Every finding on record at Hennis Care Centre of Dover

Based on record review, interview and review of facility policy, the facility failed to timely report an allegation of resident-to-resident sexual abuse to the state agency as required. This affected two (Residents #32 and #87) of three Residents reviewed for abuse. The facility census was 87.Findings include: Review of the medical record for Resident #87 revealed an admission date of 05/26/26 with diagnoses including chronic obstructive pulmonary disease, hypertension, depression, bipolar disorder, and dementia. Review of the care plan dated 06/13/26 revealed Resident #87 had behaviors related to diagnoses. Interventions included administering medications as ordered and praise Resident #87 for positive behaviors. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 had intact cognition. Resident #87 required extensive assistance for all activities of daily living. Review of the nursing progress note dated 08/23/26 at 10:00 P.M. revealed this nurse saw Resident #87 sitting in her wheelchair while Resident #32 was sitting on the couch in the common area. They were talking when she saw Resident #87 scoot her wheelchair away from the couch. The aide who was nearby went over to check on Resident #87. Resident #87 then requested the aide take her to her room. While in her room Resident #87 told the aide that Resident #32 said to her she had nice breasts. Resident #87 was upset. The aide informed this nurse. The nurse assessed Resident #87 who reported no touching and notified Resident #87's daughter. Resident #87's daughter requested that the nurse give something to the resident to calm her down. The nurse administered her as needed Vistaril 25 milligrams for anxiety. Twenty minutes later the nurse received a phone call from the local police stating Resident #87's daughter called into the police station stating her mother's breasts were grabbed by another male resident. The nurse informed the police the incident was witnessed, and they did not touch each other. While she was on the phone with the police Resident #87's daughter called in demanding her mother go to the emergency room. Resident #87 was transported to the hospital. Review of the nursing progress note dated 08/24/26 at 1:00 A.M. revealed Resident #87's hospital record revealed Resident #87 reported she felt safe in the facility and had no care or safety concerns with the facility. Resident #87 returned from the emergency department with no new orders. Resident #87 was reassessed with no concerns.Review of the medical record for Resident #32 revealed an admission date of 05/29/26 with diagnoses including type two diabetes mellitus, mild cognitive impairment, hyperlipidemia, and anxiety disorder. Review of the care plan dated 05/29/26 revealed Resident #32 had mild cognitive impairment. Interventions included reorienting him to place, time, and purpose and to encourage him to participate in activities. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had severe cognitive impairment. Resident #32 required extensive assistance for all activities of daily living. Review of the nursing progress note dated 08/24/26 revealed Resident #32's sister was notified to discuss an incident that happened the night prior. The sister reported Resident #32 never displayed any such behaviors in the past. Resident #32's sister reported she was accepting psychiatric services assessing her brother and thanked the nurse for the phone call.Review of the facility investigation into Resident #87 and #32 incident, dated 08/24/26, revealed on 08/23/26 the nurse and aide observed Resident #87 in her wheelchair in the common area with Resident #32 sitting on the couch and they were talking to each other. Resident #87 then pushed her wheelchair back fast and became upset. The aide went over to Resident #87 and asked what was wrong and she requested to go back to her room. When in her room Resident #87 told the aide that Resident #32 stated to her you have nice tits. The aide notified the nurse, and the nurse notified Resident #87's daughter. Resident #32 was placed on every 15-minute checks, Resident #32 and #87's physician was notified. Resident #87's daughter requested her mother be given something to calm down and the nurse administered Vistaril 25mg that she had ordered for increased anxiety. The facility then received a phone call from the local police department that Resident #87's daughter called them stating another resident grabbed her mother's breasts. The police were notified that the event was witnessed and at no time did Resident #32 reach out his hands to Resident #87 or touch her. She informed the police Resident #87 was back in her room and doing better and Resident #32 was being closely monitored. The daughter then called the facility demanding her mother go to the emergency room. Review of the hospital paperwork revealed Resident #87 reported to the ambulance and emergency department that she felt safe in the facility. Resident #87 then returned to the facility with no new orders. On 08/24/26 the DON interviewed all females' residents on the secure units and provided skin exams with no concerns. The incident was discussed with Resident #32's sister who reported he has never had those behaviors before. A care conference was held with Resident #87's daughter and they were assured that all was being investigated. Review of the Ohio Department of Health Certification and Licensing System self-reported incident (SRI) tracking for the facility on 08/25/26 at 9:10 A.M. revealed the last self-reported incident was filed in December 2025.An interview on 08/25/26 at 9:26 A.M. with the Director of Nursing (DON) reported she was made aware of the allegations Resident #87 and her daughter made on 08/24/26 at approximately 3:00 A.M. from her staff while Resident #87 was at the hospital. She reported she started investigating the incident immediately when she came into the building on 08/24/26. She reported after interviews and investigation there were no negative findings from staff. The DON reported she did not know why a self-reported incident wasn't filed because she forwarded all her information onto her Administrator and he usually filed the incidents. An interview on 08/25/26 at 11:30 A.M. with the Administrator confirmed he was made aware of the allegations by Resident #87 on 08/24/26 during the early hours of the morning. He reported he did not file the self-reported incident because he had locked himself out of the electronic medical record system and could not get Resident #87 or #32's demographic information. The Administrator stated he did not reach out to anyone at the Ohio Department of Health to let them know the filing would be late. Review of the facility policy Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, undated, revealed the Administrator and or his/her designee will notify the Ohio Department of Health of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation, of resident property and injuries of unknown source as soon as possible, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the Ohio Department of Health immediately, but not later than two hours after the allegation is made. This deficiency represents non-compliance investigated under Complaint Number 3175006.

Based on record review, observation, and interview, the facility failed to provide a dignified dining experience for Resident #20 who received a blood glucose check at the dining room table with other residents present. This affected one resident (Resident #20) out of five residents (#20, #38, #49, #54, and #326) observed for dining on the Gardens unit. Findings include: Review of the medical record revealed Resident #20 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, type two diabetes, history of traumatic brain injury, and dementia. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #20 had moderately impaired cognition. Review of Resident #20's physician order dated 04/08/25 revealed the resident was to have a fingerstick blood glucose check twice a day. Observation on 04/14/25 at 11:28 A.M. revealed Resident #20 was sitting at the head of the table in the dining room with Resident #28, #49, #54, and #326. Resident #20, #28, #49, #54, and #326 had the lunch meal in front of them and had started eating when Registered Nurse (RN) #232 used a small disposable needle-like device to prick a finger on Resident #20's left hand to force blood for the glucose check. The nurse then applied a drop of Resident #20's blood to a glucose test strip. The glucose test strip was placed inside the glucometer to read the residents level of glucose. Interview on 04/14/25 at 11:32 A.M. with RN #232 verified she had checked Resident #20's blood glucose level at the table in the dining room. RN #232 verified Resident #20's blood glucose level should not have been checked in the dining room at the table where other residents were eating.

Based on record review, staff interview, and Resident Assessment Instrument (RAI) Manual review, the facility failed to accurately complete the Minimum Data Set (MDS) Nutritional Status section for a resident receiving additional fluid intake via a percutaneous endoscopic gastrostomy (PEG) tube. This affected one resident (Resident #13) out of five residents reviewed for nutrition. The facility census was 75. Findings Include: Review of the medical record for Resident #13 revealed admitted on 11/19/24 and re-admitted on 02/07/25 with diagnoses including, but not limited to, paranoid schizophrenia, type two diabetes, major depression, personality disorder, high blood pressure, and osteomyelitis of vertebra. Review of Resident #13's care plan dated 02/21/25 revealed Resident #13 had a percutaneous endoscopic gastrostomy (PEG) tube with interventions to provide local care to the G-tube site as ordered and monitor for signs and symptoms of infection. Review of Resident #13's physician orders revealed an order dated 02/07/25 for low concentrated sweets diet, regular texture, regular/thin consistency for liquids, and an order dated 02/13/25 for 200 milliliters (ml) of water flush twice daily per PEG tube every shift for PEG patency and hydration. Further review of Resident #13's physician orders revealed the discontinued order from 02/08/25 to 02/13/25 for 100 ml water flush twice daily per PEG every shift for PEG patency and hydration. Review of Resident #13's February 2025 Medication Administration Record (MAR) dated 02/08/25 to 02/13/25 revealed the order for 100 ml water flush twice daily per PEG every shift for PEG patency and hydration was marked as completed. Resident #13 would have received a total of 200 ml of additional water per day. Further review of Resident #13's MAR from 02/13/25 to 02/28/25 revealed the order for 200 ml of water flush twice daily per PEG tube every shift for PEG patency and hydration was marked as being completed. Resident #13 would have received a total of 400 ml's of additional water per day. Review of Resident #13's quarterly MDS dated [DATE] revealed section K (Swallowing/Nutrition Status) provided three different response options to be marked; a) 500 cubic centimeter (cc) (also converted to the same measurement as a milliliter) per day or less, b) 501 cc/day or greater, or c) not assessed/no information. Section K was not marked as Resident #13 receiving a percentage of average fluid intake per day by tube feeding. Review of Resident #13's March 2025 MAR dated 03/01/25 to 03/31/25 revealed the order for 200 ml of water flush twice daily per PEG tube every shift for PEG patency and hydration was marked as being completed. Resident #13 would have received a total of 400 ml's of additional water per day. Review of Resident #13's quarterly MDS dated [DATE] revealed section K (Swallowing/Nutrition Status) provided three different response options to be marked; a) 500 cubic centimeter (cc) (also converted to the same measurement as a milliliter) per day or less, b) 501 cc/day or greater, or c) not assessed/no information. Section K was not marked as Resident #13 receiving a percentage of average fluid intake per day by tube feeding. Review of Resident #13's April 2025 MAR dated 04/01/25/to 04/16/25 revealed the order for 200 ml of water flush twice daily per PEG tube every shift for PEG patency and hydration was marked as being completed. Resident #13 would have received a total of 400 ml's of additional water per day. An interview on 04/16/25 at 11:36 A.M. with Dietician #157 confirmed section K in Resident #13's quarterly MDS assessments, dated 02/14/25 and 03/28/25, were not coded/completed to reflect the additional hydration Resident #13 was receiving daily per PEG tube. Dietician #157 stated section K should have been coded/completed to show Resident #13's percentage of additional water intake per PEG tube per day. Review of the Resident Assessment Instrument (RAI) Manual for Section K - Percent Intake by Artificial Route - Average Fluid intake per day by intravenous (IV) or Tube Feeding, dated 10/25/24, revealed to calculate the average of fluid intake per day, add up the total amount fluid received each day by IV and/or tube feedings only and divide the week's total fluid intake by 7. It stated the code was for the average number of cc's per day of fluid the resident received via IV and/or tube feeding, either 500 cc/day or less, or 501 cc/day or more.

Based on medical record review, observation, and interview, the facility failed to ensure infection control practices were followed when medications were being administered. This affected one (Resident #29) out of five residents observed for medication administration. The facility also failed to ensure enhanced barrier precautions were implemented for Resident #13 and Resident #276. This affected two (Resident #13 and #276) out of three residents reviewed for infection control. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #29 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included congestive heart failure, asthma, type two diabetes, and depression. Observation of medication administration on 04/15/25 at 7:34 A.M. revealed Registered Nurse (RN) #232 used her bare fingers to extract Lyrica (a medication used to treat nerve and muscle pain) from the packaging and placed it into Resident #29's medication cup for administration. Resident #29 then consumed the contaminated medication. Interview on 04/15/25 at 7:37 A.M., RN #232 verified she used her bare fingers to remove the Lyrica medication from the packaging and placed it in Resident #29's medication cup for consumption. 47569 2. Review of the medical record for Resident #13 revealed an admitted [DATE] and a re-admitted [DATE] with diagnoses including, but not limited to, paranoid schizophrenia, type two diabetes, major depression, personality disorder, high blood pressure, and osteomyelitis of vertebra. Review of Resident #13's care plan dated 02/21/25 revealed Resident #13 has a percutaneous endoscopic gastrostomy (PEG) tube with interventions to provide local care to the gastrostomy (G) tube site as ordered and monitor for signs and symptoms of infection. Review of Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13. Resident #13 required moderate assistance from staff to complete activities of daily living (ADL) tasks including personal hygiene. Resident #13 was dependent on staff for transfers by a mechanical lift. Review of Resident #13's physician orders revealed an order dated 03/06/25 for Enhanced Barrier Precautions (EBP): gown and glove use required during high contact resident care activities every shift and an order dated 02/13/25 for 200 milliliters (ml) of water flush twice daily per PEG tube. Review of Resident #13's Treatment Administration Record (TAR) revealed the order for Enhanced Barrier Precautions (EBP): gown and glove use required during high contact resident care activities every shift, was marked as completed from 03/06/25 through 03/31/25 and from 04/01/25 to 04/16/25. Observation on 04/14/25 at 10:42 A.M. revealed Resident #13 sitting in the wheelchair watching television in her room. There was a PEG tube visible under the hem of her shirt. There was no personal protective equipment (PPE) cart outside the door, there was no notification sign for EBP, and there was no bin in the room for soiled linen. An interview on 04/15/25 at 1:40 P.M. with Unit Manager (UM) #208 confirmed Resident #13 did not have EBP's implemented even though there was a physician's order for EBP's to be in place. UM #208 further stated Resident #13 should have EBP's in place due to having the indwelling PEG tube. Review of the facility's policy titled Enhanced Barrier Precautions dated 02/19/25 revealed the facility had implemented Enhanced Barrier Precautions (EBP) to prevent the spread of multidrug resistant organisms (MDRO's). Enhanced Barrier Precautions (EBP) were indicated for residents with indwelling medical devices including, but not limited to, feeding tubes. 51514 3. Review of Resident #276's medical record revealed the resident was admitted to the facility on [DATE]. Medical diagnoses included metabolic encephalopathy, urinary tract infection (UTI, an infection that can involve kidneys, ureters, bladder, or urethra), Alzheimer's disease, altered mental status, neuromuscular dysfunction of bladder (when nerves that control the bladder aren't working properly), and cerebrovascular disease (conditions that impact blood flow to the brain). Review of Resident #276's physician orders revealed an order dated 04/13/25 for Enhanced Barrier Precautions (EBP) (an infection control measure using a gown and gloves during high contact care activities for residents at risk of infection due to wounds or an indwelling medical device such as a urinary catheter): gown and glove use required during high contact resident care activities every shift for EBP Protocol, orders dated 04/13/25 for left and right Achilles wound care, and orders dated 04/13/25 for a urinary catheter with additional related orders for catheter care every shift, change the drainage bag as needed, and irrigate with 60 milliliters (ml) of normal saline as needed twice daily to maintain patency. Observation on 04/15/25 at 1:02 P.M. of Resident #276's wound care with Registered Nurse (RN) #199 and Unit Manager (UM) #208 revealed no EBP signage on Resident #276's door or in the resident's room indicating Resident #276 was in Enhanced Barrier Precautions, and there was not an equipment cart outside of the room containing personal protective equipment for use. Before wound care was initiated, Resident #276's urinary drainage catheter was noted to be present and hung on the resident bed. When wound care was provided to the left and right Achilles areas, neither RN #199 or UM #208 were noted to be wearing gowns as required by the physician's order of Enhanced Barrier Precautions during high contact resident care activities. Interview on 04/15/25 at 1:19 P.M. with RN #199 and UM #208 confirmed that Resident #276 was on EBP due to having a urinary catheter and also confirmed that gowns were not worn during Resident #276's wound care. Review of the facility's policy titled Enhanced Barrier Precautions dated 02/19/25 revealed the facility had implemented Enhanced Barrier Precautions (EBP) to prevent the spread of multidrug resistant organisms (MDRO's). Enhanced Barrier Precautions (EBP) were indicated for residents with indwelling medical devices including, but not limited to, urinary catheters. The policy stated EBP was required for activities such as providing hygiene, bathing, and wound care.

