Every finding on record at Genoa Retirement Village

Based on observation, staff interview, medical record review, and review of the Centers for Medicare and Medicaid Services (CMS) Provider History Profile document, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to address repeated infection control deficiencies identified during five consecutive comprehensive surveys. This had the potential to affect all residents in the facility. The facility census was 66.Findings include:Review of the CMS Provider History Profile document, with Certification and Survey Provider Enhanced Reporting (CASPER) system data, last updated 01/07/26, revealed the facility was issued a deficiency for infection prevention and control on the four previous comprehensive surveys in February 2018, March 2019, April 2021, and January 2024. During the current comprehensive survey, with an exit date of 01/27/26, the facility was cited for infection control for the fifth consecutive comprehensive survey.1. Review of Resident #8's medical record revealed an admission date of 03/14/25 with diagnoses including, but not limited to, Parkinson's disease, unspecified head injury, pulmonary embolism, hypertensive heart and chronic kidney disease (CKD), type two diabetes mellitus (DM2), methicillin resistant staphylococcus aureus (MRSA), unspecified open wound of scalp, depression, heart failure, anxiety, and urinary tract infection (UTI). Review of the most recent Minimum Data Set (MDS) assessment, dated 12/30/25, revealed Resident #8 had a Brief Interview of Mental Status (BIMS) score of 15, indicating she was cognitively intact. Review of the physician orders revealed Resident #8 had an order dated 08/12/25 for contact precautions for MRSA head wound. Observation on 01/21/26 at 6:30 A.M. revealed signage by the door to Resident #8's room which stated she was in contact precautions. Further observation of the signage revealed PPE, including a gown and gloves, were to be donned prior to room entry.Observation on 01/21/26 at 6:33 A.M. revealed Certified Nursing Assistant (CNA) #568 entered Resident #8's room without donning gloves or a gown prior to entry.Interview on 01/21/26 at 6:55 A.M. with CNA #568 revealed she provided incontinence care to Resident #8 when she was observed to enter the resident's room at 6:33 A.M. CNA #568 verified she did not don the appropriate PPE prior to entering Resident #8's room and providing care.Review of the facility policy titled, Guidelines for Contact Precautions, dated 11/28/16, revealed contact precautions was a method designed to reduce the risk of transmission of microorganisms by direct or indirect methods. Further review revealed to wear gloves before contact with the resident or environmental objects. Additionally, a clean non-sterile, fluid resistant gown should be worn when entering the room if it was anticipated clothing could have substantial contact with the resident or environmental surface or when there was likelihood that organisms from blood, urine, stool, or wound drainage may be on surfaces or items in the resident's room. Substantial contact was defined as when the worker could anticipate that his/her clothing would be directly in contact with the resident, resident's linens, or bed.2. Review of the medical record for Resident #1 revealed she was admitted on [DATE]. Her diagnoses included aspiration pneumonia, low back pain, lymphedema, chronic obstructive pulmonary disease (COPD), stage three CKD, white matter disease, history of falls, and cardiomegaly.Review of the most recent MDS assessment, dated 12/23/25, revealed Resident #1 was cognitively impaired and did not display any behaviors at the time of the assessment. She was incontinent of bowel and had an indwelling urinary catheter. Resident #1 required substantial assistance with activities of daily living (ADLs).Review of the physician orders dated 12/18/25 revealed Resident #1 had an order to utilize enhanced barrier precautions (EBP), wearing a gown and gloves, during high-contact care activities, including care of her indwelling urinary catheter.Review of the care plan dated 01/03/26 revealed EBP were to be utilized during care provided to Resident #1's indwelling urinary catheter to reduce the risk of infection transmission.Observation on 01/21/26 at 10:40 A.M. of Resident #1's doorway revealed a sign indicating EBP. Further observation revealed providers and staff must wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy) and any skin opening requiring a dressing. Observation on 01/21/26 at 10:50 A.M. of indwelling urinary catheter care, provided by CNA #501, revealed CNA #501 did not don a gown when she provided care for Resident #1's urinary catheter. Interview on 01/21/26 at 11:00 A.M. with CNA #501 confirmed she did not don a gown when she provided catheter care for Resident #1, and she should have. Review of the facility policy titled, Enhanced Barrier Precautions (EBP) Standard Operating Procedure, reviewed 12/03/25, revealed EBP would be in place during high-contact activities for residents with the following conditions: residents at an increased risk of multidrug-resistant (MDRO) status, which included residents with wounds and all residents with indwelling medical devices (urinary catheters, central lines, feeding tubes, and tracheostomy tubes). PPE should be used even if blood and body fluid exposure was not anticipated. At a minimum, staff should wear gloves and a gown during high-contact care activities.3. Review of the medical record for Resident #43 revealed he was admitted on [DATE]. His diagnoses included spinal stenosis, peripheral vascular disease, type two diabetes mellitus, heart disease, infection and inflammatory reaction to left hip prosthesis, and cutaneous abscess.Review of the MDS assessment, dated 01/13/26, revealed Resident #43 was cognitively intact and did not display any behaviors at the time of the assessment. He required set-up to substantial assistance with ADLs and partial assistance with transfers.Review of the physician orders for Resident #43 revealed an order for two grams (gm) of cefepime (antibiotic) to be administered every eight hours via IV.Review of the Medication Administration Record (MAR) for January 2026 revealed Resident #43 was administered two gm of cefepime via IV, as ordered, every eight hours beginning at 7:00 A.M. on 01/08/26.Observation on 01/22/26 at 2:55 P.M. of Registered Nurse (RN) #531 administering an IV medication to Resident #43 revealed the end of the IV tubing was looped into a port on the IV tubing. RN #531 prepared the medication, attached the IV tubing to the medication bag, disconnected the end of the IV tubing from the port on the tubing, then attached the end of the IV tubing to Resident #43's disinfected peripherally inserted central catheter (PICC) line, located in his upper left arm. RN #531 did not disinfect the end of the IV tubing prior to attaching it to Resident #43's PICC line.Observation on 01/22/26 at 3:00 P.M. of Resident #43's IV tubing revealed it was disconnected from his PICC line, and the end of the IV tubing was looped into a port on the IV tubing hanging from the IV pole.Interview on 01/22/26 at 3:00 P.M. with RN #531 revealed IV tubing was safe to use for 24 hours and their practice, between medication administrations, was to loop the end of the IV tubing in a port on the tubing. RN #531 verified she did not disinfect the IV tubing port nor the end of the IV tubing between the IV medication administrations for Resident #43.Interview on 01/22/26 at 3:45 P.M. with Licensed Practical Nurse (LPN) #560 revealed they utilized a sterile plastic cap, specifically designed to cover the end of IV tubing, between uses and would manually disinfect the end of the IV tubing with an alcohol swab prior to re-connecting IV tubing to a resident's PICC line port.Interview on 01/22/26 at 4:45 P.M. with RN #574 revealed they used a sterile plastic cap, specifically designed to cover the end of IV tubing, between uses and would manually disinfect the end of the IV tubing with an alcohol swab prior to re-connecting IV tubing to a resident's PICC line port. RN #574 stated they did not loop IV tubing ends into ports on the IV tubing due to the risk for infection and they should replace the IV tubing if they found it looped.Review of the facility policy titled, Catheter Insertion and Care - Administration Set/Tubing Changes, revised December 2015, revealed a sterile cap would be placed on the end of the IV tubing, between uses, when it was disconnected from the patient access point such as a PICC.4. Review of the medical record for Resident #41 revealed an admission date of 08/20/25 with diagnoses of osteomyelitis, dementia, and multiple sclerosis (MS).Review of the quarterly MDS assessment, dated 11/25/25, revealed Resident #41 had intact cognition and ambulated with a wheelchair and was dependent on staff for lower body dressing and putting on and taking off footwear, and required partial/moderate assistance for bed mobility and chair to bed transfers. Further review revealed Resident #41 had unhealed pressure ulcers. Review of the physician orders revealed Resident #41 had an order initiated 12/04/25 for as-needed (PRN) changes to the dressing on her left heel wound. Further review revealed the order stated Do not remove anything below the steri-strips on the left heel. Okay to change the outer alginate and ABD (absorbent bandage) and roll gauze every three days and as needed for drainage. Observation on 01/21/26 at 4:00 P.M. revealed LPN #502 prepared to change the ABD pad and gauze bandage to Resident #41's left heel. Resident #41 was seated in a wheelchair at bedside with both feet resting on the hard plastic footrests. LPN #502 donned a gown, washed her hands and put on disposable gloves and bent to provide wound care to Resident #41. LPN #502 removed the outer gauze, peeled off the ABD pad, then supported Resident #41's left heel with one hand while she opened the packaging of the clean ABD pad. LPN #502 used both hands, while one continued to support Resident #41's heel, to apply the clean ABD pad. After applying the clean ABD pad, LPN #502 continued to support Resident #41's heel, switching from her right hand to her left hand, and picked up the package of new gauze. LPN #502 continued to support Resident #41's heel while she used both hands to wrap the ABD paid and left foot with fresh gauze. LPN #502 then allowed Resident #41's left foot to rest on the wheelchair footrest while LPN #502 applied a piece of tape to the gauze to hold it in place. Interview on 01/21/26 at 4:09 P.M. with LPN #502 confirmed she did not change her gloves and perform hand hygiene between removing Resident #41's soiled bandage and applying the clean dressing. Review of the CDC titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/24 and located at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, revealed to change gloves and clean hands when moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurred.Review of the facility policy titled, Guideline for Handwashing/Hand Hygiene, reviewed 11/18/25, revealed Health Care Workers (HCW) shall use hand hygiene at times such as: before and after having direct physical contact with residents and after removing gloves for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled line, et cetera (etc).

