DATE] with diagnosis of infection and inflammatory reaction to right knee prosthesis. Review of the Minimum Data Set (MDS) dated [DATE] for Resident #210 revealed she was cognitively intact. Observation on 09/09/24 at 11:00 A.M. revealed fecal matter was left on the seat of the toilet riser in the bathroom for Resident #210. Observation on 09/09/24 at 5:02 P.M. revealed stool remained on the seat of the toilet riser in the bathroom of Resident #210. Interview at the time of the observation with Resident #210 revealed housekeeping had been in to clean her room for the day. Interview on 09/09/24 at 5:05 P.M. with Licensed Practical Nurse (LPN) #554 verified the fecal matter that remained on the toilet riser. Interview on 09/12/24 at 2:00 P.M. with the Administrator stated the facility does not have a facility policy for clean, homelike environment.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of the facility's Self-Reported Incident (SRI) and abuse investigation, review of employee files and review of facility in-services, the facility failed to ensure a resident was free from physical abuse. This affected one (Resident #24) of three residents reviewed for abuse. The facility census was 52. Findings include: Review of the medical record of Resident #24 revealed an admitted [DATE]. Diagnoses included altered mental status, anemia, chronic obstructive pulmonary disease, and restlessness and agitation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had severely impaired cognition and required extensive assistance of one for bed mobility, transfers, dressing, toilet use, and personal hygiene. The assessment indicated she utilized a wheelchair. Review of the progress notes dated 08/22/23 at 7:41 A.M. revealed Registered Nurse (RN) #170 was called to Resident #24's room. Stated tested Nursing Aide (STNA) #320 reported she was transferring Resident #24 from the bed to the wheelchair and the resident scrapped her left lower extremity on the side of wheelchair causing a skin tear to left lower extremity. Blood was noted on the floor next to the wheelchair. Resident #24's skin area was cleansed, and steri-strips were applied, and the area was covered with border gauze. The area measured 6.0 centimeters (cm) in length, 2.0 cm in width, and 0.3 cm in depth. Review of the facility's SRI control number 238367 revealed an allegation of physical abuse towards Resident #24 was made on 08/22/22. STNA #340 alleged that STNA #320 was aggressive with the care provided to Resident #24. STNA #320 roughly put Resident #24 into a wheelchair, and it caused a skin tear to the resident's leg. The allegation of physical abuse was substantiated and STNA #320's employment was terminated. Review of the typed statement from STNA #340 revealed on 08/22/23 around 7:10 A.M., STNA #320 and herself were getting Resident #24 ready for the day when several incidents happened that ended up causing Resident #24 to have a skin tear. STNA #320 helped STNA #340 with another resident in Resident #24's room. During that time, STNA #320 decided to get Resident #24 dressed in clean clothes for the day. STNA #320 made a comment to STNA #340 to watch her and then STNA #340 observed STNA #320 throw clean clothes and a brief at Resident #24 who was sitting on the edge of the bed. STNA #320 then aggressively handled Resident #24's legs onto the bed and had her lying flat on the bed. She forced Resident #24's pajama bottoms and panty hose off her legs. At this moment, STNA #320 told STNA #340 that this was how you must handle Resident #24 in order to get anything on her, Resident #24 was clearly upset at this time in the way she was getting handled by STNA #320. STNA #340 was moving the bed back to the wall, Resident #24 and STNA #320 were bickering again at this moment. STNA #320 reached over Resident #24's head to get to the shoe and that was when Resident #24 grabbed STNA #320's hand and bit her. STNA #320 retaliated by hitting Resident #24 on top of the head, then proceeded to hit her on the head several times after that but not as hard as the initial hit. The shoe was finally grabbed and put on the resident's foot. STNA #340 was still standing at the end of the bed trying to position it back to normal and this was when STNA #320 decided to transfer Resident #24. STNA #320 leaned over and did a hugging motion on Resident #24 and stood her up with no warning. In this process, Resident #24 fought back a little bit causing STNA #320 to throw the resident down into her wheelchair. During this time, a lot of commotion happened, and Resident #24's leg hit the metal side of the chair. Resident #24 then complained STNA #320 scratched her leg. STNA #340 pulled Resident #24's pant leg up and saw a large skin tear on her left shin and a lot of blood. Around 7:20 A.M., STNA #340 hit the staff call assist light and handed STNA #320 a towel to be placed on Resident #24's leg. STNA #320 started to panic, and STNA #340 told her she would go grab the nurse. STNA #340 walked out of the room and found Registered Nurse (RN) #170 at the B hall nurse cart and she told her they needed her help with Resident #24 due to a skin tear. RN #170 then asked how it had happened and STNA #340 said during STNA #320's transfer of Resident #24, the resident hit her leg on the wheelchair. STNA #340 walked with RN #170 to the supply room in A hall where the nurse grabbed some supplies. RN #170 then walked in the room and assessed the skin tear; STNA #340 did not report the allegation of abuse to RN #170 during this time. Review of the employee file for STNA #320 revealed a hire date of 05/12/21. A Corrective Action form dated 08/22/23 revealed STNA #320 had been suspended related to the incident reported earlier by STNA #340. STNA #320 was then terminated on 08/23/23. Interview on 09/21/23 at 2:50 P.M. with the Assistant Director of Nursing (ADON) #120 confirmed she received an email from STNA #340 on 08/22/23 at 8:30 A.M. and the email contained allegations that STNA #320 physically abused Resident #24 during the morning care. ADON #120 stated she telephoned STNA #340 on 08/22/23 at 3:50 P.M. regarding the delay in reporting and STNA #340 stated she had feared retaliation from STNA #320 and that was the reason she had not reported until the email sent to ADON #120 at 8:30 A.M Review of the facility policy titled Resident Abuse, updated 10/27/21, revealed the facility will not tolerate abuse of any manner to residents. The deficient practice was corrected on 08/23/23 when the facility implemented the following corrective actions: On 08/22/23 at 8:30 A.M., STNA #340 reported the allegation of physical abuse by email to ADON #120. On 08/22/23 at 8:45 A.M., ADON #120 notified the Administrator and DON of the allegation of physical abuse. On 08/22/23 at 9:00 A.M., STNA #320 was pulled off the floor and met with DON and ADON #120 regarding the abuse allegation and STNA #320 was notified of her suspension pending an investigation of abuse. On 08/23/23, STNA #320 was terminated from employment effective immediately. On 08/23/23, all residents residing in the facility were assessed for any signs of abuse and there were no negative findings. On 08/23/23, all staff were inserviced on the facility's abuse policy and timely reporting of allegations of abuse.