Based on observation, record review and interview the facility failed to maintain a permanent operational and functional Heating, Ventilation and Air Conditioning (HVAC) system and failed to ensure necessary repairs to the existing system were addressed/completed timely to prevent potential interruption of heating/cooling services. This had the potential to affect all 79 residents who resided in the facility. Findings include: On 12/13/24 an onsite complaint survey was initiated due to complaints there was no working heating system in the facility/building. Review of the facility survey history revealed since May 2024 the facility HVAC system was not fully operational. Observations on 12/13/24 from 9:20 A.M. to 12:45 P.M. revealed the facility HVAC system was not fully operational and approximately 12 portable heat pump units were observed providing heat throughout the facility. Air temperatures throughout the facility were ranging from 74 degrees Fahrenheit (F) to 78 degrees F. Interview with the Director of Nursing on 12/13/24 at 9:30 A.M. reveled the facility used a water type HVAC system with a water chilling tower on the roof. The facility had two busted water pipes in May of 2024 and had been using the portable heating and cooling units since then to provide heat and cooling. During the onsite investigation, the facility provided a timeline and estimates for repairs for the system. This included the following: In May 2024 there was an initial failure of the circulating pump for the water tower. This caused the several of the fittings on pipes that circulate water to the heat pumps to fail which in turn caused major flooding in one hallway of the building. The day after this occurred the facility brought in temporary HVAC units in order to maintain the appropriate temperature within the building. In June 2024 following the repairs made to the initial area of concern the system was brought back online and tested . It was then discovered that there was a larger issue as a separate part of the building had a previously undiscovered failure. The system had to be taken back offline. In July 2024 the facility received quotes for the necessary repairs needed for the HVAC system. The quote, dated 07/19/24 revealed a total of 26 new multi-head ductless mini split systems units were recommended to be installed. However, the facility did not approve the quote until 10/2024 and repair work did not begin until 11/2024. As of 12/13/24 the HVAC systems repairs had not been completed and the facility remained dependent on temporary portable heating units to maintain heating/cooling in the facility. On 12/13/24 at 12:30 P.M. interview with the Director of Nursing (DON) verified the HVAC system had not been completely installed as of this time with initial issues/concerns first occurring in May 2024. No additional information was provided as to why there was a delay in the necessary repairs or evidence the facility had a fully operational permanent HVAC system at the time of the onsite investigation. On 12/19/2024 at 10:26 A.M., interview with the Director of Maintenance revealed that he was new to the position starting sometime around the first week of November 2024 and had no knowledge pertaining to time lines. This deficiency represents non-compliance investigated under Complaint Number OH00160647 and Complaint Number OH00159348.

Based on record review, Physician Communication Book review, and interview, the facility failed to ensure physician services responded to facility requests for resident care 24 hours a day. This affected one resident (#78) of three residents reviewed with the potential to affect all 83 residents in the facility. Findings include: Review of Resident #78's medical record revealed a 07/19/19 admission with diagnoses including Alzheimer's disease, chronic atrial fibrillation, combined systolic and diastolic congestive heart failure, sick sinus syndrome, hyperlipidemia, major depressive disorder, osteoporosis, history of urinary tract infections, bulbous pemphigoid, low back pain, repeated falls, dementia, atherosclerosis of coronary artery bypass grafts, cardiomegaly, personal history of transient ischemic attack and cerebral infarction without residual affects, unsteadiness on feet, dependence on wheelchair, protein calorie malnutrition, gastroesophageal reflux disease, and anxiety disorder. The resident resided on the secured memory care unit, Homestead. The 10/07/24 Five Day Medicare Minimum Data Set (MDS) Assessment included the resident was severely impaired for daily decision making, was dependent on staff for oral hygiene, toileting, bathing, rolling side to side, sitting to standing, sitting to lying and lying to sitting. Review of the progress notes dated 09/29/24 at 7:28 A.M. revealed a Late Entry that on 09/28/24 at 10:30 A.M. Staff informed this nurse that the resident had bleeding from her left leg. This nurse assessed wound to left knee. V-shaped laceration noted. Measures six (6) centimeters (cm) x 1 cm x .02 cm on one side and 8 cm x 1 cm x 0.5 cm on the other. On call notified. On call Certified Nurse Practitioner (CNP) paged. No return call. Steri strips & dressing applied. Patient resting in bed comfortably showing no signs or symptoms of distress. There was no evidence the on call nurse practitioner returned the call. Review of the medical record revealed there was no evidence of the facility received a return call on Saturday 09/28/24 or Sunday 09/29/24 from the on call nurse practitioner and physician related to the care needs of Resident #78. Review of the medical record revealed on 09/29/24 between 3:00 A.M. and 3:30 A.M. the nurse placed a call to the on call nurse practitioner without a return call. After consult with the on call facility manager, Resident #78 was sent to the emergency room without a physician order related to the appearance of her left knee laceration. The resident was admitted to the hospital 09/29/24 with diagnoses including acute metabolic encephalopathy likely secondary to UTI (culture result negative), acute kidney disease and mild hypernatremia. Interview on 10/21/24 at 4:44 P.M. with the Administrator and the Director of Nursing revealed they had an issue earlier in the year with the responsiveness of the physician services after hours. It was part of their June 2024 Quality Assurance and Performance Improvement program. They thought they came up with a way to fix the issue but it apparently was not working. They had tried a third party provider to answer calls and changed providers. Their medical director owns the Pinnacle system and employs the physician and nurse practitioners. They have a nurse practitioner who comes to the facility Monday through Friday except holidays. Interview on 10/21/24 at 5:04 P.M. with Resident #78's representative/emergency contact revealed he was not called about his mother's knee being lacerated until after three (3) in the morning when they sent her to the emergency room . He was then surprised to see the extent of the injury. He indicated since 20 hours had passed since the laceration the wound was old and there was not enough skin left to place stitches. Interview on 10/21/24 at 5:50 P.M. with Registered Nurse (RN) #90 revealed she was the nurse who assessed Resident #78 on 09/28/24. She verified she called the on call number for the physician and did not get a call back. She included she did not place a second call on her 12 hour shift because she was busy. She verified she placed steri strips on the laceration and a dry dressing without an order. She included there was not enough skin to cover the adipose tissue and the steri strips were on the adipose tissue. RN #90 included there are times she doesn't get a return call from the on call nurse practitioner. Once the on-call nurse practitioner was out of the area and did not call back until later. There have been other times when she has not received a return call from the nurse practitioner. The nurse revealed she did not have a direct number to call the nurse practitioner. She had to call the answering service. She does not have a phone number for the physician or the Medical Director. Interview on 10/21/24 at 6:02 P.M. with the Administrator and the Director of Nursing (DON) revealed all the residents have the same physician. The Administrator and the DON verified the nursing staff do not have access to the resident's physician, the facility's Medical Director's or on call staff's phone numbers. The Administrator verified he called the Medical Director to inform him of the lack of response of on call staff. Review of the facility Communication Book with instructions revealed that to put orders to be signed, pharmacy recommendations into a notebook. There was a telephone number provided for the nurse practitioner assigned to the facility and an email provided for the Primary Care Coordinator, a Registered Nurse. Residents and families were to call the office with questions and were not to be given the phone number of the Pinnacle Staff Members. Their nurse practitioner was to be called between 3:00 and 4:00 P.M. with all issues in a batch call and as needed for emergent issues only from 6:00 A.M. till 8:00 P.M. Monday through Friday and Saturday/Sundays and Holidays call office answering service for the on-call nurse practitioner. Do not call or fax the office unless directed to do so. This deficiency represents non-compliance investigated under Complaint Number OH00158594.

Based on record review, policy review, and interview, the facility failed to ensure residents representatives were informed of changes in condition including new skin impairments. This affected two residents (#11 and #78) of three residents reviewed. Findings include; 1. Review of Resident #78's medical record revealed a 07/19/19 admission with diagnoses including Alzheimer's disease, chronic atrial fibrillation, combined systolic and diastolic congestive heart failure, sick sinus syndrome, hyperlipidemia, major depressive disorder, osteoporosis, history of urinary tract infections, bulbous pemphigoid, low back pain, repeated falls, dementia, atherosclerosis of coronary artery bypass grafts, cardiomegaly, personal history of transient ischemic attack and cerebral infarction without residual affects, unsteadiness on feet, dependence on wheelchair, protein calorie malnutrition, gastroesophageal reflux disease, and anxiety disorder. The resident resided on the secured memory care unit, Homestead. The 10/07/24 Five Day Medicare Minimum Data Set (MDS) Assessment included the resident was severely impaired for daily decision making, was dependent on staff for oral hygiene, toileting, bathing, rolling side to side, sitting to standing, sitting to lying and lying to sitting. Review of the progress notes dated 09/29/24 at 7:28 A.M. revealed a Late Entry that on 09/28/24 at 10:30 A.M. Staff informed this nurse that the resident had bleeding from her left leg. This nurse assessed wound to left knee. V-shaped laceration noted. Measures six (6) centimeters (cm) x 1 cm x .02 cm on one side and 8 cm x 1 cm x 0.5 cm on the other. On call notified. On call Certified Nurse Practitioner (CNP) paged. No return call. Steri strips & dressing applied. Patient resting in bed comfortably showing no signs or symptoms of distress. There was no evidence the resident' representative was notified of the injury. Interview on 10/21/24 at 5:04 P.M. with Resident #78's emergency contact/representative revealed he was not called about his mother's knee being lacerated until after three (3) in the morning (on 09/29/24) when they sent her to the emergency room . He was then surprised to see the extent of the injury. Interview on 10/21/24 at 5:50 P.M. with Registered Nurse #90 revealed she was the nurse who assessed Resident #78 on 09/28/24. She verified she did not notify the family of the laceration. She included a son usually comes in on Saturdays and she was going to tell him then but he did not come in. Review of the facility's policy, Accident and Incidence Investigating and Reporting policy (revised April 2013) revealed all accidents or incident involving residents, employees, visitors, vendors, etc. occurring on our premises shall be investigated and reported to the administrator. The incident report is to include the date time the injured person's family was notified and by whom. 2. Review of Resident #11's medical record revealed an 11/11/21 admission with diagnoses including Alzheimer's disease, atherosclerotic heart disease, nonrheumatic aortic stenosis, paroxysmal atrial fibrillation, chronic diastolic congestive heart failure, nonexudative age related macular degeneration, benign prostatic hyperplasia, major depressive disorder, mixed hyperlipidemia, chronic kidney disease Stage 3, hypertension, dementia, anxiety disorder, insomnia, senile degeneration of brain, abnormalities of gait and mobility, repeated falls, restlessness and agitation, osteoarthritis, presence of a cardiac pacemaker, and long term use of anticoagulants. Review of a 10/06/24 Significant Change MDS included the resident was severely impaired for daily decision-making. He had no functional limitations upper or lower extremities. He utilized the wheelchair. He was independent for eating, dependent on oral care, toileting, showering, dressing, putting on and taking off footwear and dependent on personal hygiene. He was partial to moderate assist for rolling from side to side, sitting to lying, substantial maximum assist lying to sitting on side of bed, and sitting to standing. Review of the progress notes included a note dated 10/20/24 at 6:54 A.M. incident note that revealed State tested Nurse Aides (STNAs) were assisting the resident into a wheelchair and during the course of transferring/positioning the resident, he obtained two 4 cm x 0.1 cm skin tears above his right elbow. The area was cleansed with normal saline, skin well approximated, adaptic and foam dressing applied. Hospice notified and request to remove broda chair for resident safety. There was no evidence of Resident #11's son, resident representative/ emergency contact being notified. Interview on 10/21/24 at 6:27 P.M. with Resident #11's responsible party, his son, revealed he did not receive a call that his father was injured. He included he received a call that they were calling hospice in to look at him. He was not told about the skin tears. Interview on 10/22/24 at 9:48 A.M. with the Administrator and the Director of Nursing revealed they spoke to the nurse and verified the family was not notified of the skin tear. This deficiency represents non-compliance investigated under Complaint Number OH00158594.

Based on record review, review of the facility standing orders, and interview, the facility failed to provide appropriate treatment of a skin laceration. This affected one resident (#78) of three residents reviewed. The census was 83. Findings include: Review of Resident #78's medical record revealed a 07/19/19 admission with diagnoses including Alzheimer's disease, chronic atrial fibrillation, combined systolic and diastolic congestive heart failure, sick sinus syndrome, hyperlipidemia, major depressive disorder, osteoporosis, history of urinary tract infections, bulbous pemphigoid, low back pain, repeated falls, dementia, atherosclerosis of coronary artery bypass grafts, cardiomegaly, personal history of transient ischemic attack and cerebral infarction without residual affects, unsteadiness on feet, dependence on wheelchair, protein calorie malnutrition, gastroesophageal reflux disease, and anxiety disorder. The resident resided on the secured memory care unit, Homestead. The 10/07/24 Five Day Medicare Minimum Data Set (MDS) Assessment included the resident was severely impaired for daily decision making, was dependent on staff for oral hygiene, toileting, bathing, rolling side to side, sitting to standing, sitting to lying and lying to sitting. Review of the progress notes dated 09/29/24 at 7:28 A.M. revealed a Late Entry that on 09/28/24 at 10:30 A.M. Staff informed this nurse that the resident had bleeding from her left leg. This nurse assessed wound to left knee. V-shaped laceration noted. Measures six (6) centimeters (cm) x 1 cm x .02 cm on one side and 8 cm x 1 cm x 0.5 cm on the other. On call notified. On call Certified Nurse Practitioner (CNP) paged. No return call. Steri strips & dressing applied. Patient resting in bed comfortably showing no signs or symptoms of distress. Review of the undated Pinnacle Standing Wound Orders revealed there were no standing orders for a laceration. There was no evidence of the on call nurse practitioner returned the call from the facility. Review of the physician orders revealed there was not a physician order to apply steri strips and a dressing. There was not a physician order for any treatment to the left knee laceration. Review of the treatment administration record (TAR) revealed there was not a treatment signed for the application of steri strips and a dressing to Resident #78's laceration. Review of the medical record revealed on 09/29/24 between 3:00 A.M. and 3:30 A.M. the nurse placed a call to the on call nurse practitioner without a return call. After consult with the on call facility manager, Resident #78 was sent to the emergency room without a physician order related to the appearance of her left knee laceration. The resident was admitted to the hospital 09/29/24 with diagnoses including acute metabolic encephalopathy likely secondary to UTI (culture result negative), acute kidney disease and mild hypernatremia. The resident received a dose of Rocephin, an antibiotic. The resident was discharged back to the facility on [DATE]. Review of the facility's Transfer Form revealed it was completed 09/29/24 at 1:20 P.M. by Registered Nurse (RN) #90. The Transfer Form included Resident #78 was transferred on 09/29/24 at 1:19 P.M. when the progress notes revealed the resident was transferred on 09/29/24 at 3:29 A.M. when RN #90 was not on duty. Review of Resident #78's medical record revealed there was a 10/02/24 order for wound care to left lower leg cleanse with wound wash, pat dry with a 4 x 4 then place a dime thick layer of Bactroban onto wound bed, cover with sterile gauze and wrap with Kerlix two times a day for wound care until healed. Review of the October 2024 TAR revealed the dressing change to the left knee for 10/02/24 at 9:00 P.M. was not signed off as completed. There was no evidence the treatment was competed as ordered on 10/02/24 at 9:00 P.M. Review of the medical record revealed on 10/02/24 there was a physician order for Doxycycline Hyclate (antibiotic) 100 milligrams one tablet twice a day for cellulitis (area not specified). Interview on 10/21/24 at 2:24 P.M. with State tested Nurse Aide (STNA) #94 revealed she was the aide that noticed Resident #78's knee laceration. She said she had cleaned her up and dressed her for breakfast. She wheeled her to the dining room and put her at the head of a table. She brought a resident in a tilt in space wheelchair and put him at the table at a 90 degree angle to Resident #78. She lowered his wheelchair to the sitting flat position and must have hit the resident's (#78) knee under the table while doing that. Resident #78 did not make any sound to alert her anything had happened. After Resident #78 ate her breakfast, she wheeled her to the lounge and saw blood on the resident's pants. She then alerted the nurse. Interview on 10/21/24 at 5:04 P.M. with Resident #78's representative/emergency contact revealed he was not called about his mother's knee being lacerated until after three (3) in the morning (on 09/29/24) when they sent her to the emergency room . He was then surprised to see the extent of the injury. He indicated since 20 hours had passed since the laceration they were unable to place stitches. Interview on 10/21/24 at 5:50 P.M. with Registered Nurse (RN) #90 revealed she was the nurse who assessed Resident #78 on 09/28/24. She verified she called the on call number for the physician and did not get a call back. She included she did not place a second call on her 12 hour shift because she was busy. She verified she placed steri- strips on the laceration and a dry dressing without an order. She included there was not enough skin to cover the adipose tissue and the steri strips were on the adipose tissue. She verified she did not put a progress note in the electronic documentation until the next day because she was busy. She did fill out an incident report but did not get statements from the other staff on duty. She verified she did not notify the family of the laceration. RN #90 had no explanation as to why she filled out the hospital transfer sheet on dayshift at 1:20 P.M. (09/29/24) when the resident was transferred at 3:30 A.M. Interview on 10/21/24 at 6:08 P.M. with the Director of Nursing (DON) verified the 10/02/24 at 9:00 P.M. wound dressing was not documented as completed. This deficiency represents non-compliance investigated under Complaint Number OH00158594.