Based on medical record review, observation, staff interview, review of the Centers for Disease Control and Prevention (CDC) guidelines and review of facility policy, the facility failed to ensure appropriate personal protective equipment (PPE) was utilized while providing care for residents on transmission-based precautions (TBP). This affected two (#8 and #1) of two residents reviewed for TBP. Additionally, the facility failed to ensure intravenous (IV) medication administration tubing was maintained in a sanitary manner. This affected one (#43) of one resident reviewed for IV medication administration. Lastly, the facility failed to ensure appropriate hand hygiene during wound dressing changes. This affected one (#48) of one resident reviewed for pressure ulcers. The facility census was 66. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 03/14/25 with diagnoses including, but not limited to, Parkinson's disease, unspecified head injury, pulmonary embolism, hypertensive heart and chronic kidney disease (CKD), type two diabetes mellitus (DM2), methicillin resistant staphylococcus aureus (MRSA), unspecified open wound of scalp, depression, heart failure, anxiety, and urinary tract infection (UTI). Review of the most recent Minimum Data Set (MDS) assessment, dated 12/30/25, revealed Resident #8 had a Brief Interview of Mental Status (BIMS) score of 15, indicating she was cognitively intact. Review of the physician orders revealed Resident #8 had an order dated 08/12/25 for contact precautions for MRSA head wound. Observation on 01/21/26 at 6:30 A.M. revealed signage by the door to Resident #8's room which stated she was in contact precautions. Further observation of the signage revealed PPE, including a gown and gloves, were to be donned prior to room entry. Observation on 01/21/26 at 6:33 A.M. revealed Certified Nursing Assistant (CNA) #568 entered Resident #8's room without donning gloves or a gown prior to entry. Interview on 01/21/26 at 6:55 A.M. with CNA #568 revealed she provided incontinence care to Resident #8 when she was observed to enter the resident's room at 6:33 A.M. CNA #568 verified she did not don the appropriate PPE prior to entering Resident #8's room and providing care. Review of the facility policy titled, Guidelines for Contact Precautions, dated 11/28/16, revealed contact precautions was a method designed to reduce the risk of transmission of microorganisms by direct or indirect methods. Further review revealed to wear gloves before contact with the resident or environmental objects. Additionally, a clean non-sterile, fluid resistant gown should be worn when entering the room if it was anticipated clothing could have substantial contact with the resident or environmental surface or when there was likelihood that organisms from blood, urine, stool, or wound drainage may be on surfaces or items in the resident's room. Substantial contact was defined as when the worker could anticipate that his/her clothing would be directly in contact with the resident, resident's linens, or bed. 2. Review of the medical record for Resident #1 revealed she was admitted on [DATE]. Her diagnoses included aspiration pneumonia, low back pain, lymphedema, chronic obstructive pulmonary disease (COPD), stage three CKD, white matter disease, history of falls, and cardiomegaly. Review of the most recent MDS assessment, dated 12/23/25, revealed Resident #1 was cognitively impaired and did not display any behaviors at the time of the assessment. She was incontinent of bowel and had an indwelling urinary catheter. Resident #1 required substantial assistance with activities of daily living (ADLs). Review of the physician orders dated 12/18/25 revealed Resident #1 had an order to utilize enhanced barrier precautions (EBP), wearing a gown and gloves, during high-contact care activities, including care of her indwelling urinary catheter. Review of the care plan dated 01/03/26 revealed EBP were to be utilized during care provided to Resident #1's indwelling urinary catheter to reduce the risk of infection transmission. Observation on 01/21/26 at 10:40 A.M. of Resident #1's doorway revealed a sign indicating EBP. Further observation revealed providers and staff must wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy) and any skin opening requiring a dressing. Observation on 01/21/26 at 10:50 A.M. of indwelling urinary catheter care, provided by CNA #501, revealed CNA #501 did not don a gown when she provided care for Resident #1's urinary catheter. Interview on 01/21/26 at 11:00 A.M. with CNA #501 confirmed she did not don a gown when she provided catheter care for Resident #1, and she should have. Review of the facility policy titled, Enhanced Barrier Precautions (EBP) Standard Operating Procedure, reviewed 12/03/25, revealed EBP would be in place during high-contact activities for residents with the following conditions: residents at an increased risk of multidrug-resistant (MDRO) status, which included residents with wounds and all residents with indwelling medical devices (urinary catheters, central lines, feeding tubes, and tracheostomy tubes). PPE should be used even if blood and body fluid exposure was not anticipated. At a minimum, staff should wear gloves and a gown during high-contact care activities. 3. Review of the medical record for Resident #43 revealed he was admitted on [DATE]. His diagnoses included spinal stenosis, peripheral vascular disease, type two diabetes mellitus, heart disease, infection and inflammatory reaction to left hip prosthesis, and cutaneous abscess. Review of the MDS assessment, dated 01/13/26, revealed Resident #43 was cognitively intact and did not display any behaviors at the time of the assessment. He required set-up to substantial assistance with ADLs and partial assistance with transfers. Review of the physician orders for Resident #43 revealed an order for two grams (gm) of cefepime (antibiotic) to be administered every eight hours via IV. Review of the Medication Administration Record (MAR) for January 2026 revealed Resident #43 was administered two gm of cefepime via IV, as ordered, every eight hours beginning at 7:00 A.M. on 01/08/26. Observation on 01/22/26 at 2:55 P.M. of Registered Nurse (RN) #531 administering an IV medication to Resident #43 revealed the end of the IV tubing was looped into a port on the IV tubing. RN #531 prepared the medication, attached the IV tubing to the medication bag, disconnected the end of the IV tubing from the port on the tubing, then attached the end of the IV tubing to Resident #43's disinfected peripherally inserted central catheter (PICC) line, located in his upper left arm. RN #531 did not disinfect the end of the IV tubing prior to attaching it to Resident #43's PICC line. Observation on 01/22/26 at 3:00 P.M. of Resident #43's IV tubing revealed it was disconnected from his PICC line, and the end of the IV tubing was looped into a port on the IV tubing hanging from the IV pole. Interview on 01/22/26 at 3:00 P.M. with RN #531 revealed IV tubing was safe to use for 24 hours and their practice, between medication administrations, was to loop the end of the IV tubing in a port on the tubing. RN #531 verified she did not disinfect the IV tubing port nor the end of the IV tubing between the IV medication administrations for Resident #43. Interview on 01/22/26 at 3:45 P.M. with Licensed Practical Nurse (LPN) #560 revealed they utilized a sterile plastic cap, specifically designed to cover the end of IV tubing, between uses and would manually disinfect the end of the IV tubing with an alcohol swab prior to re-connecting IV tubing to a resident's PICC line port. Interview on 01/22/26 at 4:45 P.M. with RN #574 revealed they used a sterile plastic cap, specifically designed to cover the end of IV tubing, between uses and would manually disinfect the end of the IV tubing with an alcohol swab prior to re-connecting IV tubing to a resident's PICC line port. RN #574 stated they did not loop IV tubing ends into ports on the IV tubing due to the risk for infection and they should replace the IV tubing if they found it looped. Review of the facility policy titled, Catheter Insertion and Care – Administration Set/Tubing Changes, revised December 2015, revealed a sterile cap would be placed on the end of the IV tubing, between uses, when it was disconnected from the patient access point such as a PICC. 4. Review of the medical record for Resident #41 revealed an admission date of 08/20/25 with diagnoses of osteomyelitis, dementia, and multiple sclerosis (MS). Review of the quarterly MDS assessment, dated 11/25/25, revealed Resident #41 had intact cognition and ambulated with a wheelchair and was dependent on staff for lower body dressing and putting on and taking off footwear, and required partial/moderate assistance for bed mobility and chair to bed transfers. Further review revealed Resident #41 had unhealed pressure ulcers. Review of the physician orders revealed Resident #41 had an order initiated 12/04/25 for as-needed (PRN) changes to the dressing on her left heel wound. Further review revealed the order stated Do not remove anything below the steri-strips on the left heel. Okay to change the outer alginate and ABD (absorbent bandage) and roll gauze every three days and as needed for drainage. Observation on 01/21/26 at 4:00 P.M. revealed LPN #502 prepared to change the ABD pad and gauze bandage to Resident #41's left heel. Resident #41 was seated in a wheelchair at bedside with both feet resting on the hard plastic footrests. LPN #502 donned a gown, washed her hands and put on disposable gloves and bent to provide wound care to Resident #41. LPN #502 removed the outer gauze, peeled off the ABD pad, then supported Resident #41's left heel with one hand while she opened the packaging of the clean ABD pad. LPN #502 used both hands, while one continued to support Resident #41's heel, to apply the clean ABD pad. After applying the clean ABD pad, LPN #502 continued to support Resident #41's heel, switching from her right hand to her left hand, and picked up the package of new gauze. LPN #502 continued to support Resident #41's heel while she used both hands to wrap the ABD paid and left foot with fresh gauze. LPN #502 then allowed Resident #41's left foot to rest on the wheelchair footrest while LPN #502 applied a piece of tape to the gauze to hold it in place. Interview on 01/21/26 at 4:09 P.M. with LPN #502 confirmed she did not change her gloves and perform hand hygiene between removing Resident #41's soiled bandage and applying the clean dressing. Review of the CDC titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/24 and located at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, revealed to change gloves and clean hands when moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurred. Review of the facility policy titled, Guideline for Handwashing/Hand Hygiene, reviewed 11/18/25, revealed Health Care Workers (HCW) shall use hand hygiene at times such as: before and after having direct physical contact with residents and after removing gloves for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled line, et cetera (etc).

Based on observation, record review, and staff interview, the facility failed to ensure skin assessments were completed accurately. This affected one (#24) resident reviewed for skin assessments. The facility census was 66. Findings Include: Review of the medical record for Resident #24 revealed an admission date of 01/08/26 with diagnoses of congestive heart failure, type II diabetes mellitus, and chronic kidney disease. Review of the admission Observation and Data Collection, dated 01/08/26, revealed Resident #24 was oriented to person, place, time and situation. Review of a physician order dated 01/08/26 revealed Resident #24 received weekly skin assessments. Review of the Treatments Administration History revealed Resident #24 had no skin findings identified during the skin assessment completed 01/19/26. Observation on 01/20/26 at 2:21 P.M. revealed Resident #24 sitting in his wheelchair wearing a sock on his left foot and the sock on his right foot was pushed down around the arch of his foot. A concurrent interview with Resident #24 revealed he had a wound on the outer side of his right ankle and said it had been there a couple of days and he would like some ointment for it. Observation of Resident #24's right ankle revealed a dark red area that appeared to be scabbed over and dry. Interview, and concurrent observation, on 01/20/26 at approximately 2:26 P.M. with Licensed Practical Nurse (LPN) #502 confirmed Resident #24 had a red area to his right ankle. LPN #502 stated she was not aware of the area. Observation on 01/20/26 at 2:32 P.M. with the Director of Nursing (DON) of Resident #24's right ankle revealed the area to the resident's right ankle appeared to be scabbed over. The DON confirmed, based on her observation, the wound was likely in place for more than two days (prior to the completion of the skin assessment dated [DATE]). A follow-up interview on 01/20/26 at 2:47 P.M. with the DON, and concurrent review of Resident #24's medical record revealed a skin assessment was completed 01/19/26 and the area on Resident #24's right ankle was not identified. Interview on 01/22/26 at 8:16 A.M. with LPN #595, whose tasks included weekly wound rounds to assess residents' wounds, stated she assessed Resident #24's right ankle wound on 01/21/26 and described the wound as dry, stable eschar, measuring one centimeter (cm) long x 1.5 cm wide with no depth. LPN #595 stated the wound would have been present on 01/19/26 when the weekly skin assessment was completed.

