Every finding on record at Holzer Senior Care Center

Based on observation, record review, review of wound notes, facility policy review review and interview, the facility failed to assess, develop, and implement a comprehensive and individualized prevention program to prevent the development of avoidable pressure ulcers and ensure interventions were in place as ordered to prevent new or worsening pressure injuries for Resident #8 and #34. Actual Harm occurred on 04/17/25 when it was discovered that Resident #8, who was determined to be at risk for skin breakdown with no pressure ulcers upon admission, was assessed as cognitively impaired, incontinent, and required moderate (staff) assistance with bed mobility, developed an unstageable (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound.) pressure ulcer to her coccyx. Between 05/05/25 and 05/06/25 Resident #8's low air loss mattress was set to the wrong weight settings and on 05/07/25 staff failed to turn/reposition and/or offer turning and repositioning for three hours to Resident #8 to alleviate pressure to the coccyx area. This affected two residents (#8 and #34) of two residents reviewed for pressure ulcers. The facility census was 40. Findings include: 1. Record review revealed Resident #8 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of cervix uteri, dementia, and hyperlipidemia. Review of an order dated 04/01/25 revealed Resident #8 was to receive incontinence care every two hours and as needed. Review of a nurse's note dated 04/02/25 revealed Resident #8 had edema to bilaterally lower extremities and no mention of any other skin issues. Review of physician progress note dated 04/03/25 revealed Resident #8 with skin dry and no mention of any (skin) breakdown. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had moderately impaired cognition, had no behaviors, required moderate (staff) assistance for bed mobility and transfers, was frequently incontinent of bladder, occasionally incontinent of bowel, was at risk for pressure ulcers and had no pressure injuries noted. Review of dietary note dated 04/09/25 revealed Resident #8 was assessed with skin being intact per nursing evaluation upon admission. Review of nurse's note dated 04/14/25 revealed incontinence care given to Resident #8 and protective ointment applied to coccyx area. Review of a nursing note dated 04/17/25 at 12:47 P.M. revealed Resident #8 had a discolored area to her coccyx, the provider and family were aware. Review of orders revealed an order dated 04/17/25 for Resident #8 to have an alternating air mattress to her bed and to check it every shift for proper function every day and night shift for continued care. Review of a nursing note dated 04/17/25 at 4:51 P.M. revealed new orders were received for a discolored area on Resident #8's coccyx. Resident and family wished to discontinue all medications except for comfort care. The provider was made aware. Review of a Skin & Wound Evaluation dated 04/17/25 revealed Resident #8 had an unstageable pressure area due to slough and/or eschar to the sacrum which was in-house acquired on 04/17/25. The area of the wound was 0.9 centimeters (cm) squared with the length measuring 1.3 cm, the width 1.0 cm and the depth 0.1 cm. The wound bed was 100% eschar, no exudate or odor noted. The edges, surrounding tissue, induration, edema, peri wound temperature and wound pain were not assessed. The treatment was a generic wound cleanser and foam dressing. Review of a nursing note dated 04/21/25 at 5:18 A.M. revealed Resident #8 had a pressure area to her coccyx open with creamy, yellowish slough. It was cleansed with soap and water, triad paste applied then covered with Allevyn. The note documented Resident #8 refused to lay on her side and preferred to lay on her back. However, there was no evidence the facility attempted additional effective interventions to reduce pressure to the area. Review of a nursing note dated 04/22/25 at 12:52 P.M. revealed Resident #8 had a pressure area to coccyx open with white/yellow slough, wound care was provided per orders, and incontinence care/repositioning were completed every two hours. The note included Resident #8 was refusing to stay on her side. However, there was no evidence the facility attempted additional effective interventions to reduce pressure to the area. Review of a Skin & Wound Evaluation dated 04/24/25 revealed Resident #8 had an unstageable pressure area due to slough and/or eschar on her sacrum which was in-house acquired. The wound area was 1.6 cm squared, the length was 1.3 cm and the width was 1.5 cm. The depth was not able to be determined. The wound bed had slough, but did not specify what percentage. It was not assessed for evidence of infection or other concerns. There was no exudate. The surrounding tissue had erythema (redness of the skin- may be intense bright red to dark red or purple). The edges were not assessed. The wound was not assessed for induration or edema. The peri wound temperature was normal. The wound was not assessed for pain. The previous dressing was dry and intact. No information was provided regarding the application of a treatment and new dressing. The wound was classified as stable despite growth of wound area. Review of a nursing note dated 04/26/25 at 12:57 P.M. revealed Resident #8 continued to refuse to lay on her sides and would turn over on her back after repositioning. The dressing to coccyx was changed with no sloughing notes, the wound bed was pink and peri wound was pink and blanchable with no odor or pain present. Review of a Skin & Wound Evaluation dated 05/01/25 revealed Resident #8 had an unstageable pressure area due to slough and/or eschar to the sacrum. The wound was 2.2 cm squared. The length was 1.9 cm and the width was 1.5 cm. The depth was undetermined. The wound bed contained slough, but the percentage was not specified. It was not assessed for evidence of infection or other concerns. There was no exudate. The edges were not assessed. The surrounding tissue had erythema. The wound was not assessed for induration, edema, peri wound temperature or pain. The treatment which was removed was not assessed and there was no additional about a new treatment and dressing being applied after assessment. The wound was classified as stable despite growth of the wound area. Review of an order dated 05/02/25 revealed a treatment to Resident #8's coccyx including cleanse the discolored area on coccyx, apply triad paste and cover with Allevyn every shift. An additional order for 05/02/25 revealed Resident #8 needed turned and repositioned every two hours and as needed. Review of turn and repositioning documentation from 04/08/25 through 05/06/25 revealed staff were marking turning and repositioning as completed. Review of a dietary note dated 05/07/25 revealed Resident #8 weighed 70 pounds. Observation on 05/05/25 at 9:27 A.M. revealed Resident #8 was in bed with an alternating air mattress in place set to 320 pounds. Observation on 05/06/25 at 8:37 A.M. revealed Resident #8 was resting in her bed laying flat on her back. She had an alternating air mattress in place which was set to 320 pounds (firm). Observation and interview with Certified Nursing Assistant (CNA) #168 revealed Resident #8 was laying in her bed on her back and the alternating air mattress was set to 320 pounds. CNA #168 confirmed Resident #8 weight approximately 70 pounds. CNA #168 stated she does not know who would have adjusted the bed because she applied the mattress herself and had it set to the correct weight. Continuous observations were made of Resident #8 on 05/07/25 from 9:10 A.M. to 12:03 P.M. During that time, Resident #8 was laying on her back. No staff entered the room to completed turning and repositioning every two hours as ordered. Interview on 05/07/25 at 12:03 P.M. with Registered Nurse (RN) #158 confirmed Resident #8 was laying on her back and had not been repositioned. RN #158 stated Resident #8 did not like to be turned anyway. RN #158 then stated staff should still attempt to turn Resident #8. Observation of wound care for Resident #8 was made on 05/07/25 at 4:15 P.M. with RN #158. She assisted the CNA to position the resident onto her left side. Observation of the wound revealed top layer of skin missing, no bleeding, no drainage, no odor noted. The wound bed was clean, dark pink, surrounding tissue was intact pink blanchable. RN #158 applied Triad paste to the wound, covered with the Optifoam. CNA and nurse repositioned the resident. RN #158 wanted the resident to be on her side off of her back, resident kept saying no. RN #158 asked resident if they put a pillow under hip area, to keep pressure from bottom, and will set watch for 5 minutes and come back in and reposition her. Resident agreed and was placed on her right side. Interview on 05/08/25 at approximately 2:00 P.M. with Director of Nursing (DON) confirmed Resident #8's wound was in house acquired and her wound assessments were not completed in full as noted above. 