Based on observation, record review, policy review, and interview, the facility failed to ensure infection control practices were maintained during a wound dressing change. This affected one resident (#78) of two residents observed for wound care. The census was 83. Findings include: Review of Resident #78's medical record revealed a 07/19/19 admission with diagnoses including Alzheimer's disease, chronic atrial fibrillation, combined systolic and diastolic congestive heart failure, sick sinus syndrome, hyperlipidemia, major depressive disorder, osteoporosis, history of urinary tract infections, bulbous pemphigoid, low back pain, repeated falls, dementia, atherosclerosis of coronary artery bypass grafts, cardiomegaly, personal history of transient ischemic attack and cerebral infarction without residual affects, unsteadiness on feet, dependence on wheelchair, protein calorie malnutrition, gastroesophageal reflux disease, and anxiety disorder. The resident resided on the secured memory care unit, Homestead. The 10/07/24 Five Day Medicare Minimum Data Set (MDS) Assessment included the resident was severely impaired for daily decision making, was dependent on staff for oral hygiene, toileting, bathing, rolling side to side, sitting to standing, sitting to lying and lying to sitting. Review of the progress notes dated 09/29/24 at 7:28 A.M. revealed a Late Entry that on 09/28/24 at 10:30 A.M. Staff informed this nurse that the resident had bleeding from her left leg. This nurse assessed wound to left knee. V-shaped laceration noted. Measures six (6) centimeters (cm) x 1 cm x .02 cm on one side and 8 cm x 1 cm x 0.5 cm on the other. Review of the medical record revealed a physician order dated 10/02/24 for Doxycycline Hyclate (antibiotic) 100 milligrams one tablet twice a day for cellulitis (no area specified). Review of the medical record revealed a physician order dated 10/08/24 to cleanse left knee with house wound wash, apply xeroform, dry dressing daily and as needed for laceration. Review of the medical record revealed the last assessment dated [DATE] included the left knee laceration had minimal drainage, no signs of infection, 100 percent granulation with light exudate serosanguineous drainage measuring 2.8 centimeters (cm) length, x 4.2 cm width and 0.3 cm depth. Observation on 10/21/24 at 2:03 P.M. of the dressing change to the left knee laceration revealed Registered Nurse (RN) #93 washed her hands, gowned and gloved. She elevated the height of the resident's bed and explained to the resident what she was doing. RN #93 dated the dressing and said she never saw the wound previously. RN #93 removed the old dressing dated 10/20/24. There was some serosanguineous drainage on the dressing. RN #93 did not remove her soiled gloves. She sprayed the wound with wound cleanser and dabbed the wound with a 4 x 4 gauze. She removed her gloves/washed hands and re-gloved. She folded up a xeroform and placed it over the wound. There was no drainage noted post cleansing. RN #93 removed her gloves and washed her hands, re-gloved and put a foam dressing over the laceration. Interview on 10/21/24 at 2:26 P.M. with RN #93 verified she did not remove her gloves and wash her hands after removing the soiled dressing. She verified she cleansed the wound with the gloves she had on when she removed the soiled dressing. Review of the facility's Dressing Change policy (reviewed June 2016) included remove soil dressing, discard soil dressing in an appropriate receptacle and discard gloves. Wash hands, open dressing and spread the exterior wrap touching the exterior surface. Put on gloves This deficiency represents non-compliance investigated under Complaint Number OH00158594.