Based on medical record review, review of wound clinic notes, observation, and staff interview, the facility failed to ensure pressure ulcer wound treatments and pressure reducing interventions were implemented as physician ordered. This affected one (#41) of two residents reviewed for pressure ulcers. The facility census was 66. Findings include:Review of the medical record for Resident #41 revealed an admission date of 08/20/25 with diagnoses of osteomyelitis, dementia, and multiple sclerosis (MS). Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/25/25, revealed Resident #41 had intact cognition and ambulated with a wheelchair and was dependent on staff for lower body dressing and putting on and taking off footwear, and required partial/moderate assistance for bed mobility and chair to bed transfers. Further review revealed Resident #41 had unhealed pressure ulcers. Review of the outside clinic wound assessment, dated 12/30/25, revealed Resident #41 had a stage IV pressure ulcer (full-thickness wound extending through the skin into muscle, tendon, or bone) to her left heel and was seen weekly at the wound clinic for a treatment of Kerecis (intact fish skin used for tissue regeneration) weekly for ten treatments, with the final treatment of Kerecis applied 12/30/25. During the weeks Resident #41 received Kerecis treatments at the outside wound clinic, the treatment orders for the facility to complete stated Please do not remove anything except the outer ABD (an absorbent pad), rolled gauze, and alginate if drainage seeps through. The Versatel (a silicone coated dressing) and everything underneath needs to remain in place until next visit. Do not remove anything below the steri-strips on the left heel. Additional orders were to change the outer alginate, ABD and roll gauze every three days and as needed for drainage. Then pad and protect the top of the left foot with foam or ABD pad. Measurements of the left heel wound on 12/30/25 were 2.8 centimeters (cm) in length by (x) 0.9 cm in width x 0.1 cm in depth. Review of the outside clinic wound assessment, dated 01/08/26, revealed the left heel pressure ulcer measured 3.6 cm long x 0.8 cm wide x 0.1 cm deep. The clinic initiated a new treatment on 01/08/26 of collagen, moisten with normal saline, covered with copper alginate, secured with ABD and roll gauze, change daily. Additionally, the recommendations were to wear heel boots to offload the heels even in a chair. Review of the physician orders dated 12/04/25 for Resident #41's left heel revealed do not remove anything below the steristrips on the left heel, okay to change the outer alginate and ABD and roll gauze every three days and as needed for drainage. An additional physician order, dated 08/21/25, revealed Resident #41 should be encouraged to float heels while in bed as tolerated. Further review revealed no wound care orders for daily dressing changes or wearing heel boots to offload the heels even in a chair were initiated as ordered by the wound clinic on 01/08/26. Observation on 01/21/26 at 3:53 P.M. revealed Resident #41 sitting in a wheelchair at bedside. Resident #41 had socks on both feet and her feet were resting on the hard plastic foot supports of the wheelchair. A pair of offloading boots were on the couch. Concurrent interview with Licensed Practical Nurse (LPN) #502 confirmed Resident #41's boots were on the couch. Further observation revealed LPN #502 removed the sock on Resident #41's left foot and confirmed the bandage was dated 01/14/26. LPN #502 further stated the order for Resident #41's left heel wound were to only change the exterior bandage and ABD if they were soiled. LPN #502 stated the staff were not cleaning or treating the actual wound per the orders from the wound clinic to leave the wound untouched. Interview on 01/22/26 at approximately 10:00 A.M. with the Director of Nursing (DON) confirmed the facility did not update Resident #41's wound care orders on 01/08/26 and verified Resident #41 did not receive daily wound treatments as ordered by the wound clinic from 01/08/26 through 01/21/26. Review of the wound clinic notes dated 01/22/26 revealed Resident #41's left heel wound measured 3.6 cm long, 0.9 cm wide, and 0.5 cm deep. Further review revealed the left heel wound healing status was wound stable and the wound on the left heel was progressing as expected. Interview on 01/27/26 at 10:24 A.M. with Registered Nurse (RN) #624 confirmed the facility did not implement an order on 01/08/26 to ensure Resident #41 offloaded her heels while up in the chair. Observation on 01/27/26 at 10:30 A.M. of Resident #41's left heel wound revealed red granulation tissue in the wound bed, callous peri-wound boarder, no peri-wound redness, and no drainage. Wound measurements obtained during this observation by LPN #595 were 3.6 cm long x 1.0 cm wide x 0.2 cm deep.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure consistent communication with the hemodialysis (HD) clinic. This affected one (#3) of one resident identified by the facility as receiving HD. The facility census was 66.Findings include:Review of the medical record for Resident #3 revealed an admission date of 12/28/25 with diagnoses of end stage renal disease with dependence on HD and type II diabetes mellitus. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 12/31/25, revealed Resident #3 had intact cognition and received dialysis. Review of the physician order dated 12/28/25 revealed Resident #3 went to offsite HD on Tuesdays, Thursdays, and Saturdays. Further review of the physician order revealed staff should complete a Dialysis Center Communication Observation (DCCO) form and send it with the resident. Review of Resident #24's electronic medical record (EMR) revealed two DCCO, one dated 01/10/26 and the other dated 01/17/26. Review of two additional DCCOs, revealed hard copies were available for HD completed on 01/13/26 and 01/20/26. Interview on 01/21/26 at 10:49 A.M. with Registered Nurse (RN) #508 revealed all HD communication forms (DCCOs) were scanned into the EMR and no hard copies or HD notebooks were kept for Resident #24. RN #508 stated the facility completed a pre-HD assessment on Resident #24, printed the form and sent it with Resident #24 to HD. RN #508 stated Resident #24 brought the paperwork back to the facility and staff scanned the form into his EMR. Continued interview with RN #508 and concurrent review of Resident #24's EMR confirmed there were only two HD communication forms in the resident's EMR, one dated 01/10/26 and the other dated 01/17/26. RN #508 stated she scanned the one on 01/17/26 when she worked the previous weekend. Interview on 01/22/26 at approximately 11:00 A.M. with the Director of Nursing (DON) confirmed the facility only had evidence of HD communications on 01/10/26, 01/13/26, 01/17/26, and 01/20/26 (four of 10 HD treatments) for Resident #24 and further verified no additional evidence was available. Review of the facility policy titled, Guidelines for Dialysis, reviewed 05/22/18, revealed a report (may be written or verbal) shall be requested from the Dialysis Provider that will alert the campus regarding: tolerance to procedure, vital signs, medications administered, and other information deemed necessary for the ongoing provision of care.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure resident incontinence care was provided timely. This affected one (#1) of three residents reviewed for incontinence care. The facility census was 64.Findings include:Review of Resident #1's medical record revealed an admission date of 05/21/22. Diagnoses included Parkinson's disease, dementia, anxiety disorder, seizure disorder, major depression, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, and Type II diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 07/11/25, revealed Resident #1 was severely cognitively impaired, was dependent on staff for the completion of activities of daily living (ADLs), was incontinent of bowel and bladder, utilized a wheelchair propelled by staff, and was at risk for pressure ulcer development with no current skin breakdown. Review of the plan of care, dated 06/15/22, revealed Resident #1 had episodes of incontinence related to impaired mobility, Parkinson's disease, and BPH. Interventions included to provide incontinence care and incontinence products as needed. Observation on 08/06/25 at 8:13 A.M. revealed Resident #1 was seated in a reclined wheelchair in the common area. Further observation at 10:12 A.M. revealed Resident #1 remained seated in the reclined wheelchair in the common area. Interview on 08/06/25 at 11:09 A.M. with Certified Nursing Assistant (CNA) #200 and Registered Nurse (RN) #300 revealed Resident #1 was provided with morning care, including incontinence care, at approximately 8:00 A.M. CNA #200 and RN #300 stated Resident #1 required incontinence checks every two hours and confirmed the resident had not been checked since rising at approximately 8:00 A.M. Observation on 08/06/25 at 11:19 A.M. revealed CNA #200 transported Resident #1 to his room. Continued observation revealed CNA #200 and RN #300 transferred Resident #1 to his bed, utilizing a mechanical lift. CNA #200 discovered Resident #1's pants were soiled through with a heavy amount of urine that had penetrated through an adult incontinence brief, through his pants, and onto a folded bath blanket on the seat of the wheelchair. Resident #1's shirt was also soiled with urine. Interview on 08/06/25 at 11:43 A.M. with CNA # 200, following the observation of incontinence care for Resident #1, verified the resident was to be checked every two hours to monitor his need for incontinence care and it had been approximately 3.5 hours since the resident was last checked and provided care. CNA #200 confirmed Resident #1 was heavily soiled with urine. Interview on 08/06/25 at 2:45 P.M. with the Director of Nursing (DON) revealed CNAs and nurses utilized the Resident Profile to determine the frequency of a resident's incontinence care needs. Review of the Resident Profile revealed an approach description, dated dated 07/19/22, for continence. Further review revealed to check and change Resident #1 due to incontinence of bowel and bladder. Additional review revealed frequent rounding to check on the resident's needs. No interval or time frequency of the resident's incontinence checks or patterns were indicated. Review of the facility policy titled, Bladder Continence, dated 05/10/16, revealed the purpose was to provide measures for a resident who was incontinent to receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. Clinical staff must utilize care assist entries to assist in establishing bowel and bladder patterns. Residents that were not eligible for a continence program should be assessed regularly to maintain dignity, skin integrity, and a clean and dry condition. The elimination care plan should include individualized interventions to maintain a dry condition for those unable to re-establish continence. Toileting and continence interventions shall be communicated to caregivers via the resident profile. Review of the facility policy titled, Resident Profile-Caregiver Communication Tool, dated 06/01/21, revealed the purpose was to provide a consistent communication tool for caregivers to receive pertinent and timely information regarding the residents that they (caregiver) were assigned to care for. This deficiency represents non-compliance investigated under Complaint Number 1359849.

Based on observation, staff interview, record review, and review of the policy, the facility failed to ensure dietary staff used appropriate hand hygiene during food service. This affected three (#16, #46, and #48) residents and had the potential to affect all residents in the facility. The facility confirmed all residents received food from the kitchen. The facility census was 56. Findings include: Observation during meal service on 01/03/24 beginning at 11:56 A.M., revealed Dining Services Assistant Director (DSAD) #589 serving the noon meal. DSAD #589 prepared alternative menu items, including a [NAME] sandwich with fries, a cheeseburger with fries, and over-easy eggs with buttered bread. DSAD #589 was observed to wear plastic gloves on both hands while using the spatula to flip the burger and eggs, touching the fryer basket handle to pour out fries, and opening a plastic loaf of bread, pull out a slice of bread, hold the bread in his hand and butter the bread with his other hand, and place the bread on the plate with the over-easy eggs. DSAD #589 continued to wear the same pair of gloves to place an untoasted hamburger bun on a plate and use the spatula to put the burger on the bun, then use his gloved had to put the top bun on top of the burger. DSAD #589 was further observed to use the spatula to move the [NAME] sandwich from the grill, place it on a cutting board, and hold the sandwich with his left hand while cutting it in half with a knife. DSAD #589 then picked up the sandwich with both hands and placed half on a plate. Interview on 01/03/24 at approximately 12:11 P.M., with DSAD #589 confirmed he did not change his gloves between touching serving utensils and ready-to-eat food. The facility identified Resident #16 received the eggs with buttered bread, Resident #46 received the cheeseburger, and Resident #48 received the [NAME] sandwich. Review of the policy titled Food Production Guidelines, dated 05/13/16, revealed suitable utensils, such as forks, knives, tongs, or scoops shall be provided to minimize handling of food. The policy provided no guidance regarding the handling of ready-to-eat foods.