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to implement pressure-reducing interventions and failed to properly assess a pressure ulcer once discovered. This affected two (#21 and #142) of three residents reviewed for pressure ulcers. The census was 47. Findings include: 1. Review of Resident #142's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission nursing assessment dated [DATE] revealed Resident #142 was alert to person only and exhibited confusion. Review of an assessment of Resident #142's skin on admission revealed Resident #142 had shearing on her left and right buttocks and lateral thigh, surgical wounds on the left lateral thigh, knee, and hip, and a Stage Two (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister) pressure ulcer on her coccyx. Resident #142's bilateral heels were soft with skin prep (a skin protectant) to be applied to bilateral heels and the heels elevated while in bed. Review of an admission assessment used to predict pressure ulcer development dated 02/16/22 revealed Resident #142 was at risk for pressure ulcer development. Subsequent assessments dated 02/23/22 and 03/09/22 revealed Resident #142 remained at high risk for pressure ulcer development. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medication administration records (MAR's) and treatment administration records (TAR's) from February and March 2022, between 02/16/22 and 03/08/22, revealed there was no documentation of staff applying skin prep to Resident #142's heels as ordered. Review of nursing progress notes and nurse aide tasks between 02/16/22 and 03/08/22 revealed no documentation of skin prep applied to Resident #142's heels as ordered. Review of a wound care practitioner progress note dated 02/23/22 revealed there were no pressure ulcers to Resident #142's heels but noted the left heel was boggy (soft). Review of a skin assessment dated [DATE] revealed Resident #142 continued with no wounds on the heels. Review of a wound assessment dated [DATE] revealed Resident #142 developed a pressure ulcer to the left heel measuring 4.0 cm long by 3.0 cm wide by 0.1 cm depth with no stage documented. The wound was described as granulated (beefy red), with scant drainage, a pale pink peri-wound, and wound edges intact. Interview on 03/09/22 on 10:38 A.M. with Licensed Practical Nurse (LPN) #268 stated Resident #142's skin was assessed on 03/02/22 and there were no pressure ulcers on her heels. LPN #268 stated she was off work for a couple of days and when she came back on 03/05/22 she noticed Resident #142 had a ruptured blister on her left heel. LPN #268 stated she did not know when the blister developed and verified staff were offloading Resident #142's heels while in bed to relieve pressure, but stated she nor any of the nurses were applying skin prep to Resident #142's heels. LPN #268 stated she measured the wound and contacted the wound nurse practitioner to order treatment. LPN #268 stated Resident #142's left heel wound was not staged on the initial assessment on 03/05/22 and stated the wound nurse practitioner had yet to observe the wound, but would stage the wound after her assessment. LPN #268 verified Resident #142 had an active order for skin prep to bilateral heels every day and night shift, but the staff member who put the order into the computer system never enabled the order to be seen by the nurses on their treatment orders. LPN #268 stated none of the nurses would have known the skin prep treatment was due because it was never alerted in the system. LPN #268 again stated she had not been applying skin prep to Resident #142's heels and verified there was no documentation in the medical record of skin prep ever being applied to Resident #142's heels. Observation on 03/10/22 at 7:24 A.M. revealed Resident #142 laying in bed with heels offloaded by pillows and a wound dressing in place to her left heel. Further observation revealed Wound Nurse Practitioner (WNP) #567 removed the old dressing and revealed a healing, ruptured blister on the skin surface with scant drainage, healthy surrounding skin, and no odors. WNP #567 measured the wound to be 6.0 cm long by 4.2 cm wide by 0.1 cm deep. Interview on 03/10/22 at 8:12 A.M. with WNP #567 verified 03/10/22 was the first she observed Resident #142's heel wound and stated it appeared to her as a ruptured blister and would stage the wound as a Stage Two pressure ulcer. WNP #567 stated she would continue the current treatments and encouraged to continue offloading bilateral heels. Review of a facility policy titled, Pressure Ulcer and Skin Management, dated 10/27/21, revealed residents who enter the facility without pressure ulcers do not develop pressure ulcer unless the resident's clinical condition demonstrates that they were unavoidable. The licensed nurse will review the pressure protocol to select the treatment appropriate for the resident and the type of pressure ulcer or wound. The licensed nurse will implement the wound care treatment in accordance with current standards of practice. 2. Review of the record for Resident #21 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition. He was dependent on two staff for transfers, toileting, and hygiene. Review of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The heel protectors could be removed for personal hygiene. Review of a wound assessment signed 02/09/22 for Resident #21 revealed a suspected DTI to his right heel presented on 02/08/22 and a suspected DTI to his left heel presented on 02/09/22. The recommended treatment was heel protector boots to both heels. Observation on 03/07/22 at 3:08 P.M. revealed heel protector boots in Resident #21's chair, and Resident #21 lying in bed not wearing heel protector boots. Observation and interview on 03/08/22 at 4:53 P.M. revealed Resident #21 being pushed into dining room by State tested Nursing Assistant (STNA) #230 while seated in Broda chair (a wheeled, cushioned, reclining chair). Heel protector boots were not on Resident #21 who wore only socks with his heels resting on the foot rests of the chair. Interview at that time with STNA #230 confirmed Resident #21 was not wearing heel protector boots, and she was unable to explain why he was not currently wearing boots. Observation on 03/09/22 at 2:38 P.M. revealed Resident #21 lying in bed without wearing heel protector boots, and heel protector boots were in his chair. Observation and interview on 03/09/22 at 2:42 P.M. with STNA #232 revealed Resident #21 was in bed lying on his back without wearing heel protector boots. Further interview revealed STNA #232 did not know when Resident #21 was supposed to wear the boots.