Based on closed medical record review, review of hospital records, review of an ambulance run report, facility policy review, interviews with staff, and family, the facility failed to adequately monitor and provide necessary and timely services to prevent post-operative complications for Resident #81 who was admitted for care status post closed reduction (setting a broken bone without cutting the skin) external fixation (pins and other devices sticking out of the ankle hold together the broken pieces of bones within the ankle while the bones heal) of a right tibial [NAME] fracture (a type of break that occurs at the bottom of the tibia (shinbone) and involves the weight-bearing surface of the ankle joint). This resulted in Immediate Jeopardy and the potential for serious life-threatening harm on 04/16/23 when Resident #81, who received the anticoagulant medication Eliquis and antiplatelet medication Plavix concurrently despite an identified, severe drug interaction (increased risk of bleeding) between the two medications that was not addressed with the prescriber or pharmacy, was provided post-surgical wound care on 04/17/23 and 04/18/23 without orders from the surgeon, potentially compromising the integrity of the surgical site. The resident was subsequently transferred to the emergency roiagnom on [DATE] due to uncontrolled, excessive bleeding from the (surgical) pin sites, hypotension with a blood pressure of 94/47 with symptoms including feeling lightheaded and having cold and clammy skin. The resident required multiple blood transfusions and did not return to the facility upon discharge from the hospital. This affected one resident (#81) of three residents reviewed for wounds. The facility census was 80. On 05/03/23 at 5:03 P.M., the Director of Nursing (DON) and Administrator were notified Immediate Jeopardy began on 04/16/23, when the facility failed to timely identify a change in the resident's condition, failed to ensure timely communication with the surgeon and notification of wound concerns, and failed to timely monitor and identify potential medication interactions resulting in excessive bleeding and abnormal laboratory results requiring hospital intervention. The Immediate Jeopardy was removed on 05/04/23 when the facility implemented the following corrective actions: On 04/19/23 at 2:00 A.M. Resident #81's surgical wound was noted to be bleeding excessively. The resident's nurse, Registered Nurse (RN) #183, contacted the nurse practitioner, (NP) #504, and Resident #81 was sent to the emergency room for evaluation. On 05/03/23, at 5:30 P.M. the DON reviewed the medical records for 45 residents, Resident #1, #2, #5, #9, #10, #11, #15, #16, #20, #21, #24, #29, #33, #35, #36, #38, #39, #40, #41, #43, #44, #45, #47, #48, #49, #51, #53, #57, #59, #60, #62, #64, #65, #66, #72, #73, #74, #76, #77, #78, #79, #80, #83, #84, and #85 who were ordered blood thinning medications, including Plavix and/or Eliquis, to ensure that care plans were in place for blood thinners and any possible drug interactions were clarified with the physician. None were noted. On 05/03/23 at 5:10 P.M., the Administrator, DON, and Medical Director had an Ad Hoc Quality Assurance Performance Improvement meeting to discuss the Immediate Jeopardy (IJ) form and the action plan. The Administrator spoke with Pharmacist #508 separately to discuss the IJ form and potential medication interactions. On 05/03/23, at approximately 6:30 P.M. the DON reviewed the medical records for all 81 residents in the facility, over a seven-day lookback period, for evidence of unreported change in condition requiring physician intervention and none were noted. On 05/04/23, at approximately 8:00 A.M. the DON drafted and began educating all licensed nursing staff via one or more of the following formats: text, email, phone calls, in-person, and Relias. The education included the topics: facility policy and procedure for monitoring change in condition and reporting the same to the physician; timely treatment for identified change in condition and procedure for identifying medication interactions and clarifying relevant medication orders with the physician when interactions are identified; and expectations for surgical wound care and need to notify physician and/or surgeon with any abnormal wound findings. As of 05/04/23, all seven Licensed Practical Nurses and 18 Registered Nurses were educated. Additionally, Wound Nurse Practitioner #502 and Nurse Practitioner #503 were educated. On 05/04/23 at 2:55 P.M., the DON made a change to the Medication Administration Record (MAR) to have nurses document any changes in condition, abnormal wound findings, and any potential medication interactions before the end of their shift. On 05/08/23, the DON and designees implemented a plan for random audits and monitoring of three residents daily/five days a week to ensure medication interactions were identified by the nurse and reported to the physician for clarification, as indicated; resident changes in condition are reported timely to the physician; and surgical wounds are being monitored appropriately and the physician is notified timely of any changes to the wound. These audits will be done until receipt of the 2567, at which time the facility will re-evaluate the audit scope and frequency. Staff responsible for completing the audits will be the DON, RN #164, #193, #224, LPN #213, STNA #107, and (Physical Therapy Assistant) PTA #178. Although the Immediate Jeopardy was removed on 05/04/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of Resident #81's closed electronic medical record revealed an admitted [DATE] with diagnoses including closed reduction and external fixation of right tibial [NAME] fracture, iron deficiency anemia, hypertension, and ischemic cardiomyopathy (oxygen-rich blood is prevented from entering the heart and the heart muscle becomes enlarged, dilated, and weak). Review of Resident #81's hospital discharge orders (prior to his admission to the facility) dated 04/16/23 revealed to keep the external fixators (surgical wound site) clean and dry. (Apply) ice, elevate (the right lower extremity), and non-weight bearing to the right lower extremity. The hospital discharge orders indicated to call the doctor if you have persistent or heavy bleeding, redness, swelling, or pus or drainage from the wound. (Surgeon #503 was listed as the primary physician for Resident #81's case). The hospital discharge orders also noted to continue Eliquis (anticoagulant medication) five milligrams (mg) twice daily (the resident was taking this medication prior to his hospitalization ) and Plavix (antiplatelet medication) 75 mg daily. Review of Resident #81's facility admission orders, dated 04/16/23, revealed no evidence of a treatment/dressing change order to the external fixator (surgical) site of the right tibial [NAME] fracture. The resident's admission medication orders included Eliquis 5 mg twice daily in the A.M. and P.M. and Plavix 75 mg daily in the A.M. As part of the facility ' s admission protocol, the resident was ordered to have a complete blood count (CBC), basic metabolic panel (BMP) and Vitamin D level obtained on 04/17/23. Review of Resident #81's order note, dated 04/16/23 at 2:10 P.M. and authored by Registered Nurse (RN) #226, revealed there was a severe drug to drug interaction of increased bleeding when Plavix and Eliquis are administered together. Further review of the progress notes revealed no evidence the drug-to-drug interactions were reported to the resident ' s primary care provider, surgeon and/or discussed with pharmacy. No changes or new orders were noted following the order note. In addition, there was no evidence the facility implemented a plan to timely identify or monitor for increased bleeding. Review of Resident #81's admission note, dated 04/16/23 at 3:00 P.M. and authored by RN #212, revealed the resident had a surgical dressing intact and external fixator in place to the right lower leg. Old drainage was noted around the pins. This was the only information provided regarding the surgical wound in this progress note. Review of Resident #81's admission skin assessment (part of the electronic health record) and paper admission skin assessment, dated 04/16/23 and authored by RN #212, revealed the resident had a right leg fixator and dressing intact with old drainage noted around pins. There was no other documentation or description of the area noted. Review of Resident #81's nurse's note, dated 04/16/23 at 7:54 P.M. and authored by RN #212, revealed the Certified Nurse Practitioner (CNP) (name not provided) was updated of the resident's admission and medication were reviewed. There were no additional notes related to a possible drug interaction or increased bleeding from the concurrent administration of Eliquis and Plavix noted at this time. Review of Resident #81's brief interview for mental status (BIMS) evaluation dated 04/17/23 revealed the resident's BIMS score was 15 (out of 15), reflecting the resident's cognition was intact. Review of Resident #81's laboratory results, dated 04/17/23, revealed the resident's laboratory testing, CBC, BMP, and Vitamin D levels were collected at 8:48 A.M. on 04/17/23 and the results were faxed to the facility on [DATE] at 4:20 P.M. The resident hemoglobin results were 8.5 grams per deciliter (g/dL) (normal range of 14-18 g/dL). On 04/17/23 at 1:38 P.M. a progress note, entered by Licensed Practical Nurse (LPN) #120, revealed the LPN documented she called the surgeon's office to report bleeding from the pin site on the right ankle. The LPN entered another skilled note, dated 04/17/23 at 2:10 P.M. which indicated the resident had developed a new area of edema to the right toes. There was no evidence an assessment was completed of the areas or surgical wound at this time. Review of Resident #81's progress note, dated 04/17/23 at 3:35 P.M. and authored by RN #140, revealed the resident's (surgical) dressing was changed due to wet dressing to heel, serosanguineous (clear yellowish fluid with some blood). Resident tolerated dressing change well. No redness to pin site or odor observed. The yellow pin site lateral has a small amount of dried blood. The leg was iced and elevated on a pillow. There was a 0.3 (centimeter) by 0.3 (centimeter) scabbed area noted on the bottom of the heel. Resident reported the area was old. Review of Resident #81's progress note, dated 04/17/23 at 4:23 P.M. and authored by RN #140, revealed the resident would follow up with the physician to monitor pin sites on Thursday (04/20/23). Updated on dressing change due to the dressing was saturated at the heel. There was no documentation of who was updated on the dressing change or a description of what saturated the dressing. Review of Resident #81's paper shower sheet, dated 04/17/23 and completed by State tested Nursing Assistant (STNA) #219 (no time indicated), revealed Resident #81's right lower extremity was wrapped in kerlix, heel saturated. Notified nurse of dressing. There was no documentation describing what saturated the dressing. Review of Resident #81's telephone orders revealed on 04/17/23 RN #140 wrote a telephone order from Surgeon #501, which was not signed by Surgeon #501 or any of the resident's healthcare providers, okay for dressing change to right lower extremity (RLE) done by this nurse. No further orders. Okay to continue antibiotic and surgeon to monitor pin sites at follow up appointment. Review of Resident #81's progress note, dated 04/17/23 and authored by Nurse Practitioner (NP) #504, revealed nursing (not identified) reported there was some bleeding noted to the resident's surgical dressing after he (the resident) reported he bumped it (the right lower extremity) on the bed throughout the night several times and an episode when staff had rolled him., (No clarifying information was provided regarding the episode). Blood was noted to the dressing on the right lower extremity. The plan was to follow up with surgical team to check the bleeding as well as perhaps need an x-ray to assess continued stability of this moving forward. The note indicated the resident was on Eliquis for deep vein thrombosis prophylaxis at this point of time. No changes were made to the resident's medication regimen at that time. In addition, there was no evidence the surgical site was assessed by the CNP or the resident's surgeon was consulted. Review of Resident #81's progress note, dated 04/18/23 at 12:46 A.M. and authored by RN #180, revealed dressings were clean, dry, and intact. There was no description or location of the dressings. Review of Resident #81's skin note, dated 04/18/23 at 11:23 A.M. and authored by LPN #213, revealed the resident was seen by the wound team today. External fixator to the right lower extremity was present on admission. The skin note indicated to cleanse each pin site with Dakin's (a solution of sodium hypochlorite (diluted bleach) and other stabilizing ingredients, traditionally used as an antiseptic to prevent infection) quarter strength using a different Q-tip for each pin. Apply Xeroform (a yellow non-adherent dressing for wounds without much drainage that promotes a moist wound environment) around each site, cover with dry dressing and wrap with Kerlix (gauze) daily and as needed. Review of a handwritten verbal order, dated 04/18/23, authored by LPN #213 and given by Wound NP #502, revealed to cleanse the right lower extremity pin sites with Dakin's 0.25% solution, use a different Q-tip to cleanse each pin site. Apply Xerofoam around the pin sites cover with dry dressing and wrap with Kerlix daily and as needed. Review of Resident #81's paper wound note, dated 04/18/23 and authored by Wound NP #502 revealed the resident had a right lower extremity external fixator that was present on admission. There were seven pin sites, small bloody, no erythema (redness). Previous treatment Dakin's half (1/2) strength to pin sites daily. New orders were cleansing each pin site with Dakin's 0.5% solution, use different Q-tip to cleanse each site, apply Xeroform around pin sites, cover with dry dressing, wrap with kerlix, change daily and as needed. Review of Resident #81's treatment administration records (TAR), dated 04/2023, revealed an order was written on 04/18/23 to use Dakin's half strength solution to external fixation- apply sufficient amount externally every day to ulcer. The treatment was administered on 04/18/23, then the order was clarified on 04/18/23 to cleansing each pin site with Dakin's 0.5% solution, use different q-tip to cleanse each site, apply Xeroform around pin sites, cover with dry dressing, wrap with kerlix, change daily and as needed. Review of Resident #81's skilled note, dated 04/18/23 at 12:35 P.M. and authored by LPN #510, revealed the resident's right toes were edematous and surgical wound to right lower leg needed reviewed. Review of Resident #81's progress note, dated 04/18/23 and authored by NP #504, revealed the resident reported yesterday an episode where he had been rolled over by nursing staff during changes and he had bumped his leg which resulted in bleeding. The note indicated the surgeon's office was notified of bleeding from the pin sites with no new orders as the patient would be seen in the office on Thursday (04/20/23). Patient on Eliquis with no abnormal bruises. The right lower extremity was wrapped with gauze, dried blood noted on gauze, however wound team canged the dressing, and some bleeding was seen. The resident's hemoglobin was 8.5. Continue to monitor closely. There was no documentation of who notified or when the surgeon's office was notified. Review of Resident #81's progress note, dated 04/19/23 at 2:05 A.M. and authored by RN #183, revealed the resident was sent to the emergency room due to excessive bleeding from the pin sites. The resident was hypotensive with a blood pressure of 94/47, pulse 68. Resident #81 was assessed to be lightheaded, cold, and clammy. The (unidentified) on call CNP was updated with orders to send to the emergency department for evaluation. Review of the Ambulance Run Report, dated 04/19/23, revealed the ambulance company was called on 04/19/23 at 1:52 A.M. and arrived at 1:52 A.M. The report contained the following information: Upon arrival a [AGE] year-old man was found in semi-fowlers position (on his back with the head of the bed elevated 30-45 degrees). The resident presented with bleeding. Initial impression post-operative procedure complication. The male was bleeding from post operation surgery site that was cleaned at approximately 9:00 A.M. and had been bleeding slowly and steadily (since that time). The nursing home changed the dressing twice and it was full of blood prior to Emergency Medical Service (EMS) arrival. EMS were informed the resident had surgery four days prior. The bleeding was not completely controlled, there was clotting of blood on outside of dressing. Placed two abdominal pad bandages (larger and thicker than gauze and used for heavily draining wounds) to medial side of lower leg. Local hospital advised to take patient to general hospital due to surgery was performed there. Bleeding had slowed down but not controlled during transport. Arrived at the emergency room at 3:13 A.M. Review of a physician communication note entered on 04/19/23 at 4:49 A.M., (after the resident had been discharged ) as a late entry for 04/18/23 at 6:42 P.M. and authored by the DON, revealed Resident #81's was bleeding from pin sites of his fixator. The lower right foot. New dressing applied and resident was currently on blood thinner. Nurse Practitioner #504 ordered to reinforce the dressing and ordered a complete blood count (CBC) and basic metabolic profile (BMP) in the morning (04/19/23). Review of Resident #81's transfer to hospital summary note, dated 04/19/23 at 10:39 A.M. and authored by RN #228, revealed the resident was admitted to the hospital with post operative hemoglobin drop. Review of Resident #81's hospital emergency room notes, dated 04/19/23 revealed Resident #81's chief complaint was bleeding. The resident was on Eliquis and Plavix and presented with acute blood loss. His hemoglobin was 7.1 then 5.9 (normal 14-18 for males) on 04/19/23 and two units of packed red blood cells (PRBC) were ordered. The resident was hypotensive in the 90's (systolic blood pressure) but after receiving blood products, intravenous fluids (IVF), and controlled bleeding, his blood pressure (BP) stabilized. The resident stated his leg started bleeding at the facility yesterday morning and the staff were changing the dressings. He woke up overnight in a pool of blood and came to the emergency room . The resident leg was bleeding heavily, saturating chux pads (large, disposable waterproof pads generally used for urinary incontinence) underneath as well as his bandages and (the blood) dripped to floor. Dressings and soaked chux pad taken off and pad replaced. The source of bleeding was found, and pressure applied Orthopedics notified and would be down to assess. The resident was admitted to the hospital for further evaluation and treatment for right lower extremity bleeding from recent surgical site, acute blood loss anemia, hypotension, and leukocytosis (high white blood cell count). On 04/28/23 at 12:00 P.M. an interview with Medical Secretary (MS) #503 from Surgeon #501's office revealed the surgeon's orders were usually to keep the (surgical) dressing dry, clean, and intact until the first appointment. MS #503 reported she had no documented evidence the facility had called on 04/17/23 or 04/18/23 regarding Resident #81. MS #503 reported she would have documented a call if it was received. On 04/28/23 at 2:00 P.M., interview with Registered Nurse (RN) #140 revealed she spoke to the surgeon's nurse via phone on 04/17/23 and relayed that she had changed the resident's dressing earlier as it had been saturated down to the heel. The surgeon's nurse did not give any new dressing orders. RN #140 revealed she had replaced the dressing with the same dressing she had taken off (Petroleum gauze, abdominal pad, and wrapped with Kerlix). RN #140 verified she did not have an order for the dressing changes and did not document the supplies she used to change the dressing. RN #140 revealed the yellow (surgical) pin had old blood noted on it. In addition, there was a scabbed area on the right heel that was not observed on admission because it had been covered with a dressing. When asked to clarify what saturated down to the heel meant and what was saturating the dressing, RN #140 indicated she was unable to recall due to her lack of documentation and the time that had elapsed since the date in question. On 04/28/23 at 11:09 A.M., interview with Licensed Practical Nurse (LPN) #213, who rounded with the Wound NP #502 on 04/18/23 revealed she believed Wound Nurse Practitioner (WNP) #502 must have thought the resident was previously receiving Dakin's solution wound care to the surgical incision and continued the order adding to use a different Q-tip with each pin site. LPN #213 verified the Dakin's order was to be to the right heel and not the resident's surgical site. On 05/02/23 at 11:05 A.M., interview with the Director of Nursing (DON) verified there were no orders from the surgeon for routine care of the surgical wound to the right lower extremity until 04/18/23, after RN #140 had already provided wound care to the resident. On 05/02/23 at 11:23 A.M., during a telephone interview with Resident #81's wife, the wife voiced concerns regarding the care provided by the facility to her husband. The wife stated the facility had no business removing the surgical dressing. The wife stated the dressing was to remain intact until the resident followed-up with the surgeon on 04/20/23. Resident #81's wife indicated on 04/17/23 the dressing was changed, and the dressing was not saturated with blood. On 04/18/23 a staff member (not identified by Resident #81's wife) used a Q-tip with peroxide and removed the scabbed areas to the surgical site as reported to her by Resident #81. The surgical area then started bleeding and did not stop all day. The resident's wife stated she had reported her concerns to staff (not named by Resident #81's wife) regarding the resident's continued bleeding, but the staff kept telling her the bleeding was due to the resident being on blood thinners. Further interview revealed the resident's wife had the DON come in and look at the resident's leg and the DON acted like it didn't phase her and said it was because the resident was on blood thinners. On 05/02/23 at 12:02 P.M. interview with the DON revealed, despite not having orders to provide care at the surgical site and not contacting the surgeon for treatment orders, she believed the nurse was acting within her scope of practice and changed the dressing as part of her assessment. The DON also verified there was no documentation of the treatment RN #140 performed to the surgical sites on 04/17/23. The DON confirmed Resident #81's dressing was changed prior to notification of the surgeon on 04/17/23. On 05/02/23 at 1:00 P.M., an interview with State tested Nursing Assistant (STNA) #219 revealed she had completed Resident #81's bed bath and shower sheet on 04/17/23. STNA #219 clarified the dressing to the right lower extremity was saturated with blood. A follow-up telephone interview with STNA #219 was attempted on 05/08/23 but no return call was provided. On 05/02/23 at 1:42 P.M. interview with the DON confirmed Resident #81's laboratory results with the low hemoglobin level of 8.5 was received on 04/17/23, NP #504 saw the laboratory results on 04/18/23 and signed the lab report indicating the results were reviewed. There was no evidence of any new orders at that time. On 05/02/23 at 3:10 P.M., interview with RN #140 revealed she doesn't know what time she notified the provider of Resident #81's lab results from 04/17/23 because she did not document a time or specifically who she notified. RN #140 revealed the nurses usually wait until the end of the day and review all abnormal labs with the provider and then the provider would sign the laboratory results the next day. RN #140 confirmed there was no documented evidence of when and what results were discussed with the provider or if any new orders were received. On 05/02/23 at 4:23 P.M. a telephone interview with Surgeon #501 confirmed there was no evidence (nothing noted on the call logs in his office or through the call logs with his answering service, no record of calls or texts to his cell phone) the facility had contacted him on 04/17/23 or 04/18/23 with the Resident #81's condition change or that he was bleeding and had a low hemoglobin level. The surgeon reported he was unsure how it got past medical at the hospital that the resident was taking both Plavix and Eliquis (as they increased the resident's risk of bleeding and complications). Further interview revealed with the resident having a hemoglobin level of 8.5 with fresh bleeding, that would warrant a blood transfusion. The surgeon also verified he did not, and he would not have given orders to cleanse the pin sites because cleaning the pin sites could be a contributing factor in the resident's bleeding. The surgeon stated his orders were always to keep the dressing intact until the resident's surgical follow-up as the surgical areas need additional pressure to clot properly. On 05/03/23 at 12:19 P.M., telephone interview with Pharmacist #508 revealed every facility electronic medical record was set up differently, however the facility would enter the admission orders and (medication) interactions, she believed, would pop up on the notes. On 05/03/23 at 3:11 P.M. telephone interview with NP #504 and Wound NP #502 concurrently revealed the wound nurse had reported the Dakin's order was already in place for Resident #81 on 04/18/23 and the new order change following this order was just to use a different Q-tip with each site. Neither NP indicated they were sure where the original order came from to use Dakin's and neither acknowledged being able to access the electronic medical record to review the information. NP #504 reported he did not have access to the electronic medical record (he relied on the nurse with him when he does rounds), he stated he would be notified of drug interactions by facility/pharmacy, and he reviewed resident medications on admission. NP #504 confirmed he was aware of the resident's surgical complication and ordered a CBC and BMP to be collected on 04/19/23 and not immediately. On 05/04/23 at 12:53 P.M., interview with LPN #213 revealed the order provided by Wound NP #502 on 04/18/23 to cleanse the external fixator with Dakin's solution, was incorrectly entered and the Dakin's order was not to be applied to the external fixator and was ordered to be applied to a pressure ulcer on the left heel. A follow-up interview on 05/08/23 at 1:20 P.M. with LPN #213, who rounded with the Wound NP #502 on 04/18/23 and was present during the wound care provided to Resident #81, revealed Wound NP #502 performed the treatment to Resident #81's surgical incision. There was a golf ball size of dark moist blood noted on the old dressing. The pins had scabs and dried blood around them. LPN #213 reported Wound NP #502 had used Dakin's and Q-tips to cleanse the pins and at least one scab did come off during the treatment administration. Review of the facility undated policy titled Wound Care revealed the facility would strive to provide the most appropriate and individualized treatment of wounds. The nurse would perform a skin assessment during the initial admission assessment. Wounds shall be assessed and documented on with dressing changes. Wound documentation shall include, but was not limited to: etiology, description, and staging of the wound; measurements of the wound, including length, width, and depth (including tunneling measurements); wound bed description, granulation, type and description of drainage and odor. Review of the facility policy Change in Resident's Condition or Status dated 06/2006 and revised 05/15/20 revealed the facility shall promptly notify the resident, his/her attending physician, and responsible party of changes in the resident's condition or status. Nursing services shall notify the resident's physician when: there was a significant change in the resident's physical, mental or psychological status; there was a need to alter the resident's treatment significantly; deemed necessary or appropriate in the best interest of the resident. In the event of a medical emergency or a rapid deterioration in the resident's condition, family and physician notification would be made immediately. The deficiency represents non-compliance investigated under Complaint Number OH00142280.

Based on observation, photograph review and interviews the facility failed to ensure resident rooms were sanitary and in good repair. This affected eight residents residing in six rooms (Resident #4, #5, #23, #25, #26, #32, #36 and #50) of eight rooms observed for physical environment. The census was 80. Findings included: Observation on 04/28/23 from 7:48 A.M. to 8:09 A.M., revealed there were no base boards in the rooms of Resident #4, #5, #23, #25, #26, #32, #36 and #50. The walls in Resident #23's room had gouges above the bed with paint and dry wall missing as well. Interview and observation on 04/28/23 at 8:04 A.M., with Licensed Practical Nurse (LPN) #213 confirmed Resident #23's room had gouges in the walls and no base boards. Interview on 04/28/23 at 8:31 A.M., with the Maintenance Director (MD) revealed he started two years ago, and the floors were replaced before he started. The baseboard was removed when the floors were replaced and the facility had trouble getting new baseboards. Homestead unit had about ten rooms that needed remodeled at this time. Interview on 04/28/23 at 9:27 A.M., with Resident #23's family revealed the resident's room was filthy and provided photos of Resident #23's room condition. The resident's mattress had white flakes all over it, there was bowel movement on the comforter, a broken table, gouges in the wall, and no baseboards. The family member reported the room had been in those conditions since the resident was admitted . Interview on 04/28/23 at 2:44 P.M., with Licensed Practical Nurse (LPN) #213, confirmed the photos accurately reflected the condition of the resident's mattress, comforter, walls, and table. The LPN reported she had removed the table immediately, took the comforter to laundry, and had the mattress wiped down. She was not aware of the family's concerns with the walls and baseboards and did not report those concerns to maintenance. Interview and observation on 05/02/23 at 8:23 A.M., with LPN #213 revealed Resident #23 was moved next door over the weekend and the family was very happy with the room change. This deficiency represents non-compliance investigated under Complaint Number OH00141626.