Based on medical record review, observation, staff interview and policy review, the facility failed to ensure hand hygiene was completed prior to the administration of eye medication. Additionally the facility failed to ensure staff properly transported soiled linen. This affected one (#50) of three residents reviewed for medication administration. This had the potential to affect 19 additional residents (#24, #25, #21, #44, #10, #22, #4, #2, #40, #48, #36, #39, #32, #8, #30, #6, #57, #28, #53) residing on the 100-hall. Findings include Review of the medical record revealed Resident #50 had an admitted [DATE]. Diagnoses included Parkinson's disease, dementia, atrial fibrillation, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Observation on 01/03/24 at 8:50 A.M., revealed Licensed Practical Nurse (LPN) #543 administered oral medications to Resident #50. LPN #543 had not sanitized or washed her hands after administering the resident medications and touching the residents medication cup, bedside table and beverage cup with ungloved hands. LPN #543 then donned gloves and administered the resident Lotemax drops 0.5%, one drop in each eye. LPN #543 failed to wash or sanitize hands prior to donning gloves to administer the eye drop. Observation on 01/03/24 at 8:53 A.M., revealed LPN #543 picked up a soiled wet washcloth off of Resident #50's bedside table. LPN #543 carried the washcloth out of the room without first placing the washcloth in a bag. LPN #543 carried the washcloth down the 100-hall to the soiled utility room. Interview on 01/03/24 at 8:53 A.M., LPN #543 revealed she had not completed hand hygiene prior to the administration of the resident's eye drops. LPN #543 revealed she had not placed the soiled linen in a bag before transporting it through the hall. Interview on 01/03/24 at 10:17 A.M., the Director of Nursing (DON) revealed staff should bag soiled linens. The DON also verified staff should wash their hands or use hand sanitizer before putting on gloves. Review of policy titled Guidelines for Handling Linen, dated 05/11/16 revealed to place soiled linens in a plastic bag if wet or soiled with feces then discard soiled linen in soiled linen containers. Review of the policy titled Hand Hygiene, dated 01/18/23 revealed handwashing may also be used for routinely decontaminating hands before having direct contact with patients, before and after preparing medication, and after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Review of the policy titled Medication Administration: General Guidelines, last revised Nonmember 2018, revealed handwashing or hand sanitization would be completed before and after administration of ophthalmic medications.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure a resident had access to a call light. This affected one (#7) of one residents reviewed for call lights being within reach. The facility census was 56. Findings include: Medical record review for Resident #7 revealed he was admitted on [DATE], with diagnoses of cognitive impairment and arthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 revealed the resident is cognitively impaired. Observation on 01/03/24 at 4:19 P.M., revealed the call light for Resident #7 was laying on the floor under the bed and not within his reach. Interview on 01/03/24 at 4:19 P.M., with Registered Nurse (RN) #549 confirmed the call light for Resident #7 was not within his reach and was laying on the floor under the bed. Review of the policy titled Guidelines for Answering Call Lights revised May 2016 revealed the purpose is to respond to resident's requests and needs.

Based on medical record review, resident interview, staff interview, and policy review, the facility failed to timely address resident concerns. This affected one (#18) of one resident reviewed for concerns. The facility census was 56. Findings include: Review of the medical record for Resident #18 revealed an admitted [DATE], with diagnoses of depression and morbid obesity. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition. Review of the diet order dated 04/08/23 revealed Resident #18 received a regular diet with regular textures and thin liquids. Review of the current nutrition care plan revealed Resident #18 would benefit from weight loss. Review of the current care plan revealed Resident #18 planned to remain in long term care. Review of a nursing progress note dated 10/04/23 revealed Resident #18 expressed wanting to go on a diet to lose weight. Review of a nursing progress note dated 10/28/23 revealed Resident #18 stated he does not like this place and social services was notified. Review of the Nutrition Quarterly assessment dated [DATE] revealed Resident #18 would likely benefit from gradual weight loss. Review of a physician progress note dated 12/08/23 revealed Resident #18 complained about his weight and diet at the facility and thought the facility meals were the reason he was not losing weight. Interview on 01/02/24 at 10:03 A.M., with Resident #18 revealed he was unhappy at the facility. Resident #18 also stated he wanted to lose weight. Resident #18 stated he had talked to the Director of Social Services and the Registered Dietitian but neither provided any assistance or guidance. Interview on 01/03/24 at 10:12 A.M., with Director of Social Services (DSS) #513 revealed he felt Resident #18 was well adjusted in the facility. DSS #513 stated he was unaware of the progress note dated 10/28/23 wherein Resident #18 stated he did not like this place and did not address this concern with Resident #18. Telephone interview on 01/03/24 at 2:00 P.M., with Registered Dietitian #623 stated he visited the facility approximately one day per week and received consults from facility staff. RD #623 stated he did not receive any consults for weight loss diet education for Resident #18. RD #623 further stated he had not provided any weight loss diet education to Resident #18. Review of the policy titled Resident Concern Process, reviewed 12/31/22, revealed the facility would review concerns and assign them for follow up and resolution.

Based on observation, staff interview, record review, and policy review, the facility failed to have fall mats in place to reduce risk of injury if the resident falls out of bed. This affected one (#7) of one resident reviewed for falls. The facility census was 56. Findings include: Medical record review for Resident #7 revealed he was admitted on [DATE], with diagnoses of cognitive impairment and arthritis. Review of the quarterly Minimum Data Set (MDS) assessments dated 10/16/23 for Resident #7 revealed the resident is cognitively impaired. Review of the care plan dated December 2022 for Resident #7 revealed he was care planned for falls with the following interventions bilateral floor mates to each side of the bed and call light in reach. Observation on 01/03/24 at 8:31 A.M., of Resident #7 revealed the resident was lying in bed and fall mats were not in place to both sides of the bed. Observation on 01/03/24 at 4:19 P.M., of Resident #7 revealed the resident was lying in bed and the fall mats were not in place to both sides of the bed. Interview on 01/03/24 at 4:19 P.M., with Registered Nurse (RN) #549 confirmed the fall mats for Resident #7 were not in place to both sides of the bed. Review of the policy titled Fall Management Program Guidelines, dated May 2017 revealed the facility strives to maintain a hazard free environment and prevent implement preventative measures.

Based on medical record review, staff interview, and review of the policy, the facility failed to ensure the provider addressed pharmacist recommendations. This affected one (#3) of five residents reviewed for unnecessary medications. The facility census was 56. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE], with diagnoses of atrial fibrillation (an irregular heart rhythm), and hypertension. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #3 had severely impaired cognition. Review of a current physician order dated 01/31/23 revealed Resident #3 received metoprolol tartrate 12.5 milligrams (mg) twice daily for atrial fibrillation. Review of a current physician order dated 01/31/23 revealed Resident #3 received sotalol tablet, 120 mg twice daily for atrial fibrillation. Review of the document Pharmacy Recommendations dated 07/24/23 revealed a recommendation to review a potential duplication in therapy with metoprolol and sotalol because both medications had similar actions. Interview on 01/04/24 at approximately 3:00 P.M., with the Director of Nursing (DON) confirmed the facility could not provide evidence the provider addressed the pharmacist's recommendation for Resident #3. Review of the policy titled, Pharmacy Services, revised Nonmember 2018, revealed pharmacist recommendations should be acted upon and documented by the facility personnel and/or the prescriber.