Based on review of the medical record, staff interview, and policy review, the facility failed to provide restorative care as care planned. This affected two (#24 and #28) of two residents reviewed for range of motion. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #28 was admitted on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the minimum data set (MDS) assessment, dated 12/15/21, revealed the resident was severely cognitively impaired. Review of the care plan, revised 01/19/22, revealed Resident #28 was at risk for impaired weakness due to displaced fracture of first cervical vertebra, spinal stenosis, and muscle weakness. Interventions include active range of motion both lower extremities seated leg program with two pound weights, twenty reps all planes and active range of motion to bilateral extremity twenty to thirty reps all planes with no weights, raise arms shoulder height only not above head for six to seven days a week for at least fifteen minutes a day. Review of range of motion documentation, dated 01/25/22 to 03/08/22, Resident #28 had active range of motion restorative services provided as follows: 01/14/22 to 01/15/22 one out of two potential days, 01/16/22 to 01/22/22 four out of seven days; 01/23/22 to 1/29/22 four out of seven potential days; 01/30/22 to 02/05/22 five out of seven potential days; 02/06/22 to 02/12/22 six out of seven potential days; 02/13/22 to 02/19/22 two out of seven potential days; 02/20/22 to 02/26/22 one out of seven potential days; 02/27/22 to 03/05/22 three out of seven potential days; and 03/06/22 to 03/08/22 one out of three potential days. Interview on 03/09/22 at approximately 4:00 P.M. with the Director of Nursing (DON) verified restorative care was not provided as care planned for Resident #28. 2. Review of the medical record revealed Resident #24 was admitted on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 01/21/22, revealed Resident #24 was cognitively intact. Review of the care plan, dated 01/20/22, revealed Resident #24 has impaired functional range of motion of left upper and lower extremities related [CONDITION(S)] ([CONDITION(S)]) with [CONDITION(S)] to the left side. Interventions include Active Range of Motion (AROM) program to right shoulder, elbow, wrist, hip, knee and ankle one time a day, six to seven days a week for at least 15 minutes a day in at least one set of fifteen to twenty reps per joint. To the left aide perform Passive Range of Motion (PROM) to all above listed joints of upper and lower extremities, one set of fifteen reps per joint as tolerated. Review of range of motion documentation, dated 01/25/22 to 03/08/22, Resident #24 had active range of motion restorative services provided as follows: 01/25/22 to 01/29/22 three out of five potential days; 01/30/22 to 02/05/22 four out of seven potential days; 02/06/22 to 02/12/22 four out of seven potential days; 02/13/22 to 02/19/22 one out of seven potential days; 02/20/22 to 02/26/22 one out of seven potential days; and 02/27/22 to 03/05/22 three out of seven potential days. Interview on 03/08/22 at 4:23 P.M. with Licensed Practical Nurse (LPN) #261 verified Resident #24 has not received restorative care as care planned. LPN #261 reports restorative aides are at times reassigned to work as a hall aide when the facility is short staffed. Interview on 03/09/22 at 9:45 A.M. with State tested Nursing Assistant (STNA) #202 verified working as a restorative aide. It was reported Resident #24 is cooperative and has not refused restorative services. STNA #202 reported a restorative aid is scheduled seven days a week but is often reassigned to work as an aide which results in not being able to provide the restorative program to residents. Review of the facility policy, Restorative Program, dated 03/01/10, revealed special restorative nursing program will be initiated as ordered and the restorative nurse, licensed nurse, along with floor aides or restorative aides will implement the program documenting on a daily basis.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure fall interventions were in place as ordered and care planned. This affected one (#142) of four residents reviewed for accidents. The census was 47. Findings include: Review of Resident #142's medical record revealed an admitted [DATE]. Diagnoses included displaced intertrochantric fracture of the left femur, cognitive communication deficit, unspecified dementia with behavioral disturbances, heart failure, muscle weakness, and unsteadiness on feet. Review of an admission nursing assessment dated [DATE] revealed Resident #142 was alert to person only and exhibited confusion. Review of an admission fall risk assessment dated [DATE] revealed Resident #142 was assessed at high risk for falls. Review of a baseline care plan dated 02/16/22 revealed Resident #142 was at risk for falls with a history of a falls at home with her daughter that required surgery. Review of a fall investigation report dated 03/02/22 revealed Resident #142 was found on the floor in her room beside her bed on her left side. Resident #142 was last observed in a low bed with her call light in reach and assessed with no injuries. Further review of the fall investigation revealed immediate interventions implemented were a mat placed on the floor and Resident #142 was given a body pillow. Review of a physician order dated 03/02/22 revealed Resident #142 was ordered a mat to the floor next to the bed while Resident #142 was in bed. Review of the comprehensive care plan dated 03/08/22 revealed Resident #142 was at risk for falling with an intervention to have a mat to the floor next to Resident #142's bed and utilize a body pillow in bed. Observation on 03/08/22 at 1:12 P.M. revealed Resident #142 sitting in her wheelchair in her bedroom. Observation on 03/08/22 at 2:28 P.M. revealed Resident #142 laying in bed on her right side with a body pillow at the edge of the right side of the bed mattress. The left side of Resident #142's bed was against the wall with a gray mat standing on end horizontally and wedged between the bed and the wall measuring approximately two inches thick. There was no mat noted to the floor next to Resident #142's bed. Interview on 03/08/22 at 2:39 P.M. with State tested Nurse Aide (STNA) #203 stated Resident #142 was laid down in bed at approximately 1:30 P.M. on 03/08/22 but she was not one of the staff members that assisted with her transfer. Observation of Resident #142 on 03/08/22 at 2:41 P.M., with STNA #203, revealed Resident #142 laying in bed with no mat to the floor next to her bed. Interview on 03/08/22 at 2:42 P.M. with STNA #203 confirmed she was in Resident #142's bedroom at approximately 2:15 P.M. and verified Resident #142 was in bed but no mat was on the floor at that time either. STNA #203 stated the mat the was between the wall and the left side of the bed should have been on the floor on the right side to prevent injuries if Resident #142 were to fall out of bed. STNA #203 confirmed the active order for Resident #142 to have a mat to the floor next to her bed at this time. Review of a facility policy titled, Falls - Protocol, dated October 2021, revealed for an individual who has fallen, staff and the interdisciplinary team will attempt to define possible causes and analysis each incident to determine root causes. Based on the preceding assessment, the staff will identify pertinent interventions to try to prevent subsequent falls and address risks of serious consequences of falling.

