Every finding on record at Fulton Manor Nursing & Rehab C

Based on medical record review, staff interview, and facility policy review, the facility failed to establish adequate monitoring of medication side effects for anticoagulant and antianxiety medications. This affected one (#3) of five residents reviewed for unnecessary medications. The facility census was 65. Findings include:Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnoses included autistic disorder, Asperger's syndrome, chronic kidney disease stage four, heart failure, and diabetes mellitus type two.Review of the Minimum Data Set (MDS) assessment, dated 02/07/26, revealed Resident #3 was cognitively intact. Review of the most recent care plan revealed Resident #3 was care planned for use of antianxiety medications and interventions included to monitor, document, and report any adverse reactions to antianxiety therapy. Review of the physician order, dated 02/15/23, revealed Resident #3 was prescribed Xarelto (an anticoagulant) 20 milligrams (mg) by mouth one time a day for atrial fibrillation. Review of the physician order, dated 03/19/26, revealed Resident #3 was prescribed buspirone (antianxiety) 10 mg with instructions to give one tablet by mouth two times a day for anxiety.Review of Resident #3's medical record revealed no evidence of facility staff monitoring for side effects of Xarelto or buspirone. Interview on 04/14/26 at approximately 12:30 P.M. with the Director of Nursing (DON) verified Resident #3 did not have documentation of side effects being monitored for Xarelto or buspirone. Review of an undated policy titled, Behavior Management Program, revealed behavior documentation was initiated in the electronic medical record for all psychoactive medications that are in use to include monitoring for effectiveness, side effects, and adverse effects of the medication. Review of an undated policy titled, Anticoagulant Therapy, revealed all residents receiving anticoagulant therapy will be monitored daily for any signs or symptoms of internal bleeding such as hematuria or excessive bruising or any change in mental status.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure supplemental oxygen tubing was properly labeled and dated. This affected one (#40) of two residents reviewed for respiratory care. The facility census was 65.Findings include: Review of the medical record for Resident #40 revealed an admission date of 03/04/14 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, hypertensive heart disease with heart failure, and congestive heart failure (CHF). Review of the Minimum Data Set (MDS) assessment, dated 03/24/26, revealed Resident #40's cognition was moderately impaired. Review of physician orders for Resident #40 revealed an order dated 01/07/26 for oxygen administration via nasal cannula at three liters per minute and an order to change and date the oxygen tubing weekly on Monday during night shift for infection prevention.Observation on 04/13/26 at 2:05 P.M. revealed Resident #40 was seated in her wheelchair with supplemental oxygen in use via nasal cannula connected to an oxygen concentrator set at three liters per minute. The oxygen tubing was not dated.Interview on 04/13/26 at 2:07 P.M. with Unit Manager #467 verified Resident #40 was receiving oxygen at three liters per minute and acknowledged the tubing was not dated.Review of the facility policy titled, Oxygen Administration, dated 09/19/23, revealed all disposable items will be changed over weekly on Mondays and will be dated on the day they are changed. This includes oxygen tubing, aerosol tubing, aerosol chambers, masks, oxygen water canisters, trach tubing and other supplies used to provide oxygen or respiratory treatment.

Based on medical record review and staff interview, the facility failed to obtain resident weights as ordered to determine gains and losses for weight monitoring. This affected one (#62) of two residents reviewed for weight. The facility census was 65.Findings include:Review of the medical record revealed Resident #62 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease (COPD), and hypertension.Review of the MDS assessment dated [DATE] for Resident #62 revealed no the resident was assessed as cognitively intact. Review of Resident #62's medical record revealed a physician order dated 10/28/24 directing staff to monitor, record, and report to the physician significant weight loss of three (3) pounds (lbs.) in one week, greater than 5 percent (%) in one month, greater than 7.5% in 3 months, or greater than 10% in six (6) months.Review of Resident #62's medical record revealed a physician order dated 10/15/25 for staff to weigh the resident weekly and to notify the physician of any 3 lbs. or greater weight gain in a day or 5 lbs. in a week with the resident to be weighed every day shift every Saturday for weight monitoring.Review of the weight-record summary for Resident #62 reveled the resident had no documented weights between 09/14/25 through 09/29/25 and 10/04/25 through 10/17/25 to determine if the resident lost more than 3 lbs. in one week. Further review revealed Resident #62 was not weighed weekly and/or daily to determine if 3 lbs. was lost or 5 lbs. were gained in one week or 3 lbs. were gained in one day from 10/19/25 through 11/05/25, 11/07/25 through 12/05/25, 01/01/26 through 01/06/26, 01/25/26 through 01/31/26, 02/02/26 through 02/20/26, 02/22/26 through 02/27/26, 03/03/26 through 03/06/26, 03/08/26 through 03/13/26, 03/15/26 through 03/20/26, and 03/22/26 through 03/31/26.Review of Resident #62's progress notes for September 2025 through March 2026 revealed no evidence of the resident being weighed for any of the missing time frames as noted above. Interview on 04/16/26 at 8:42 A.M. with Assistant Director of Nursing (ADON) #450 verified Resident #62 did not have any documentation of her daily or weekly weights being obtained to determine if the resident had gains or losses per the physician orders.

Based on review of the medical record, staff interview, and review of a facility policy, the facility failed to adequately monitor bowel movements and implement bowel protocol as needed. This affected one (#6) of one residents reviewed for bowel and bladder. The facility census was 65.Findings include:Review of the medical record revealed Resident #6 was admitted on [DATE]. Diagnoses included spinal stenosis, paroxysmal atrial fibrillation, hypertensive chronic kidney disease, chronic kidney disease stage III, hyperlipidemia, hypothyroidism, fibromyalgia, and dysphagia.Review of the Minimum Data Set (MDS) assessment, dated 02/25/26, revealed Resident #6 was moderately cognitively impaired and required partial/moderate assistance with toileting. The resident was occasionally incontinent of bladder and always continent of bowel.Review of the most recent care plan verified Resident #6 had a focus areas for constipation due to decreased mobility, diminished appetite, and use/side effects of medication. Interventions were numerous and included to record bowel movement pattern each day (describe amount, color, and consistency) and follow facility bowel protocol for bowel management. Review of bowel tracking for the last 30 days revealed Resident #6 did not have a documented bowel movement beginning 03/31/26 to 04/06/26. Further review of Resident #6's medical record revealed no evidence of the facility addressing the lack of bowel movements over this time frame.Interview on 04/16/26 at 1:01 P.M. with the Director of Nursing (DON) verified the lack of documentation for the facility addressing Resident #6's bowel movements or if the facility implemented a bowel protocol as needed. The DON reported Resident #6, at times, would take herself to the bathroom. The DON reported on 04/07/26 at the clinical meeting, Resident #6's lack of documented bowel movements in six days were discussed. The facility nurse spoke to the resident and determined she recently had a bowel movement. The DON verified the facility did not document or monitor Resident #6's bowel movements until there had been no documented bowel movement for six days. Review of the facility undated bowel protocol policy revealed bowel movements will be documented at the end of each shift by the aide responsible for the resident's care. The bowel protocol includes the following standing order medications being provided each shift until the resident has a bowel movement: prune juice, milk of magnesia, Dulcolax suppositories, and Fleets enemas. Nurses will monitor bowel movements each day. The third shift nurse will run a report that will indicated which residents have had no bowel movement in the past two days. When this is noted the nurse will review the medication administration record to determine if bowel medications are needed per the protocol and will contact the physician to obtains orders as appropriate.