Based on observation, staff interview, review of facility's guidelines, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) Coronavirus Disease 2019 (COVID-19) Pandemic guidance, the facility failed to ensure healthcare personnel applied appropriate transmission based infection control precautions and personal protective equipment (PPE) to potentially prevent the spread of COVID-19. Additionally, the facility failed to ensure medications were administered to prevent cross contamination. This had the potential to affect all 39 residents residing in the facility. The facility census was 39. Findings include: Observation on 04/20/21 at 12:45 P.M. revealed Physical Therapy Director(PTD) #1 exited Resident #141's room. PTD #1 removed an isolation gown, and disposable gloves, and walked into the corridor. PTD #1 was noted to keep a disposable surgical mask applied. Interview with PTD #1 at the time of the observation revealed Resident #141 was in quarantine for Covid-19 precautions due to being a new admission. PTD #1 revealed facility policy required disposable masks, goggles/face shield, gown, and gloves. The disposable surgical mask could be worn from room to room and did not need to be changed unless soiled. PTD #1 further revealed therapy staff provided care to residents through out the facility and wore the same mask in and out of those non-quarantine or isolation rooms also. On 04/20/21 at 1:15 P.M. interview with Registered Nurse (RN) #501 who was identified as the facility's Infection Control Preventionist, revealed she was assigned to the quarantine unit and also worked with non-quarantine residents. RN #501 identified four residents (#24, #141, #142, #143) residing on the hall who were currently in quarantine for Covid-19 precautions. RN #501 revealed the facility infection control policy allowed staff to wear a disposable surgical mask from room to room and not wear a N95 mask when providing care to quarantine residents. Review of facility Covid-19 guidelines for PPE revised 03/23/21, revealed staff working with quarantine residents are recommended to wear a N95 mask or loop mask. The mask should be removed and discarded at the end of the shift or if the mask becomes soiled, damaged or hard to breathe through. According to CDC Strategies for Optimizing the Supply of N95 FFRs updated October 19, 2020 follow a continuum using the surge capacity approach in the order of conventional (everyday practice), contingency (expected shortages), and crisis (known shortages) capacities. N95 FFRs are meant to be disposed after each use. CDC developed contingency and crisis strategies to help healthcare facilities conserve their supplies in the face of shortages. When the availability of N95 FFRs become limited due to an expected shortage, supplies first should be conserved using contingency strategies. Contingency Strategies include with extended use, N95 FFRs are worn for a prolonged period, for multiple patient contacts, before being removed and discarded (unlike conventional strategies in which an N95 FFR is used for one patient contact then discarded). This will slow the N95 FFR burn rate to help alleviate supply concerns. N95 FFRs are used beyond the manufacturer designated shelf-life for fit testing and training. After attempting the above contingency strategies and there is still a known shortage of N95 FFRs and available supplies cannot meet needs based on the current burn rate, crisis capacity strategies can be used. Crisis Capacity Strategies: Respirators (including N95 FFRs and other types of respirators) are used beyond the manufacturer-designated shelf life for health care delivery. Respirators are used that are similar to NIOSH-approved respirators but are not NIOSH approved and are approved according to standards used in other countries. The performance of some internationally approved respirators was evaluated by NIOSH and the results can be found on the CDC website. Respirators are used that have reached the manufacturer-designated shelf life but have not been evaluated by NIOSH. With limited reuse, an N95 FFRs is donned for one patient contact, then doffed and stored before being used for another patient contact for a limited number of donning's. The use of N95 FFRs and facemask's is prioritized by healthcare activity type. This guidance provides information on how to determine if, and when, a healthcare facility should be operating under N95 FFR crisis capacity situations during the COVID-19 pandemic and how to appropriately implement limited reuse of N95 FFRs, including their reuse after decontamination. How to determine if an N95 FFR crisis capacity strategy is needed because crisis capacity strategies are not compatible with US standards of care, crisis capacity strategies should only be implemented when there are known shortages of N95 FFRs and only after conventional and contingency strategies have been implemented. The ability to implement specific crisis capacity strategies will depend on the on-hand inventory. The flow chart provided on the CDC website can assist healthcare facility respiratory program managers in determining if their healthcare facility should operate under a crisis capacity situation. Use the PPE Burn Rate Calculator to help you plan and optimize the use of PPE. On 04/21/21 at 10:15 A.M. observation with Regional Registered Nurse (RRN) #1 noted a significant amount of N95 mask, gowns, gloves, face shields, and goggles in storage. RRN #1 stated the facility was not experiencing a shortage of N95 mask or PPE. 2. Observation of medication administration on 04/21/21 at 8:07 A.M. with RN #500 revealed the nurse was dispensing medication for Resident #27. The RN was observed pushing the tablet medication directly from the blister packet into her bare hand. After putting the medication into her hand, RN #500 placed the tablets in a medication cup. Interview with RN #500 at the time of the observation confirmed she failed to use infection control protocol for medication administration. Review of the facility policy titled Equipment and Supplies for Administering Medications, dated 11/2018, revealed to provide proper hand hygiene prior to handling tablets and examination gloves must be worn to prevent the touching of tablets.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure a resident's privacy was not compromised during personal care. This affected one Resident (#82) of 16 reviewed for privacy and dignity. The facility census was 39. Findings include: Medical record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had moderate cognitive impairment and had a urinary indwelling catheter in place. Observation and interview on 04/21/21 at 2:00 P.M. with State tested Nurse Aide (STNA) #101 revealed the STNA obtained supplies, entered Resident #82's room, closed the door, and proceeded to the bedside. The STNA then exposed the resident completely from the waist down. It was noted the resident's blinds were open to the outside. During the procedure STNA#101 fully opened the resident's door to request assistance for additional wash cloths. Resident #82 remained uncovered and exposed to the hallway while the door was open. At no time during the catheter care procedure did STNA#101 close the window blinds to the outside. Interview with STNA #101 at the time of the observation revealed she was unaware of exposing the resident during procedure by opening door and not closing the blinds. Review of the facility policy titled, Catheter Care Policy, dated 05/23/18, revealed the room door and blinds were to remain closed during the procedure. Additionally, provide privacy and cover the resident with a sheet, exposing only the perineal area.

Based on medical record review, observation, resident and staff interview, the facility failed to ensure interventions to prevent incontinence and potential associated urinary tract infections (UTIs) were implemented timely. This affected one Resident (#8) of 16 reviewed for incontinence care. The facility census was 39. Findings include: Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 6:00 A.M., and the second daily dose between 11:00 A.M. and 1:00 P.M. No documentation was noted in the record to address the increased frequency of urination experienced as a result of the diuretic medication administration. Review of Resident #8's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, and dependent on staff for the completion of activities of daily living (ADLs) including bed mobility, transfer, the use of a wheelchair for mobility, and frequently incontinent of bladder. Further review recorded the daily administration of an anti-depressant medication and diuretic medication. Review of Resident #8's plan of care dated 03/01/19, and revised on 03/24/21 revealed a plan of care was developed to address the resident experiencing episodes of incontinence related to immobility, medication use, and needs assistance with toileting and transfers. Interventions included encourage fluids unless contraindicated, observe for signs and symptoms of UTI, notify physician as needed, observe skin and report any signs of breakdown as needed, offer and assist with toileting as needed and/or per request, provide incontinence care as needed, provide incontinence products as needed. There was no evidence in the medical record identified or implemented specific to toileting or incontinence monitoring schedules for Resident #8. Review of Resident #8's laboratory urinalysis (U/A) and culture sensitivity (C&S) testing completed on 03/08/21 revealed the resident tested positive for UTI. The physician was contacted and an antibiotic [MEDICATION(S)] was ordered twice daily for seven days. On 04/15/21 a U/A and C&S revealed the resident tested positive for UTI. The physician was contacted and the antibiotic [MEDICATION(S)] was ordered twice daily for seven days. There was no evidence of any additional interventions put in place to address the prevention of further UTIs or to address incontinence. Review of the bladder activity report between 04/16/21 and 04/21/21 revealed Resident #8 was noted to be incontinent 15 of 22 times. The report also listed the resident as frequently incontinent of bladder. Observation and interview on 04/19/21 at 1:16 P.M. with Resident #8 revealed the resident was concerned due to her frequent UTIs. The resident revealed she was dependent on staff for ADLs and slept in her recliner. Observation and interview with Resident #8 on 04/21/21 at 10:20 A.M. revealed the resident was incontinent of urine frequently and staff had to place her on the toilet to clean her. She revealed there was no specific schedule for toileting and has had to wait at times, causing incontinence. On 04/21/21 at 10:24 A.M. interview with State tested Nurse Aide (STNA) #100 verified Resident #8 was incontinent of urine and confirmed no specific schedule is set for the resident to be assisted with toileting, and the resident would call out if care was needed. The STNA revealed they would place the resident on the toilet to conduct incontinence care. At 11:58 A.M. interview with STNA #100 revealed Resident #8 was just asked if she needed to use the restroom and she stated no, the STNA verified the resident was incontinent. The STNA revealed they would ask again around 1:00 P.M. or 2:00 P.M. Additional interview at 1:45 P.M. with the STNA revealed she had went in to ask the resident if she needed to use the bathroom and the resident said she was fine. The STNA verified she did not check for incontinence and last toileted the resident at 10:15 A.M. STNA #100 revealed her shift was complete at 2:00 P.M., and verified the resident was frequently incontinent and not on a toileting schedule or check/change schedule. On 04/22/21 at 2:30 P.M. interview with Corporate Nurse (CN) #1 and Assessment Nurse (AN) #2 verified the nurse aide care delivery data base indicates Resident #8 was to be checked every two hours. However, the two hour checks were not specific to Resident #8's continence/incontinence needs and verified no individualized interventions were established to address the residents incontinence or toileting needs for direct care staff to utilize.

Based on observations, staff interview, review of the facility policy and review of the Center for Disease Control (CDC) guidelines, the facility failed to ensure proper screening procedures were in place for employees and outside personnel to assess for signs and symptoms of Coronavirus Disease 2019 (COVID-19). This had the potential to affect 27 of 27 residents who reside in the facility. Facility census was 27. Findings include: Observations on 07/06/20 at 6:10 A.M. revealed State tested Nursing Aide (STNA) #200 unlocked the main entrance of the facility and allowed the surveyor to enter. Once inside STNA #200 and the surveyor walked down the 100 hallway to a nurses station to be screened for possible COVID-19. The 100 hall had a census of eight residents (#7, #8, #9, #10, #11, #12, #13 and #14). STNA #200 was observed to complete a self screen and documented the findings. The surveyor was screened by Licensed Practical Nurse (LPN) #110 which included a temperature check and health assessment. Interview with LPN #100 and LPN #110 on 07/06/20 at 6:16 A.M. verified STNA #200 completed a self-screening. LPN #100 stated the facility did not have visitors at certain hours of the day, therefore kept the screening equipment and log at the nurses station. The visitors were required to walk past the dining room and down the 100 hallway to access the screening area. LPN #110 further stated the visitor screening was completed at the nurses station during the night time hours because there were no visitors in the building. During normal business hours the visitors and employees were screened at the front entrance. Interview with the Director of Nursing (DON) on 07/07/20 at 2:04 P.M. revealed the front entrance was their main door was the main point of entry for employees. They would be coming in and out of that door only which required the third and first shift staff to walk through the 100 hall to be screened. The DON confirmed by having staff/visitors walk past the dining room and down the 100 hallway to be screen this placed all 27 residents in the facility at risk of potential COVID-19 exposure. Review of the CDC guidelines titled, Preparing for COVID 19 in Nursing Homes, updated 06/25/20, revealed to screen all Health Care Personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Fever is either measured temperature greater than 100.0 degrees Fahrenheit (F) or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., Nonsteroidal anti-[MEDICAL CONDITION] drugs (NSAIDS'). Clinical judgement should be used to guide testing of individuals in such situations. Post signs at the entrances to the facility advising visitors to check-in with the front desk to be assessed for symptoms prior to entry. Screen visitors for fever of 100.0 degrees, symptoms consistent with COVID-19, or known exposure to someone with COVID-19. Restrict anyone with fever, symptoms, or known exposure from entering the facility. Review of facility policy titled The Enhanced Infection Prevention and Control Program (IPCP) for COVID-19, dated 03/10/20, revealed the facility is to ensure screening of all employees, visitors and personnel is completed when entering the campus and to maintain a log. This deficiency substantiates Complaint Number OH 810.

Based on medical record review, observation and staff interview, the facility failed to ensure continued assessment and circulation monitoring was provided to one resident during the application of casting. This affected one (Resident #14) of one resident reviewed for the application of a fiberglass cast for the treatment of [REDACTED]. The facility census was 67 residents. Findings include: Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the minimum data set assessment ((MDS) dated [DATE] identified the resident with moderate cognitive impairment, and required supervision for the completion of activities of daily living. On 02/06/19, a Magnetic-Resonance Imaging (MRI) was obtained of the left foot and ankle due to reports of pain. The MRI results identified a comminuted [MEDICAL CONDITION] and distal tibia and talus fracture. On 02/15/19, the resident had a fiberglass cast applied to the left foot for the treatment of [REDACTED]. Nurses notes on 02/24/19 at 4:40 A.M., discovered the resident voicing extreme pain and wanted the cast off of the left foot. The resident was medicated for pain and encouraged to ask for pain medication before the pain became so severe. The nurse noted the top of the cast with chisel marks in it as if the resident was taking his tools to try and remove cast. The medical record was silent to ongoing assessments of the casted extremity. Surveyor observation on 03/12/19 at 7:40 A.M., identified the resident propelling them self in a wheel chair. The resident had a left foot/ankle cast applied and up on the foot pedal. On 03/13/19 at 07:13 A.M. interview with Registered Nurse (RN) #200 revealed no specific observations or circulation assessments had been conducted regarding Resident #14's casted extremity. Interview with Corporate Registered Nurse (RN) #1 on 03/13/19 at 9:30 A.M., verified no specific observations or circulation assessments had been documented in the medical record. Corporate RN#1 stated ongoing assessments including circulation checks of the casted extremity should have been recorded.