28923 2. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, atrial fibrillation, peripheral vascular disease, generalized osteoarthritis, and obesity. Review of Resident #34's admission MDS assessment dated [DATE] revealed the resident had a functional limitation in her range of motion of her bilateral upper extremities. A wheelchair was one of the mobility devices being used. She was dependent on staff for transfers and ambulation had not occurred. She was assessed as being at risk for pressure ulcers, but did not have any unhealed pressure ulcers at that time. Review of Resident #34's nurses' progress notes revealed a nurse's note dated 04/10/25 at 8:00 P.M. that indicated the nurse was notified by a nursing assistant that the resident had a red area to her heel. Upon assessment, the nurse noted a non-blanchable red area to resident's left heel. The area measured 1 centimeter (cm) x 0.5 cm. Treatment was initiated and skin prep was applied and a pillow was placed under the resident's heels. Review of Resident #34's skin and wound evaluation dated 04/11/25 revealed the resident was assessed as having a pressure ulcer to her left heel that was staged as a deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration. It was indicated to be facility acquired with an onset date of 04/10/25. It measured 0.7 cm x 0.6 cm. An assessment of peri-wound area, presence of pain, and any additional care provided was not documented on the wound evaluation. The wound evaluation form used by the facility included a place for the nurse assessing the pressure ulcer to complete an assessment of those areas as part of the wounds overall assessment. The nurse assessing the wound left those areas of the assessment blank. Review of Resident #34's active care plans revealed she had a care plan in place for having an actual deep tissue injury on her left heel. The care plan was initiated on 04/16/25. The goal was for her pressure ulcer to show signs of healing and remain free from infection through the review date. The interventions included the need to have heel boots to her bilateral feet while up in her chair. They were also to assess her wound and record/ monitor the status of the wound weekly. They were to measure the wound, assess and document the status of the wound perimeter, wound bed, and healing progress. Review of Resident #34's physician's orders revealed an order was put in place for her to have a heel boot to her left foot while up in a chair every shift due to a pressure ulcer. The order was written on 05/05/25 at 2:53 P.M. The physician's orders were updated on 05/07/25 for the resident to use heel boots to her bilateral feet when up in her chair. Further review of Resident #34's weekly skin and wound evaluations completed after the initial wound evaluation on 04/11/25 revealed the nurses continued to not complete a comprehensive and thorough assessment of the resident's pressure ulcer to the left heel on a weekly basis. The skin and wound evaluation completed on 04/17/25 and 05/01/25 did not include an assessment of the peri-wound area, presence of any wound pain, and additional care provided to promote wound healing. The skin and wound evaluation completed on 04/24/25 did not identify the presence of any pain or additional care provided to promote wound healing. It included an assessment of the resident's wound bed, which indicated epithelial tissue was present, which could not have been present due to the wound bed being intact and epithelial tissue would only be present with the development of new skin. On 05/06/25 at 9:10 A.M., an observation of Resident #34 noted her to be sitting up in her wheelchair in her room. Her feet were edematous and she was wearing non-skid socks. She had her feet resting on the foot pedals of the wheelchair, but was not wearing any heel protectors at the time the observation was made. Ongoing observations on 05/06/25 at 12:15 P.M., and again on 05/07/25 at 8:32 A.M., noted Resident #34 to be up in her wheelchair, without her heel protector(s) on. It was not until 05/07/25 at 8:58 A.M. when the resident was observed for the first time in the past two days to have heel boot(s) on either of her feet while up in her wheelchair. On 05/07/25 at 9:01 A.M., an interview with the RN #500 confirmed Resident #34 just had her heel protectors put on her bilateral feet that were not previously in place, when an observation was made earlier that morning of the resident being up in her wheelchair without them. She was asked who applied the heel protectors on the resident's feet. She reported the facility's Administrator was just in there and had applied them to the resident's feet. She was informed the resident was observed on 05/05/25, 05/06/25, and again on 05/07/25, without heel protectors on either feet while the resident was up in her wheelchair. She claimed she had seen the resident with them on the day before, but that was while the resident was in bed. She acknowledged the use of heel protectors on the resident's feet while up in her chair was one of the interventions added to promote wound healing of her existing pressure ulcer to the left heel and to prevent any additional areas from developing. On 05/07/25 at 9:05 A.M., an interview with Resident #34 revealed she just had her heel protectors put on that morning. She denied that she had one on her left foot when she was up in her wheelchair the prior two days (05/05/25, 05/06/25) and did not have any on her feet while up in her chair earlier that morning, until the Administrator put them on her around 8:58 A.m. that morning. She reported her heel felt better when her heel boot was on compared to when she sat in the wheelchair without them. On 05/08/25 at 8:50 A.M., an interview with RN #500 revealed she was the facility's nurse that completed the weekly wound assessments for pressure ulcers. She stated she completed her assessments every Thursday. She denied the facility had a visiting wound physician or a nurse practitioner that came to the facility to assess wounds. If the resident would need to be seen by a wound doctor they sent them out to the local wound clinic. She confirmed the weekly wound assessments were not comprehensive, as not all areas on the assessments were being completed. She acknowledged there were missing assessments of the peri-wound area, presence of any pain, and additional care being provided to promote wound healing. She further acknowledged a couple of the assessments had the wound bed having epithelial tissue, which was not accurate as there would not have been the presence of any new skin if the wound had always been intact. She stated she did not complete the assessments that showed epithelial tissue being present in the wound bed and those assessments had been completed by another nurse in her absence. Review of the facility's procedure on Prevention of Pressure Injuries from Nursing Services Policy and Procedure Manual for Long-Term Care copyrighted in 2001 by Med_Pass Inc. revealed the purpose of the the procedure was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. They were to review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Under mobility/ repositioning, they were to reposition all residents with or at risk of pressure ulcers on an individualized schedule, as determined by the interdisciplinary care team. They were to provide support devices and assistance as needed.