Based on medical record review, observation, medical record review, staff interview, facility Infection Prevention Control Plan (COVID-19), and review of Centers for Disease Control (CDC) Coronavirus Disease 2019 (COVID-19) Pandemic guidance, the facility failed to ensure healthcare personnel (HCP) applied appropriate transmission based infection control precautions and personal protective equipment (PPE) to prevent the spread of COVID. This had the potential to affect all 55 residents. Findings include: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. No documentation contained in the medical record indicated a Covid-19 test had been completed. On 09/28/20 a consent was signed for Covid-19 testing to be performed at the facility. 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. No documentation contained in the medical record indicated a Covid-19 test had been completed. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. Review of a Covid-19 test result dated 09/25/20 (prior to admission) revealed a negative result. Observation on 10/07/20 at 10:30 A.M. on the 600 hall revealed Registered Nurse (RN) #100, Licensed Practical Nurse (LPN) #200, and State tested Nurse Aide (STNA) #300 were wearing a KN95 mask. Interview with RN #100 at the time of the observation revealed the facility provided staff the KN95 mask and the 600 unit had designated rooms for newly admitted residents that required 14 day quarantine. The KN95 mask were worn in all resident rooms. On 10/07/20 at 10:32 A.M. tour of the 600 unit discovered resident rooms #4, #5, #6, #7, #8, #9, #10, #11 with doors closed and signs posted at the entry indicating Isolation, mask, faceshield- use of aerosol treatment/coughing clean with santi wipe with each use, gloves. On 10/07/20 at 10:46 A.M., STNA #300 was observed entering Resident #5's room wearing a KN95 mask, protective glasses, disposable gloves, and a protective gown. Observation on 10/07/20 at 11:00 A.M. identified nursing staff working with residents on the 500 unit in A, B, C halls with KN95 masks applied. Interview with LPN #201 on 10/07/20 at 11:23 A.M. revealed staff were to wear eye protection when residents were in isolation. Per LPN #201 currently no residents on the 500 unit in A, B, C halls were in isolation. LPN #201 also stated no eye protection was provided to nursing or direct care staff to wear when caring for residents that were not in isolation. Interview on 10/07/20 at 11:45 A.M. with the Administrator confirmed knowledge of the CDC recommendation for HCP to wear eye protection but stated the facility had not implemented the intervention of equipping direct care staff with eye protection. Further interview verified the facility staff were provided with ear loop KN95 mask. However, no documentation was available indicating the ear loop KN95 mask were authorized for healthcare and confirmed the same KN95 mask were being worn by staff when entering quarantine resident rooms Review of the CDC guidance Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services, Appendix 2 Terminology, dated 2019, revealed the CDC defined Health Care Personnel (HCP) as all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials. It further defined healthcare settings as places where healthcare is delivered and includes, but not limited to acute care facilities, long term acute care facilities, inpatient rehabilitation facilities, nursing homes and assisted living facilities. Review of the CDC guidance Interim Infection Prevention and Control Recommendations for HCP During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 07/15/20, revealed HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with COVID-19 infection. The guidance further noted HCP should also wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Review of facility Infection Prevention Control Plan (COVID-19) dated 03/06/20 revealed airborne precautions includes wearing a CDC approved N95 mask or higher level respirator, glove, gown, and goggles/face shield prior to entering isolated resident rooms. Review of the CDC and Prevention website (https://www.cdc.gov/niosh/npptl/usernotices/counterfeitResp.html) updated 08/25/20, revealed per CDC information and guidelines: Counterfeit respirators are products that are falsely marketed and sold as being NIOSH-approved and may not be capable of providing appropriate respiratory protection to workers. Signs that a respirator may be counterfeit: No markings at all on the filtering facepiece respirator No approval (TC) number on filtering facepiece respirator or headband No NIOSH markings NIOSH spelled incorrectly Presence of decorative fabric or other decorative add-ons (e.g., sequins) Claims for the of approval for children (NIOSH does not approve any type of respiratory protection for children) Filtering facepiece respirator has ear loops instead of headbands

Based on medical record review, observation, medical staff interview, and facility falls protocol, the facility failed to ensure fall prevention interventions were implemented to address a resident identified at high risk of falling from self transferring and ambulating without assistance. This affect one (#1) of three residents reviewed for falls. The facility census was 55. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the most current minimum data set (MDS) assessment dated [DATE] revealed the resident was identified with severe cognitive impairment. The resident was dependent on one staff for the completion of activities of daily living, including transfer and ambulation. The assessment also indicated the resident had unsteady balance and was unable to stabilize without staff assistance. The resident utilized a wheelchair or walker for mobility. The resident was occasionally incontinent of bladder and frequently incontinent of bowel. The MDS further indicated the resident with no current skin breakdown, received hospice services, and was on a scheduled pain medication regimen. On 09/14/20 a nursing plan of care was revised to address the residents risk of falling. Interventions included: assist resident to get out of bed, easy touch (adaptive) call light, appropriate footwear, call light in reach, frequently used items in reach, assist with transfers and ambulation, and mechanical lift with difficult transfers. On 09/23/20 the resident was assessed at high risk of falling. Review of resident fall history revealed a post fall assessment dated [DATE] at 10:47 A.M. indicated the nurse was called to the residents room by staff. The resident was attempting to take herself to the restroom and sustained a fall without injury. The assessment indicated immediate interventions put into place included new signs with large print and bold writing placed on walker, walls, and small sign placed on adaptive call light that states; for help use call light and wait for assistance. Further review revealed the resident was assessed with [REDACTED]. No documentation indicated interventions were placed to prevent the resident from ambulating without assistance. Review of nurses notes dated 07/27/20 at 2:26 A.M. revealed Resident #1 put on her call light and got up out of bed using her walker, she was found walking to the bathroom twice. The nurse indicated the resident was reminded to wait for staff before getting up on her own. Review of nurses notes dated 08/11/20 at 9:45 A.M., revealed when the nurse entered the residents room to give her medications the resident had self ambulated to the toilet. The nurse assisted the resident back in to bed. The call light was not on and the resident was educated on use of call light. Safety devices were put into place when the nurse exited the room. Review of nurses notes dated 08/26/20 at 9:00 P.M. revealed staff observed the resident up walking out of the bathroom during medication pass. The nurse helped Resident#1 from the bathroom to her bed, and then noticed the resident's clothing was damp. The nurse and a state tested nurse aide (STNA) helped the resident back into the bathroom. The resident was cleaned up and her clothes were changed with clean pajamas and a new brief. The nurse and STNA helped the resident back into bed with her call light and walker within reach. Review of nurses note dated 09/26/20 at 10:00 P.M., revealed Resident#1 with multiple bruises on the bilateral lower extremities (BLE) all in healing stage. One bruise was on the left lower extremity (LLE) by the