Based on medical record review, pharmacy recommendations, interview and facility policy review, the facility physician failed to timely address the gradual dose reduction (GDR) recommendations for one (Resident #12) of five residents reviewed for unnecessary medications. The facility census 67. Findings included: Review of the medical record for Resident #12 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 was receiving antipsychotic, antianxiety and antidepressant medications. Review of the Plan of Care revised 01/23/19 revealed Resident #12 was at risk for adverse consequences related to receiving antipsychotic medications. Interventions included to attempt GDR in two separate quarters (with at least one month between the attempts) during the first year the resident received an antipsychotic medication, unless clinically contraindicated. Attempt to give the lowest dose possible. Review of the current physician orders revealed Resident #12 had [MEDICATION NAME] 0.5 milligrams (mg) twice daily, [MEDICATION NAME] 15 mg daily at bedtime, [MEDICATION NAME] 100 mg daily, [MEDICATION NAME] 50 mg daily at bedtime and [MEDICATION NAME] 7.5 mg daily at bedtime. These medications were all originally ordered on [DATE], then reordered on [DATE] and reordered again on 11/21/18 with no changes to the medication doses or administration times. Review of the facility pharmacist GDR recommendation dated 04/04/18 revealed When a resident is admitted on an antipsychotic a gradual dose reduction must be attempted within the first two weeks of admission (with an exception if treating [MEDICAL CONDITIONS]'s, or [MEDICAL CONDITION]'s). Resident #12 was admitted on [MEDICATION NAME] 7.5 mg daily at bedtime. Do you feel a gradual dose reduction is appropriate? If not, please provide an explanatory note. Thank you. The physician was notified on 04/04/18. The physician never responded to the pharmacy recommendation. The physician did not agree or disagree, did not provided a justification for Resident #12 to remain on the [MEDICATION NAME]. The pharmacy recommendation was noted as closed on 04/24/18. Review of the MDS dated [DATE] revealed Resident #12 was discharged to the hospital. The MDS dated [DATE] revealed Resident #12 returned to the facility on [DATE]. Review of the facility pharmacist GDR recommendation dated 04/24/18 revealed Resident #12 was readmitted on [MEDICATION NAME] 7.5 mg daily at bedtime on 04/23/18, do you feel a gradual dose reduction is appropriate? If not, please provide an explanatory note. In the evaluation notes section of the recommendation the pharmacist noted the Physician has not responded to recommendations after contact on 04/24/18, 05/01/18 and again on 05/04/18. There was no response from the physician. The physician did not agree or disagree. The recommendation was documented as closed on 05/09/18. Review of the scanned pharmacy recommendation document dated 04/24/18 revealed the recommend was address by the physician and declined. The physician did not date the note. The date of the physician's response was unknown. Review of the facility pharmacist recommendation dated 06/05/18 revealed a request to please clarify [DIAGNOSES REDACTED]. The response to the recommendation was a [DIAGNOSES REDACTED]. The recommendation was closed on 08/20/18 by a facility Registered Nurse (RN). The was no documentation by the physician regarding the recommendation. Review of the facility pharmacist recommendation dated 07/05/18 revealed a note to the nurses indicating a physician recommendation was made on 04/04/18, 04/24/18, and 06/05/18. The 06/05/18 recommendation was still open and needed to be addressed. The other recommendations made on 04/04/18 and 04/24/18 were closed with the statement that physician has not responded after three attempts. This is not acceptable. If recommendations are not responded to, they must be followed up with a phone call to physician to be compliant with state regulations. The only response was this was noted. The recommendation was closed 07/16/18. Review of the facility pharmacist GDR recommendation dated 08/06/18 revealed when a psychopharmacological medication was being used to manage behavior, stabilize mood, or treat a psychiatric disorder, gradual dose reductions should be attempted twice within the first year (in two separate quarters with at least one month between attempts), and then yearly thereafter. This resident was due for an attempted GDR. If the resident was deemed unsuitable for GDR, the following conditions must be met in order for GDR to be clinically contraindicated: the continued use was in accordance with current standards of practice, AND the physician had documented clinical rationale or the resident's target symptoms returned or worsened after the most recent tapering attempt within the facility, and the physician had documented clinical rationale. This resident's medication that was due for evaluation was [MEDICATION NAME] 7.5 mg daily at bedtime, [MEDICATION NAME] 15 mg daily at bedtime, [MEDICATION NAME] 50 mg daily at bedtime, [MEDICATION NAME] 100 mg daily, and [MEDICATION NAME] 0.5 mg twice daily. The physician was notified on 08/07/18 with a note stating, Awaiting a response. The physician did not agree or disagree. The recommendation was closed on 08/07/18. Review of the facility pharmacist GDR recommendation dated 09/05/18 the exact same recommendation from 08/06/18 was submitted to the facility again for a GDR of [MEDICATION NAME] and [MEDICATION NAME]. This GDR was declined by the physician with justification on 09/06/18. Interview with Corporate RN #1 on 03/13/19 at 4:23 P.M., verified the physician never responded to the pharmacy recommendation dated 04/04/18. She verified the recommendation was issued again by the pharmacist on 04/24/18. RN #1 verified the pharmacist added additional information to the 04/24/18 recommendation which stated the Physician has not responded to recommendations after contact on 04/24/18, 05/01/18 and again on 05/04/18. The recommendation was documented as closed on 05/09/18. RN #1 verified the recommendation was addressed by the physician, however, the physician did not date the response. RN #1 verified it was unknown when the physician actually completed her response. RN #1 verified the recommendation dated 04/24/18 was not addressed timely by the physician. RN #1 verified the recommendation dated 06/05/18 was never addressed by the physician and it was not closed until 08/20/19. RN #1 verified on 07/05/18 the pharmacy notified the facility regarding the 06/05/18 recommendation was still open and needed to be addressed and the physician had not responded after three attempts to the recommendations made on 04/4/18 and 04/24/18. RN #1 verified on 08/06/18 the pharmacist submitted another GDR recommendation to which the physician never responded until after it was resubmitted on 09/05/18. Review of the facility policy titled Guidelines for Physician Services revised 05/11/16 revealed the resident's attending physician shall participate in the resident's assessment and care planning, monitor changes in the resident's medical status and provide consultation or treatment as required by resident condition, regulations and or when consulted/called by the facility. The physician is responsible to ensure that the resident receives quality care and medical treatments.

Based on medical record review, observation, staff interview and review of a facility policy, the facility failed to ensure appropriate infection control techniques and procedures were followed while provided incontinence and urinary catheter care. The facility further failed to provide proper storage of urinary catheters and promote the isolation of infectious diseases. This affected three residents (#34, #30, and #8) of 17 residents reviewed for infection control practices during the annual survey. The facility census was 67. Findings include: 1. Medical record review revealed Resident #34 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment, dated 01/09/19, revealed the resident had impaired cognition. Further review of the medical record revealed the resident was diagnosed with [REDACTED]. Review of Resident #34's physician orders [REDACTED]. Observation on 03/13/19 at 11:25 A.M., revealed State tested Nursing Assistant (STNA) #401 and STNA #402 provided incontinence care and urinary catheter care for Resident #34. Both STNA's washed their hands and put on clean gloves prior to providing care. STNA #401 provided peri-care for Resident #34 while STNA #402 assisted to position the resident. After providing per-care, STNA #401 proceeded to provide catheter care. STNA #401 was observed holding onto the tubing of Resident #34's catheter with her left gloved hand while cleansing the tube with her right gloved hand. After providing the care, STNA #401 entered the bathroom to obtain a graduate (container to collect and measure urine drained from the catheter collection bag), placed a paper towel barrier onto the floor under the urinary catheter collection bag and placed the graduate onto the paper towel . She then opened the drain spout and drained the urine into the graduate. STAN #401 then used alcohol wipes to clean the drainage bag spout. STNA #401 emptied the graduate, used wipes to clean the graduate after use, removed her gloves, and washed her hands. At no time during the provided care was STNA #401 observed washing her hands or changing her gloves. Interview on 03/13/19 at 11:39 A.M., STNA #401 verified she did not remove her gloves and wash her hands after providing incontinence and and/or prior to providing urinary catheter care. STNA #401 revealed it was the facility's policy to remove her gloves and wash her hands after providing incontinence care and before providing urinary catheter care. STNA #401 stated she should have removed her gloves and washed her hands prior to providing catheter care. Review of a facility policy titled, Urinary Catheter Care, dated 05/11/2016, revealed to perform urinary catheter care staff were to wash and dry their hands thoroughly and put on gloves. Staff were to then wash the resident's genitalia and perineum thoroughly, place the soiled linens into a designated container, remove their gloves and discard them into the designated container. Further review revealed staff were to again wash their hands thoroughly and put on clean gloves and then proceed with providing the resident with catheter care. After the procedure staff were to again wash their hands thoroughly. 2. Review of Resident #8's medical record re admitted to the facility on [DATE] following hospitalization with the [DIAGNOSES REDACTED]. According to the most current minimum data set assessment ((MDS) dated [DATE] identified the resident with moderate cognitive impairment, and dependent on staff for the completion of activities of daily living. On 02/28/19, the physician ordered the resident to be on contact precautions until [MEDICAL CONDITION] was resolved. Observation on 03/11/19 at 7:40 P.M. isolation cabinets containing isolation gowns, gloves and mask were located outside Resident #8's entry door. On 03/12/19 at 2:33 P.M. no isolation equipment was located outside the residents room. On 03/12/19, a laboratory test was received indicating a positive [MEDICAL CONDITION] result. Interview with Licensed Practical Nurse (LPN) #300 on 02/12/19 at 2:35 P.M. verified the isolation equipment had been removed. LPN#300 stated no negative C-Dff stool specimen had been received for Resident #8 and was unaware why the equipment had been removed. Additional observation on 03/13/19 at 07:11 A.M., with Registered Nurse(RN) #200 revealed Resident #8 was still in [MEDICAL CONDITION] isolation and a isolation cart(cabinet) was maintained outside room. RN#200 looked in the direction of the residents room and verified no cart(cabinet) was present. On 03/13/19 at 8:03 A.M., State tested Nurse Aide ((STNA) #400 was observed providing Resident #8 with a bed bath which included incontinence care of liquid stool. STNA #400 had gloves donned. However, no further isolation equipment was applied. At 8:13 A.M., STNA#400 requested Physical Therapy Assistant (PTA) #500 to assist in pulling the resident up in bed. PTA #500 was observed to handle the resident and associated linens without donning isolation equipment. At the conclusion of the observations, interview with STNA#500 stated the resident was no longer on isolation and isolation equipment was no longer required during the provision of care. On 03/13/19 at 9:10 A.M., interview with Corporate RN #1 verified no negative [MEDICAL CONDITION] test result had been obtained and isolation equipment had been removed from Resident #8's room. Corporate RN #1 indicated isolations remained in place. Review of facility guidelines for management of residents with [MEDICAL CONDITION] revised 05/11/16 revealed staff are to wear gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the residents environment. Donning a gown and gloves upon room entry and discarding before exiting the patient room was done to contain pathogens. 3. Resident #30 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the most current minimum data set assessment ((MDS) dated [DATE] identified the resident as cognitively impaired, dependent on staff for the completion of activities of daily living, and requires the use of an indwelling urinary catheter. On 03/02/19 a physician order [REDACTED]. Surveyor observation on 03/12/19 at 2:17 P.M., 03/13/19 at 6:25 A.M., 7:56 A.M., 9:00 A.M., 1:21 P.M. Resident #30 was in bed with the excess urinary catheter tubing resting on the floor. On 03/13/19 at 1:50 P.M., interview with Licensed Practical Nurse (LPN) #300 during observation verified resident with the catheter tubing on floor. LPN#300 proceeded to contain the tubing off the floor and verified catheter tubing was to be off the floor to prevent urinary tract infection. Additional observation on 03/14/19 at 7:43 A.M. noted Resident #30 in bed with the catheter tubing resting on the floor. Review of urinary catheter care policy revised 05/11/16 ensure the catheter tubing and drainage bag are kept off the floor.