Based on record review and interview, the facility failed to ensure Pre-Admission Assessment/Resident Reviews (PASRRs) were completed accurately to reflect diagnoses of serious mental illness. This affected four (#7, #12, #13, and #28) of four residents reviewed for PASRRs. The facility census was 40. Findings include: 1. Record review revealed Resident #7 admitted to the facility on [DATE] with diagnoses including cerebral infarction, unspecified psychosis, delusional disorders, major depression, and anxiety disorder. Review of a care plan revised on 10/31/18 revealed Resident #7 had depression related to diagnosis and signs and symptoms including false accusations, anger with shaking, sad facial expressions, tearfulness, and agitation. Review of a significant change PASRR completed 11/30/21 revealed Resident #7 had diagnoses including delusional disorders and other psychotic disorders. The PASRR did not reflect diagnoses of mood disorder (major depression) or anxiety disorders. Interview on 05/06/25 at 10:10 A.M. with Director of Resident Services (DRS) #300 revealed when a resident admits from the hospital, the hospital completes the PASRRs. Once a resident is in the facility, Admissions Coordinator (AC) #38 will complete them. DRS #300 stated she completes audits on PASRRs for their name, date of admission, and date the application was completed, then makes sure it was uploaded to the electronic medical record. DRS #300 confirmed Resident #7's PASRR was inaccurate and did not reflect diagnoses of major depression or anxiety. 2. Record review revealed Resident #12 admitted to the facility on [DATE] with diagnoses including type II diabetes, major depression, and anxiety disorder. A diagnosis of hallucinations was received on 09/18/23 and a new diagnosis of post-traumatic stress disorder (PTSD) was added on 01/16/24. Review of a PASRR completed 10/03/23 revealed Resident #12 had diagnoses of an anxiety disorder and other psychotic disorder (hallucinations). There was no indication Resident #12 had a mood disorder (major depression) or another mental disorder that may lead to chronic disability (PTSD). Review of a care plan revised on 02/06/25 revealed Resident #12 had a mood problem related to diagnoses of PTSD, anxiety, and depression. Interview on 05/06/25 at 10:18 A.M. with DRS #300 confirmed Resident #12's PASRR was not updated to reflect diagnoses of PTSD and depression. 34299 3. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including diabetes mellitus type two, atrial fibrillation and dementia with other behavioral disturbances. A new diagnosis of delusional disorder was added on 09/18/23. Review of the physician orders dated 05/25 revealed Resident #13 was ordered donepezil hydrochloride (a medication used to treat dementia) 10 milligrams by mouth one time daily for dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had intact cognition with no behaviors documented. Resident #13 required minimal assistance from the staff to complete activities of daily living. The assessment indicated Resident #13 diagnoses included dementia with behaviors and delusional disorder. Resident #13 did not receive psychoactive or antipsychotic medications. The nursing progress notes were silent related to adverse behaviors. Review of the plan of care initiated on 08/08/23 revealed Resident #13 had impaired cognitive function/dementia or impaired thought process related to dementia. The goal stated Resident #13 would maintain current level of decision making ability through the review date. The interventions included to administer medications as ordered, communicate with Resident #13 regarding capabilities and needs, reminisce using photos of family and friends, and use task segmentation to support short term memory deficits. Review of the PASSAR dated 06/08/23 on admission revealed Resident #13 had dementia with no serious mental illness. An interview with the Administrator on 05/06/25 at 1:22 P.M. confirmed a new PASSAR was not completed for Resident #13 with the new diagnosis of delusional disorder, dated 09/18/23. 28923 4. Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included the mental illness diagnoses of anxiety disorder and major depressive disorder at the time of his admission. Review of Resident #28's Pre-Admission Screening and Resident Review (PASARR) Identification Screen completed on 02/05/20 (prior to his admission into the facility) revealed the PASARR was being completed as an Ohio resident seeking a nursing facility admission. Section (D.) of the PASARR Identification Screening was to include any indications of serious mental illness by checking the box of any of the eight diagnoses listed to include: a.) schizophrenia, b.) mood disorder, c.) delusional (paranoid) disorder, d.) panic or other severe anxiety disorder, e.) Somatoform disorder, f.) personality disorder, g.) other psychotic disorder, and h.) another mental disorder other than mental retardation (MR) that may lead to a chronic disability; if so, describe. The resident was not listed as having any of those mental illness disorders. Review of Resident #28's Pre-admission determination dated 02/05/20 revealed, based on the information submitted, the resident did not have any indications of serious mental illness or a developmental disability. An in-person assessment was not required. Review of a PASARR result notice for Resident #28 dated 11/30/22 revealed a second PASARR had been submitted for a resident review. The PASARR identification screen that had been completed as part of that review was not included in resident's electronic medical record (EMR) or made available for review upon request from the facility's social service designee (SSD). It was not clear what mental illness diagnoses had been included on the identification screen during the resident's last review. The result notice only indicated that a referral had been made for a Level II evaluation to determine if the resident required any specialized services while in the facility. Review of Resident #28's notice of PASARR Level II outcome dated 12/05/22 revealed the resident had been ruled out from further PASARR review. It indicated based on the information they reviewed, they had determined that the resident was not subject to further review by the Ohio Department of Mental Health and Addiction Services. The evaluation at the time determined, through information obtained from a facility nurse, the resident had the diagnoses of anxiety disorder and dementia in other disease classified elsewhere, unspecified severity, without behavioral disturbance, mood disturbance, and anxiety; major depressive disorder, single episode, unspecified. Review of Resident #28's active diagnoses list (under the profile tab of the electronic medical record) revealed the resident had newly added mental illness diagnoses added, after he had been admitted to the nursing facility. Dementia, severe with psychotic disturbance and agitation was added on 04/06/23. Delusional disorder and unspecified psychosis were added on 06/12/23. Unspecified mood (affective) disorder was added on 09/13/23. Neurocognitive disorder with Lewy Bodies was added on 06/01/24. Resident #28's electronic medical record (EMR) was absent for any documented evidence of the resident having had another resident review completed since the last PASARR resident review was completed on 11/30/22. There was no evidence a new resident review had been submitted since the resident was given new diagnoses of mental illnesses beginning on 04/06/23. On 05/06/25 at 4:15 P.M., an interview with Social Service Designee #300 revealed she was not able to find Resident #28's resident review identification screen for the PASARR that was completed on 11/30/22. She confirmed there was no evidence of a new PASARR resident review being completed after the resident received new mental illness diagnoses beginning April 2023. She acknowledged the resident should have had another resident review completed following him receiving new diagnoses that were considered serious mental illnesses to determine the need for any Level II services. She denied she was the employee that submitted PASSAR reviews indicating they were usually completed by the facility's admissions coordinator. She denied the admissions coordinator was there that day and she was filling in for her, as she did when a PASARR was needing to be completed. She did not feel the facility was good about identifying when a new mental illness diagnoses was added that would require a new resident review.

Based on observation, interview and review of the Tuberculin or purified protein derivative (PPD) solution manufacturer guidelines revealed the multi dose vial was dated as opened on 03/19/25 and should be discarded in 30 days after opened. This had the potential to effect all new admissions to the facility from 03/19/25 through 05/07/25. The facility census was 40. Findings include: Observation of the medication storage room refrigerator on the Laural Hall of the facility revealed a multi dose vial of Tuberculin or purified protein derivative (PPD), a solution injected under the skin to determine if a person had been infected with the Tuberculosis bacteria, dated as opened on 03/19/25. Per the manufacturers guidelines and standards of practice, the multi dose vial of Tuberculin solution should be discarded 30 days after opened. An interview on 05/07/25 at 1:46 P.M. with Registered Nurse (RN) #158 confirmed the multi dose vial of Tuberculin was opened and dated 03/19/25. RN #158 confirmed the vial should have been discarded in 30 days after opened. The facility did not provide a policy related to storage of Tuberculin solution.