knee and three were on the right lower extremity (RLE), one by the knee, one on the calf and one on the right foot. Review of nurses notes on 09/29/20 at 5:21 P.M. revealed Resident #1 had multiple bruises on BLE all in stage 3. One on the LLE by the knee and three on the RLE, one by the knee, one on calf and one on right foot. Resident #1 self transfers often and hits her legs on the bed. On 09/30/20 at 5:05 P.M. the assistant director of nursing documented a restorative note indicating Resident #1 was starting to come to meals in the main dining room and not isolating self to room as much. Resident #1 continued to be impulsive in her room, found getting up unassisted when writer was entering room. Further review of the medical record revealed a lack of interventions to prevent Resident #1 from self transferring and ambulating. Observation on 10/07/20 at 11:00 A.M., revealed the resident in a low bed with a specialized air mattress in place and the head of the bed elevated. The residents left side of the bed was against the wall and the open right side had a matt to the bedside floor. An adaptive call light was noted within three to four inches of the residents left hand, supplemental oxygen was being administered via nasal cannula at two liters per minute. On 10/08/20 at 12:30 P.M. interview with the Administrator and Director of Nursing during a review of Resident #1's medical record verified no intervention was documented to prevent the resident from attempting to self transfer and ambulate unattended. Review of the facility falls protocol last reviewed 11/11/19 revealed based on fall risk assessments the staff will identify pertinent interventions to try and prevent subsequent falls and to address risk of serious consequences of falling. This deficiency substantiates Complaint Number OH 221.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure one resident was properly secured in the lift sling when being transferred using a Hoyer mechanical lift. This resulted in actual harm when Resident #10 fell from the sling of the mechanical lift, sustaining a [MEDICAL CONDITION] and cervical fracture and was admitted to the hospital. This affected one (#10) of five residents reviewed for falls. The facility census was 57. Findings include: Review of Resident #10's record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE], revealed an Entry MDS was completed. On 07/16/19, a Discharge MDS with return not anticipated was completed. Review of Resident #10's base line care plan dated 07/12/19, revealed a self-care deficit with one person physical assistance was required for transfer. Review of Resident #10's physician orders [REDACTED]. Review of Resident #10's Fall Risk Assessment completed 07/16/19, revealed Resident #10 was at high risk for falls. Resident #10 was unable to independently come to the standing position, used an assistive device and had decreased muscle coordination. Review of Resident #10's Transfer/Discharge Form dated 07/16/19, revealed Resident #10 was transferred to the hospital on [DATE] at 4:45 P.M. The form documented Registered Nurse (RN) #301 was called to Resident #10's room by State tested Nursing Assistant #105. Resident #10 was observed on the floor, between the legs of the Hoyer lift. One Hoyer lift leg was under Resident #10's head and the other under his right hip. Resident #10 was non-responsive to verbal stimuli. RN #301 verified the presence of vital signs and bleeding was noted under Resident #10's head. RN #301 gently removed the Hoyer lift from underneath Resident #10, while attempting to maintain the cervical spine stability. Resident #10 aroused to verbal commands after approximately one minute. Oxygen was applied, and pressure held to the un-visualized head wound. Emergency medical services (911) was notified. Notifications were made to Resident #10's family and physician. Further review of the form noted Resident #10 had no behavior issues and used a manual wheelchair for mobility. Resident #10 required staff assistance with activities of daily living (ADLs), and required Hoyer mechanical lift for transfers. Review of Resident #10's progress notes revealed on 07/16/19 at 4:27 P.M., a Post Fall Follow Up was noted. Resident #10's vital signs included a heart rate of 76, and pulse oxygen level of 77% on room air. Oxygen was applied via nasal cannula at four liters per minute and Resident #10's pulse oxygen level increased to 91%. The noted event details revealed Registered Nurse (RN) #301 was called to Resident #10's room by STNA #105. Resident #10 was observed on the floor between the legs of the Hoyer lift. One Hoyer lift leg was under Resident #10's head and the other was under the right hip. Resident #10 was non-responsive to verbal stimuli and the presence of vitals were verified. Bleeding was noted under Resident #10's head. RN #301 noted she gently removed the Hoyer lift from underneath Resident #10, while attempting to maintain the cervical spine stability. Resident #10 aroused to verbal commands after approximately one minute. Oxygen was applied, and pressure held to un-visualized head wound. Emergency medical services (911) was notified. The note documented Resident #10 was being transferred from the recliner by STNA #105 to the wheelchair utilizing the Hoyer lift. Fall preventions were in place and included Resident #10's call light and personal items were in reach. Notifications were noted as being made to Resident #10's family and physician. Resident #10 was transferred to the hospital. On 07/17/19, it was noted the hospital was contacted and Resident #10 had been admitted . Review of the Fall Investigation witness statements, revealed STNA #105 was interviewed on 07/16/19, regarding Resident #10's fall. STNA #105 reported Resident #10 had a shower and she was getting him dressed to go to dinner. STNA #105 reported she put Resident #10 in the lift so she could finish dressing him. STNA #105 reported she made sure he was properly centered on the sling and he was in the proper position to be placed in his chair. STNA #105 reported all the clips were in place and he was aligned so she raised the lift to transfer him. STNA #105 indicated Resident #10 had no behaviors and was in a good mood. STNA #105 went on to report she believed Resident #10 was in need of a larger sling due to him not having any extra room in the one being used. STNA #105 reported she had to move the arms of the lift back and forth to get the clips on. She further stated she should have double checked all the clips to ensure they were still in place tightly before transferring Resident #10 to his chair. Interview on 11:32 [NAME]M. with the Administrator, revealed she was aware of the fall from the Hoyer lift and reiterated the information contained in the Post Fall Follow up. The Administrator provided additional information from the fall investigation. The Administrator reviewed STNA #105's witness statement and verified STNA #105, indicated she should have rechecked the clips before transferring Resident #10 to the chair. The Administrator reported STNA #105 had to do a turn with the lift. Mid-turn toward the chair a clip came undone and Resident #10 fell out of the sling and onto the floor. The Administrator stated from an investigation stand point, they looked at the lift and found no mechanical fault. The sling was inspected, and no integrity issues were found. The Administrator stated there was no explanation for the accident. The Administrator verified STNA #105 completed the transfer with one person. The Administrator reported the Mai Move Hoyer lifts were able to be used by one staff person as long as the resident was assessed for one assist for transfer. The Administrator provided Resident #10's Safe Handling Assessment to show Resident #10 was assessed for a Hoyer lift with one-person assistance. Interview on 10/30/19 at 11:52 [NAME]M. with STNA #103, revealed the facility required two staff assistance for all Hoyer lift transfers. STNA #103 reported prior to the change, they were able to transfer a resident with one staff assisting as long as the resident was assessed and safe to transfer with one staff. Interview on 10/30/19 at 1:01 P.M. with MDS Nurse (MDSN) #304, revealed she was in her office on 07/16/19 and heard STNA #105 call out for the nurse. MDSN #304 reported she observed Resident #10 on the floor and STNA #105 stated he fell out of the lift. MDSN #304 reported