Based on medical record review, resident and staff interview, review of resident and employee written statements, review of an employee personnel file, review of a Self-Reported Incident (SRI), and review of a staff expectations form, the facility failed to provide care and services to residents in a dignified and respectful manner. This affected three (#1, #5, and #7) of 61 residents residing in the facility. Findings include: Review of a SRI (Tracking Number 5) dated 11/27/18 revealed Resident #1 reported a facility nurse (Licensed Practical Nurse (LPN) #200) told her to shut up and closed her bedroom door when she was calling out for her husband and for help on 11/26/18. 1. Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment completed 11/11/18 revealed Resident #1 had moderately impaired cognition. Interview on 12/16/18 at 9:56 A.M., with Resident #1 stated she was in her room and wanting help to go to bed when LPN #200 told her to shut up and slammed her door closed. Resident #1 stated LPN #200 never came back to assist her and said the incident made her upset. Resident #1 stated LPN #200 never acted like this toward her before and nothing like the incident has happened since. Resident #1 stated she did not feel afraid or abused. Review of a written statement from Resident #1 dated 11/28/18 revealed she wanted to go to bed but no one was available so she was yelling for husband and LPN #200 told her to shut up and then closed the door. 2. Review of Resident #7's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment completed 09/24/18 revealed Resident #7 had intact cognition. Interview on 12/16/18 at 10:11 A.M., with Resident #7 stated he heard LPN #200 and Resident #1 yelling but did not hear the door slam or anyone say shut up on 11/26/18, but has heard LPN #200 tell Resident #1 to shut up in the past. Resident #7 stated he has seen LPN #200 slam the bedroom door on Resident #5 when he was asking for help. Review of a written statement from Resident #7 dated 11/28/18 revealed he heard LPN #200 tell Resident #1 to go to sleep and shut up a while ago. 3. Review of Resident #5's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment completed 10/19/18 revealed Resident #5 had intact cognition. Interview on 12/16/18 at 10:23 A.M., with Resident #5 stated LPN #200 has yelled at him before but he just yelled right back at her. Resident #5 verified LPN #200 has closed his bedroom door on him and not come back to give care or services he had asked for. Review of a written statement from Resident #5 dated 11/28/18 revealed LPN #200 yelled at him and he yelled back at her because she did not come in his room enough. Resident #5 wrote LPN #200 has shut his door and told him she does not have time to care for him because she was with other residents. Review of a written statement from State tested Nurse Aide (STNA) #100 dated 11/28/18 revealed he witnessed LPN #200 tell Resident #5 and #7 to shut up and take their medications, witnessed LPN #200 close the door on Resident #5's bedroom door when he was complaining about his medications and calling out for help, and witnessed LPN #200 call Resident #7 a big baby. Review of a written statement from STNA #135 dated 11/29/18 revealed he witnessed LPN #200 telling Resident #5 to shut up when he screams out instead of using his call light. Review of a written statement from STNA #175 dated 11/29/18 revealed she heard LPN #200 tell an unidentified resident on the 300 Hall to shut up about a month ago. Review of LPN #200's personnel file revealed a hire date of 11/28/17 and a termination date of 12/04/18. Review of an employee counseling form dated 12/03/18 revealed LPN #200 violated resident rights of being treated with respect and dignity when resident and staff interviews reported LPN #200 told residents to shut up, indicated she did not have time to help residents, called a resident a big baby, and closed or slammed the door after making these statements. Interview on 12/16/18 at 2:25 P.M., with Clinical Support Nurse #1 verified LPN #200 did not provide care and services to Residents #1, #5, and #7 in a respectful and dignified manner. Review of a form titled Nursing Services - Licensed Staff Expectations of Excellence, dated 10/13/18, revealed when staff are performing their duties they would always cheerfully and sincerely greet residents, families, and fell ow team members. If a resident or family needs assistance staff should help them get the assistance they need. This deficiency substantiates Master Complaint Number OH 546.

Based on record review, policy review and staff interview, the facility failed to ensure a residents pressure alarm was functioning properly to prevent accidents. This resulted in harm when Resident #67 fell , acquired a closed head injury and a laceration on the forehead, was transferred to the emergency room and required five sutures. This affected one (Resident #67) of three residents reviewed for falls with assistive devices. The facility identified 22 residents who required personal safety alarms. The facility census was 75. Findings include: Review of Resident #67's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of Resident #67's medical record revealed a physician order [REDACTED]. The placement and functions were to be checked every shift. Review of Resident #67's most recent Minimum Data Sheet (MDS) assessment revealed a severely impaired cognition and need for the assistance of two people for transferring. Review of Resident #67's most recent care plan revealed acute care needs included a pressure alarm to be in place at all times and to check placement and function every shift. Stand up lift with two assist was required for transfers. In addition, the individual care plan revealed Resident #67 forgets she can not walk requiring a pressure alarm in her wheelchair. Review of Resident #67's medical records revealed on 07/24/14 the resident was found on the floor in her room with a forehead laceration and closed head injury. Review of the facility form titled Fall Circumstance Assessment and Intervention revealed on 07/24/14 at 10:00 A.M. Resident #67 was leaning over in her wheelchair picking up items off the floor, fell out of her wheelchair and received a laceration to the forehead. Furthermore Resident #67 was sent to the emergency room and required five sutures in her forehead. At the time of the fall, the safety equipment was in place but not functioning. The fall was unwitnessed. Prevention update included to check alarm on the wheelchair and to remove the resident's bottom drawer and put items in a tote to prevent her from needing to lean over. Review of Resident #67's Situation, Background, Assessment, Recommendation (SBAR) dated 07/24/14 revealed Resident #67 was leaning forward and the alarm was in place but not alarming. Resident #67 reached forward, fell and struck her head resulting in a laceration. On 09/02/15 at 8:24 A.M. an interview with Licensed Practical Nurse (LPN) #10 revealed nurses and nurses aides check the alarms each shift during a transfer or have the residents raise off their wheelchairs. Staff then sign off in the treatment book record confirming the alarm is in working condition. Interview with the Assistant Director of Nursing (ADON) #111 on 09/02/2015 at 9:44 A.M. revealed it was the nurse and aides responsibility to check the personal alarms each shift. Pertaining to Resident #67's fall on 07/24/14, the facility was unaware of why the alarm was not working. A new alarm was initiated as soon as the incident happened. ADON #111 revealed no employee was counseled nor was any additional education initiated. ADON #111 verified there were no new interventions put into place for Resident #67. Interview on 09/02/15 at 11:31 A.M. an interview with LPN #5 revealed she was the nurse on duty at the time of Resident #67's fall and found Resident #67 lying on the floor. LPN #5 stated she was unaware of why the pressure alarm was not working. LPN #5 revealed she received no further education or discipline regarding the fall. Review of facility policy titled Procedure Guidelines Alarm Checks dated 10/19/07 revealed resident wanderguard alarms, bed, chair and personal body alarms should be checked for proper functioning. Alarm checks should be part of routine daily care; with daily dressing, bathing, toileting, at meals. Batteries should be scheduled for replacement on a routine basis. Alarms should be replaced per the manufactures recommendations. Residents alarms found to be non-functioning should have the alarm replaced/repaired immediately or another intervention implemented to protect the safety of the resident until the alarm is back in proper working order.