Based on observation, medical record review, resident grievance/complaint forms review, staff education review, and interviews the facility failed to ensure a resident was dressed appropriately to promote and maintain dignity. This affected one (Resident #23) of three residents reviewed for dignity. The census was 80. Findings included: Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including dementia, hypertension, Alzheimer's disease, insomnia, anxiety, osteoporosis, edema, and allergic rhinitis. Review of Resident #23's quarterly Minimum Date Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. The resident required one person supervision for dressing, toileting, and personal hygiene. Observation on 04/28/23 at 7:48 A.M., revealed Resident #23 was observed sitting at her bedside with the door to the hallway open. The resident was not wearing clothes from the waist down, and had a shirt laying across her legs. The resident's room was located in a high traffic area and other residents, visitors and staff were able to easily look into the resident's room. Interview on 04/28/23 at 8:04 A.M., with Licensed Practical Nurse (LPN) #213, confirmed the resident was undressed from the waist down and required her assistance to get dressed. A phone interview on 04/28/23 at 9:27 A.M. with Resident #23's family member revealed, when she visits, Resident #23 never has pants on. She voiced her concerns to the facility staff. Interview on 04/28/23 at 9:45 A.M. with the Director of Nursing (DON) revealed Resident #23 was known to remove her pants when she was incontinent of urine. Interview on 04/28/23 at 11:19 A.M., with LPN #213, revealed Resident #23 was on two hour checks due to her removing her clothing and hiding her soiled clothing in her room. LPN #213 reported she would talk to Resident #23's daughter to discuss other options since the resident continues to remove clothing. Review of resident grievance/complaint forms dated 03/27/23 revealed on 03/26/23 Resident #23's daughter had concerns with her mom not being fully dressed at all times, wearing pull ups, and having dry/clean pants in her clothes drawers. The action plan was to educate staff, discuss cognitive decline with the family, two-hour checks, and trialing removing the underwear and putting pull ups in her clothes drawer per family request. Review of staff education regarding Resident #23 revealed a letter dated 04/14/23 that stated Resident #23 was on two-hour checks to maintain dignity. Please ensure Resident #23 was wearing a pull up or pants. Underwear had been taken away and replaced with pull ups. Please make sure the resident was fully dressed before leaving the room. Please be vigilant of hidden soiled laundry. The staff signatures were dated 03/14/23, not 04/14/23 like the letter and there were only 15 staff signatures. This deficiency represents non-compliance investigated under Complaint Number OH00141626.

Based on observation, medical record review, interview, and policy review the facility failed to ensure comprehensive pressure ulcer assessments were completed on admission, pressure ulcer treatments were administered timely and pressure relieving interventions were in place. This affected two residents (Resident #32 and #81) of three resident records reviewed. The census was 80. Findings included: 1. Review of Resident #81's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including closed reduction and external fixation of right tibial [NAME] fracture, iron deficiency anemia, hypertension, and ischemic cardiomyopathy. The resident was discharged on [DATE]. Review of Resident #81's admission skin assessment dated [DATE] revealed the resident had an area of black eschar area to left heel. There was no evidence of a skin assessment being completed; Review of Resident #81's progress note dated 04/17/23 revealed there was a 3.0 centimeter (cm) by 3.0 cm by 0.0 cm scab area on the resident's right heel. There was no evidence of a description for the area to the right heel. Review of Resident #81's orders and treatment administration records dated 04/2023 revealed no evidence of a treatment administered to the left heel, right heel, or right anterior shin on 04/16/23 or 04/17/23. There was an order to apply Dakin's solution to the left foot ulcer, however it was discontinued on admission and not administered. Review of Resident #81's wound note dated 04/18/23 revealed the left heel had resolved and was treated with Santyl (wound debriding agent) and foam dressing change every three days. There were two additional pressure ulcers that were noted on admission. There was a deep tissue injury (DTI) measuring 3.5 cm by 6.2 cm by 0.0 cm to the right dorsal foot that was dark purple and non-blanching and unstageable area to the right anterior shin measuring 1.7 cm by 2.7 cm by undetermined depth due to 100 percent eschar covering the wound bed. Interview on 05/02/23 at 11:05 A.M. with the Director of Nursing (DON) revealed the resident's wife refused to allow staff to apply Dakin's (diluted bleach) solution to the left heel upon admission per orders. The wife wanted Santyl to be ordered and told staff to wait until he saw the podiatrist in three days. The facility nurse discontinued the Dakin's solution to the left heel per admission orders and did not receive clarification to use Santyl per the wife's request. Interview on 05/02/23 at 1:26 P.M. with the DON revealed the areas on the right heel and right anterior shin may have been covered by the dressing on 04/16/23, however the nurse did change the dressing on 04/17/23. The wound nurse practitioner only comes once a week to assess wounds. The floor staff don't comprehensively assess wounds. The DON confirmed the resident did not receive treatment by staff on the left heel, however the wife had completed the treatments using Santyl. The right shin and right heel were not treated on 04/17/23 until the wound NP saw the resident on 04/18/23. 2. Review of Resident #32's record revealed the resident was admitted to the facility on [DATE] with diagnoses including protein calorie malnutrition, dementia, and hypertension. Review of Resident #32's skin/wound note dated 04/18/23 revealed staff were called to the resident's room. The resident had a noted deep tissue injury (purple or maroon localized of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) (DTI) to his left heel measuring 2.5 centimeters (cm) by 2.5 cm by 0.0 cm. The area was dark purple and non-blanchable. The wound nurse practitioner was notified, and new order received for skin prep to area daily, cover with abdominal pad, and wrap with Kerlix to pad and protect, offload heels, Prafo (pressure relief ankle foot orthotic) boot at all times. Will follow up next week for wound rounds. Review of Resident #32's skin/wound note dated 04/25/23 revealed the DTI area on the left heel measured 3.5 cm by 4.0 cm by 0.0 cm. The area was non-blanchable and was a red/maroon/purple discoloration. Review of Resident #32's care plan revealed no evidence of a pressure ulcer plan of care or care plan to offload heels or Prafo boots. Review of Resident #32's task list revealed no evidence to offload heels or Prafo boots. Review of Resident #32's orders dated 04/2023 revealed no evidence to offload heels or Profo boots. Review of Resident #32's treatment administration records (TAR) dated 04/2023 revealed no evidence to offload heels or Profo boots. Observation on 04/28/23 at 3:00 P.M. with Licensed Practical Nurse (LPN) #213 revealed no evidence the resident's left heel was offloaded or Profo boots were in place. A visitor reported the boot was not on when he got there. LPN #213 confirmed there was no order, pressure ulcer care plan, or evidence on the TAR or task the new order on 04/18/23 to offload the heels or for the Profo boots were implemented/ordered. The LPN confirmed staff would have not known unless the order was entered into the electronic medical records. The LPN reported she would put the order in immediately and update the plan of care. Review of the facility's policy Wound Care, un-dated, revealed the facility will strive to provide the most appropriate and individualized treatment of wounds. The nurse will perform a skin assessment during the initial admission assessment. Wounds shall be assessed and documented on with dressing changes. Wound documentation shall include, but is not limited to: etiology, description, and staging of the wound; measurements of the wound, including length, width, and depth (including tunneling measurements); wound bed description, granulation, type and description of drainage and odor. This deficiency represents non-compliance investigated under Complaint Number OH00142280.

Based on interview and record review, the facility failed to notify Resident #79's emergency contact in a timely manner, after Resident #79 had a fall and was sent to the hospital. This affected one (#79) out of three residents reviewed for falls. The facility census was 77. Findings include: Review of the medical record for Resident #79 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included atrial fibrillation, muscle weakness, dementia, and anxiety. Review of the admission Minimum Data Set (MDS) assessment for Resident #79 revealed moderately impaired cognition, extensive assist of one person was required for transfers and toilet use, limited assist of one staff person for dressing, supervision with set-up for eating, and needed supervision of one staff person for personal hygiene. Resident #79 was assessed as not being steady and could only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving and off toilet, and surface to surface transfers. Resident #79 believed he was capable of increasing independence in at least some activities of daily living (ADLs). Review of the contact information in the electronic medical record (EMR) for Resident #79 revealed Family Member #800 was the emergency contact for Resident #79 and Family Member #801 had no contact type assigned. Review of the 11/15/22 progress note revealed Family Member #801 was notified Resident #79 sustained a fall. Review of the 11/23/22 progress note revealed Resident #79 sustained a fall and was transported to the hospital and an unspecified family member was made aware of these circumstances. There was no documentation to indicate Family Member #800 was notified of this fall and transfer to the hospital. Interview on 12/16/22 at 8:51 A.M. with Family Member #801 revealed she was unaware of Resident #79's fall and his transfer to the hospital on 11/23/22. Interview on 12/16/22 at 2:19 P.M. with Director of Nursing (DON) confirmed Family Member #801 was notified of Resident #79's falls and transfer to the hospital on 11/23/22. The DON acknowledged Family Member #800 was listed as the emergency contact and was not notified of either of Resident #79's falls on 11/15/22 and 11/23/22 and hospital transfer. The DON was not sure why Family Member #800 was not notified. Interview on 12/16/22 at 2:47 P.M. with Registered Nurse #525 confirmed, if there was no Power of Attorney (POA) listed in the chart, the person listed as the emergency contact number one, would be informed of any significant changes. Interview on 12/16/22 at 3:00 P.M. with the DON confirmed the hospital called Family Member #800 before the facility had the opportunity to notify her of Resident #79's fall and transfer to the hospital. Review of facility policy, Policy and Procedure for Falls, revised 10/25/18, revealed the resident would be assessed completely and treatment would be provided immediately as needed. Staff were to notify the physician, POA, and unit manager. Safety interventions, as appropriate, would be implemented immediately. Review of facility policy, Change in Resident's Condition or Status, revised 05/15/20, revealed, unless instructed by the resident, the nurse would notify the resident's next of kin when it was necessary to transfer the resident to the hospital. In the event of a medical emergency, family would be notified immediately. Review of undated facility document, [NAME] Care Centre of Dover: Resident Rights and Facility Training, revealed the residents have a right of to be notified of changes in condition, transfer and discharge, change in room or roommate, and any changes in resident rights. This deficiency represents non-compliance investigated under Master Complaint Number OH00138039.

Based on record review and interview, the facility failed to ensure minimum data set (MDS) assessments for Resident #67 and Resident #79's were completed and submitted within required timeframes. This affected two residents (#67 and #79) of three residents reviewed for assessments. The facility census was 77. Findings include: 1. Review of the medical record for Resident #79 revealed an admitted [DATE] and a discharge date of [DATE]. Medical diagnoses included atrial fibrillation, dementia, and anxiety. Resident #79's admission/Medicare five-day MDS assessment, with an assessment reference date of 11/14/22, was in progress and not completed. Resident #79's discharge return anticipated/end of Perspective Payment System (PPS) Part A stay MDS assessment, with an assessment reference date of 11/23/22, was completed but not submitted. Interview on 12/16/22 at 2:31 P.M. with the Director of Nursing (DON) confirmed the admission MDS assessment for Resident #79 was not completed within 14 days and the discharge assessment for Resident #79 was not submitted within the required time frames. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1 October 2019, revealed an admission MDS assessment should be completed no later than the 14th calendar day of the resident's admission (admitted plus 13 days) and submitted no later than 45th day of the resident's admission (admitted plus 44 days). A quarterly MDS assessment should be completed no later than the 14th day from the assessment reference date and submitted 14 days after the completion of the MDS assessment. A discharge assessment should be completed no later than 14 days after discharge (discharge date plus 14 days) and should be submitted no later than 14 days after the MDS completion date (MDS completion date plus 14 days). 2. Review of the medical record for Resident #67 revealed an admitted [DATE]. Diagnoses included dementia, behavioral disturbance, chronic pain syndrome, obesity, anxiety disorder, and major depressive disorder. Review of Resident #67's quarterly MDS assessment, with an assessment reference date of 11/11/22, was completed but not submitted. Interview on 12/16/22 at 2:31 P.M. with the DON confirmed the quarterly assessment for Resident #67 was not submitted within the required time frame. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1 October 2019, revealed a quarterly MDS assessment should be completed no later than the 14th day from the assessment reference date and submitted 14 days after the completion of the MDS assessment.