Based on record review, interview, and facility policy review, the facility failed to follow diagnostic criteria prior to the administration of antibiotics and failed to follow blood pressure medication parameters. This affected four (#16, #31, #34, and #194) of four residents reviewed for antibiotic stewardship. The facility census was 40. Findings include: 1. Record review revealed Resident #16 admitted to the facility on [DATE] with diagnoses including congestive heart failure, type II diabetes, and ileus. Review of a urinalysis dated [DATE] revealed urinalysis results did not meet the accepted criteria for culture to be performed. Review of a medication administration record (MAR) for [DATE] revealed Resident #16 received Cefdinir oral capsule (antibiotic) 300 milligrams (mg) one capsule by mouth two times a day for a urinary tract infection (UTI) for three days. The medications were administered as ordered. Review of the infection control log revealed no evidence of diagnostic criteria (McGeer's) being charted on for Resident #16. 2. Record review revealed Resident #194 admitted to the facility on [DATE] with diagnoses including vascular dementia, hyperlipidemia, and insomnia. Review of a urine culture dated [DATE] revealed Resident #194's urine contained 100,000 cfu/mL of Escherichia coli and ESBL. Review of a MAR from February 2025 revealed Resident #194 received Keflex oral capsule 500 mg one capsule by mouth two times a day for UTI for seven days. The medication was administered once on [DATE], twice on [DATE], and once on [DATE] before it was discontinued. Review of the infection control log revealed no documented diagnostic criteria (McGeer's) was completed for Resident #194 to determine if she met the criteria to receive an antibiotic for a UTI. Interview on [DATE] at 1:07 P.M. with Director of Nursing (DON) revealed Resident #16 did not have a McGeer's filled out because she admitted to the facility from the hospital with diagnosis of UTI and the prescribed antibiotic. DON stated Resident #193 had a fever and malaise in addition to the positive culture but was unable to provide evidence of a completed McGeer's criteria form, but did acknowledge while reviewing a blank McGeer's criteria for wound infection, it was required for a resident to have a positive culture and four symptoms of infection and Resident #193 only had two. DON stated Resident #194 had a positive urine culture but the McGeer's criteria was not completed to show what symptoms she had to meet criteria for antibiotics. DON stated Resident #194 had increased behaviors and confusion but acknowledged behaviors and confusion do not meet criteria for symptoms of infection per McGeer's criteria. DON stated she completes the McGeer's criteria by looking at the blank for and mentally checking the boxes but does not fill out a form for each potential infection. 34299 3. Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disorder, oxygen dependence, peripheral vascular disease, congestive heart failure, anxiety, dementia, depression, malignant neoplasm of unspecified kidney and diabetes mellitus type two. Review of the physician order dated [DATE] revealed Resident #31 was ordered doxycycline monohydrate 100 milligrams (mg) by mouth two times daily for a urinary tract infection for 11 days until finished. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 was cognitively intact with verbal behaviors directed towards others. Resident #31 was independent with toileting hygiene, personal hygiene and transfers. Resident #31 had occasional incontinence of the bladder. Resident #31 received oxygen therapy continuous and nebulizer breathing treatments. Review of the nursing progress notes revealed a note authored by the Director of Nursing (DON) dated [DATE] at 10:15 A.M. indicated Resident #31 complained of chest pain to the Certified Nursing Assistant (CNA). The nursing assessment revealed Resident #31 stated the pain was more of aching all over but grabbing at her chest. The vital signs included a temperature of 99.2 degrees Fahrenheit (F), respirations were 24, pulse was 61, oxygen saturation was 91%, and blood pressure was ,d+[DATE]. Resident #31 was up in her wheelchair with oxygen in place. Resident #31 was baseline confused however typically aware that husband was deceased . Resident #31 stated she had forgotten her husband had passed away, stated they just went to a party yesterday. The family was notified at this time of need to send to the emergency department for evaluation. Resident #31 refused but it was explained of need for evaluation and that family would be there with her and she agreed to go. 911 (emergency services) was notified of need to transport and report was called to the emergency department nurse. A nursing progress note authored by the DON on [DATE] at 10:58 A.M. revealed Resident #31 physician was made aware of resident being sent to emergency department for evaluation and agreed. A nursing progress note authored by Licensed Practical Nurse (LPN) #100 on [DATE] at 1:58 P.M. revealed she received report from the hospital that Resident #31 would be returning to the facility. Resident #31 had a little bit of excess fluid which was treated with Lasix (antidiuretic medication) 40 milligrams intramuscular and a slight urinary tract infection which was treated with Rocephin (antibiotic medication) intravenous and a prescription for a Z pack (Azithromycin, antibiotic medication). Resident #31 was ready for discharge and return to the facility. A nursing progress note authored by LPN #100 on [DATE] at 2:55 P.M. revealed Resident #31 returned to the facility via ambulance transport. Vital signs included temperature of 97.7 degrees F, respirations 24, pulse 68, oxygen saturation with oxygen on at four liters per minute via nasal cannula was 92% and blood pressure ,d+[DATE]. Resident #31 was happy to be back home and family was at bedside. A nursing progress note authored by Registered Nurse (RN) #176 on [DATE] at 6:39 P.M. revealed Resident #31 was in and out of bed this morning and complained of not feeling well. Resident #31 currently received an antibiotic for urinary tract infection, and denied any urinary signs and symptoms. There were no adverse reactions to the antibiotic observed. The nursing progress notes revealed no assessments, or signs and symptoms of urinary tract infection prior to being sent to the hospital on [DATE]. Observations made on [DATE], [DATE] and [DATE] of Resident #31 revealed no discomfort. Interview on [DATE] at 10:35 A.M. with Resident #31 revealed no complaints of pain, discomfort with urination, no incontinence, no urgency of urination, no nausea, or pain in back or flank area. Interview on [DATE] at 11:08 A.M. with Certified Nursing Assistant (CNA) #165 revealed Resident #31 had not complained of burning with urination or pain in back or flank area. CNA #165 stated Resident #31 did not have a fever in the past week. Review of the emergency department notes per the physician dated [DATE] revealed Resident #31 presented to the ED with complaints of flu like symptoms, headache, and body aches for tow to three days. The nursing home reported the resident wears oxygen at three liters per minute via nasal cannula. Review of systems revealed no abdominal pain, no nausea or vomiting and no urgency for urination. Vital signs included blood pressure ,d+[DATE], pulse 64, respirations 20 and temperature was 97.9 degrees F. Review of the urinalysis results revealed the following abnormalities: Resident #31 had small amount of protein and blood in her urine, a trace of Leukocyte esterase, and few bacteria. Resident #31 complete blood count results revealed no elevated white blood cell count (indication of infection). The physician progress note revealed Resident #31 chronic kidney disease was at baseline, urinalysis was infected-treat with Rocephin one gram intravenous and Azithromycin to cover upper respiratory and urine as the culture and sensitivity was pending. The diagnosis was urinary tract infection, upper respiratory infection and acute/choric congestive heart failure. Review of the preliminary culture and sensitivity of the urine date [DATE] revealed Resident #31 had presumptive gram negative growth. The final results will take 72 hours. An interview with the DON on [DATE] at 8:54 A.M. confirmed the attending physician was not notified of the Resident #31 return to the facility and an antibiotic for urinary tract infection. Also confirmed Resident #31 did not meet the criteria for antibiotic use for a urinary tract infection and remained on the antibiotic. The DON stated the facility policy was to wait for the culture and sensitivity results to start the antibiotic unless the physician documented otherwise. 28923 4. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included essential hypertension, congestive heart failure, and atrial fibrillation. Review of Resident #34's physician's orders revealed the resident had orders in place to receive Metoprolol Tartrate (beta blocker used in the treatment of hypertension) 25 milligrams (mg) by mouth (po) two times a day for hypertension. The order included parameters to hold the medication, if the resident's heart rate was below 60, or her systolic blood pressure (top number of a blood pressure reading) was less than 110. The resident also had an order to receive Amiodarone HCl (an antiarrhythmic used for the treatment/ prevention of an irregular heartbeat) 200 MG po two times a day for hypertension. The order included parameters to hold the medication if the resident's systolic blood pressure (SBP) was less than 110. Review of Resident #34's medication administration record (MAR) for [DATE] revealed on [DATE] at 8:00 P.M. the resident's blood pressure was recorded as being ,d+[DATE]. The nurse initialed the MAR to reflect the resident was given a dose of Amiodarone HCL 200 mg on [DATE] at 8:00 P.M. despite her SBP being less than 110 and the medication should have been held based on the parameters included in the order. On [DATE] at 8:00 P.M., the resident's heart rate was recorded as being 58 beats/ minute. The nurse initialed the MAR to reflect the resident was given her evening dose of Metoprolol Tartrate on [DATE] at 8:00 P.M. The Metoprolol Tartrate was not held as per the parameters included in the physician's orders when her heart rate was less than 60 beats/ minute. On [DATE] at 11:16 A.M., an interview with the facility's Director of Nursing (DON) and Administrator confirmed Resident #34 had received both her Amiodarone HCL and Metoprolol Tartrate twice in [DATE] when the medications should have been held, as specified in the parameters included with each order. They verified doses of those medications were given as indicated by the nurses adding their initials and not placing any code in the box on the MAR to reflect the medications had been held and not given. They were asked to provide any documented evidence to show the medications had not been given. No additional information was provided. Review of the facility's policy on Administering Medications from the Nursing Services Policy and Procedure Manual for Long-Term Care copyrighted in 2001 by Med-Pass, Inc. revealed medications were to be administered in a safe and timely manner, and as prescribed. Medications were to be administered in accordance with prescriber orders.