Based on medical record review, staff interview, and review of policy, the facility failed to notify the physician of weight deviations in accordance with physician orders. This affected one (#62) of two residents reviewed for weight. The facility census was 65.Findings include:Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included renal failure, type II diabetes mellitus, hypertension, hypertensive heart and chronic kidney disease with heart failure with stage five chronic kidney disease, disorder of the kidney and ureter, and peripheral vascular angioplasty with implants and grafts.Review of the Minimum Data Set (MDS) assessment, dated 03/31/26, revealed Resident #2 was assessed with no cognitive impairment and received dialysis treatments. Review of the care plan dated 02/27/26 revealed Resident #2 was to be weighed at the same time of day and recorded as ordered. Review of the clinical record revealed a physician order, dated 03/03/26, to weigh Resident #2 daily for three days with no end date. Further review revealed to notify the physician of weight gains of three (3) pounds (lbs.) in twenty-four (24) hours or five (5) lbs. in one week.Review of the weight record summary from 02/26/26 to 04/13/26 revealed Resident #2 had weight fluctuations of three or more pounds of weight gain in 24 hours on the following days; from 02/26/26 (183.0 lbs.) to 02/27/26 (186.2 lbs.), the resident gained 3.2 lbs.; from 03/01/26 (186.2 lbs.) to 03/02/26 (191.7 lbs.), the resident gained 5.5 lbs., from 03/15/26 (169.9 lbs.) to 03/16/26 (175.5 lbs.), the resident gained 5.6 lbs.; from 03/19/26 (168.0 lbs.) to 03/20/26 (176.2 lbs.), the resident gained 8.2 lbs.; from 04/02/26 (164.0 lbs.) to 04/03/26 (168.3 lbs.), the resident gained 4.3 lbs., from 04/05/26 (165.3 lbs.) to 04/06/26 (176.4 lbs.), the resident gained 11.1 lbs.; from 04/08/26 (164.1 lbs.) to 04/09/26 (171.6 lbs.), the resident gained 7.5 lbs.; and from 04/09/26 (171.6 lbs.) to 04/10/26 (175.4 lbs.), the resident gained 3.8 lbs.Review of the progress notes dated 02/26/26 to 04/13/26 for Resident #2 revealed no evidence of documentation verifying the physician was notified of Resident #2's weight deviations of more than 3 lbs. of weight gain in 24 hours on the above dates per physician's orders. Interview on 04/14/26 12:49 P.M. with Registered Nurse (RN) #501 verified she was unable to locate any documentation in Resident #2's medical record where the physician was notified of the resident's weight gain in 24 hours as listed above.Interview on 04/14/26 1:05 P.M. with Assistant Director of Nursing (ADON) #359 verified Resident #2 did not have any documentation of daily or weekly weight gains being communicated to the physician by the nursing staff for the above dates in February, March, and April 2026.Review of the undated policy titled, Change of Status Notification, revealed the facility will notify the attending physician and the resident's advocate of any significant change in the resident's medical condition immediately. The Facility will use the following means to notify the residents advocate or the physician including telephone notification within the specified time, written notification within the specified time, interoffice memo within the specified time, e-mail with the specified time, or secured messaging service within the specified time.

Based on medical record review, staff interview, review of staff witness statements, review of facility submitted Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to report allegations of abuse to the state survey agency (SSA). This affected one (#57) of three residents reviewed for abuse. The facility census was 64.Findings include:Review of the medical record revealed Resident #57 was admitted on [DATE]. Diagnoses included unspecified dementia, moderate with agitation; major depressive disorder, recurrent; Alzheimer's disease; and Type II diabetes mellitus without complications. Review of the Minimum Data Set (MDS) assessment, dated 11/23/25, revealed the resident was moderately cognitive impaired. The resident had physical, verbal, rejection of care, wandering, and other behaviors and was (staff) dependent for toileting, lower body dressing, and personal hygiene. Review of the care plan, dated 09/17/25, revealed Resident #57 had a behavior problem due to accusing others, expressing frustration/anger at others, screaming at others, threatening others, disruptive sounds, repetitive motions, agitated, anxious/restless, and verbalizing persistent beliefs that were not true. Review of a nursing progress note, dated 11/08/25, revealed Resident #57 was yelling and making false accusations about staff throughout the day. Specifically, that staff were hitting her in the stomach, kicking her in the head, and punching her in the face. Additionally, the resident stated she was going to throw herself on the floor and attempted to do so several times, although unsuccessful. Resident #57's family visited and the resident was verbally abusive to them. The physician was notified and orders were received for a urinalysis, blood work, and a one-time dose of Ativan (antianxiety). Review of a nursing progress note, dated 11/09/25, revealed Resident #57 continued the same behaviors as the day prior. The resident was yelling, making false accusations of being abused by staff, and threatening to throw herself on the floor. As needed medication was provided but was not effective. Review of Registered Nurse (RN) #223's witness statement, undated, revealed Certified Nursing Assistant (CNA) #313 reported that she was walking down a hall when she heard feet hustling, she turned around and began to walk back when she observed RN #265 hustling away and Resident #57 yell out in pain. CNA #313 stated she heard a smack noise. After that, RN #265 came up behind her and asked what the resident was yelling about. A few moments later, CNA #313 had Resident #57 in the bathroom and Resident #57 inquired if she had seen what happened between her and RN #265. Resident #57 reported RN #265 had hit her in the head. In another situation, Resident #57 had accused staff of rape. In yet another situation, RN #223 was sitting next to Resident #57 when she stated, Did you see that? and the resident pointed to RN #265 and stated that he had just come over and kicked her in the foot and now her feet hurt. RN #223 stated she explained to Resident #57 that no one had come over and touched her. The physician and family were notified. Review of CNA #355's witness statement, dated 11/10/25, revealed on 11/09/25, Resident #57 stated the man hit her on the head twice. CNA #313 was in the common area and CNA #355 came from a resident's room. CNA #355 stated she assisted CNA #313 in toileting Resident #57. Resident #57 kept repeating that the man had hit her. CNA #313 reported to CNA #355 that she was in the common area and RN #265 was on the phone while Resident #57 was calling out. From her peripheral view, she reportedly observed RN #265 dart quickly to the day area, heard a smack, and Resident #57 say ouch. CNA #313 reportedly hurried toward the resident and assisted her with toileting. Resident #57 identified RN #265 as the man who hit her. Review of the Certification and Licensure System (CALS) from 11/08/25 through 12/08/25 revealed no evidence the facility submitted an SRI related to the allegation of abuse involving Resident #57 and RN #265. Interview on 12/08/25 at 1:15 P.M. with RN #223 revealed on 11/09/25, CNA #313 requested her to come to the shower room. CNA #313 reported she was walking down the hall and heard Resident #57 yell out. CNA #313 thought she heard a slap and observed RN #265 walk away from Resident #57. Resident #57 reported to CNA #313 that RN #265 had hit her. RN #223 stated Resident #57 was often confused and had accused staff of many things. RN #223 stated she called the Director of Nursing (DON), with no response, and spoke with Assistant Director of Nursing (ADON) #354, who instructed her to call the Administrator. RN #233 called the Administrator to report the allegation. Interview on 12/08/25 at 1:38 P.M. with ADON #354 verified RN #223 reported Resident #57's allegation of abuse. ADON #354 stated he believed the allegation was investigated and unsubstantiated. Interview on 12/08/25 at 1:42 P.M. with the Administrator verified she had received a call from RN #223 stating Resident #57 alleged that RN #265 popped her on the head. The Administrator stated the same day the resident had stated she was getting raped, punched in the stomach, and exhibited hallucinations. The Administrator reported she was on vacation through 11/11/25 and when she returned there were witness statements under her door. The Administrator verified the allegation was not reported to the SSA due to the resident having a history of making allegations. Review of the facility policy titled, Resident Abuse, Neglect, Misappropriation of Property and Injury of Unknown Source, dated 08/28/23, revealed incidents that must be reported to the Ohio Department of Health (SSA) included allegations of abuse involving employees. The Administrator or designee would complete the online submission of self-reported incidents immediately, within two hours if abuse allegation or serious injury, and 24 hours for others. The DON and social worker would assist in completing the investigation and submit the results to the Administrator or designee. This deficiency represents non-compliance investigated under Master Complaint Number 2685832 and Complaint Number 2625736.