she assisted with his vitals and Resident #10 was not conscious at the time but had a pulse and was breathing. MDSN #304 reported Resident #10 was bleeding from his head and after about a minute, he came around and was asking for his wife. MDSN #304 reported seeing the Hoyer lift sling having three clips connected and one clip undone. MDSN #304 reported they investigated how he could have fallen out of the sling and they could not find any fault with the lift or the sling. They only thing they could conclude was the clip was not secured and pulled all the way to the smaller area of the lift arm, and when Resident #10's weight shifted, the clip came undone. MDSN #304 reported 911 was notified and Resident #10 was transferred to the hospital. MDSN #304 reported Resident #10 was admitted to the hospital for an inoperable neck fracture before being discharged from the hospital to inpatient hospice care. MDSN #304 stated it was a family decision to go to hospice care and he was discharged from the facility. Interview on 10/30/19 at 4:05 P.M. with STNA #105, verified she was the STNA who was transferring Resident #10 at the time of his fall from the Hoyer lift. STNA #105 reported she had just showered Resident #10 and was getting him dressed and back in his wheelchair. STNA #105 reported she reached around to position the chair underneath Resident #105 and he fell out of the sling. STNA #105 reported the clip on the Hoyer lift under Resident #10's shoulder had come undone and Resident #10 fell out of the sling and onto the floor. STNA #105 reported she immediately got the nurse who assessed him and was immediately went out to the hospital. STNA #105 reported she was not informed of what happened to Resident #10, but she was aware he did not return to the facility. STNA #105 stated she did transfer Resident #10 alone but stated the lifts they used allowed for one staff assistance as long as the resident was assessed, and was appropriate. STNA #105 reported Resident #10 was a one person Hoyer lift. STNA #105 reported Resident #10 was not a large man, but his arms were contracted which made it difficult to get him positioned in the sling. STNA #105 stated Resident #105 was not having behaviors but if he moved around a lot in the sling, it could have come undone. STNA #105 reported she could not say that was what happened but said it could have been possible. Review of the Maxi Move Hoyer Lift Manufacturers guidelines revealed the lift was designed for safe usage with one caregiver. Review of facility policy titled, Safe Resident Handling, dated 11/27/12, revealed the facility staff were to take reasonable care of their own health and safety as well as the residents during resident handling activities. Staff should avoid hazardous resident handling and use mechanical lifting devices in accordance to the resident's care plan, instructions, and training. This deficiency substantiates Complaint Number OH 834.

Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents had a dignified dining experience when residents were not served their meals at the same time as other residents at their table. This affected one resident (#25) of 22 residents who were eating lunch in the main dining room. The facility identified 18 residents who required assistance with eating. The facility census was 59. Findings include: Review of Resident #25's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the physician orders, dated 01/09/19, revealed an order for [REDACTED].>Review of the Minimum Data Set (MDS) assessment, dated 04/21/19, revealed Resident #25 was rarely or never understood and was totally dependent on staff for eating. Review of the resident's care plan, revised on 04/18/19, revealed the resident was at risk for aspiration due to dysphagia, required a mechanically altered diet and was dependent for feeding. Observation on 06/10/19 from 11:56 A.M. through 12:33 P.M. of the main dining room revealed Resident #25, #26, #33 and #46 seated at a table. Resident #33 was provided her meal of mashed potatoes with gravy, grilled cheese, cottage cheese and fruit. At 11:57 A.M., Resident #26 was provided her meal. At 12:01 P.M., Resident #46 was provided her meal. All three residents, Resident #26, #33 and #46 were observed feeding themselves while Resident #25 waited. At 12:17 P.M., Resident #25 still seated at the table with no meal. Resident #25 was observed chewing on her right thumb and hand while Resident #33, #26 and #46 ate. At 12:21 P.M., State tested Nursing Assistant (STNA) #110 assisted Resident #46 with reaching her french fries. STNA #110 looked at Resident #25 and adjusted her clothing protector. Resident #25 still did not have a meal. At 12:23 P.M., the kitchen staff started delivering dessert of mint pie to residents who had completed their meals. Resident #33, #46 and #26 were offered pie. Resident #25 still did not have a meal. At 12:28 P.M., Resident #25 was still seated at the table with Resident #26, #33, and #46. Resident #26, #33, and #46 had completed their meals including dessert and Resident #25 still had not been provided her food. Interview on 06/10/19 at 12:30 P.M. with STNA #110 verified Resident #25 had not received her food and the other three residents at Resident #25's table were done eating. STNA #110 stated Resident #25 required physical assistance with eating so Resident #25 had to wait for staff to be available to assist her before she could get her meal. STNA #110 verified Resident #25 had waited over thirty minutes and had not yet received her food. STNA #110 reported Resident #25 always sat at the same table in the main dining room and stated this was a longer wait than Resident #25 typically had. Observation on 06/10/19 at 12:33 P.M. found Resident #25 was provided her lunch including dessert. STNA #110 was seated next to Resident #25 providing eating assistance. Resident #25 was observed eagerly taking bites of her food. Review of the facility policy titled, Dining Choices, revised 03/05/18, revealed restaurant style dining was available to residents during meals daily. Dietary staff members served the requested food items the resident ordered and assisted residents as needed. The policy was silent to the timeliness of meals provided to residents who required staff assistance verses unassisted residents.

Based on medical record review and staff interview, the facility failed to obtained liver function test laboratory values as indicated by a physician or prescriber. This affected two (#55 and #15) of six reviewed for unnecessary medications with potential to affect six resident with orders to obtain liver function test laboratory values. The census was 57. Findings include: 1. Review of Resident #55's medical record revealed an admission date of [DATE], with a most recent admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a pharmacy recommendation for Resident #55 dated 09/22/17 revealed a consideration to obtain a liver function test now and every six months with a [MEDICATION NAME] acid level in order to monitor drug therapy. The pharmacy recommendation was agreed and signed by a nurse practitioner on 09/27/17. Review of laboratory values dated 10/20/17 revealed Resident #55's liver function test was obtained and reviewed with no further instructions at that time. As of 05/31/18, review of Resident #55's medical record revealed no liver function test obtained following the 10/20/17 laboratory values. 2. Review of Resident #15's medical record revealed an admission date of [DATE], and a most recent admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a pharmacy recommendation dated 03/22/18 revealed a consideration to check Resident #15's complete blood count (CBC), lipid panel, liver function test, hemoglobin A1c (HGBA1c), and magnesium level now and every six months in order to monitor his drug therapy. The consideration was agreed and signed on 03/29/18 by the physician. Review of Resident #15's laboratory values dated 04/02/18 revealed the CBC, lipid panel, HGBA1c, and magnesium level were all obtained and reviewed; however, the liver function test was not completed on this date. As of 05/31/18, Resident #15 had no documentation of a liver function test laboratory value completed. Interview on 05/31/18 at 12:05 P.M. with Director of Nursing #1 verified Resident #55 and Resident #15 did not have their liver function tests obtained as indicated from the pharmacy recommendations.