Based on record review, interview, and facility policy review, the facility failed to follow diagnostic criteria prior to the administration of antibiotics. This affected four (#16, #31, #193 and #194) of four residents reviewed for antibiotic stewardship. The facility census was 40. Findings include: 1. Record review revealed Resident #16 admitted to the facility on [DATE] with diagnoses including congestive heart failure, type II diabetes, and ileus. Review of a urinalysis dated [DATE] revealed urinalysis results did not meet the accepted criteria for culture to be performed. Review of a medication administration record (MAR) for [DATE] revealed Resident #16 received Cefdinir oral capsule (antibiotic) 300 milligrams (mg) one capsule by mouth two times a day for a urinary tract infection (UTI) for three days. The medications were administered as ordered. Review of the infection control log revealed no evidence of diagnostic criteria (McGeer's) being charted on for Resident #16. 2. Record review revealed Resident #193 admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, peripheral vascular disease, and anxiety disorder. Review of a wound culture dated [DATE] revealed Resident #193 had staphylococcus haemolyticus of an unstated amount in a wound. Review of a MAR from [DATE] revealed Resident #193 received Moxifloxin 400 mg one tablet by mouth one time a day for wound infection for one week. The medication was administered on [DATE] and Resident #193 was hospitalized starting on [DATE] and did not receive the rest of the ordered treatment in the facility. Review of the infection control log revealed no documented diagnostic criteria was completed for Resident #193 to determine if resident met wound infection criteria. 3. Record review revealed Resident #194 admitted to the facility on [DATE] with diagnoses including vascular dementia, hyperlipidemia, and insomnia. Review of a urine culture dated [DATE] revealed Resident #194's urine contained 100,000 cfu/mL of Escherichia coli and ESBL. Review of a MAR from February 2025 revealed Resident #194 received Keflex oral capsule 500 mg one capsule by mouth two times a day for UTI for seven days. The medication was administered once on [DATE], twice on [DATE], and once on [DATE] before it was discontinued. Review of the infection control log revealed no documented diagnostic criteria (McGeer's) was completed for Resident #194 to determine if she met the criteria to receive an antibiotic for a UTI. Interview on [DATE] at 1:07 P.M. with Director of Nursing (DON) revealed Resident #16 did not have a McGeer's filled out because she admitted to the facility from the hospital with diagnosis of UTI and the prescribed antibiotic. DON stated Resident #193 had a fever and malaise in addition to the positive culture but was unable to provide evidence of a completed McGeer's criteria form, but did acknowledge while reviewing a blank McGeer's criteria for wound infection, it was required for a resident to have a positive culture and four symptoms of infection and Resident #193 only had two. DON stated Resident #194 had a positive urine culture but the McGeer's criteria was not completed to show what symptoms she had to meet criteria for antibiotics. DON stated Resident #194 had increased behaviors and confusion but acknowledged behaviors and confusion do not meet criteria for symptoms of infection per McGeer's criteria. DON stated she completes the McGeer's criteria by looking at the blank for and mentally checking the boxes but does not fill out a form for each potential infection. 34299 4. Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disorder, oxygen dependence, peripheral vascular disease, congestive heart failure, anxiety, dementia, depression, malignant neoplasm of unspecified kidney and diabetes mellitus type two. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 was cognitively intact with verbal behaviors directed towards others. Resident #31 was independent with toileting hygiene, personal hygiene and transfers. Resident #31 had occasional incontinence of the bladder. Resident #31 received oxygen therapy continuous and nebulizer breathing treatments. Review of the physician order dated [DATE] revealed Resident #31 was ordered doxycycline monohydrate 100 milligrams (mg) by mouth two times daily for a urinary tract infection for 11 days until finished. Review of the nursing progress notes revealed a note authored by the Director of Nursing (DON) dated [DATE] at 10:15 A.M. indicated Resident #31 complained of chest pain to the Certified Nursing Assistant (CNA). The nursing assessment revealed Resident #31 stated the pain was more of aching all over but grabbing at her chest. The vital signs included a temperature of 99.2 degrees Fahrenheit (F), respirations were 24, pulse was 61, oxygen saturation was 91%, and blood pressure was ,d+[DATE]. Resident #31 was up in her wheelchair with oxygen in place. Resident #31 was baseline confused however typically aware that husband was deceased . Resident #31 stated she had forgotten her husband had passed away, stated they just went to a party yesterday. The family was notified at this time of need to send to the emergency department for evaluation. Resident #31 refused but it was explained of need for evaluation and that family would be there with her and she agreed to go. 911 (emergency services) was notified of need to transport and report was called to the emergency department nurse. A nursing progress note authored by the DON on [DATE] at 10:58 A.M. revealed Resident #31 physician was made aware of resident being sent to emergency department for evaluation and agreed. A nursing progress note authored by Licensed Practical Nurse (LPN) #100 on [DATE] at 1:58 P.M. revealed she received report from the hospital that Resident #31 would be returning to the facility. Resident #31 had a little bit of excess fluid which was treated with Lasix (antidiuretic medication) 40 milligrams intramuscular and a slight urinary tract infection which was treated with Rocephin (antibiotic medication) intravenous and a prescription for a Z pack (Azithromycin, antibiotic medication). Resident #31 was ready for discharge and return to the facility. A nursing progress note authored by LPN #100 on [DATE] at 2:55 P.M. revealed Resident #31 returned to the facility via ambulance transport. Vital signs included temperature of 97.7 degrees F, respirations 24, pulse 68, oxygen saturation with oxygen on at four liters per minute via nasal cannula was 92% and blood pressure ,d+[DATE]. Resident #31 was happy to be back home and family was at bedside. A nursing progress note authored by Registered Nurse (RN) #176 on [DATE] at 6:39 P.M. revealed Resident #31 was in and out of bed this morning and complained of not feeling well. Resident #31 currently received an antibiotic for urinary tract infection, and denied any urinary signs and symptoms. There were no adverse reactions to the antibiotic observed. The nursing progress notes revealed no assessments, or signs and symptoms of urinary tract infection prior to being sent to the hospital on [DATE]. Observations made on [DATE], [DATE] and [DATE] of Resident #31 revealed no discomfort. Interview on [DATE] at 10:35 A.M. with Resident #31 revealed no complaints of pain, discomfort with urination, no incontinence, no urgency of urination, no nausea, or pain in back or flank area. Interview on [DATE] at 11:08 A.M. with Certified Nursing Assistant (CNA) #165 revealed Resident #31 had not complained of burning with urination or pain in back or flank area. CNA #165 stated Resident #31 did not have a fever in the past week. Review of the emergency department notes per the physician dated [DATE] revealed Resident #31 presented to the ED with complaints of flu like symptoms, headache, and body aches for tow to three days. The nursing home reported the resident wears oxygen at three liters per minute via nasal cannula. Review of systems revealed no abdominal pain, no nausea or vomiting and no urgency for urination. Vital signs included blood pressure ,d+[DATE], pulse 64, respirations 20 and temperature was 97.9 degrees F. Review of the urinalysis results revealed the following abnormalities: Resident #31 had small amount of protein and blood in her urine, a trace of Leukocyte esterase, and few bacteria. Resident #31 complete blood count results revealed no elevated white blood cell count (indication of infection). The physician progress note revealed Resident #31 chronic kidney disease was at baseline, urinalysis was infected-treat with Rocephin one gram intravenous and Azithromycin to cover upper respiratory and urine as the culture and sensitivity was pending. The diagnosis was urinary tract infection, upper respiratory infection and acute/choric congestive heart failure. Review of the preliminary culture and sensitivity of the urine date [DATE] revealed Resident #31 had presumptive gram negative growth. The final results will take 72 hours. An interview with the DON also the Infection Preventionist on [DATE] at 8:54 A.M. confirmed the attending physician was not notified of the Resident #31 return to the facility and an antibiotic for urinary tract infection. Also confirmed Resident #31 did not meet the criteria for antibiotic use for a urinary tract infection and remained on the antibiotic. The DON stated the facility policy was to wait for the culture and sensitivity results to start the antibiotic unless the physician documented otherwise. Review of a policy titled Antibiotic Stewardship dated 2016 revealed antibiotic usage and outcome data with be collected and documented using a facility-approved antibiotic surveillance tracking form which will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. The form will include resident name and medical record number, unit and room number, date symptoms appeared, name of the antibiotics, start date for antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome and adverse events.