Based on medical record review, staff interview, review of witness statements, and review of facility policy, the facility failed to investigate allegations of abuse. This affected one (#57) of three residents reviewed for abuse. The facility census was 64.Findings include:Review of the medical record revealed Resident #57 was admitted on [DATE]. Diagnoses included unspecified dementia, moderate with agitation; major depressive disorder, recurrent; Alzheimer's disease; and Type II diabetes mellitus without complications. Review of the Minimum Data Set (MDS) assessment, dated 11/23/25, revealed the resident was moderately cognitive impaired. The resident had physical, verbal, rejection of care, wandering, and other behaviors and was (staff) dependent for toileting, lower body dressing, and personal hygiene. Review of the care plan, dated 09/17/25, revealed Resident #57 had a behavior problem due to accusing others, expressing frustration/anger at others, screaming at others, threatening others, disruptive sounds, repetitive motions, agitated, anxious/restless, and verbalizing persistent beliefs that were not true. Review of a nursing progress note, dated 11/08/25, revealed Resident #57 was yelling and making false accusations about staff throughout the day. Specifically, that staff were hitting her in the stomach, kicking her in the head, and punching her in the face. Additionally, the resident stated she was going to throw herself on the floor and attempted to do so several times, although unsuccessful. Resident #57's family visited and the resident was verbally abusive to them. The physician was notified and orders were received for a urinalysis, blood work, and a one-time dose of Ativan (antianxiety). Review of a nursing progress note, dated 11/09/25, revealed Resident #57 continued the same behaviors as the day prior. The resident was yelling, making false accusations of being abused by staff, and threatening to throw herself on the floor. As needed medication was provided but was not effective. Review of Registered Nurse (RN) #223's witness statement, undated, revealed Certified Nursing Assistant (CNA) #313 reported that she was walking down a hall when she heard feet hustling, she turned around and began to walk back when she observed RN #265 hustling away and Resident #57 yell out in pain. CNA #313 stated she heard a smack noise. After that, RN #265 came up behind her and asked what the resident was yelling about. A few moments later, CNA #313 had Resident #57 in the bathroom and Resident #57 inquired if she had seen what happened between her and RN #265. Resident #57 reported RN #265 had hit her in the head. In another situation, Resident #57 had accused staff of rape. In yet another situation, RN #223 was sitting next to Resident #57 when she stated, Did you see that? and the resident pointed to RN #265 and stated that he had just come over and kicked her in the foot and now her feet hurt. RN #223 stated she explained to Resident #57 that no one had come over and touched her. The physician and family were notified. Review of RN #265's witness statement, undated, revealed on the night of 11/09/25, he had been on the phone with the pharmacy at the nurses' station. Resident #57 was in her wheelchair in the common area. Resident #57 started to exit her wheelchair and RN #265 dropped the phone and ran to the resident who was nearly halfway out of the chair, leaning over the left side. RN #265 secured the resident and placed her back in the wheelchair. RN #265 asked Resident #57 what she needed and if he could help her. The resident's response was that she did not need anything and she was going home. RN #265 stated he explained she was a resident of the facility and it was her home. At this time, an aide came to the lounge to assist, and the resident was placed in the recliner. RN #265 returned to the nurses' station to resume the phone call. Review of CNA #355's witness statement, dated 11/10/25, revealed on 11/09/25, Resident #57 stated the man hit her on the head twice. CNA #313 was in the common area and CNA #355 came from a resident's room. CNA #355 stated she assisted CNA #313 in toileting Resident #57. Resident #57 kept repeating that the man had hit her. CNA #313 reported to CNA #355 that she was in the common area and RN #265 was on the phone while Resident #57 was calling out. From her peripheral view, she reportedly observed RN #265 dart quickly to the day area, heard a smack, and Resident #57 say ouch. CNA #313 reportedly hurried toward the resident and assisted her with toileting. Resident #57 identified RN #265 as the man who hit her. Interview on 12/08/25 at 1:15 P.M. with RN #223 revealed on 11/09/25, CNA #313 requested her to come to the shower room. CNA #313 reported she was walking down the hall and heard Resident #57 yell out. CNA #313 thought she heard a slap and observed RN #265 walk away from Resident #57. Resident #57 reported to CNA #313 that RN #265 had hit her. RN #223 stated Resident #57 was often confused and had accused staff of many things. RN #223 stated she called the Director of Nursing (DON), with no response, and spoke with Assistant Director of Nursing (ADON) #354, who instructed her to call the Administrator. RN #233 called the Administrator to report the allegation. RN #223 revealed she wrote a statement and put it under the Administrator's door. RN #223 verified she was not given instructions to send RN #265 home, complete a skin assessment on Resident #57, or interview like residents. Interview on 12/08/25 at 1:29 P.M. with RN #265 revealed he became aware of the allegation through rumors, and he went to the Administrator approximately a week and a half ago for clarification. He reported the Administrator stated the DON would be talking with him about it. The DON spoke with him, and he wrote a statement at that time. RN #265 verified he was never put on leave pending an investigation. Interview on 12/08/25 at 1:38 P.M. with ADON #354 verified RN #223 reported Resident #57's allegation of abuse. ADON #354 stated he believed the allegation was investigated and unsubstantiated. Interview on 12/08/25 at 1:42 P.M. with the Administrator verified she had received a call from RN #223 stating Resident #57 alleged that RN #265 popped her on the head. The Administrator stated the same day the resident had stated she was getting raped, punched in the stomach, and exhibited hallucinations. The Administrator reported she was on vacation through 11/11/25 and when she returned there were witness statements under her door. The Administrator verified the facility did not conduct an investigation into Resident #57's allegation because the resident had a history of making false allegations.Interview on 12/08/25 at 3:50 P.M. with CNA #313 revealed on 11/09/25 at approximately 4:00 P.M. to 6:00 P.M., RN #265 was taking a phone call and then she heard feet scuffling and Resident #57 making noises. CNA #313 stated she saw RN #265 go towards Resident #57 then heard what sounded like a stack of papers rustling in the air. CNA #313 stated she did not know what happened but she took Resident #57 to the bathroom. Resident #57 reported that a staff, identified as RN #265, hit her in the head with something heavy and asked if her head was bleeding. CNA #313 verified reporting the allegation to RN #223 and she wrote a statement related to the allegation. CNA #313 stated the situation made her feel uneasy. CNA #313 confirmed she was never interviewed related to the allegation.A telephone interview on 12/08/25 at 4:32 P.M. with CNA #355 verified that while assisting CNA #313 with Resident #57 in the bathroom, the resident reported a man had hit her. CNA #355 stated she wrote a statement, but confirmed she was never interviewed related to the allegation. Interview on 12/08/25 at approximately 4:45 P.M. with the Administrator verified the facility did not have a witness statement from CNA #313. Review of the facility policy titled, Resident Abuse, Neglect, Misappropriation of Property and Injury of Unknown Source, dated 08/28/23, revealed residents shall be secured, the resident shall be assessed including injury or psychosocial changes, the alleged perpetrator shall be identified, and the Administrator, DON, physician, and family shall be notified. Additionally, interviews or witness statements shall be obtained from reporter, victim, alleged perpetrator, and potential witnesses. This deficiency represents noncompliance investigated under Master Complaint Number 2685832 and Complaint Number 2625736.

Based on medical record review and staff interview, the facility failed to ensure residents were free from significant medication errors. This affected one (#16) of three residents reviewed for medication errors. The facility census was 64.Findings include:Record review for Resident #16 revealed an admission date of 02/19/24. Diagnoses included Parkinson's disease and dementia.Review of the Minimum Data Set (MDS) assessment, dated 11/21/25, revealed Resident #16 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. Review of a physician order dated 06/27/25 revealed Resident #16 was ordered ropinrole HCI (used to treat Parkinson's symptoms) oral tablet 0.5 milligrams (mg) three times daily.Review of a nursing nursing note dated 06/27/25 revealed an order was received for ropinrole HCI oral table 0.5 milligrams (mg) three times a day.Review of the June 2025 Medication Administration Record (MAR) revealed on 06/27/25, the order for ropinrole 0.5 mg three times daily was entered into the electronic medical record (EMR) as five mg four times daily. Further review of the MAR revealed Resident #16 was administered ropinrole five mg on 06/27/25 at 4:00 P.M. and 9:00 P.M.; 06/28/25 at 6:00 A.M., 11:00 A.M., 4:00 P.M., and 11:00 P.M.; and 06/29/25 at 6:00 A.M. On 06/29/25, the order for ropinrole was updated to 0.5 mg three times daily. Review of the nursing progress notes revealed on 06/28/25, Resident #16 experienced hypertension, headache, hallucinations, and increased anxiety. On 06/29/25, Resident #16 experienced dizziness. Interview on 12/09/25 at 2:22 P.M. with the Director of Nursing (DON) verified Resident #16's ropinrole order was entered into the EMR incorrectly and the medication was subsequently administered at the wrong dosage. Interview on 12/10/25 at 9:37 A.M. with Licensed Practical Nurse (LPN) #206 verified she incorrectly entered Resident #16's ropinrole order on 06/27/25. LPN #206 stated there was no warning sign indicating the order was incorrect when she placed the order. While LPN #206 acknowledged she erroneously entered the order, she did not understand why the pharmacy or manager did not notice her mistake. This was an incidental finding identified during the complaint investigation.