Based on observation, interview, record review, and policy review, the facility failed to ensure proper infection control practices were maintained upon entering Resident #55's room who was on transmission based precautions. This had the potential to affected 60 of 62 residents residing in the facility. It did not affect Resident #45 and Resident #46, as the residents had COVID-19 at the time of the survey. Findings include: Review of Resident #55 record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated that the resident was unvaccinated for COVID-19. Review of Resident #55's physician order, dated 12/21/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a list of COVID-19 positive residents provided by the facility, revealed Resident #45 and Resident #46 had COVID-19. Observation on 12/27/21 at 11:47 A.M. of Resident #55's room revealed a sign indicating to see the nurse before entering, and an isolation bin full of personal protective equipment sitting outside of the resident's room. Observation on 12/27/21 at 11:48 A.M. of Hostess #209 revealed she was wearing a N95 respirator mask and goggles. Hostess #209 picked up Resident #55's lunch tray from the cart and walked into Resident #55's room without applying additional personal protective equipment (PPE) prior to entering. Hostess #209 sat the residents food on the tray directly in front of the resident and assisted to set up the residents meal, including touching the resident's bedside table, so the resident could begin eating. Continued observation at 11:51 A.M. revealed Hostess #209 walk out of the resident's room without cleaning her goggles or applying a new N95 mask since her N95 mask was unprotected while in the resident's room. Interview on 12/27/21 at 11:52 A.M. with Hostess #209 confirmed she should have applied a gown, gloves, and a surgical mask over her N95 mask before entering Resident #55's room. She continued she usually does but today she forgot. She continued to confirm she did not clean her goggles after exiting the resident's room. Interview on 12/27/21 at 11:56 A.M. with Registered Nurse #202 confirmed Resident #55 was in droplet precautions and everyone who enters the room should apply a gown, gloves, N95 mask, and goggles. She also stated that upon leaving the room staff should sanitize their goggles and remove their gowns and gloves. Review of the undated facility policy, COVID-19 Residents: Screening and Management revealed residents who are exposed to COVID-19, that staff should wear an N95 respirator, face mask, eye protection, gloves and a gown. This deficiency is an example of continued non-compliance from the survey dated 11/22/21.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO 20-39-NH, revised 11/12/21, Nursing Home Guidance from the Centers for Disease Control (CDC), record review, review of a facility COVID-19 timeline, review of the county community COVID-19 positivity rate, review of staff time sheets, review of staff screening forms, review of resident and staff COVID-19 laboratory results (PCR) and rapid point of care (POC) test results, review of the facility COVID-19 procedure policy, staff interview and observation the facility failed to implement effective and recommended infection control practices including the adequate monitoring, documented testing and prevention of the transmission of COVID-19 in the facility. The facility failed to ensure staff did not provide direct resident care to residents while symptomatic of COVID-19, failed to ensure staff screening for COVID-19 upon entrance into the facility was monitored and failed to ensure all staff utilized appropriate personal protective equipment (PPE) during a COVID-19 outbreak to help reduce the spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy on 11/06/21 when Temporary Nursing Assistant (TNA) #1 completed a self-screening for COVID-19 at the beginning of her shift (6:54 A.M.) indicating she had symptoms (of COVID-19) on the screening form (sore throat) and proceeded to work/providing direct care to residents on the Homestead and/or Gardens unit. TNA #1 worked on 11/06/21 until 6:54 P.M. TNA #1 also worked a 12-hour shift on 11/07/21 after completing a self-screening for COVID-19 at the beginning of her shift indicating she had a sore throat and cough. There was no evidence the screening forms were reviewed by management or a qualified staff member, no evidence the employee was sent home (due to COVID-19 symptoms) and no evidence TNA #1 was tested for COVID-19 until 11/08/21 when a PCR test was completed as part of facility mandatory testing of non-vaccinated staff. Laboratory results, dated 11/10/21 revealed TNA #1 was positive for COVID-19. TNA #1 worked on 11/11/21 from 6:54 A.M. to 9:00 A.M. before being sent home with COVID-19. Registered Nurse (RN) #2, who worked on the same unit as TNA #1 on 11/07/21 started to exhibit symptoms of COVID-19 on 11/10/21 while working and tested positive for COVID-19 via a rapid test which was positive and confirmed with a PCR test. The facility identified nine unvaccinated residents, Resident #2, #15, #25, #35, #41, #42, #46, #47 and #48 who resided on the Homestead and Garden units who TNA #1 and RN #2 had provided direct care to who were not placed in quarantine following their possible exposure. The risk for hospitalization , serious harm and/or death are likely related to a COVID-19 outbreak in the nursing home resident population. This had the potential to affect all 29 residents residing on the Gardens Unit and all 26 residents residing on the Homestead Unit. The facility census was 74. On 11/18/21 at 11:25 A.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 11/06/21 when TNA #1 worked a 12-hour shift after documenting she had symptoms associated with COVID-19 on the facility screening log. TNA #1 also worked on 11/07/21 with continued symptoms of COVID-19 providing direct resident care. TNA #1 tested positive for COVID-19 from a PCR test obtained on 11/08/21. RN #1, who worked with TNA #1 on 11/07/21 subsequently developed symptoms of COVID-19 and tested positive for COVID-19 on 11/10/21. Continued observations during the onsite investigation revealed the facility was not following acceptable infection control practices to prevent the spread of COVID-19 related to personal protective equipment (PPE) use, contact tracing for non-vaccinated residents with exposure to COVID-19 positive staff and insufficient monitoring of staff screenings upon entrance into the building. The Immediate Jeopardy was removed on 11/18/2021 when the facility implemented the following correction actions: · On 11/10/21, the charge nurses (Registered Nurse (RN) #119, RN #178, RN# 223 and Licensed Practical Nurse (LPN) #248 rapid tested all the residents in the facility for COVID-19 and all tested negative. · On 11/11/21, the charge nurse (RN #154) rapid tested all 29 residents on the Garden unit for COVID-19 and all tested negative. · On 11/15/21, the charge nurses (RN #154, RN #175, RN #182 and RN #246) rapid tested all residents in the facility for COVID-19 and all tested negative. · As of 11/18/21 facility unit managers and nursing staff continued to monitor all residents on the Homestead and Garden units for signs and symptoms for COVID-19 and none had been reported. · On 11/18/21, the DON/Infection preventionist and Administrator reviewed the facility infection control and testing policies and procedures and the testing procedures were revised. · On 11/18/21, all resident records were reviewed by the DON/Infection Preventionist to ensure all unvaccinated, potentially exposed residents were placed in quarantine for COVID-19. The facility identified nine residents, Resident #2, #15, #25, #35, #41, #42, #46, #47 and #48 who were unvaccinated and placed in quarantine on 11/18/21. · On 11/18/21, the charge nurses (RN #108, RN #175, RN #181 and LPN #300) obtained PCR and rapid tests for all residents in the facility for COVID-19. All rapid tests were negative and PCR test results were pending as of this date. · On 11/18/21, the DON and Administrator revised the facility policy on personal protective equipment (PPE) usage, to ensure staff were wearing eye protection in accordance with county positivity rate as recommended by the CDC. · On 11/18/21, the DON began educating all staff via one or more of the following formats: text, email, phone calls, in-person, and Relias training on the following: facility policy and procedure screening, testing, exclusion from work, PPE use and quarantine procedures. · On 11/18/21, the Administrator in-serviced the DON/Infection Preventionist and COVID-19 tester on the CDC recommendations for contact tracing. · On 11/18/21 the facility implemented a plan for the supervisor on duty to monitor the staff screening logs every shift. · On 11/18/21, the Administrator, DON/Infection Preventionist and Medical Director had an ad hoc Quality Assessment Performance Improvement (QAPI) meeting to discuss the identified concerns and facility abatement plan. · On 11/18/21 the facility developed a plan for the DON/designees to audits screening forms, COVID-19 testing, PPE use and quarantine procedures to ensure all were being conducted/utilized in accordance with CDC recommendations and CMS guidance. Audits would be completed five times a week for four weeks. Although the Immediate Jeopardy was removed on 11/18/2021, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of CMS QSO-20-39-NH, revised 11/12/21 noted: Nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality. The vulnerable nature of the nursing home population combined with the inherent risks of congregate living in a healthcare setting have required aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes. 1. Review of the facility staff positive COVID-19 log, dated 08/09/21 to 11/10/21 revealed from 09/25/21 until 11/10/21 one or more staff members had tested positive for COVID-19 weekly except for the week 10/31/21 to 11/06/21 when no staff were identified to have tested positive during that week. In addition, between 10/11/21 and 10/20/21, seven residents, Resident #26, #34, #37, #44, #75, #76, and #77 had tested positive for COVID-19 in the facility. Review of the facility undated COVID-19 positive staff and resident list revealed TNA #1 (who was not vaccinated for COVID-19) tested positive on 11/08/21 and RN #2 (who was vaccinated for COVID-19) tested positive on 11/10/21. Review of the staff screening log, dated 11/06/21 revealed TNA #1 had a sore throat (symptom of COVID-19). The screening log reflected on 11/07/21 TNA #1 had a cough and sore throat (symptoms of COVID-19). There was no indication who the screening form was completed by or reviewed by, no evidence TNA #1 was sent home (related to having symptoms of COVID-19) and no evidence TNA #1 was tested for COVID-19 on either of these dates. Review of TNA #1's time sheet documentation revealed TNA #1 worked on 11/06/21 from 6:54 A.M. to 6:54 P.M., 11/07/21 from 6:54 A.M. to 6:58 P.M. and on 11/11/21 from 6:54 A.M. to 9:00 A.M. The facility provided a timeline of information related to TNA #1 and RN #2 testing positive for COVID-19. The timeline documented TNA #1 worked 11/07/21 day shift (7 A.M. to 7:00 P.M.) and 11/11/21 from 7:00 A.M. to 9:00 A.M. on the Gardens Unit. The timeline information revealed RN #2 worked dayshift on 11/07/21 and 11/08/21 and on 11/10/21 from 7:00 A.M. to 9:45 A.M. The timeline did not include evidence the facility had reviewed the staff screening logs for the dates in question or any evidence of COVID-19, rapid or PCR testing being completed for the employees. Review of TNA's #1 polymerase chain reaction (PCR) COVID-19 test revealed the specimen was collected on 11/08/21 and final report was completed on 11/10/21. The final report indicated the staff member was positive for COVID-19. An undated local health department notification form, completed by the facility documented TNA #1 had symptoms of COVID-19 being on 11/07/21. The symptoms reported were a cough, headache and sore throat. On 11/17/21 at 8:24 A.M. interview with TNA #1 revealed she had worked on the Homestead unit on 11/06/21 and 11/07/21. TNA #1 reported symptoms (associated with COVID-19) had started on 11/06/21. The TNA revealed she had reported these symptoms to the nurse (name not provided) and also obtained a nasal swab (for a rapid COVID test) on herself on both 11/06/21 and 11/07/21 that she stated she gave to a nurse (name not provided) to test. TNA #1 was unable to recall which nurse she gave the swabs to or which nurse performed a COVID test; however, she stated she was later told the tests were negative. During the interview, TNA #1 revealed she always collected her own nasal specimen for all the COVID-19 testing done in the facility. TNA #1 denied receiving any type of training on how to collect specimens for COVID-19 testing. TNA #1 revealed the tests obtained on 11/06/21 and 11/07/21 were likely thrown in the trash and verified there were no records of them being obtained. On 11/17/21 between 9:15 A.M. and 12:09 P.M. and on 11/18/20 at 9:06 A.M. interview with the facility COVID-19 Coordinator, (CC) #200 revealed TNA #1 worked in the facility on 11/06/21 and 11/07/21 and had no symptoms but tested positive for COVID-19 on 11/11/21 for COVID-19 via a PCR test that was collected on 11/08/21 and part of the facility unvaccinated mandatory testing (for COVID-19). After reviewing the staff screening logs (dated 11/06/21 and 11/07/21) with CC #200, the CC verified TNA #1 recorded she had a sore throat on 11/06/21 and sore throat and cough on 11/07/21. CC #200 revealed TNA #1 had not reported these symptoms to any other staff member nor was she tested for COVID-19 on either of these dates. CC #22 revealed TNA #1 worked on the Garden unit on 11/06/21, 11/07/21 and 11/11/21. However, during the interview (above) with TNA #1, the TNA reported she had worked on the Homestead unit on 11/06/21 and 11/07/21. During the interview with CC #200, the CC verified TNA #1 had worked the Garden unit on 11/06/21 and 11/11/21 and Homestead unit on 11/07/21. CC #200 also confirmed the TNA's PCR test (obtained on 11/08/21) was completed by the laboratory on 11/10/21 but stated she was not notified of the of the results until 11/11/21 at approximately 8:45 A.M. at which time TNA #1 was sent home. CC #200 revealed she was not aware of when TNA #1's symptoms had started until she had called the TNA to complete the form to send to the local health department. At the time TNA #1 tested positive, the facility had just completed outbreak testing from previous positive COVID cases in the facility. Review of RN 2's time sheet documentation revealed RN #2 worked on 11/07/21 from 7:00 A.M. to 6:15 P.M. on 11/08/21 from 6:52 A.M. to 7:33 P.M. and on 11/10/21 from 6:51 A.M. to 9:45 A.M. Review of the facility staff screening logs, dated 11/07/21, 11/08/21 and 11/10/21 all documented RN #2 had reported she had no symptoms (of COVID-19). A rapid point of care test, obtained on 11/10/21 revealed RN #2 was positive for COVID-19. RN #2 reported at that time she had a runny nose. A PCR test, obtained on 11/10/21 with results on 11/11/21 was also positive for COVID-19. The local health department was notified RN #2 tested positive for COVID-19 with symptoms of a runny nose which started on 11/10/21. On 11/17/21 between 9:15 A.M. to 12:09 P.M. and on 11/18/21 at 9:06 A.M. interview with CC #200 revealed RN #2 worked the Homestead unit on 11/07/21, 11/08/21 and 11/10/21. The RN was exhibiting symptoms ([MEDICATION(S)] drainage) the morning of 11/10/21 so CC #200 performed a rapid COVID-19 test that was positive for COVID-19 and then sent a PCR sample to the laboratory for confirmation. The PCR test was positive as well. RN #2 was sent home immediately after the positive rapid test. CC #200 revealed RN #2 and TNA #1 had worked together on the Homestead unit on 11/07/21. CC #22 revealed on 11/11/21 she had interviewed all staff to determine if any other staff had contact with TNA #1 or RN #2 for more than 15 minutes without PPE, however the dates of exposure were not indicated. Review of the facility policy titled COVID-19 Infection Control-Staff, dated 2020 revealed prior to coming to work, all health care personnel (HCP) must perform a daily self-assessment for any symptoms. Symptomatic HCP should stay home, immediately notify their supervisor and the DON and contact their primary care provider. Review of the facility policy titled COVID-19: Suspected or Confirmed Cases, revised 11/05/21 revealed employees who develop symptoms of COVID-19 would be restricted from work and must contact their supervisor for return to work instruction(s). The policy also included rapid testing of symptomatic staff, if symptomatic staff were negative (rapid test) then a PCR test should be performed within 48 hours, residents would be placed on appropriate precautions, and staff would be excluded from work and remain in contact with their supervisor who would follow return to work criteria. Review of the CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated 09/10/21 revealed health care personal (HCP) should not work while acutely ill, even if COVID-19 testing was negative, to minimize the risk of transmission of other infectious pathogens, including respiratory pathogens such as influenza. 2. Review of the undated facility resident vaccination log revealed six residents, Resident #35, #41, #42, #46, #47 and #48 who resided on the Homestead unit and three resident, Resident #2, #15 and #25 who resided on the Garden unit were not vaccinated and had not tested positive for COVID-19 in the last 90 days. On 11/17/21 from 7:38 A.M. to 8:03 A.M. and at 1:30 P.M. observations on the Homestead and Garden units revealed no evidence Resident #2, #15, #25, #35, #41, #42, #46 #47 or #48, or any other residents on the units were in quarantine/isolation related to possible exposure to COVID-19. On 11/17/21 at 7:52 A.M. interview with LPN #248 revealed she was the nurse on the Homestead unit on this date. The LPN verified there were currently no residents in isolation or quarantine for COVID-19. The facility had a COVID-19 unit, at the end of the hall, however there were no residents currently residing on the COVID-19 unit. On 11/17/21 at 12:11 P.M. interview with CC #200 confirmed the unvaccinated residents listed above were not placed in quarantine after possibly having close contact with TNA #1 and RN #2. CC #200 revealed the facility encouraged residents to stay in their rooms. However, per CC #200 this was difficult on the Homestead unit due to the number of residents residing on the unit with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the undated facility list of residents in quarantine/isolation revealed no residents on the Homestead or Garden units were in isolation/quarantine related to COVID-19. Review of the facility policy titled COVID-19 Infection Control-Staff, dated 2020 revealed residents who were exposed to COVID-19 HCP should be placed in a private room in quarantine and cared for using all recommended COVID-19 PPE (this included an N95 mask, eye protection, gown, and gloves). If a private room or observation unit was not available, the local health department should be consulted for possible co-horting of exposed residents. Review of the CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Home, dated 09/10/21 revealed unvaccinated residents who had close contact (being within six feet for a cumulative total of 15 minutes or more of a 24 hour period with someone with COVID-19) should be placed in quarantine for 14 days after their exposure, even if [CONDITION(S)] testing was negative. HCP caring for these residents should use full PPE (gowns, gloves, eye protection and N95 mask or higher level respirator). 3. Review of the staff screening logs, dated 11/06/21 to 11/10/21 and 11/16/21 to 11/17/21 revealed there was a line for each staff member to sign their name, write their temperature, and then to circle yes or no for each of the following questions: cough, sore throat, shortness of breath or difficulty breathing, vomiting or diarrhea, chills or repeated shaking with chills, muscle pain, headache, loss of taste or smell, been exposed to hot spots outside the facility, exposed to a (COVID-19) positive person, exposed to someone who was generally ill, been in a group of 10 or more people without wearing PPE, traveled out of the state, tested for COVID-19 outside the facility and asked to go home. Further review of the logs revealed many of the staff who had documentation on the logs from these dates were just drawing one straight solid line through all the question and not answering each question individually by circling yes or no per the directions. In addition, the following negative findings were noted on the logs with no evidence of follow up: On 11/06/21 and 11/07/21 the staff screening log for Administration #123 revealed the employee had circled she had a cough. On 11/09/21, 11/10/21, and 11/17/21 the staff screening log for LPN #208 revealed the employee had circled she had a cough. On 11/17/21 at 10:14 A.M. interview with LPN #208 revealed she had had a cough for approximately six weeks. LPN #208 revealed she had seen a physician and was COVID-19 tested on ce or twice weekly at the facility. The LPN revealed the physician thought she might have an upper respiratory infection. On 11/09/21 and 11/10/21 the staff screening log for Housekeeper #131 revealed the employee had circled she had a cough, shortness of breath/difficulty breathing, exposed to a positive person and tested outside the building. On 11/09/21 the staff screening log for Hospitality Aide (HA) #195 revealed the employee circled she had a cough. On 11/09/21 the staff screening log for HA #115 revealed the employee had cough, been in a hot spot and was exposed to someone with COVID-19 and critically ill. On 11/17/21 at 7:51 A.M. Maintenance Director (MD) #207 was observed screening himself for COVID-19 upon entrance to the facility. No staff reviewed the screening log or verified the screening was accurate and complete. On 11/17/21 at 7:52 A.M. interview with LPN #248 revealed sometimes she screens herself and sometimes there would be another staff member to screen staff upon arrival to the facility. On 11/17/21 at 11:11 A.M. and 12:09 P.M. interview with CC #200 revealed staff should be circling each question on the screening log forms and indicated it was each staff members responsibility to report any signs and symptoms to the nurse or management. CC #200 revealed the screening log forms were not monitored/reviewed daily by a qualified employee or administration. CC #200 revealed Housekeeper #131 had tested positive for COVID-19 on 10/25/21 and was still having symptoms and HA #115 had tested positive for COVID-19 on 10/07/21. CC #200 revealed she called HA #195 today about the log forms and the HA indicated she marked she had a cough in error. CC #200 was unable to reach Administration #123 to follow up with her documentation on the screening logs on this date. CC #200 revealed she was not aware LPN #208 had been marking symptoms as well. CC #200 revealed she would start reviewing the staff screening logs daily. Review of the facility policy titled COVID-19 Infection Control-Staff, dated 2020 revealed at the beginning of every HCP's shift, the facility would actively screen for symptoms. HCP whose screening indicated presence of (COVID-19) symptoms would be subject to additional investigation and/or testing and would be excluded from or permitted to work in accordance with the CDC guidance or local health department orders. Symptomatic HCP who had been sent home may return to work in accordance with the COVID-19 return to work policy. If symptoms developed at work, staff should immediately apply a facemask, inform their supervisor and inform the facility infection preventionist, to determine whether the employee needed to leave work and contact their primary care provider. 