Based on record review and interview, the facility failed to ensure residents being offered a COVID vaccination received education regardless of if the vaccine was administered or not. This affected four (#7, #12, #22 and #25) of five residents reviewed for vaccination administration. The facility census was 40. Findings include: 1. Record review revealed Resident #7 admitted to the facility on [DATE] with diagnoses including cerebral infarction, locked-in state, and type II diabetes. Review of a COVID vaccination consent form dated 11/12/24 revealed Resident #7 provided consent to receive the vaccination, but did not specify if they received education on the vaccination prior to administration. 2. Record review revealed Resident #12 admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic obstructive pulmonary disease, and hyperlipidemia. Review of a COVID vaccination consent form dated 11/07/24 revealed Resident #12 provided consent to receive the vaccination, but did not specify if they received education on the vaccination prior to administration. 3. Record review revealed Resident #22 admitted to the facility on [DATE] with diagnoses including respiratory failure, type II diabetes, and chronic obstructive pulmonary disease. Review of a COVID vaccination consent form dated 11/07/24 revealed Resident #22 provided consent to receive the vaccination, but did not specify if they received education on the vaccination prior to administration. 4. Record review revealed Resident #25 admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic obstructive pulmonary disease, and asthma. Review of a COVID vaccination consent form dated 09/23/24 revealed Resident #25 provided consent to receive the vaccination, but did not specify if they received education on the vaccination prior to administration. Interview on 05/07/25 at 4 P.M. with Director of Nursing confirmed there was no evidence residents or family were educated prior to receiving the COVID vaccination.

Based on record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure comprehensive care plans were in place to address mental illness disorders and care plans were implemented in the areas of fall prevention, incontinence care, and pressure ulcer prevention. This affected four (Resident #12, #13, #21, and #34) of 17 residents reviewed for care planning. Findings include: 1. Review of Resident #21's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, vascular dementia, major depressive disorder, heart failure, osteoarthritis, chronic kidney disease (Stage II (mild), and irritable bowel syndrome. Review of Resident #21's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any speech and was rarely/ never able to make herself understood and was rarely/ never able to understand others. Her vision was highly impaired without the use of corrective lenses. She had short and long term memory impairment and her cognitive skills for daily decision making was severely impaired. She was known to have physical behaviors directed at others, but was not known to reject care. She was dependent on staff for bed mobility, transfers, and toileting hygiene. The resident was always incontinent of her bowel and bladder and not on a toileting program. 1 a.) Review of Resident # 21's physician's orders revealed the resident had an order in place for her to be in a low bed at all times. The physician's order was dated 08/04/23. Review of Resident #21's active care plans revealed she had a care plan in place for being at risk for falls related to confusion and incontinence. She was indicated to be unaware of her safety needs and also had an unsteady gait. The goal was for her to have a minimal risk for falls. The interventions included the need for her bed to be maintained in the lowest position while she was in bed. That intervention was added on 09/16/24. On 05/06/25 08:36 AM, an observation of Resident #21 noted her to be in bed with the head of her bed (HOB) raised at a 45 degree angle. Her bed was not noted to be in it's lowest position, but she did have fall mats on the floor at the bedside. She was awake and was looking around her room. There were no staff present with the resident when the observation was made. On 05/06/25 at 8:50 A.M., an interview with Certified Nursing Assistant (CNA) #335 revealed she had been in Resident #21's room that morning when assisting her with her breakfast. She stated she left the resident's HOB elevated to help her digest her food. She confirmed she did not lower the resident's bed to it's lowest position, when she left the resident unattended in her room. She stated it was around 8:00 A.M. when she finished feeding the resident and left the room. At the time of the interview, the resident's bed had been placed in it's lowest position. She denied that she re-entered the resident's room to lower her bed, but one of the other aides (CNA #400) had been in there, after the resident was assisted with her breakfast and may have lowered the bed to it's lowest position. On 05/06/25 at 9:01 A.M., an interview with CNA #400 confirmed he had been in Resident #21's room, after she was assisted with her breakfast by another aide. He indicated he was in the resident's room sometime around 8:45 A.M. and lowered the resident's HOB and the height of her bed to it's lowest position. He noted the resident's bed was not in it's lowest position, as it should have been, when he was walking down the hall and looked into her room. He further confirmed keeping the resident's bed in it's lowest position was one of her fall prevention interventions. Review of the facility's policy on Managing Falls and Fall Risk from Nursing Services Policy and Procedure Manual for Long-Term Care copyrighted in 2001 revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input from the attending physician, would implement a resident- centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If interventions have been successful in preventing falling, staff would continue the interventions or reconsider whether those measures were still needed if a problem that required the intervention had resolved. 1 b.) Review of Resident #21's active care plans revealed the resident had a care plan in place for being at risk for pressure ulcer development or skin integrity complications related to incontinence. The goal was for her to have minimal skin related issues i.e. her skin would remain intact, free of redness, blisters, or discoloration through the review date. Review of Resident #21's physician's orders revealed it included the need to provide the resident with incontinence care every two hours and as needed (prn). That order originated on 05/27/22. On 05/06/25 at 9:05 A.M., an observation of Resident #21 noted CNA #400 to enter her room to assist the resident with personal care. The resident was still in bed when CNA #400 entered her room, but was noted to have been dressed and placed in her wheelchair at the time he left her room. Ongoing observations made of Resident #21 on 05/06/25 from 9:05 A.M. through 1:30 P.M. revealed she had not been assisted with incontinence care or even checked for incontinence by the facility staff every two hours as ordered/ per her plan of care. Direct observations of the resident in her room was maintained from the nurse's station through 11:34 A.M., when the resident was taken out of her room to the dining room for lunch by her husband. On 05/06/25 at 12:20 P.M., an observation noted Resident #21 to be back in her room, after her lunch, with her husband still present. An interview with the resident's husband revealed none of the facility's staff had been in to check on the resident or offer to change her while he had been in the facility and with the resident since 10:45 A.M. The last time the resident would have been checked and changed would have been at 9:05 A.M., when CNA #400 was observed in her room assisting her with care (3 hours and 15 minutes earlier). The resident's husband reported he typically visited the resident twice a day and was usually there for two or two and a half hours for every lunch and