Based on medical record review, staff interview, and review of facility policy, the facility failed to timely notify the physician and resident representative of a change in condition. This affected one (#16) of three resident's reviewed for change in condition. The facility census was 64.Findings include:Record review for Resident #16 revealed an admission date of 02/19/24. Diagnoses included Parkinson's disease and dementia.Review of the Minimum Data Set (MDS) assessment, dated 11/21/25, revealed Resident #16 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. Review of a physician order dated 06/27/25 revealed Resident #16 was ordered ropinrole HCI (used to treat Parkinson's symptoms) oral tablet 0.5 milligrams (mg) three times daily. Review of the June 2025 Medication Administration Record (MAR) revealed on 06/27/25, the order for ropinrole 0.5 mg three times daily was entered as 5 mg four times daily. Further review of the MAR revealed Resident #16 was administered ropinrole 5 mg on 06/27/25 at 4:00 P.M. and 9:00 P.M.; 06/28/25 at 6:00 A.M., 11:00 A.M., 4:00 P.M., and 11:00 P.M.; and 06/29/25 at 6:00 A.M. On 06/29/25, the order for ropinrole was updated to 0.5 mg three times daily. Review of the nursing progress notes revealed on 06/28/25, Resident #16 experienced hypertension, headache, hallucinations, and increased anxiety. On 06/29/25, Resident #16 experienced dizziness. Further review of Resident #16's medical record revealed no evidence the resident's physician or family were notified of the medication error until 06/30/25. Interview on 12/09/25 at 2:22 P.M. with the Director of Nursing (DON) confirmed Resident #16's ropinrole order was entered incorrectly and the resident was administered the wrong dosage. Additionally, the DON confirmed the resident experienced symptoms during the time she was administered the incorrect dosage of ropinrole. While the medication error was discovered on 06/29/25, the DON verified the physician and Resident #16's family were not notified until 06/30/25.Review of the facility policy titled, Change of Status Notification, undated, revealed the facility would notify the attending physician and the resident's advocate of any significant change in the resident's medical condition immediately.This deficiency represents noncompliance investigated under Complaint Number 2564492.

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 facility policy and facility documentation, the facility failed to ensure medications were administered without significant errors. This affected one (Resident #01) of the six residents reviewed for medication administration. The facility census 52. Findings include: Review of the medical record for Resident #01, revealed the resident was admitted to the facility on [DATE] with the diagnosis including, non-pressure chronic ulcer to back, paraplegia, diabetes mellitus, osteomyelitis, pressure ulcer of sacral region, varicose veins with ulcer to lower extremity, and hypertension. Review of the Minimum Data Set (MDS) assessment 3.0 dated 08/27/23 for Resident #01, revealed the resident was assessed with intact cognition, able to make needs known, dependent on staff for activities of daily living, utilized an ostomy, required intermittent catheterization and received antibiotics. Review of the physician orders dated 08/15/23 for Resident #01, revealed the resident was ordered to receive intravenous (IV) antibiotic administration of Cefepime HCL one gram (gm) in 50 milliliters (ml) every eight hours. Review of the nurse's notes dated 09/13/23 at 3:56 P.M. for Resident #01 and authored by Registered Nurse (RN) #200, revealed the resident was given an incorrect IV antibiotic this morning and was discovered by this nurse. The physician was notified and ordered to continue giving the ordered antibiotic as scheduled and continue monitoring the resident for adverse reactions. Review of a facility document titled Employee Coaching Form dated 09/14/23 was provided to RN #201 due to giving the incorrect antibiotic to Resident #01 on 09/13/23. Review of a facility document titled Incident Review dated 09/15/23 at 6:41 P.M., revealed a medication error was recorded for Resident #01. The documented noted on 09/13/23 at 2:30 P.M., RN #200 went into Resident #01's room to hang the scheduled IV antibiotic, Cefepime HCL one gm/50 ml and upon removal of the previous bag hung by third shift nurse (RN #201), RN #200 noticed it was the wrong dose, wrong medication, and the wrong patient's name on the bag. Resident #01 was given Ceftriaxone two grams (gms) /100 ml and the entire medication had already been infused. The physician was unaware of the situation and was notified at 3:00 P.M. The physician noted if there were no adverse reactions from the resident, continued with the scheduled IV antibiotics and to continue monitoring the resident for any adverse effects. Review of the facility policy titled Medication Administration Policy revised on 09/19/23, revealed medications shall be administered only upon the order of a physician or other licensed independent practitioner who is authorized to provide care to the resident. The person administering the medication will verify the accurate medication, dosage, route of administration, appropriate time for administration, and correct resident. Interview with the Director of Nursing (DON) on 10/23/23 at 11:25 A.M., verified Resident #01 received the wrong IV antibiotic which resulted in a medication error. The DON stated corrective action was taken following the incident. The deficiency was corrected on 09/29/23 after the facility implemented the following corrective actions. On 09/13/23 at 3:00 P.M., the physician was notified of the medication error and no new orders were obtained. On 09/14/23, RN #201 received an Employee Coaching due to giving Resident #01 an incorrect antibiotic. On 09/19/23, the facility revised their medication administration policy to include medication packages to be electronically scanned which will perform a double check to indicate if the correct medications are being dispensed. After scanning the medications, the nurse administering the medication may remove it from the packaging and prepare it as necessary to be given to the resident. The nurse then returns to the electronic medication administration record (MAR) and electronically signs all medications that were provided and accepted by the resident. On 09/21/23, 10/12/23, and 10/17/23, medication administration observation and audits were conducted by the DON. On 09/28/23, all facility nurses were given in-service training in the prevention of medication errors and the medication administration policy, including six rights and three checks. On 10/23/23 between 7:51 A.M. and 8:32 A.M., observation of medication administration with Licensed Practical Nurse (LPN) #300 and RN #204 noted medications were given to three residents (#04, #05, and #06) in accordance with the physician orders. On 10/23/23 at 1:14 P.M., an interview with LPN #300 confirmed attending in-service training related to medication error prevention. On 10/23/23 at 1:20 P.M., an interview with RN #205 confirmed attending in-service training related to medication error prevention. This deficiency represents non-compliance investigated under Complaint Number OH00146874.

Based on medical record review, and staff interview, the facility failed to ensure urinary intermittent straight catheterization was provided in accordance with physician orders. This affected one (#01) of three sampled residents reviewed for urinary catheterization. Facility census 52. Findings include: Review of the medical record for Resident #01, revealed the resident was admitted to the facility on [DATE] with the diagnosis including, non-pressure chronic ulcer to back, paraplegia, type 2 diabetes mellitus, osteomyelitis, pressure ulcer of sacral region, varicose veins with ulcer to lower extremity, and hypertension. Review of the Minimum Data Set (MDS) assessment 3.0 dated 08/27/23 for Resident #01, revealed the resident was assessed with intact cognition, able to make needs known, dependent on staff for activities of daily living, utilized an ostomy and required intermittent catheterization. Review of the physician orders dated 08/14/23 for Resident #01, revealed the resident was ordered to be catheterized via a straight catheter (device used to empty the bladder) every six hours and as needed (PRN) due to paralysis and urinary retention. The orders dated 08/15/23 revealed the staff would document urinary output every shift. Review of the August 2023 treatment administration records (TARs) for Resident #01 revealed no documented evidence the facility provided the resident with a straight catheterization (cath) every six hours as ordered. The TARs indicated the resident did not receive a straight cath every six hours as ordered on the following dates: 08/15/23, 08/16/23, 08/18/23 08/19/23 08/21/23, 08/22/23, 08/24/23, 08/26/23, 08/27/23, 08/28/23 and 08/31/23. The TARs on those dates were marked with an x for the missed procedures. The TARs indicated no straight cath was performed for the entire day on 08/17/23 and no documented evidence a straight cath was performed on 08/20/23 (day shift), 08/23/23 (night shift), and 08/30/23 (night shift). The TARs also indicated no urinary output was recorded on 08/17/23 (day and night shifts), 08/23/23 (day and night shifts) and 08/30/23 (night shift) Review of the September 2023 TARs for Resident #01, revealed the resident was only scheduled for straight cath once during the day shift and once during the night instead of the ordered every six hours. The TARs indicated the resident did not receive a straight cath every six hours as ordered from 09/01/23 through 09/22/23 when the orders were discontinued. The TARs revealed no documented evidence the resident received a straight cath on 09/10/23 (night shift), 09/15/23 (day shift), 09/18/23 (night shift), and 09/21/23 (day shift). The TARs also indicated no urinary output was recorded for the resident on 09/03/23 (night shift), 09/08/23 (day shift), 09/10/23 (night shift), 09/15/23 (day shift) 09/16/23 (day shift), 09/18/23 (night shift) and 09/21/23 (day shift) Interview with Director of Nursing (DON) on 10/23/23 at 11:25 A.M. confirmed Resident #01 was not provided with intermittent urinary catheterization every six hours as ordered by the physician and confirmed the resident's urinary output was not recorded as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00146874.