4. On 11/17/21 at 7:38 A.M. an initial tour of the facility with the Director of Nursing (DON) confirmed the facility was currently in outbreak testing for COVID-19 due to positive staff members. During the tour, the DON was observed constantly touching her ill fitted (loose) N95 mask with her bare hands. The DON did not perform hand hygiene after touching her N95 mask even when it was brought to her attention. The DON reported all masks irritated her face so that was why she was touching her mask so frequently. The DON was noted touching objects and binders at the nurse's station after touching her N95 mask without performing hand hygiene. The DON confirmed her N95 did not fit properly. The ear bands were stretched out and the N95 did not fit snug against her face. The DON was not wearing any type of eye protection. When asked about the use of eye protection, the DON reported the local health department told the facility they didn't have need to wear face shields because they should try to preserve them. The DON was not able to provide documented evidence from the health department regarding not wearing eye protection during and outbreak. Additional observations on 11/17/21 revealed: At 7:38 A.M. a Minimum Date Set (MDS) nurse was observed walking in the hallway without eye protection. At the time of the observation, the DON confirmed the MDS nurse was not wearing any type of eye protection. At 7:51 A.M. MD #207 was observed in a resident hallway without any type of eye protection. At the time of the observation, interview with MD #207 confirmed he was not wearing eye protection. At 7:52 A.M. LPN #248 was observed with one strap of her N95 pulled over her ear the strap on the right ear was hanging. The N95 was ill fitting and not flush to her face. The LPN also had a surgical mask over the N95. The nurse did have eye protection in place. At the time of the observation, the LPN revealed there were no current residents on the Homestead unit who were positive for COVID-19, nor were there any residents in quarantine for COVID-19. During the observation, LPN #248 was observed touching her mask with her hands. The LPN confirmed the N95 was ill fitting and not properly applied. At 8:04 A.M. interview with the DON revealed since there were only positive staff (and no residents) that staff were only required to wear N95 masks and not eye protection. The DON revealed if there was a COVID-19 outbreak of residents then staff would wear an N95 mask and eye protection. At 12:26 P.M., Housekeeper #131 was observed with an ill-fitting N95 mask and no eye protection. Interview with the housekeeper confirmed the N95 mask was not snug against her face and indicated the ear straps were too long and did not fit tight. Housekeeper #131 also confirmed she was not wearing eye protection. At 1.26 P.M., observation on the Garden unit revealed four staff members, LPN #162, STNA #135, LPN #208 and STNA #224 were observed with no eye protection. The staff members reported they had been wearing eye protection and then they were just told (by the DON) they didn't have to wear eye protection anymore so they removed it. At 1:28 P.M., observation of the Homestead unit revealed STNA #129 and STNA #256 did not have eye protection in place. Both STNA staff reported they were told they did not need to wear eye protection and only needed eye protection if there were COVID-19 positive residents in the building. Both STNA staff also revealed they had just started wearing N95 masks again on 11/10/21 when another staff member had tested positive for COVID-19. On 11/18/21 at 8:09 A.M. interview with CC #200 revealed facility staff were using surgical masks between 11/08/21 until the morning of 11/10/21 when RN #2 tested positive for COVID-19. She could not recall when the facility stopped utilizing eye protection. Review of the Centers for Medicare and Medicaid (CMS) facility positivity rate/transmission levels for 11/2021 revealed on 11/01/21 the rate was 12.8% (red/high), on 11/08/21 the rate was 10.3% (red/high) and on 11/15/21 the rate was 12.86% (red/high). Review of the facility policy titled COVID-19 Infection Control-Staff, dated 2020 revealed eye protection was required in addition to facemask, if the facility was in a county that has been designated by the State department as Level 2 or higher public emergency based on community transmission of COVID-19. Review of the CDC Eye Protection Guidance, dated 09/13/21 revealed in areas of substantial to high transmission in which HCP were using eye protection for all patient encounters, extended use of eye protection may be considered as a conventional capacity strategy. Once availability of eye protection returned to normal, healthcare facilities should promptly resume conventional practices. Consideration affecting the decision would include the level of COVID-19 transmission in the community. Review of the CDC Interim Infection Prevention and Control Recommendation for HCP During the COVID-19 guidance, dated 09/10/21 revealed source control referred to use of respirators or well-fitting masks or cloth mask to cover a person's mouth nose to prevent the spread of respiratory secretions when they were breathing, talking, sneezing or coughing. If COVID-19 infections were not suspected in a patient presenting for care, HCP working in facilities located in counties with substantial or high transmission should also use N95 or equivalent or higher and eye protection (goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. Textile (cloth) mask were not PPE appropriate for use by HCP. This deficiency substantiates Complaint Number OH 453.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, observation, review of Nursing Home Guidance from the Center for Disease Control (CDC), review of the facility COVID-19 Screening and Management policy and procedure, review of the facility COVID-19 test results, review of daily resident census reports, interview with the local health department staff, interview with the facility Medical Director and staff interview, the facility failed to implement effective infection control procedures to prevent the spread of infectious disease and move COVID-19 positive residents out of rooms with COVID-19 negative residents. With positive and negative residents cohorting, the likelihood exists for serious harm or death related to the spread of the COVID-19 virus. This resulted in Immediate Jeopardy on 10/18/20 when Resident #4 tested positive for COVID-19 and remained in the same room shared with Resident #3, a COVID-19 negative resident. From 10/19/20 through 10/29/20 three additional residents (#5, #42 and #6) tested positive for COVID-19 and remained in their room being shared with a COVID-19 negative resident (#2, #44 and #1). Subsequent testing on 10/29/20 revealed Resident #2 who was previously COVID-19 negative was now COVID-19 positive and on 11/06/20 Resident #44 and #1, who had been previously been COVID-19 negative were now COVID-19 positive. In addition, the facility failed to ensure the proper use of personal protective equipment (PPE) by staff to prevent the spread of COVID-19. This had the potential to affect all 88 residents residing in the facility and specifically affected four COVID-19 negative residents (#1, #2, #3 and #44) residing with COVID-19 positive residents. The facility census was 88. On 11/06/20 at 2:26 P.M. the Administrator was notified that Immediate Jeopardy began on 10/18/20 when facility wide testing for COVID-19 completed for all staff and residents revealed Resident #4, who tested positive for COVID-19, was not moved to a private room and remained in a room with Resident #3 who tested negative for COVID-19. From 10/19/20 through 10/29/20 three additional residents, #5, #6 and #42 tested positive for COVID-19, were not moved to a private room and remained in rooms shared with COVID-19 negative residents. On 10/22/20 Resident #2 tested positive for COVID-19 and on 11/06/20 Resident #44 and Resident #1 tested positive for COVID-19. The Immediate Jeopardy was removed on 11/08/20 when the facility completed the following corrective actions: · On 11/05/20, Resident #1 and Resident #42 were moved to private rooms and continued on transmission-based precautions. Resident #3 refused to be moved to another room. However, upon additional assessment, her roommate, Resident #4 had been medically cleared at this time after testing positive for COVID-19 on 10/18/20 and no longer required isolation for COVID-19. · On 11/06/20, all resident records were reviewed by the DON, Infection Preventionist and designee to ensure all positive residents were on transmission-based precautions residing on a COVID-19 unit and any exposed residents were on transmission-based precautions in a private room. The audit revealed no current residents who were positive for COVID-19 were residing in a room with a COVID-19 negative resident. · On 11/07/20 resident rooms were cleaned and sanitized to prepare for room moves based on the Centers for Disease Control guidelines. Additional PPE stations were made available throughout all units. · On 11/07/20, the DON and Administrator revised the policy on PPE usage. The policy revisions included staff caring for residents should have full PPE, including face shield or goggles, N95 respirator, isolation gown and gloves. Exposed residents who were not symptomatic would have transmission-based precautions with staff utilizing full PPE. Ideally, confirmed, or suspected cases should be isolated individually, and Close Contacts/Exposures should be quarantined individually. Exposed residents who were not symptomatic and new admissions and readmissions from the hospital or community would be segregated away from other residents for a period of 14 days from the exposure in a private room, if available. · On 11/07/20, all staff education began and continued through 11/09/20. Staff were educated on the revised policy for PPE used in cohorted negative but exposed room. All staff were educated on appropriate usage of PPE and when to use it. As of 11/09/20 29 of 181 staff members had not been educated. The facility initiated a plan requiring all staff to complete training or they would not be permitted to work. · On 11/07/20 PPE equipment was place inside and outside of all rooms. PPE usage audits would be completed daily by the Administrator and Director of Nursing on varying shifts for four weeks. The PPE usage audit included proper donning and doffing, wearing of shield/goggles, wearing new gown and gloves, and wearing the proper masks. · On 11/09/20 between 11:37 A.M. and 11:42 A.M. a tour of the COVID-19 unit confirmed residents who had tested positive for COVID-19 were in rooms with other COVID-19 residents or were in a private room on the designated COVID-19. Although the Immediate Jeopardy was removed on 11/08/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/03/20 revealed CMS is committed to taking critical steps to ensure America's healthcare facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (Covid-19). As part of CMS guidance, information provided to facilities revealed we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). Review of the CDC guidelines for COVID-19 revealed the facility should identify a space that could be dedicated to monitor and care for residents with COVID-19, such as a dedicated floor, unit or wing in the facility. The CDC considerations for establishing a designated COVID-19 unit for residents with confirmed COVID-19 included ideally the unit should be physically separated from other rooms/units housing residents without confirmed COVID-19, assign dedicated staff to work the COVID-19 care unit, the unit should have a restroom, break room and work area that are separate from staff working in other areas of the facility. Dedicated resident care equipment should be dedicated to the COVID-19 unit and should not leave the unit. a. Review of the facility's COVID-19 test results revealed Resident #4 tested positive for COVID 19 on 10/18/20. Resident #3 (roommate of Resident #4) tested negative and remained in the same room with Resident #4. On 11/06/20 Resident #3 was retested and remained negative for COVID-19. Review of the facility's COVID-19 test results revealed Resident #5 tested positive for COVID-19 on 10/22/20. Resident #2 (roommate of Resident #5) tested negative on 10/22/20 and remained in the same room with Resident #5. On 10/29/20 Resident #2 was retested and tested positive for COVID-19. Review of the facility's COVID-19 log test results revealed Resident #42 tested positive for COVID-19 on 10/22/20. Resident #44 (roommate of Resident #42) tested negative on 10/22/20 and remained in the same room with Resident #42. On 11/06/20 Resident #44 was retested and was positive for COVID-19. Review of the facility's COVID-19 log test results revealed Resident #6 tested positive for COVID-19 on 10/29/20. Resident #1 (roommate of Resident #6) tested negative on 10/29/20 and remained in the same room with Resident #6. There was no evidence the facility attempted to move Resident #6 to a private room on the COVID-19 unit at the time the positive test was completed. On 11/06/20 Resident #1 was retested and was positive for COVID-19. During a tour of the facility on 11/05/20 between 9:50 A.M. and 12:20 P.M. the following facility layout and designated units were identified: The New Rehab (100 and 300) units were for negative COVID-19 residents. The 200 unit also on the New Rehab unit was for negative COVID-19 residents and overflow for those residents in quarantine. Pat's Porch (900) was in a separate building and was a quarantine unit. The Homestead (700 and 800) and Garden (400 and 500) units were isolation units. Review of the facility's resident daily census report for 11/05/20 confirmed resident locations in the facility to be correct and the above COVID-19 positive residents in the same room as COVID-19 negative residents. However, review of the census report revealed open rooms were available on the COVID-19 isolation unit where these residents could have been transferred to. On 11/05/20 at 12:27 P.M. interview with the DON revealed some of the residents had been medically cleared after being COVID-19 positive but had not been taken off isolation precautions. During the interview, the DON verified residents (including Resident #4, #5, #42 and #6) who tested COVID-19 positive and had roommates had not been moved to a private room on the COVID-19 isolation unit or to a room cohorted with another COVID-19 positive resident. The DON stated a COVID-19 outbreak started in the facility around 09/29/20 and from that point in time, the facility staff felt that everyone would get COVID-19 anyway so moving the residents could just spread it more. The DON stated this was all new and they had to learn as the outbreak developed. On 11/09/20 at 11:55 A.M. interview with Communicable Disease Nurse (CDN) #300 for the Local Health Department revealed the facility had been communicating and reporting positive COVID-19 cases. CDN #300 revealed facilities were always encouraged to separate COVID-19 positive and negative residents. CDN #300 stated she was not aware the facility had COVID-19 positive and negative residents residing in the same room. On 11/09/20 at 2:43 P.M. interview with the Medical Director revealed he believed COVID-19 testing had a 20% rate of false positives and negatives. The medical director stated it was difficult to tell if a resident was truly negative after exposure. The Medical Director stated the facility notified him when there were new positive cases and he felt more needed considered before a resident was moved (to a new room or unit). The Medical Director stated he was aware some facilities used a red unit for those who were positive, a yellow unit for those who were exposed or new admissions, and a green unit for those who were negative. The Medical Director stated he did not feel a positive case was the only reason a resident should be moved. He felt it also depended on the resident's cognitive status. If a cognitively impaired person was moved, they were at a higher risk for falls, injuries and increased behaviors. Review of CDC guidelines revealed for residents with new-onset suspected or confirmed COVID-19 test results the facility should: · Ensure the resident was isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. · Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions were in place to decrease the risk of cross-transmission. · If the resident was confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. · Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Review of facility undated policy titled COVID-19 Residents: Screening and Management revealed cohorting was the practice of isolating multiple laboratory-confirmed COVID-19 cases together as a group or quarantining Close Contacts/Exposures of a particular case together as a group. Ideally, confirmed or suspected cases should be isolated individually, and Close Contacts/Exposures should be quarantined individually. Exposed residents who were not symptomatic and new admissions and readmissions from the hospital or community would be segregated away from other residents for a period of 14 days from the exposure in a private room, if available. Residents should not share a room with another resident until the 14 days were complete, unless the resident had been sharing the room with a roommate prior to the exposure, in which case the current shared room may be maintained if a private room was not available. If a test determines the resident was COVID positive or if the resident becomes symptomatic, the resident should be transferred to the COVID-19 unit/area. If 14 days have passed since the exposure or date of admission and the resident has no symptoms, the resident should be removed from Quarantine/Transmission-Based Precautions. Residents with a positive COVID-19 test should be placed in transmission-based precautions and ideally on a separate unit/wing for residents with COVID-19 (COVID Unit). Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 for 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 Unit). Staff caring for residents should have full PPE, including face shield or goggles, N95 respirator, isolation gown and gloves. Residents who have tested positive for COVID-19 may leave the COVID Unit and/or transmission-based precautions in accordance with the following: Asymptomatic residents who are not severely immunocompromised- at least 10 days have passed since the date of their first positive [MEDICAL CONDITION] diagnostic test. b. On 11/05/20 at 8:49 A.M. during an interview with the DON, the DON was wearing an N95 mask. However, she kept pulling the N95 mask down and uncovered her nose and mouth while she was talking. In addition, the DON stated she could not hear the surveyor talking and kept getting closer to the surveyor (within six feet of the surveyor). The surveyor had to ask the DON to place her mask back over her mouth and nose. On 11/05/20 at 12:03 P.M. State tested Nursing Assistant (STNA) #200 was observed sitting in Resident #28's room. Resident #28 had transmission-based precautions in place and resided on the COVID-19 unit. Resident #28 was tested for COVID-19 on 11/03/20 and COVID-19 positive results were received on 11/06/20. STNA #200 was sitting in Resident #28's chair next to the head of bed. STNA #200 did not have proper PPE in place; she did not have any gloves, gown, or goggles/face shield in place. On 11/05/20 at 12:05 P.M. interview with STNA #200 verified she was not wearing a gown or gloves in Resident #28's room. The STNA verified the resident resided on the COVID-19 unit and had an order for [REDACTED]. On 11/09/20 at 12:12 P.M. interview with the Administrator revealed STNA #200 should have been wearing PPE in Resident #28's room. During the interview the Administrator verified Resident #28's COVID-19 test on 11/06/20 was positive. Review of the facility undated COVID-19 Residents: Screening and Management Policy revealed PPE must be donned correctly by staff before entering the patient area/room. For residents who were symptomatic or had pending COVID-19 results, staff should wear an N95 mask, eye protection, gloves, and gown when entering the resident's room. Review of the Infection Control Guidance dated 11/04/20 from the Centers for Disease Control and Prevention (CDC) revealed health care providers should follow standard precautions (hand hygiene, use of PPE such as gloves, masks, and eyewear) and transmission-based precautions (PPE equipment including gowns and gloves). They should also wear eye protection in addition to an N95 or higher-level respirator.