Based on medical record review, review of a facility's Self-Report Incident and investigation, staff interview, and review of facility policy, the facility failed to prevent the misappropriation of resident's medications. This affected five residents (#1, #2, #3, #4, and #5) of five resident reviewed for misappropriation. The census was 58. Findings included: 1. Review of the medical record for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of resident's physician orders [REDACTED]. 2. Review of the medical record for Resident #2 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 04/24/18, revealed the resident was cognitively intact. Review of resident's physician orders [REDACTED]. 3. Review of the medical record for Resident #3 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment assessment, dated 03/05/18, revealed the resident was cognitively intact. Review of Resident 3's physician orders [REDACTED]. 4. Review of the medical record for Resident #4 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 02/14/18, revealed the resident was cognitively intact. Review of Resident#4's physician orders [REDACTED]. 5. Review of the medical record for Resident #5 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #5's physician orders [REDACTED]. Review of the facility's Self-Reported Incident (SRI) control number 1 revealed on 05/01/18, the Director of Nursing (DON) was notified by staff of possible missing medications. The facility completed an investigation and found Resident #1 was missing 11 [MEDICATION NAME] 10 mg, Resident #2 was missing 11 [MEDICATION NAME] 5 mg, Resident #3 was missing 30 [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, Resident #4 was missing 52 [MEDICATION NAME] 5 mg, and Resident #5 was missing 20 [MEDICATION NAME] 50 mg. The facility suspected Registered Nurse (RN) #500. The Ohio Board of Nursing and the local police department were notified. The facility substantiated the SRI and terminated RN #500's employment with the facility. Interview on 05/16/18 at 8:00 A.M., the Director of Nursing (DON) revealed the facility investigation indicated theft of medications had occurred by RN #500. The DON verified Resident #1 was missing 11 [MEDICATION NAME] 10 mg, Resident #2 was missing 11 [MEDICATION NAME] 5 mg, Resident #3 was missing 30 [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, Resident #4 was missing 52 [MEDICATION NAME] 5 mg, and Resident #5 was missing 20 [MEDICATION NAME] 50 mg. Review of facility policy titled Resident Abuse, most recent revision date 11/28/16, revealed it was the facility's policy to investigate all alleged violations involving misappropriation of resident property. The facility was to provide training to staff on the importance of prevention, identification, investigation, resident protection, and reporting. Further review revealed any employee who witnessed or became aware of or suspected misappropriation were to report it immediately to the Administrator and/or designee and to the Ohio Department of Health. This deficiency substantiates Control Number OH 796.

Based on medical record review, review of a facility Self-Report Incident and investigation, staff interview, and review of facility policy, the facility failed to implement their abuse policy when they failed to prevent the misappropriation of resident's medications. This affected five residents (#1, #2, #3, #4, #5) of five resident reviewed for misappropriation. The census was 58. Findings included: 1. Review of the medical record for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of resident's physician orders [REDACTED]. 2. Review of the medical record for Resident #2 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 04/24/18, revealed the resident was cognitively intact. Review of resident's physician orders [REDACTED]. 3. Review of the medical record for Resident #3 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment assessment, dated 03/05/18, revealed the resident was cognitively intact. Review of Resident 3's physician orders [REDACTED]. 4. Review of the medical record for Resident #4 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 02/14/18, revealed the resident was cognitively intact. Review of Resident#4's physician orders [REDACTED]. 5. Review of the medical record for Resident #5 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #5's physician orders [REDACTED]. Review of the facility's Self-Reported Incident (SRI) control number 1 revealed on 05/01/18, the Director of Nursing (DON) was notified by staff of possible missing medications. The facility completed an investigation and found Resident #1 was missing 11 [MEDICATION NAME] 10 mg, Resident #2 was missing 11 [MEDICATION NAME] 5 mg, Resident #3 was missing 30 [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, Resident #4 was missing 52 [MEDICATION NAME] 5 mg, and Resident #5 was missing 20 [MEDICATION NAME] 50 mg. The facility suspected Registered Nurse (RN) #500. The Ohio Board of Nursing and the local police department were notified. The facility substantiated the SRI and terminated RN #500's employment with the facility. Interview on 05/16/18 at 8:00 A.M., the Director of Nursing (DON) revealed the facility investigation indicated theft of medications had occurred by RN #500. The DON verified Resident #1 was missing 11 [MEDICATION NAME] 10 mg, Resident #2 was missing 11 [MEDICATION NAME] 5 mg, Resident #3 was missing 30 [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, Resident #4 was missing 52 [MEDICATION NAME] 5 mg, and Resident #5 was missing 20 [MEDICATION NAME] 50 mg. Review of facility policy titled Resident Abuse, most recent revision date 11/28/16, revealed it was the facility's policy to investigate all alleged violations involving misappropriation of resident property. The facility was to provide training to staff on the importance of prevention, identification, investigation, resident protection, and reporting. Further review revealed any employee who witnessed or became aware of or suspected misappropriation were to report it immediately to the Administrator and/or designee and to the Ohio Department of Health. This deficiency substantiates Control Number OH 796.