Based on medical record review, resident and staff interview, pharmacy staff interview, and review of a facility policy, the facility failed to ensure medications were administered per physician order. This affected one (#39) of three residents reviewed for medication administration. The facility census was 51. Findings include: Review of Resident #39's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), hypertension, osteoarthritis, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was severely cognitively impaired. Review of the plan of care initiated 02/20/23 revealed Resident #39 was at risk for shortness of breath related to COPD. Interventions included to administer medications as ordered and monitor for adverse side effects. Review of a current physician order dated 07/13/23 revealed Resident #39 was ordered the combination inhaled medication to treat COPD Breztri Aerosphere to receive two puffs orally two times a day. Review of Resident #39's medication administration record (MAR) from 08/01/23 through 08/30/23 revealed Breztri Aerosphere was documentated on 08/07/23 at the evening dose, on 08/08/23 at the morning dose, on 08/09/23 at the evening dose, on 08/11/23 at the evening dose, on 08/12/23 at the morning dose, on 08/28/23 at the evening dose, and on 08/29/23 at the morning dose with the MAR code of 9. Further review of the MAR revealed the code 9 indicated the medication was unavailable. Review of Resident #39's nursing progress notes related to administration of Breztri Aerosphere revealed on 08/07/23 the facility was waiting on pharmacy, on 08/08/23 the medication was on order, on 08/09/23 the medication was not available from pharmacy, on 08/11/23 the medication was not available, on 08/12/23 the medication was on order, and on 08/28/23 the medication was not available pharmacy was called. Interview on 08/28/23 at 12:27 P.M., with Resident #39 stated he had not received his Breztri Aerosphere inhaler as physician ordered. Resident #39 stated nursing staff told him it had been ordered, but the pharmacy had not delivered it. Resident #39 stated he was concerned he did not have his medication like he was supposed to because he had blood clots in his lungs in the past. Interview on 08/30/23 at 3:46 P.M., with the Director of Nursing (DON) verified Resident #39 did not receive Breztri Aerosphere as ordered on 08/08/23, 08/09/23, 08/11/23, 08/12/23, and 08/28/23. The DON stated she became aware on 08/28/23 the inhaler was not available, and it was believed it was accidentally thrown away. The DON stated the medication was reordered on 08/28/23, but it was too early to refill the medication. As a result, the DON authorized the refill with the facility paying for the cost of the medication. The DON verified the medication should have been in the facility for administration, and Resident #39 did not receive the inhaler as ordered. Interview on 08/30/23 at 3:55 P.M., with Pharmacy Order Entry Technician (POET) #507 confirmed Resident #39's Breztri Aerosphere was filled and delivered to the facility on [DATE] and 08/13/23. On 08/28/23, the pharmacy received a refill request but since each order was a 30-day supply, it was too soon to fill the order request. POET #507 confirmed the facility authorized payment and the medication was delivered on 08/29/23. Review of an undated facility policy titled, Medication Administration Policy, revealed medications shall be administered only upon the order of a physician or other Licensed Independent Practitioner who is authorized to provide care to the resident. If a medication is not available during the process, the nurse indicates this in the electronic medication administration record (EMAR). Additionally, a note is documented in the EMAR by the nurse detailing the communication to the pharmacy regarding the missing medication. This deficiency represents non-compliance investigated under Complaint Number OH00131350.

Based on medical record review and staff interview, the facility failed to provide treatment for pressure ulcers per physician order. This affected one (#7) of one residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 51. Findings include: Review of Resident #7's medical record revealed an admitted [DATE]. Diagnoses included atherosclerosis of native arteries of extremities, hypotension, atrial fibrillation, type II diabetes chronic kidney disease, chronic obstructive pulmonary disease (COPD), and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, was at risk for pressure ulcers, and had one stage II pressure ulcer (partial-thickness skin loss with exposed dermis). Review of the plan of care dated 06/07/21 revealed Resident #7 was at risk for skin breakdown. Interventions included wound treatment per facility protocol or wound care. Review of a wound care note dated 07/03/23 revealed Resident #7 had a stage II pressure wound to the coccyx which was acquired on 05/11/23. Additional review of wound care notes dated 07/10/23, 07/17/23, 07/24/23, and 08/01/23 revealed no worsening of the wound, and Resident #7 refused to lay down during the day to reduce pressure. Review of an assessment used to predict pressure ulcer development dated 08/12/23 revealed Resident #7 was at moderate risk for pressure sores. Review of physician orders dated 06/20/23 revealed Resident #7 was ordered to cleanse the sacral area with normal saline, pat dry, pack the wound with a thin strip of Mesalt, cover with Allevyn dressing, and change daily and as needed. Review of Resident #7's treatment administration record (TAR) for July 2023 revealed sacral treatments were not documented as provided on 07/04/23, 07/06/23, 07/11/23, 07/13/23, 07/18/23, 07/19/23, 07/20/23, and 07/22/23. Interview on 08/29/23 at 3:58 P.M. with the Director of Nursing (DON) verified the facility had no evidence Resident #7's wound treatments were administered as ordered by the physician on 07/04/23, 07/06/23, 07/11/23, 07/13/23, 07/18/23, 07/19/23, 07/20/23, and 07/22/23. Interview on 08/30/23 at 8:59 A.M. with Licensed Practical Nurse (LPN) #505 stated she was the treatment nurse. LPN #505 stated while Resident #7 was not always compliant with repositioning to relieve pressure, the resident was compliant with wound treatments.

Based on medical record review, observation, and staff interview, the facility failed to ensure a dependent resident received adequate assistance with shaving. This affected one (#13) of one residents reviewed for activities of daily living. The facility census was 51. Findings include: Review of Resident #13's medical record revealed an admitted [DATE]. Diagnoses included dementia, hypertension, atherosclerotic heart disease, anxiety disorder, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was severely cognitively impaired and required extensive assistance with personal hygiene. Review of the plan of care initiated 08/13/21 revealed Resident #13 required assistance with activities of daily living (ADLs) due to physical limitations secondary to dementia and anxiety. Interventions included to set up supplies needed to assist with completion of ADLs, provide needed assistance of one staff member for proper completion of ADLs, encourage the resident to do as much as possible for herself, and give simple direct steps and allow ample time to complete the task at hand. Observations on 08/29/23 at 8:12 A.M. and on 08/30/23 at 8:05 A.M. of Resident #13 revealed the resident had several long hairs on her chin, approximately one-quarter inch in length. Interview on 08/30/23 at 9:26 A.M. with State tested Nurse Aide (STNA) #504 stated Resident #13 required staff assistance with hygiene and grooming. STNA #504 stated shaving was typically done on shower days and she assisted Resident #13 with a shower on 08/29/23. STNA #504 stated she did not shave residents who did not have an electric razor because she was afraid of disposable razors. STNA #504 verified the hair growth on Resident #13's chin and confirmed she did not assist the resident with shaving during her shower on 08/29/23.