dinner meal. He denied the staff would come in and check the resident or offer to change her when he was there. There had been times he noted the resident to have an odor to her and he would have to go out and tell the staff he thought she may need checked for incontinence. On 05/06/25 at 1:30 P.M., an interview with CNA #335 revealed Resident #21 was incontinent. She denied the resident knew when she was incontinent and was supposed to be on a check and change schedule every two hours. She reported the aides working on that side of the building all helped one another, but she was not the CNA assigned to the resident's room that day. She covered the back half of the hall the resident resided on. She denied she had been in the resident's room to change her that day and indicated CNA #400 was assigned to the resident's room. She had seen him in there earlier that morning, but was not sure of the time. On 05/06/25 at 1:31 P.M., an interview with CNA #400 revealed Resident #21 was known to be incontinent of her bladder at all times. He denied she was able to alert them when she was incontinent or when she needed to use the bathroom. The last time he provided care to her was around 9:00 A.M., when he reported he was in there to get her up for the day. They would check and change her again after lunch. He indicated they tried to check and change her every two hours. He acknowledged, with the last time he checked the resident, it had been four and a half hours since she had been provided any incontinence care and that was not following her orders or plan of care. The facility's Administrator denied they had a policy specific to completing rounds or assisting incontinent resident's with incontinence care. She provided a policy on Briefs/ Underpads, but that was the procedure that should be followed on how to change briefs/ underpads and not the frequency in which that should be done. 2. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, atrial fibrillation, peripheral vascular disease, generalized osteoarthritis, and obesity. Review of Resident #34's admission MDS assessment dated [DATE] revealed the resident had a functional limitation in her range of motion of her bilateral upper extremities. A wheelchair was one of the mobility devices being used. She was dependent on staff for transfers and ambulation had not occurred. She was assessed as being at risk for pressure ulcers, but did not have any unhealed pressure ulcers at that time. Review of Resident #34's active care plans revealed she had a care plan in place for having an actual deep tissue injury (a type of pressure injury where damage occurs in the underlying soft tissues, often beneath the skin's surface, due to pressure or shear forces) on her left heel. The care plan originated on 04/16/25. The goal was for her pressure ulcer to show signs of healing and remain free from infection through the review date. The interventions included the need to have a heel boot to her left heel while up in her wheelchair. Review of Resident #34's physician's orders revealed an order was put in place for her to have a heel boot to her left foot while up in a chair every shift due to a pressure ulcer. The order was written on 05/05/25 at 2:53 P.M. On 05/06/25 at 9:10 A.M., an observation of Resident #34 noted her to be sitting up in her wheelchair in her room. Her feet were edematous and she was wearing non-skid socks. She had her feet resting on the foot pedals of the wheelchair, but was not wearing any heel protectors at the time the observation was made. Ongoing observations on 05/06/25 at 12:15 P.M., and again on 05/07/25 at 8:32 A.M., noted Resident #34 to be up in her wheelchair, without her heel protectors on. It was not until 05/07/25 at 8:58 A.M. when the resident was observed for the first time in the past two days to have heel boots on her bilateral feet while up in her wheelchair. On 05/07/25 at 9:01 A.M., an interview with the RN #500 confirmed Resident #34 just had her heel protectors put on her bilateral feet that was not previously in place, when an observation was made earlier that morning of the resident being up in her wheelchair without them. She was asked who applied the heel protectors on the resident's feet. She reported the facility's Administrator was just in there and had applied them to the resident's feet. She was informed the resident was observed on 05/05/25, 05/06/25, and again on 05/07/25, without heel protectors on while the resident was up in her wheelchair. She claimed she had seen the resident with them on the day before, but that was while the resident was in bed. She acknowledged the use of heel protectors on the resident's feet when up in her wheelchair was one of her skin prevention interventions used. She further acknowledged the resident had a DTI to her left heel that they continued to treat. On 05/07/25 at 9:05 A.M., an interview with Resident #34 revealed she just had her heel protectors put on that morning. She denied that she had one on her left foot when she was up in her wheelchair the prior two days (05/05/25 and 05/06/25). She reported her heel felt better when her heel boot was on compared to when she sat in the wheelchair without them. 47985 3. Record review revealed Resident #12 admitted to the facility on [DATE] with diagnoses including type II diabetes, major depression, and anxiety disorder. A diagnosis of hallucinations was received on 09/18/23 and a new diagnosis of post-traumatic stress disorder (PTSD) was added on 01/16/24. Review of orders revealed Resident #12 has an order in place dated 11/10/23 for prazosin 2 milligrams by mouth daily for PTSD. Review of an MDS completed on 10/22/24 revealed Resident #12's cognition remained intact, had no behaviors, and had diagnoses including anxiety disorder, depression, and PTSD. Review of a care plan revised on 02/06/25 revealed Resident #12 had a mood problem related to PTSD, ADHD, anxiety and depression. The goal was to maintain or improve mood state with interventions including, but not limited to, administer meds as ordered, encourage to express feelings, monitor for mood patterns and report to provider. There was no evidence of a comprehensive care plan to explain circumstances of PTSD, triggers or interventions specific to PTSD. Interview on 05/07/25 at 10:12 A.M. with Director of Resident Services (DSR) #300 confirmed Resident #12 did not have any sort of care plan specific to PTSD, triggers and interventions. 34299 4. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including diabetes mellitus type two, atrial fibrillation and dementia with other behavioral disturbances. A new diagnosis of delusional disorder was added on 09/18/23. Review of the physician orders dated 05/25 revealed Resident #13 was ordered donepezil hydrochloride (a medication used to treat dementia) 10 milligrams by mouth one time daily for dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had intact cognition with no behaviors documented. Resident #13 required minimal assistance from the staff to complete activities of daily living. The assessment indicated Resident #13 diagnoses included dementia with behaviors and delusional disorder. Resident #13 did not receive psychoactive or antipsychotic medications. The nursing progress notes were silent related to adverse behaviors. Review of the plan of care initiated on 08/08/23 revealed Resident #13 had impaired cognitive function/dementia or impaired thought process related to dementia. The goal stated Resident #13 would maintain current level of decision making ability through the review date. The interventions included to administer medications as ordered, communicate with Resident #13 regarding capabilities and needs, reminisce using photos of family and friends, and use task segmentation to support short term memory deficits. The plan of care for Resident #13 did not address delusional behaviors and was not added to the dementia plan of care. An interview with the Administrator on 05/06/25 at 1:22 P.M. confirmed the plan of care for Resident #13 did not address the diagnosis of delusional behaviors.