Based on observation, staff interview, review of manufacturer's guidelines, review of pharmacy information sheets, and policy review, the facility failed to properly store medications in manufacturer's packages, failed to store medications with labels, and failed to date medications when opened. This affected three (A/B Hall, C Hall, and B Hall) of six medication carts in the facility. The facility census was 60. Findings include: Observation on 03/09/17 between 9:30 A.M. and 10:30 A.M. of the A/B Hall medication cart revealed there were seven pills lying loose in the top drawer of the medication cart. Five pills were identified to be omeprazole 20 milligram (mg) tablets. The third drawer contained an opened and undated bottle of Travatan Z Ophthalmic 0.004% solution eye drop and an opened and undated Advair Diskus 250/50. Interview on 03/09/17 at 9:35 A.M., Licensed Practical Nurse (LPN) #302 verified the loose pills in the medication cart. Interview on 03/09/17 at 9:43 A.M. Registered Nurse (RN) #304 verified the eye drops and Advair Diskus medication were opened and not dated. She stated they were supposed to be dated when it was opened. Observation on 03/09/17 at 9:55 A.M. of the C Hall medication cart revealed a omeprazole 20 mg tablet loose in the top drawer of the cart. The third drawer on the right contained two albuterol sulfate 2.5 mg/3 milliters (ml) solution vials in the box not stored in the foil pouch. There were five Spiriva Handihaler 18 microgram (mcg) tablets loose in the drawer. Interview on 03/09/17 at 9:55 A.M. RN #304 verified the loose pills in the cart and the albuterol sulfate was not stored in the foil pouch. Observation on 03/09/17 at 10:07 A.M. of the B Hall med cart revealed the top drawer had two loose pink tablets stored in a medication cup. There was one vial of Ipratropium Bromide 0.5 mg and one vial of albuterol sulfate inhalation solution 3 mg/3ml loose in the third drawer on the right side of the cart. Neither of these were labeled. Interview on 03/09/17 at 10:07 A.M. the Director of Nursing (DON) verified the improperly stored medications at the time of the observation. Review of the facility policy titled Medication Storage in the Facility, revised 01/11/10, revealed medication are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The policy indicated the pharmacy would dispense medications in containers that meet legal requirements. Medications are kept and stored in these containers. Review of the pharmacy information sheet titled Expiration Dating, dated 09/23/15, revealed eye medications expire six months after being opened. Review of the manufacturer's prescribing information for Advair Diskus revealed the inhaler was to be dated when the medication was removed from the foil pouch. The user should write the date it was opened and write the use by date on the label. The use by date was one month after it was opened. Advair Diskus should be discarded 30 days after opening the medication. Review of the manufacturer's prescribing information for albuterol sulfate inhalation solution revealed it should be stored in the foil pouch until time to use it.

Based on medical record review, observation and staff interview, the facility failed to maintain the medication error rate less than five percent. The medication error rate was 6.4% for two errors out of 31 observed opportunities. This affected two (#42 and #69) of six residents observed for medication administration. The facility census was 60. Findings include: 1. Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent recapitulated and signed physician orders [REDACTED].½ tablets by mouth daily. The prescribed dose was 15 mg by mouth daily. Observation on 03/08/17 beginning at 7:14 A.M. with Registered Nurse (RN) #301 revealed while preparing the medications for Resident #42 RN #301 obtained [MEDICATION NAME] one half of a ten mg tablet which equaled a 5 mg dose. Interview at 8:01 A.M. after obtaining all the medications RN #301 counted the number of pills she had in the medication cup and verified there were 12 pills in the cup. RN #301 then administered the medications to Resident #42. Interview with RN #301 on 03/08/17 at 9:27 A.M. verified Resident #42 only received 5 mg [MEDICATION NAME]. She verified that in addition to the half ten mg tablet, Resident #42 should have also received a whole ten mg tablet of [MEDICATION NAME]. RN #301 verified the physician ordered dose was [MEDICATION NAME] 15 mg by mouth daily. 2. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent recapitulated and signed Physician orders [REDACTED]. Observation on 03/08/17 at 7:51 A.M. with Registered Nurse (RN) #300 revealed RN #300 obtained the [MEDICATION NAME] Flextouch pen for Resident #69 from the medication cart. She applied a needle to the [MEDICATION NAME] Flextouch pen. RN #300 dialed the pen to ten for the dose of ten units of [MEDICATION NAME] insulin. RN #300 did not prime the needle with two units of insulin. RN #300 proceeded to Resident #69's room and administered the insulin at her left abdomen. Interview with RN #300 immediately after she administered the insulin verified she did not prime the [MEDICATION NAME] Flextouch pen prior to administering the insulin for Resident #69. RN #300 stated she had never primed a Flextouch pen prior to administering insulin. Interview with The Director of Nursing (DON) on 03/08/17 at 8:25 A.M. stated the facility follows the manufacture's guidelines when administering insulin via [MEDICATION NAME]. The DON verified a [MEDICATION NAME] should be primed with two units prior to dialing in the dose to be administered to the resident. Review of the Manufacture's instruction for use of the [MEDICATION NAME] Flextouch pen revealed Step Seven Priming your [MEDICATION NAME] Flextouch Pen the dose selector was to be turned to select two units. Step eight revealed the pen should be held with the needle pointing up then tap the top of the pen gently to let any air bubbles rise to the top. Step nine revealed while maintaining the pen upright, press and hold in the dose button until the dose counter shows 0. A drop of insulin should be seen at the needle tip. If a drop of insulin is not seen, repeat steps seven, eight and nine until a drop of insulin is seen. After priming the pen, the instructions continue with how to select the dose of insulin to be administered. A total of 31 medications were observed with two medication errors. This resulted in a medication error rate of 6.4%.

Based on medical record review, observation, interview and manufacturer's instructions, revealed the facility failed to ensure the proper dose of [MEDICATION NAME] (a long-acting insulin) was administered to Resident #69 resulting in a significant medication error. This affected one resident (#69) of two residents observed receiving insulin administration via [MEDICATION NAME]. The facility identified four residents in the facility who received insulin administration via [MEDICATION NAME]. The facility census was 60. Findings include: Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent recapitulated and signed Physician orders [REDACTED]. Observation on 03/08/17 at 7:51 A.M. with Registered Nurse (RN) #300 revealed RN #300 obtained the [MEDICATION NAME] Flextouch pen for Resident #69 from the medication cart. She applied a needle to the [MEDICATION NAME] Flextouch pen. RN #300 dialed the pen to ten for the dose of ten units of [MEDICATION NAME] insulin. RN #300 did not prime the needle with two units of insulin. RN #300 proceeded to Resident #69's room and administered the insulin at her left abdomen. Interview with RN #300 immediately after she administered the insulin she verified she did not prime the [MEDICATION NAME] Flextouch pen prior to administering the insulin for Resident #69. RN #300 stated she had never primed a Flextouch pen prior to administering insulin. Interview with The Director of Nursing (DON) on 03/08/17 at 8:25 A.M. stated the facility follows the manufacture's guidelines when administering insulin via [MEDICATION NAME]. DON verified a [MEDICATION NAME] should be primed with two units prior to dialing in the dose to be administered to the resident. Review of the Manufacture's instruction for use of the [MEDICATION NAME] Flextouch pen revealed Step Seven Priming your [MEDICATION NAME] Flextouch Pen the dose selector was to be turned to select two units. Step eight revealed the pen should be held with the needle pointing up then tap the top of the pen gently to let any air bubbles rise to the top. Step nine revealed while maintaining the pen upright, press and hold in the dose button until the dose counter shows 0. A drop of insulin should be seen at the needle tip. If a drop of insulin is not seen, repeat steps seven, eight and nine until a drop of insulin is seen. After priming the pen the instructions continue with how to select the dose of insulin to be administered.