Based on electronic and paper medical record review, staff interview, and review of the facility policy, the facility failed to ensure accurate advanced directives were located in each medical record. This affected one (#13) of one resident reviewed for advanced directives. The facility census was 51. Findings include: Review of Resident #13's medical record revealed an admitted [DATE]. Diagnoses included dementia, hypertension, atherosclerotic heart disease, anxiety disorder, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was severely cognitively impaired. Review of a Do Not Resuscitate (DNR) Order Form dated 09/01/22, and located in Resident #13's paper medical record, revealed the resident's advanced directives were DNR Comfort Care (meaning the DNR protocol was effective immediately). Review of a current physician order dated 07/31/23, and located in the electronic medical record (EMR) revealed Resident #13's advanced directives were Do Not Resuscitate Comfort Care-Arrest (DNRCC-A), meaning providers will treat the resident as any other without a DNR order until the point of cardiac or respiratory arrest at which point all life saving interventions will stop and the DNR Comfort Care protocol will be implemented. Interview on 08/31/23 at 12:14 P.M. with Registered Nurse (RN) #510 stated staff members could check either the paper chart or the EMR to determine a resident's advanced directives, if needed. RN #510 verified Resident #13's advanced directives order in the EMR did not match the order in the the paper chart, and stated she would take care of it. Review of an undated facility policy titled, Advance Directives, revealed documentation of advanced directives will be maintained by the facility in the resident's current chart throughout the course of the stay.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident receiving supplemental oxygen therapy had a physician order for use. This affected one (#301) of residents reviewed for oxygen therapy. The facility identified nine residents that use supplemental oxygen. The facility census was 51. Findings include: Review of the medical record for Resident #301 revealed an admitted [DATE] with diagnoses of heart failure and atrial fibrillation. Review of an initial assessment dated [DATE] revealed the resident was alert and oriented to person, place, and time, and was noted to have supplemental oxygen at two liters per minute by way of nasal cannula. Review of Resident #301's current physician orders for August 2023 revealed there were not any orders for supplemental oxygen therapy. Observation on 08/28/23 at 3:26 P.M. revealed Resident #301 was resting in bed after lunch and therapy with supplemental oxygen on at two liters per minute via nasal cannula. Interview on 08/28/23 at 3:26 P.M. with Resident #301 stated she was on oxygen at home only in the afternoon and during the night. Observation on 08/29/23 at 7:45 A.M. revealed Resident #301 was resting in bed with supplemental oxygen in place via nasal cannula at two liters per minute. Observation on 08/31/23 at 8:04 A.M. revealed Resident #301 was sitting in her recliner eating breakfast with supplemental oxygen on via nasal cannula at two liters per minute. Interview on 08/31/23 at 8:05 A.M. with Registered Nurse (RN) #508 verified Resident #301 was receiving supplemental oxygen by nasal cannula at two liters per minutes, and verified the medical record for Resident #301 contained no orders for supplemental oxygen therapy. Review of an undated facility policy titled, Oxygen Use/Administration, revealed oxygen must be prescribed by a physician, and a complete order must be obtained to include liter flow per minute, titration instructions, and type of delivery device (nasal cannula, simple mask).

Based on observation, staff interview, and policy review the facility failed to follow infection control practice for droplet isolation precautions and hand hygiene. This had the potential to affect 36 Residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #39, #40, #41, #42, #43, #44, #45, and #46) of 46 who resided in the facility. The facility census was 46. Findings include: Observation on 11/30/20 at 1:05 P.M., revealed Dietary Staff #200 came out of a resident room into the 220-221 hallway with a meal tray wearing a reusable isolation gown and gloves, and carried the tray to a cart by the nurses station. Interview with Dietary Staff #200 verified when they leave a room they were to dispose of the isolation gown in a cart on the 220-221 hallway. There was one cart observed in the hallway for disposal of gowns. Observation on 11/30/20 at 1:05 P.M., revealed Housekeeping #210 was doing a deep clean of an empty room. Housekeeping #210 removed her gloves and threw them away in her trash can on the housekeeping cart, and then put on a new pair of gloves before going into another room. Interview with Housekeeping #210 verified she did not perform hand hygiene after removing her dirty gloves and stated she does not usually wash her hands after removing her gloves because she thought they were considered clean. Observation on 11/30/20 at 1:24 P.M., revealed State tested Nurse Aide (STNA) #100 walked out of a shower room with a disposable isolation gown on and walked into the nurses station and spoke to another staff member and walked back into the shower room. STNA #100 left the shower room pushing a wheelchair with a resident in it and STNA #100 had an isolation gown on with gloves and pushed the resident down the 410-415 hallway to her room. Observation on 11/30/20 at 1:26 P.M., revealed STNA #110 put on an isolation gown and then walked down the hallway and entered the room on the 400-410 to answer a call light. The resident asked for a diet soda and STNA #110 left the room with the isolation gown on and walked down the hall and went into the pantry to get a diet soda and walked back down the hallway to the room with her isolation gown on the entire time. Interview with STNA #110 verified she did not remove the isolation gown prior to leaving room and walked down the hall to get the resident a drink. Interview on 11/30/20 at 1:45 P.M., STNA #100 verified the staff have to wear a new gown for every resident and change between every room. STNA #100 was unsure if she had to remove the gown before she left a room. Interview on 11/30/20 at 2:00 P.M., the Director of Nursing (DON) revealed the staff were to remove their gown before walking down the hallway and they should be taking the cart with them to the room to dispose of their dirty gown. She stated she would start education right away with them. She also stated they might be getting mixed up with all the changes they have had. The DON verified the facility followed the Centers for Disease Control and Prevention (CDC) guidelines for donning and doffing personal protective equipment (PPE). Review of the policy titled Hand Hygiene, dated 04/88, revealed indications for hand washing and hand antisepsis includes when hands are visible dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water. If hands are not visibly soiled, use an alcohol-based rub for routinely decontaminating hands in all other clinical situations such as, before having direct contact with patients, after contact with a patient's intact skin, after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled, after contact with inanimate objects in the vicinity of the patient and after removing gloves. Review of the policy titled Procedures for Airborne, Contact and Droplet Isolation, undated, revealed for precautions wear clean gloves when entering the resident's room or unit if a multi-bed room. During care, change gloves after having contact with infectious material. Remove gloves before leaving resident area. Wash hands immediately with soap and water or alcohol hand sanitizer if handwashing facilities are unavailable. If the organism being isolated is [MEDICATION NAME] resistant [MEDICATION NAME], antimicrobial soap is recommended. Wear a gown when entering the resident area if you anticipate that you will have a substantial contact with the resident, resident items, or environmental surfaces or if the resident is incontinent. Remove the gown carefully before leaving the room and wash hands.