Based on medical record review, observations, staff interview and review of facility policy, it was determined that the facility failed to ensure physician ordered interventions and care planned interventions for pressure relief were implemented. This affected two (#21 and #24) of three residents reviewed for pressure ulcers. The facility identified a total of three current residents with pressure ulcers. This resulted in actual harm for Resident #21 who developed three Stage II pressure ulcers on the buttocks. Findings include: 1. Review of Resident #21's medical record revealed she was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent quarterly minimum data set (MDS) assessment dated [DATE] identified the resident with normal recall. She required extensive assistance for transfers, bed mobility and hygiene. She was usually continent of bowel and bladder and had no history of pressure ulcers. Review of the RAP assessment for pressure ulcers revealed it was triggered due to the resident's bed mobility and bowel incontinence. Review of the July 2010 monthly physician's orders [REDACTED]. Review of the potential for alteration in skin integrity care plan developed on 12/07/09 revealed interventions to assess/record changes in skin status; turn and reposition when the resident requests it; a pressure reducing mattress and chair cushion; provide incontinence care after each incontinent episode; a protective skin barrier cream as ordered; and treatments to the coccyx area which were updated twice. Review of the "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" dated 08/26/10 revealed a right upper buttock Stage II pressure ulcer that measured 2.0 centimeters (cm) in length by 2.0 cm in width with no depth measurement. The open area was noted as red in color. Review of the Pressure/Stasis/Arterial/Diabetic Ulcer assessment dated [DATE] revealed a Stage II pressure ulcer was found on the right lower buttock that measured 2.0 cm in length by 2.0 cm in width with no depth measurement. The wound bed was noted as red in color. Review of the Pressure/Stasis/Arterial/Diabetic Ulcer assessment dated [DATE] revealed the resident had a Stage II left buttock pressure ulcer that measured 2.0 cm in length by 2.0 cm in width with no depth measurement. The wound bed was noted as red in color. On 09/02/10 at 9:55 A.M., Licensed Practical Nurse (LPN) #11 measured all of Resident #21's pressure areas on her buttocks. The left buttock area measured 1.3 cm in length by 0.9 cm in width. The wound bed was beefy red with small scattered areas of yellow slough. No depth measurement was obtained. The right lower buttock measured 3.0 cm in length by 1.5 cm in width. The wound bed was beefy red with scattered areas of yellow slough. The nurse did not measure the depth of the wound. The right upper buttock measured 1.1 cm in length by 1.0 cm. in width. The wound bed was beefy red with yellow slough towards the bottom half of the wound. The nurse did not measure the depth of the wound. On 08/31/10 at 4:10 P.M., Resident #21 was observed up in her recliner in her room with her feet up on the footrest. A regular bed pillow was noted under the resident in the seat of the recliner. At 5:15 P.M., the resident remained up in the recliner with her feet up and a pillow under her lower legs and in the seat of the recliner. On 09/01/10 at 10:50 A.M., Resident #21 was up in her recliner in her room with her feet up on the footrest. A regular pillow was noted in the seat of the recliner. At 1:05 P.M., the resident was still up in the recliner in her room with her feet up on the footrest and a regular bed pillow in the seat of the recliner. On 09/02/10 at 7:01 A.M., Resident #21 was again observed up in the recliner in her room with her feet on the floor. A regular bed pillow was in the seat of the recliner. On 09/02/10 at 10:20 A.M., a regular bed pillow was observed in the seat of the recliner. This was verified with the LPN #11 and the Director of Nursing (DON). When questioned about the pressure relieving cushion that was ordered to be in the resident's chair, LPN #11 stated that it was in the resident's wheelchair. She produced a thin, black cushion approximately one inch thick from the seat of the wheelchair. The DON stated Resident #21's cushion should be in whatever chair the resident is sitting in at the time, whether it was the wheelchair or the recliner. 2. Review of Resident #24's medical record revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. In addition, on 03/31/10, the resident was diagnosed with [REDACTED]. Review of the initial Resident Assessment Protocol (RAP) dated 10/20/09 revealed the resident was at risk for developing pressure areas due to decreased mobility from the [MEDICAL CONDITION]. The nurse was to assess the skin on a weekly basis and staff were to assess the skin during bathing and morning and afternoon care. Review of the alteration in skin integrity plan of care developed on 01/22/10 revealed interventions for pressure/wound assessment per schedule, assess the skin daily for signs of redness and discoloration, assess areas prone to breakdown-especially over bony prominences, turn and reposition the residents every two hours and as needed, pressure reducing mattress to bed and pressure reducing cushion to chair, vitamin and mineral supplements, utilize pillows/pads to prevent skin to skin contact and enhance positioning, foam heel protectors and heels must be off of the bed. On 07/20/10, the care plan was updated with interventions for the resident to be up in the wheelchair for breakfast, lunch and supper for a limit of one hour and to keep the heels off of the bed. Further review of the resident's medical record revealed [REDACTED]. Resident #24 currently has an open wound on her left heel that is healing. On 07/19/10, the area on the left heel measured 6.6 centimeters (cm) by 4.3 cm. On 08/23/10 the area on the left heel measured 5.8 cm in length by 3.2 cm in width. On 08/30/10 the area measured 3.6 cm in length by 2.6 cm in width. The resident has regular appointments at the wound clinic for the treatment of [REDACTED]. On 08/25/10, the wound clinic physician orders [REDACTED]. On 08/30/10 between 4:00 A.M. and 5:25 A.M., on 08/31/10 at 7:45 A.M., 8:35 A.M., 9:52 A.M. and 10:30 A.M., Resident #24 was observed in supine position in bed with a pillow under her lower legs and both heels resting directly on the pillows. On 08/31/10 at 1:10 P.M., the resident was laying in bed with her heels resting directly on the mattress. On 09/01/10 at 7:37 A.M., Resident #24 was observed in bed with pillows under her lower legs and her heels were resting directly on the mattress. On 09/01/10 at 1:15 P.M., she was observed in bed on her right side her right heel resting directly on the mattress and her left heel resting directly on the pillow. On 09/01/10 at 3:40 P.M., Resident #24 was observed in bed on her right side with her left knee bent and the bottom of her left foot resting directly on the mattress. The lateral side of her left foot was also resting directly on the mattress. In addition, Resident #24 currently has a healing stasis ulcer on the top of her left foot that measured 2.3 cm in length by 2.0 cm in width. However, review of the "Pressure/Stasis/Arterial/Diabetic/ Ulcer Assessment" revealed the wound was not measured weekly as care planned and according to facility policy. There was no evidence that the wound was measured from 05/10/10 to 06/14/10, 35 days. Also, the wound was assessed on 07/05/10, 07/13/10 and 08/30/10 but no measurements were obtained and documented. Review of the facility's undated policy entitled "General Wound and Skin Care Guidelines" revealed general wound and skin care guidelines should be followed for all residents with potential and/or actual impairment in skin integrity. Staff should document the type of the wound, location, stage (if applicable), length, width, depth (in cms), base, drainage, periwound tissue, and treatment of [REDACTED].

Based on medical record review, surveyor observation, review of published literature from the Mayo Clinic regarding burns, review of the "Manual for Physical Agents-Hot Packs" and staff interview, it was determined the facility failed to properly apply a hot pack to one resident's knee. This affected one (#45) of eight residents reviewed for accidents and hazards. The facility identified a total of 25 residents with accidents. This resulted in actual harm for Resident #45 who sustained a second degree burn to his left knee cap. The facility census was 85. Findings include: Review of Resident #45's medical record revealed a readmitted d of 04/18/10. [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment dated [DATE] indicated he was not cognitively impaired and could understand and be understood when communicating. He required the extensive assistance of one person with bed mobility and transfers. He had full loss of voluntary movement on one side of his body, including his arm, hand, leg and foot. Further review of the record revealed a physician order [REDACTED].#45. On 04/13/10 at 8:00 P.M., Licensed Practical Nurse (LPN) #10 sent Resident #45's physician a "Change in Condition Form" which indicated a warm compress was applied to the resident's knee cap and left a 3.0 centimeter in diameter blister. The physician ordered a treatment to the blistered area on 04/13/10 that included the daily use of an antibiotic ointment, a non-adhesive dressing and gauze wrap. According the website "MayoClinic.com" a second-degree burn occurs when the first layer of skin has been burned through and the second layer of skin (dermis) is also burned. The website indicates blisters develop and the skin takes on an intensely reddened, splotchy appearance. Second-degree burns produce severe pain and swelling. Review of Resident #45's care plan for alteration in comfort related to arthritis, initiated on 06/30/08, revealed multiple interventions to address the resident's discomfort. However, the care plan contained no intervention for the use of hot packs to relieve his pain. Review of the "Accident/Incident Report" dated 04/13/10 revealed a warm compress was applied to Resident #45's knee which left a 3.0 centimeter (cm) in diameter blister. The Director of Nursing (DON) documented on the report that a warm compress was applied to the resident's right knee (blister actually on left knee) for discomfort. The DON noted the nurse was educated to check the temperature of the compress and wrap appropriately to ensure no injury occurs. Further review of physician orders [REDACTED]. On 06/01/10, the left knee wound was ordered to be open to air. On 08/31/10 at 11:00 A.M., Resident #45 was observed laying in bed. His left side was noted to have obvious paralysis. His left leg and foot were extended and stiff and his left arm did not move. His right arm and leg were moving about in bed without difficulty. During interview on 08/30/10 at 3:00 P.M., Physical Therapy (PT) Director #1 stated the nurses have a key to the hydrocolator that contains the canvas covered hot packs which are soaked in water. She stated the hot packs can be accessed at any time. PT Director #1 provided a temperature log that indicated the water temperature in the hydrocolator ranged from 159 to 165 degrees Farenheit. She verified the temperature log noted on 04/13/10 the water temperature where the hot packs were stored measured 160 degrees Farenheit. PT Director #1 further stated that when the hot packs are utilized, there should be six to eight layers of covering over the hot pack before it is placed on the resident's skin. She also stated that more layers should be applied if the resident has thin skin, which most of the elderly population in the facility has. During interview with Resident #45 and his wife on 08/30/10 at 5:15 P.M., he stated that when the hot pack was applied on 04/13/10, he never felt any pain or discomfort and was unaware that a blister had formed on his left knee cap. The resident's wife stated the compress was used due to the pain the resident has experienced since his stroke eight years ago. During interview with the DON on 08/30/10 at 5:45 P.M. she acknowledged that a resident with paralysis might be unable to identify if something would be too hot on their skin due to their decreased sensation in that area. She indicated that if she were to use a hot pack for a resident, she would put a towel around the hot pack and then use the commercial terry cloth cover. The DON could not recall if the nurses were ever inserviced on the use of the hot packs from the physical therapy department. The DON also verified that there is no specific nursing policy and procedure for the use of hot packs. According to the undated "Manual for Physical Agents-Hot Packs" 1993, Fourth Edition, which is kept in a book in the physical therapy department, revealed a commercial hot pack is a conductive means of delivering moist heat to the patient. The pack is made of canvas and filled with silica gel. It is immersed in water of about 170 degrees Farenheit in a thermostatically controlled heater. The manual indicated that patients with sensory loss may be unreliable judges of heat levels and may also have diminished vascular supplies. If treatment with heat is justifiable, the patient should be carefully monitored. Further review of the manual revealed instructions to cover the area to be treated with a clean terry cloth towel. Then remove a pack (hot pack) and place it on a commercial terry cloth cover or on two terry cloth towels folded lengthwise and arranged as shown in the picture in the manual. The manual instructed to fold the towels so that there are six to eight layers of toweling covering the pack or use an equivalent amount of commercial covering or bath blanketing. Then cover the commercial covers with a clean towel. The manual further noted that intensity is governed by patient tolerance and is accomplished by adding or removing toweling as needed. Provide the patient with a call system. Furthermore, the physical therapy practioner should remain nearby to make necessary adjustments and to check the skin periodically during treatment. Duration of treatment is 15 to 30 minutes. On 08/31/10 at 1:30 P.M., LPN #10, the nurse who had applied the hot pack on Resident #45's left knee, was interviewed. She stated she took two towels and wrapped them around the hot pack and applied them to Resident #45's left knee. She verified that she did not use the commercial terry cloth cover around the hot pack. On 08/31/10 at 3:00 P.M., an interview with Resident #45's Primary Care Physician (PCP) revealed she acknowledged that extra care should be given to someone who has decreased sensation in an area or are paralyzed, such as Resident #45, when applying a hot pack. Interview with Certified Occupational Therapy Assistant (COTA) #5 on 08/31/10 at 9:50 A.M. revealed LPN #10 applied the wrong type of hot pack to Resident #45's knee. COTA #5 stated she should have used the hot pack that had the center cut out for the knee cap. Observation and measurement of Resident #45's left knee wound on 09/01/10 at 4:20 P.M. revealed the area was pink with dry, white skin and scab formations scattered on top of the pink area of the wound. There was no drainage or odor present. It measured 3.0 cm. in width by 3.3 cm in length.