Based on observation and staff interview the facility failed to ensure the kitchen was maintained in a clean and sanitary manner to prevent contamination. This had the potential to affect 114 of 114 residents receiving nutritional services from the kitchen. The facility identified seven residents (#32, #56, #68, #90, #93, #102 and #117) not receiving nutritional services from the facility kitchen. The facility census was 121. Findings include: Observation of the kitchen on 03/10/2020 at 10:45 A.M. revealed a suspended heating unit above the food cook/prep area with a large amount of dust and grease build up and an extremely dirty air filter. Additional observation of the flat top back splash also revealed a moderate amount of grease and dust build up. Additional observation and interview with Dietary Staff #121 on 03/11/2020 at 9:00 A.M. verified the grease and dust to the suspended heating unit, dirty air filter to the heating unit and greasy and dusty flat top back splash.

Based on record review, interview and policy review the facility failed to ensure Hospice care was accurately reflected, care planned and coordinated for Resident #427 and failed to ensure an effective bowel regimen and/or bowel monitoring was completed for Resident #64, Resident #90 and Resident #110. This affected one resident (#427) of one resident reviewed for Hospice services and three residents (#64, #90 and #110) of five residents reviewed for unnecessary medication use. Findings include: 1. Record review revealed Resident #427 was admitted to the facility on [DATE] with stage four [MEDICAL CONDITION]. Medical record documentation revealed the resident was admitted with Hospice services. However, further review of Resident #427's medical record revealed no evidence of a Hospice certification. There was no evidence the type of Hospice services the resident required including frequency of nursing, aides, chaplain or social service visits. Interview on [DATE] from 11:15 A.M. to 12:44 P.M. with Registered Nurse (RN) #20 verified Resident #427's record did not contain a Hospice certification. The RN reported she did not know the frequency of visits the hospice nurse, aides, chaplain or social service were to make or what services they were to provide. She confirmed the Hospice plan of care that was developed for the resident was not resident specific and did not include this information. RN #20 called the Hospice provider on this date to obtain a copy of the Hospice certification. The Hospice provider faxed the certification, which upon review revealed it expired on [DATE]. RN #20 then called the provider back and they sent another certification, which expired [DATE] and reflected the resident was living at home with his daughter. RN #20 then reported the Hospice provider finally sent another certification, dated [DATE] to [DATE]. This certification revealed the the resident had chronic and acute [MEDICAL CONDITION] and required Hospice services. The certification still indicated the resident was living at home with his daughter (versus in a skilled nursing facility), however Hospice was able to provide RN #20 with a meeting review note, dated [DATE] that included the resident's diagnoses, medication list, durable medical supplies, diet, allergies [REDACTED]. During the interview, RN #20 revealed she wished Hospice would report to the unit mangers after each visit to coordinate care instead of reporting to the floor nurses as the floor nurses could float throughout the building. RN #20 revealed the facility State tested Nursing Assistants (STNA) did not have access to the Hospice plan of care and verified there were concerns regarding coordination of care between the facility and Hospice for Resident #427 after receiving a copy of the current certification and meeting minutes. Interview on [DATE] at 12:55 P.M. and 1:18 P.M. with Hospice Staff #37 revealed the last verification on file indicated the resident was living at home with his daughter and it had expired on [DATE]. Hospice #37 reported she would get medical records and fax an updated certification to the facility as soon as possible. Interview on [DATE] at 1:12 P.M. with STNA #400 revealed Hospice staff usually don't report or talk with the STNA staff at the facility. She reported in the past the Hospice aides visited on Tuesday and Thursday and she assumed the Hospice aides provide activities of daily living care to the residents, however she was not sure. 2. Review of Resident #64's medical record revealed and admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #64's current Minimum Data Set (MDS) 3.0 assessment revealed she was cognitively intact. Review of the resident's current plan of care, (initiated [DATE]) revealed the resident would have have regular bowel movements which was considered to be every two-three days. Review of Resident #64's Bowel Movement Record revealed the facility did not document the resident had any bowel movements from [DATE] to [DATE] or from [DATE] to [DATE]. Review of the [DATE] Medication Administration Record [REDACTED]. The February 2020 MAR indicated [REDACTED]. Interview on [DATE] at 3:22 P.M. with RN #20 confirmed the facility was not accurately tracking bowel movements or providing as needed medications to help prevent constipation for Resident #64. Review of the undated policy titled, Preventing Constipation, Doing Your Part revealed for any resident who had not had a bowel movement for greater than 72 hours, administer as needed medications as ordered for the resident. 3. Review of Resident #110's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED].>anxiety disorder, muscle weakness and major [MEDICAL CONDITION]. Review of the MDS 3.0 assessment, dated [DATE] revealed the resident was cognitively intact. Review of the resident's physician's orders [REDACTED]. Review of the resident's bowel movement form revealed the resident did not have a bowel movement from [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE] or [DATE] to [DATE]. Review of MAR indicated [REDACTED]. In February she only received Lubiprostone on [DATE] and [MEDICATION NAME] 5 mg on [DATE]. Interview on [DATE] at 2:00 P.M. with Resident #110 revealed she occasionally has problems with constipation. Interview on [DATE] at 03:19 P.M. with RN #20 revealed the resident was not documented to have had a bowel movement during the dates noted above and the nurses were not providing as needed medication for constipation as it was ordered for the resident. Review of the undated policy titled Preventing Constipation, Doing Your Part revealed for any resident who has not had a bowel movement for greater than 72 hours, administer as needed medications as ordered for the resident. 4. Review of Resident #90's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record including tracking of bowel movements revealed bowel movement tracking was not completed daily and/or every shift. Review of the State tested Nurse Aide (STNA) care tracker records revealed for the month of February 2020, there was no evidence of documentation regarding bowel movements recorded on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] [DATE] and [DATE]. Interview with RN #22 on [DATE] at 2:25 P.M. verified the above dates with no results recorded for bowel movements for Resident #90.

Based on observation, record review, policy review and interview the facility failed to comprehensively assess and implement an effective pain management program for Resident #111. Harm occurred to Resident #111 when the facility failed to assess and implement effective pain management during wound care which resulted in the resident having increased pain, moaning and crying during a treatment observation. This affected one resident (Resident #111) of two residents observed for pressure ulcer treatments. Findings include: Record review revealed Resident #111 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the record revealed no pain assessments were completed between 10/17/16 and 11/09/16. Review of the care plan titled, Pain revised 04/18/16 revealed no evidence the care plan was revised when the resident developed pressure ulcers. Interventions included to medicate the resident for pain as ordered and needed, encourage relaxation techniques, reposition and refer to therapies for interventions specific to cause of pain. Review of the Pain long term care (LTC) tool assessment dated [DATE] through 11/17/16 revealed pain assessments were only completed on 11/09/16 and 11/16/16. There was no evidence the resident was assessed for pain prior to pressure ulcer dressing changes. Review of the physician orders, dated (MONTH) (YEAR) revealed Resident #111 received [MEDICATION NAME] 5 milligrams (mg) sublingual (SL) four times a day and [MEDICATION NAME] 5 mg SL every four hours as needed (PRN) for pain or shortness of breath. On 11/16/16 between 11:00 A.M. and 11:31 A.M., observation of Resident #111's pressure ulcer dressing changes revealed the following: Licensed Practical Nurse (LPN) #500 and Registered Nurse (RN) #251 gathered supplies for treatment to Resident #111's left third finger and right lateral ankle. LPN #500 and RN #251 washed their hands, applied gloves, and removed a rolled wash cloth from the resident's contracted left hand. LPN #500 then applied saline wash to the wound, cut a square piece of polymem and placed it between the third and fourth finger. The rolled washcloth was then placed back in the resident's hand. Resident #111 was observed moaning and crying during the dressing change and no pain relieving interventions were attempted. LPN #500 and RN #251 then pulled the blanket up exposing the resident's lower extremities. Kling wrap was observed at mid-calf and the resident's right ankle did not have a dressing on it. The right ankle was pressed against the pillow and dried red drainage was observed on the pillow when the nurse lifted the resident's foot off the pillow. The resident cried out when the nurse lifted the right foot off the pillow and tears were observed in the resident's eyes. The nurse continued with the treatment without implementing any pain interventions. Review of the Medication Administration Record [REDACTED].M On 11/16/16 at 11:32 A.M., interview with LPN #500 verified Resident #111 was moaning and crying during the dressing changes, [MEDICATION NAME] PRN was not administered prior to the dressing change and she should have administered [MEDICATION NAME] PRN before the dressing change because she knew the dressing changes caused the resident pain. LPN #500 verified no pain interventions were implemented during Resident #111's pressure ulcer dressing change. On 11/16/16 at 3:10 P.M., interview with RN #301 verified Resident #111 complained of pain during the dressing change. RN #301 stated the resident cried, but it was a behavior the resident had. RN #301 verified the resident had a history of [REDACTED]. On 11/16/16 at 6:00 P.M., interview with RN #301 verified Resident #111's pain care plan had not been revised when the resident developed two pressure ulcers, pain assessments were not completed and interventions including to medicate for pain as needed was not implemented prior to the resident's dressing change. Review of the Pain Management Protocol dated 10/15/16 revealed residents were to receive the best level of pain control that can be safely provided. The presence of pain was to be assessed initially and at regular intervals including any new report or after any known pain producing event.

Based on medical record review and staff interviews, the facility failed to ensure medications to prevent blood clots (anticoagulants) were administered as ordered by the physician. This resulted in actual harm for Resident #1 who developed a blood clot in the leg and was admitted to the hospital. This deficient practice affected one (#1) of three residents reviewed for anticoagulant use. The facility identified 26 residents residing in the facility receiving anticoagulants. The total facility census was 129. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge instructions sent to the facility revealed the resident was to receive Xarelto (a drug for the prevention of venous blood clots) 10 milligrams (mg) every morning. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 11/07/13 at 10:14 A.M., an interview with the DON confirmed the facility missed the Xarelto order on the resident's admission. The DON stated when the error was found, the facility called the orthopedic surgeon, the family, the Nurse Practioner ,the primary care physician and the facility physician. Resident #1 was sent for a doppler ultrasound (a test that uses reflected sound waves to evaluate blood as it flows through a blood vessels). The doppler ultrasound indicated the resident had a [MEDICAL CONDITIONS], also known as a blood clot. The DON verified Resident #1 was subsequently admitted to the hospital with [REDACTED]. On 11/07/13 at 12:43 P.M. an interview with the DON verified Resident #1's anticoagulant medication was missed for five days due to a computer error. This deficiency substantiated complaint #OH 469.

Based on medical record review, review of hospital records, laboratory testing records, and staff interview, the facility failed to ensure safe and adequate monitoring of anti-convulsant medications. This affected three of 10 sampled residents of 13 residents who were identified as having [MEDICAL CONDITION] disorder (Residents #33, #62, and #72). Harm occurred when Resident #62 required hospitalization for [MEDICATION NAME] Toxicity on 07/24/11 following inadequate medication monitoring and improper medication administration. Findings include:1a. Review of Resident #62's medical record revealed re-admission to the facility occurred on 05/21/11 following [MEDICATION NAME] Toxicity.Review of the hospital records dated 05/20/11 revealed "mental status change secondary to [MEDICATION NAME] toxicity." Resident #62 was noted in the emergency room to have a [MEDICATION NAME] level of 26 microgram per milliliter (mcg/ml) (Normal values 10-20 mcg/ml). Review of the hospital discharge records dated 05/21/11 directed to "hold [MEDICATION NAME] for 24 hours" and repeat the [MEDICATION NAME] level daily for the next 5 days." Resident #62's [MEDICATION NAME] level at discharge from the hospital was 25 mcg/ml.Review of laboratory testing values dated 05/22/11 revealed the [MEDICATION NAME] level was 23.0 mcg/ml. On that date, the physician ordered the [MEDICATION NAME] held. Review of the [MEDICATION NAME] laboratory test completed 05/23/11 revealed the [MEDICATION NAME] level was 22.2 mcg/ml and remained high. On that date, the physician ordered the [MEDICATION NAME] to be held on 05/23/11 and 05/24/11. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., 05/23/11 at 8:30 A.M., and on 05/24/11 at 8:30 P.M., [MEDICATION NAME] 100 mg was administered. 1b. Resident #62's physician's orders [REDACTED]." Review of the medical record revealed no evidence any [MEDICATION NAME] level was obtained on 07/19/11. Review of the nursing notes evidenced other labs were drawn on that date, but, not a [MEDICATION NAME] level. Review of the record revealed a [MEDICATION NAME] level was obtained on 07/23/11. Resident #62's [MEDICATION NAME] level was critically high at 25.0 mcg/ml. Review of nursing notes dated 07/24/11 at 2:30 P.M. revealed Resident #62 was admitted to the hospital at 1:30 P.M. with [MEDICATION NAME] toxicity. 2. Review of Resident #72's medical record revealed admission to the facility occurred on 04/11/11 with medical [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. On 10/13/11 at 12:10 P.M., interview with Registered Nurse (RN) #98 confirmed the facility did not complete the laboratory testing as ordered by the physician on 08/31/11.The laboratory test for the [MEDICATION NAME] level was completed on 10/13/11. The [MEDICATION NAME] level was 6.7 mcg/ml, and was low. The normal range of [MEDICATION NAME] was 10-20 mcg/ml. The physician was notified on 10/13/11 and increased the dosage of [MEDICATION NAME] medication and ordered a monitoring of the blood level for 2 weeks. 3. Review of Resident #33's medical record revealed admission to the facility occurred on 08/30/10 with medical [DIAGNOSES REDACTED]. Review of the record revealed a physician's orders [REDACTED].Review of the laboratory results for Resident #33 revealed the [MEDICATION NAME] level was not obtained until 09/06/11. The laboratory test dated 09/06/11 revealed the [MEDICATION NAME] level was low at 4.9 mcg/ml. Review of the medical record revealed as of 10/14/11 no further laboratory testing or changes in medications were noted for Resident #33. On 10/14/11 at 10:58 A.M., interviews with Licensed Practical Nurses (LPNs) #770 and #780 confirmed the above resident's laboratory testings were not completed as ordered by the physician. The interviews further confirmed a low level of anticonvulsant medications could cause residents to have [MEDICAL CONDITION] and high levels could cause toxicity. This certification deficiency was an incidental finding identified during investigation of Complaint Number OH 741.