Based on record review, observation, staff interview and review of the facility's policy, the facility failed to ensure the residents were protected against infection with the appropriate use of personal protective equipment (PPE) and hand hygiene. This affected four residents (#9, #26, #32 and #52) of 19 residents who received a hall tray. This had the potential to affect all 64 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #52 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 11/14/19, revealed the resident's cognition was intact and had no behaviors. Review of Influenza A & B laboratory result, dated 02/23/20, revealed the active flu A was detected. Review of the physician's orders [REDACTED]. Observation on 03/02/20 at 1:42 P.M. of Resident #52 revealed she was in her room on droplet precautions and was actively coughing. The resident's room had a sign indicating to enter the room, you need a mask and gloves, which were outside the room. Resident #52 had her call light on. State tested Nursing Assistant (STNA) #440 went into the room without a mask or gloves. Resident #52 asked for new ice and no water in her personal big gulp cup. STNA #440 took the big gulp cup and stated she would return. The STNA returned with ice in the big gulp cup. During this observation, the STNA was observed to not wash her hands when she entered or left the resident's room. Interview on 03/02/20 at 1:46 P.M. with STNA #440 confirmed she had not washed her hands before and after care and did not put gloves and a mask one. The STNA verified she put ice in the same cup as she took from the resident's room and the cup was not sanitized. The STNA #440 revealed she was an agency STNA and she didn't know what they were doing to pass ice water while on droplet precautions. The STNA then confirmed she did not see the sign on the door. 2. Observation on 03/02/20 at 12:02 P.M. during the lunch trays being passed on the 400-hall revealed Dietary Aide (DA) #516 was observed putting on personal protective equipment (PPE) and did not wash or sanitize hands prior. DA #516 applied a mask and then gloves. The DA touched her face with the gloves as she positioned the mask. She then served a tray to Resident #32 in her room and assisted the resident (on droplet precautions) with organizing the items on her bedside table and setting up food tray. Observation of a sign posted on the door of Resident #32 stated to wear a mask and gloves when entering and the supplies were outside of the room. The DA #516 did not do hand hygiene after removing the PPE or assisting with the next tray. The DA #516 came out of the room with the PPE and removed the PPE as she walked down the hall. The DA #516 threw the PPE in the trash can in a room titled Nourishment. She then went to the cart and picked up a tray and delivered it to Resident #9 in the resident's room. She touched Resident #9's clothing, blanket, and bedside table then assisted with food set up. The DA did not do hand hygiene before or after assisting the resident in the room. The DA then proceeded to assist Resident #26 in her room (on droplet precautions) by getting the food tray off the cart, then putting the tray back on the cart to apply PPE. Again, the DA did not do hand hygiene before or after assisting Resident #26. The DA once again walked down to the room titled Nourishment to dispose of the PPE. The DA then applied PPE and took the last tray off the food cart and delivered to Resident #52 in her room (on droplet precautions). The DA came out of the room into the hallway with PPE on and was questioned about her knowledge of infection control, hand hygiene and PPE. Interview on 03/02/20 at 12:19 P.M. with DA #516 confirmed she did not use hand hygiene in between residents, before and after applying PPE. The DA #516 revealed she did not know the order PPE was applied and stated it was her first day passing trays to resident rooms. Interview on 03/02/20 at 12:22 P.M. with Dietary Manager (DM) #517 revealed the DA #516 was on her first day of training passing trays. The DM revealed DA #516 had not had infection control training prior to working the floor. The DM revealed they were short staffed, and DA #516 was pulled from orientation to help with food service. The DM was asked for clarification two times revealing no orientation with infection control was done for the DA #516 previously. Interview on 03/02/20 at 12:40 P.M. with the Administrator revealed she had no knowledge of DA #516 serving food prior to infection control training. Interview on 03/02/20 at 1:10 P.M. with Food Service Director (FSD) #510, DM #517 and the Administrator. The FSD stated DA #516 had infection control orientation in a different department and has worked for them since October 2019 passing trays in the dining room and in the hospital. The FSD verified the same infection control practices would be used in all work environments. He provided a signed statement from DA #516 stating she had previously been trained in infection control. The Administrator and FSD #510 revealed DA #516 would be trained again on infection control. Review of the facility's policy titled, Water Pass, dated 12/31/18, revealed for residents on isolation precautions as per the Infection Preventionist, the staff will take a disposable cup into the room, fill the reusable cup and then dispose of the foam cup along with their PPE upon leaving the room. Review of the facility's policy titled, Guidelines for the Control of Healthcare-associated infections, dated 10/11/18, revealed PPE must be readily available near the resident's room, donned upon entering the resident room, removed and hand hygiene performed when leaving the room. Review of the facility's policy titled, Standard Precaution-Personal Protective Equipment, dated 06/14/18, revealed hands must be decontaminated prior to putting on gloves. The policy further revealed hands should be washed or use alcohol-based hand sanitizer after gloves are removed. The policy revealed gloves should not be worn in the hallways.

Based on record review, observation, staff interview, and review of the facility's policy, the facility failed to ensure a resident had privacy during incontinence care. This affected one (Resident #18) of one resident reviewed for privacy. The facility census was 64. Findings include: Review of Resident #18's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 12/26/19, revealed the resident was moderately cognitively impaired. He was dependent upon staff for transfers and toileting and was frequently incontinent. Review of the care plan, dated 06/15/17, revealed the resident required assistance with activities of daily living (ADLs) due to physical limitations related to difficulty with walking and generalized weakness. Resident #18 required assistance with elimination due to being incontinent and was unable to use the toilet himself. Observation on 03/02/20 at 1:02 P.M. revealed Resident #18 and #20 shared the same room number and their rooms were set up like a jack-and-jill style bathroom that leads into each other's side of the room. During an interview with Resident #20, Resident #18 was observed laying on his right side with his shirt slightly pulled up and his pants pulled down while State-tested Nurse Aides (STNA) #429 and #440 provided incontinence care. Resident #18's door was closed, however his privacy curtain located between Resident #18's room and his roommate's room (Resident #20) was not pulled and Resident #18's buttocks could be seen from Resident #20's side of the room. Interview on 03/02/20 at 1:03 A.M. with STNA #429 verified Resident #18's privacy curtain was not closed while Resident #18 received incontinence care. Review of the facility's undated policy titled, Residents Rights and Dignity Issues, revealed privacy curtains are used to ensure the resident's privacy.

Based on observation, staff interview and review of the facility's policy, the facility failed to ensure garbage cans were covered with lids when not in use. In addition, the facility failed to ensure trays were distributed in a safe and sanitary manner. This had the potential to affect all 64 of 64 residents who receive food from the kitchen. Findings include: Observation on 03/02/20 at 8:51 A.M. revealed there were four trash cans located in the main kitchen were uncovered and trash was exposed. No lids were available and the trash cans were not in use. Interview on 03/02/20 at 8:56 A.M. with Dietary Manager #515 verified the lids were not used to cover the trash cans. Dietary Manager #515 further explained lids were not utilized because staff would touch them often and would have to wash and re-glove their hands. Observation on 03/02/20 at 9:10 A.M. revealed two trash cans located in the nursing home serving kitchen were uncovered and trash was exposed. No lids were available and the trash cans were not in use. Interview on 03/02/20 at 9:14 A.M. with Dietary Staff #518 confirmed the trash lids were not used to cover trash cans. Interview on 03/02/20 at 11:15 A.M. with Dietary Manager #510 stated the lids have never been utilized to cover the trash can. Observation on 03/03/20 at 9:22 A.M. of the trash cans remained uncovered with no lids in the nursing home serving kitchen. The trash cans were not in use. Observation on 03/03/20 at 9:29 A.M. of the main kitchen found one trash can was not in use and remained uncovered with no lid. Review of the facility's policy titled, Fulton Manor/Fulton Suites Food and Nutrition Services, last revised September 2017, revealed all garbage and refuse is disposed of according to the health department regulations.

Based on surveyor observation, staff interview, review of the medical record, review of facility policies, review of personnel files and review of facility investigation of self reported incident, the facility failed to transfer a resident with a mechanical lift. This resulted in Resident #33 receiving a spiral fracture to the left arm, when the staff used a two person lift instead of the mechanical lift. This affected one (#33) of three residents reviewed for assisted transfers. The facility identified seven current residents who required the use of a full mechanical lift for transfers. The facility census was 68. Findings include: Review of Resident #33's medical record revealed an admitted 11/16/10, following a right ischemic stroke. Her [DIAGNOSES REDACTED]. Resident #33 was non-ambulatory utilizing a tilt in space wheel chair and dependent on staff for all activities of daily living. She was to be transferred between bed and chair with a full mechanical lift (Marisa). Review of Resident #33's care plan/information revealed the Kardex was available for nursing assistant use. Resident #33's care plan documented a yellow binding sling was used for full mechanical lift for all transfers. Review of the nurses notes dated 02/28/14 documented Resident #33 was crying with pain. Assessment by Licensed Practical Nurse (LPN) #3 showed limited motion and increased pain with movement. Subsequently a x-ray was ordered and showed a spiral fracture of the left humerus. A sling and pain medication was ordered and an orthopedic consultation was requested. Review of the facility investigation dated 02/28/14 revealed the facility administrator started an immediate investigation to determine source of the fracture. Upon interview, Resident #33 was not always lucid and was unable to describe what had happened. The investigation revealed that on 02/24/14 on the evening shift, State tested Nurse Assistant (STNA) #12 and STNA #14 had completed a two man lift to transfer her to bed from her wheel chair. Review of STNA#12's statement indicated while completing the transfer, Resident #33 had grabbed a pad on the bed and her arm was pulled behind her back. STNA #12 stated, they heard a "pop" sound and the resident started crying and told the aides that she wanted to go back to bed. There was no injury apparent to the aides and they did not report to the nurse. Review of STNA #14's witness statement revealed, initially she denied the two man lift or any possibility of injury. Both STNAs had been taken off the schedule immediately and resigned as a result of the investigation. The facility substantiated poor judgement was used and the staff caused the injury to the resident. Review of the undated policy entitled, "Resident Alarm Identification" revealed the facility used a numbered magnet system on the resident's doorframe to indicate the level of assistance the resident needed. Number "4" was the number used to indicate that a resident needed a full lift (Marisa) for transfers. Review of the undated policy entitled, "Alpine 600 patient lift" revealed the mechanical lifts were used to transfer residents "for their safety and well-being and decreasing strain to staff's musculoskeletal system. The lifts were to be used by two staff who had been inserviced in the use of the lifts. Interview on 03/17/14 at 9:32 A.M., with the Director of Nursing (DON) revealed the staff have skills check-offs for the mechanical lifts. These check offs were completed during orientation and annually to determine that staff know how to properly use them. The DON additionally verified the Alpine 600 patient lift policy is the same instructions used for the Marisa and Sara Lifts also used by the facility. Review of STNA #14's personnel record revealed a hire dated of 09/19/13 and her lift program skills check-off was completed on 11/18/13. Review of STNA #12's personnel record revealed a hire date of 12/09/13 and her lift program skills check-off was completed on 12/11/13. On 03/17/14 at 12:21 P.M., STNA #16 and STNA #18 were observed transferring Resident #33 from her bed to her wheel chair. The staff were observed to use the yellow binded sling with the lift to transfer the resident. The door frame outside the room Had a magnetic sign with a "4" indicating to use the lift. Interview on 03/17/14 at 4:18 P.M., with LPN #3, revealed he was the nurse who discovered the injury. He stated an aide reported to him that resident #33 seemed to have more pain than usual. LPN #3's assessment did not reveal any bruising. She only complained when touched and she moaned when her arm was moved upward. He was unsure what had happened to her and called the physician.

Based on surveyor observation, medical record review, staff and resident interview and review of facility policy, the facility failed to implement interventions to prevent the development of an avoidable pressure ulcer. This resulted in actual harm when Resident #61 developed a Stage Three avoidable pressure ulcer. This affected one (#61) of three residents reviewed for pressure ulcers. The facility identified two current residents with pressure sores. The facility census was 66. Findings include: Review of Resident #61's medcial record revealed an admission date of [DATE], from the hospital, following an open reduction internal fixation (ORIF) of a right [MEDICAL CONDITION]. Other [DIAGNOSES REDACTED]. He also had a history of [REDACTED]. His laboratory results of 10/26/13 documented low proteins and low [MEDICATION NAME]. The resident was discharged on [DATE] to the hospital for pneumonia and readmitted on [DATE]. Review of the minimum data set (MDS) assessment dated [DATE], revealed Resident #61 was alert and oriented in all areas and scored 15 (full cognition) on the brief mini mental status (BIMS). The MDS assessed him to need extensive assist of two persons for activities of daily living (ADLs) except for eating, which he was independent. ADLs included toileting, transfers, bed mobility, locomotion, dressing and hygeine. The MDS also assessed him to be occasionally incontinent of urine and frequently incontinent of bowel. Review of admitting physician orders [REDACTED]. Review of the admitting nursing assessment dated [DATE] documented no skin issues except the right hip incision and bruises secondary to labatory procedures while in the hospital. Resident #61 was not assessed at high risk for developing pressure ulcers. Review of nurse's notes dated 11/01/14 at 10:02 P.M., revealed State tested Nurse Assistants (STNAs) reported some redness and irritation to buttocks. Resident was encouraged to get up from bed but resident remained in bed all of second shift. Review of nurse's notes on 11/04/13 at 12:29 P.M., documented Resident #61 scratched his left buttocks, causing an abrasion, two centimeters (cm) by one centimeter on the left buttocks. The physician was notified and ordered a barrier cream until healed. Review of nurse's notes dated 11/04/13 at 5:13 P.M., revealed Resident #61 had redness and irritation to the buttocks. The notes documented he was educated not to scratch. He was also encouraged to get out of bed but remained in bed all of second shift. Review of the nurse's notes on 11/05/13 at 11:36 A.M., revealed the barrier cream was continued to the buttocks. At 12:18 P.M., notes document the resident encouraged to get up out of bed during the day with no success. At 6:13 P.M., nurse's notes document the resident was encouraged to get up from bed for position change. Review of nurse's notes dated 11/07/13 at 10:33 A.M., documented the abrasion was now a "large open area to left buttock", measuring 3.4 cm by 5.3 cm. The wound had a red moist wound bed with scant dried sanguineous (bloody) drainage on the brief. There was no active drainage. A [MEDICATION NAME] dressing (a biodegradable, non breathable and adheres to the skin so no separate taping is needed) was applied after the wound was cleansed. Resident #61 educated on plan for treatment and need to reposition per self and request of others. At 10:53 A.M., a trapeze was added to his bed for increased bed mobility. Review of nurse's notes dated 11/09/13, 11/10/13, 11/11/13, 11/12/13 and 11/14/13 document the resident was up in the reclining chair for most of the day. The documentation did not contain any information concerning pressure releif being provided in the reclining chair. Review of nurse's notes dated 11/14/13 at 8:00 P.M., revealed the dressing was coming off. When the nurse changed the dressing, she documented the wound had a moderate amount of serosanguineous (mixture of blood and fluids) drainage with two blackened areas of skin measuring 3.0 cm by 4.0 cm each. Resident #61 complained of tenderness in the area when cleansed. Resident re-educated on the necessity of repositioning. Review of nurse's notes dated 11/15/13 at 3:312 P.M., LPN #22 documented a foul odor when the dressing was removed. She documented eschar present on the wound. The attending physician was called and assessed the wound and arranged for surgical [MEDICATION NAME] to be done on the same day. The resident was transfered to the emergency room for debridement. After the debridement, the physician ordered a waffle cushion to the wheel chair and the recliner, a dietary consultant and change the dressing type (moist to dry dressing twice a day) packing the wound. At this time the wound to the left buttock was assessed as a Stage III pressure ulcer. Review of the outpatient progress note dated 11/15/13, revealed a [DIAGNOSES REDACTED]. The report documented the debridement of the wound went to depth of 1.0 cm. Review of telephone physician orders [REDACTED]. On 12/20/13, a egg crate mattress was orderd for pressure releif. On 12/29/13, protein shakes were ordered three times a day with meals or snack. On 01/09/14, a pressure reduction cushion was ordered to the recliner. The resident was to be positioned in bed on side to side and change position every two hours. On 01/29/14, an alternating air mattress to bed was ordered. Review of Resident #61's progress notes revealed two more surgical debridements of the wound (12/08/13 and 12/26/13) and multiple dressing changes on 12/16/13, 12/22/13, 12/27/13, 01/09/14, 01/13/14, 01/16/14 to promote healing. Interview on 02/04/14 at 2:40 P.M., with Licensed Practical Nurse (LPN) #22 revealed she is involved in wound care and helping determine proper treatment. She stated she first saw Resident #61 on 11/15/13 and staged the wound as a stage III. She was unable to explain the progression of the wound from the scratch to the stage III wound in a short period of time. She verified there were no interventions prior to 11/15/13 and a care plan was then developed. Interview on 02/04/14 at 2:45 P.M., with Staff Development Coordinator #3 reviewed the information and stated she observed the wound. She was unable to explain why the wound progressed to a stage three. Observation on 02/06/14 at 10:07 A.M., with LPN #25, revealed she was completing wound care for Resident #61. The air mattress was observed on the bed. The wound was observed as a circular opening on the left upper buttocks. There was a moderate amount of serosanguineous drainage on the soiled dressing. The skin around the wound opening was dark in color but there was no bleeding or purulent drainage. The wound opening was four cm in diameter and was one cm in depth. There was tunneling from 10:00 o'clock to 2:00 o'clock. LPN #25 cleansed the wound and packed wound with calcium alginate and covered with ABD (abdominal) pad as ordered. There was a white cream on the lower left buttocks-identified by the nurse as barrier cream. The resident was observed to be cooperative. Interview with Resident #61 on 02/06/14 at 10:10 A.M., revealed he got the pressure sore at the facility and he was not sure about a scratch causing the sore. He stated nothing special (mattress, etc.) was done until he had the sore. He stated I have a [MEDICAL CONDITION],"that's nothing to mess with". Review of facility policy (revised 11/20/12) entitled, "Pressure Ulcer Management", documented the facility would "continuously assess resident's need for and implementation of pressure reduction/relief devices and positioning support in bed and chair."