Based on record review and interview the facility failed to notify the state agency of a significant change to the Pre Admission Screening and Resident Review (PASSAR) for Resident #13. This effected one (Resident #13) of four residents reviewed for PASSAR. The facility census is 40. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including diabetes mellitus type two, atrial fibrillation and dementia with other behavioral disturbances. A new diagnosis of delusional disorder was added on 09/18/23. Review of the physician orders dated 05/25 revealed Resident #13 was ordered donepezil hydrochloride (a medication used to treat dementia) 10 milligrams by mouth one time daily for dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had intact cognition with no behaviors documented. Resident #13 required minimal assistance from the staff to complete activities of daily living. The assessment indicated Resident #13 diagnoses included dementia with behaviors and delusional disorder. Resident #13 did not receive psychoactive or antipsychotic medications. The nursing progress notes were silent related to adverse behaviors. Review of the plan of care initiated on 08/08/23 revealed Resident #13 had impaired cognitive function/dementia or impaired thought process related to dementia. The goal stated Resident #13 would maintain current level of decision making ability through the review date. The interventions included to administer medications as ordered, communicate with Resident #13 regarding capabilities and needs, reminisce using photos of family and friends, and use task segmentation to support short term memory deficits. Review of the PASSAR dated 06/08/23 on admission revealed Resident #13 had dementia with no serious mental illness. An interview with the Administrator on 05/06/25 at 1:22 P.M. confirmed a new PASSAR was not completed for Resident #13 with the new diagnosis of delusional disorder, dated 09/18/23. Additionally, the state mental health authority was not notified to complete a Level two assessment. The facility did not provide a facility policy for completing a PASSAR.

Based on observation, interview, review of the manufacturer's guidelines and per the standards of practice the facility failed to ensure Resident #31's insulin was administered per the standard of practice and manufacturer's guidelines. This effected one ( Resident #31) of two residents reviewed for insulin administration. The facility census was 40. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disorder, oxygen dependence, peripheral vascular disease, congestive heart failure, anxiety, dementia, depression, malignant neoplasm of unspecified kidney and diabetes mellitus type two. Review of the Medication Administration Record (MAR) dated 05/25 revealed Resident #31 had an order for accucheck blood sugar before meals and at bedtime and an order for sliding scale insulin based on the blood sugar results. Resident #31 sliding scale order stated Novolog Insulin Aspart injection solution to inject subcutaneous as per sliding scale: if 100-149 inject two units, if 150-199 inject four units, if 200-249 inject six units, if 250-299 inject eight units, if 300-349 inject 10 units, if 350-399 inject 12 units, if 400-449 inject 14 units and notify the physician. Review of the last seven days Resident #31 received insulin as ordered. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 was cognitively intact with verbal behaviors directed towards others. Resident #31 was independent with activities of daily living requiring oversight only. Resident #31 received insulin injection seven of seven days during the look back period. Review of the plan of care initiated 09/11/23 revealed Resident #31 was at risk for complications related to diabetes mellitus fluctuations in blood sugar. The goal stated Resident #31 would have minimal complications related to diabetes through the review date. The interventions included to administer diabetic medication as ordered by physician, monitor and document side effects and effectiveness, monitor for compliance with diet and document any problems, and offer substitutes for foods not eaten. Observation of the medication administration on 05/07/25 at 11:15 A.M. with Registered Nurse (RN) #158 revealed Resident #31 accucheck blood sugar was 137. Resident #31 was to receive two units of the Novolog Insulin Aspart subcutaneous per the sliding scale physician order. RN #158 hand sanitized, donned gloves, used an alcohol prep wipe to clean the end of the insulin pen, and placed the needle on the end of the injection pen. RN #158 then dialed back to two and one half units to prime the injection pen. RN #158 then pushed the plunger until it reached two units. RN #158 administered the two units of Novolog insulin to Resident #31, holding the plunger down for two to three seconds, and removed. Discarded the needle into the red sharps container on the medication cart. An interview with RN #158 on 05/07/25 at 11:43 A.M. confirmed that priming the insulin injection pen should include pushing the entire two units out and observe the insulin coming from the needle to ensure the insulin pen was primed. Also, confirmed with RN #158 she held the insulin pen injector plunger in place for two to three seconds and the guidelines stated to hold in place for 10 seconds. Review of the Novolog insulin flexpen instructions/guidelines revealed for each injection the nurse should select a dose of two units. Take off the outer needle cap (save it) and inner needle cap (throw it away), and with the pen pointing up, tap the insulin to move the air to the top, press the plunger button all the way in and make sure insulin comes out of the needle. May repeat up to two more times with the same needle if needed. If the insulin does not come out after three times, change the needle and try again. If the insulin still does not come out after changing the needle, the pen may be broken. The nurse should check the dose counter to ensure it showed zero, after the safety test. Turn the dose counter to the number of Novolog flexpen units that equals the dose, clean the injection site with an alcohol swab and wait for the alcohol to dry. Put the needle into the skin all the way, press and hold the button (plunger) to give the dose and slowly count to 10 before taking the needle out of the skin. The facility did not provide a policy for insulin pen injector procedure.

Based on record review, observation, and interview, the facility failed to ensure residents who were dependent on staff for personal care received the assistance needed with incontinence care and the removal of unwanted facial hair as per their plan of care. This affected two (Resident #1 and #21) of two residents reviewed for activities of daily living (ADL's). The facility census was 40. Findings include: 1. Review of Resident #21's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, vascular dementia, major depressive disorder, heart failure, osteoarthritis, chronic kidney disease (Stage II (mild), and irritable bowel syndrome. Review of Resident #21's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was non-verbal and was rarely/ never able to make herself understood. She was also rarely/ never able to understand others. She had short and long term memory impairment and her cognitive skills for daily decision making was severely impaired. She was known to have physical behaviors directed at others, but was not known to reject care. She was dependent on staff for bed mobility, transfers, and toileting hygiene. The resident was always incontinent of her bowel and bladder and not on a toileting program. Review of Resident #21's quarterly bladder profile dated 03/12/25 revealed the resident's causative risk factors for incontinence included dementia, obesity, constipation, age over 65, and being incontinent. She was indicated to have been incontinent for years and was always incontinent. She had confusion and was dependent on staff for transfers and toileting. She was not able to comprehend and could not request toilet use. Disposable undergarments were used and the resident was a check and change every two hours. No change in her bladder function had been noted since her prior assessment and were going to continue her current toilet plan. Review of Resident #21's active care plans revealed she had a care plan in place for having the potential for skin impairment related to a history of yeast in her peri-area and buttocks. The interventions included the need to keep her skin clean and dry. She also had a care plan for being at risk for pressure ulcer development or skin integrity complications related to incontinence and impaired mobility. The interventions for that care plan indicated the resident was to receive incontinence care every two hours and as needed. Review of Resident #21's physician's orders revealed she had an order in place for incontinence care to be provided every two hours and as needed (prn). That order originated on 05/27/22. Barrier cream was to be applied to her buttocks every shift and prn as preventative. On 05/06/25 at 9:05 A.M., an observation of Resident #21 noted Certified Nursing Assistant (CNA) #400 to enter her room to assist the resident with personal care. The resident was still in bed when CNA #400 entered her room, but was noted to have been dressed and placed in her wheelchair at the time he left her room. Ongoing observations made of Resident #21 on 05/06/25 from 9:05 A.M. through 1:30 P.M. revealed she had not been assisted with incontinence care or even checked for incontinence by the facility staff every two hours as ordered/ per her plan of care. Direct observations of the resident in her room was maintained from the nurse's station through 11:34 A.M., when the resident was taken out of her room to the dining room for lunch by her husband. On 05/06/25 at 12:20 P.M., an observation noted Resident #21 to be back in her room, after her lunch, with her husband still present. An interview with the resident's husband revealed none of the facility's staff had been in to check on the resident or offer to change her while he had been in the facility and with the resident since 10:45 A.M. The last time the resident would have been checked and changed would have been at 9:05 A.M., when CNA #400 was observed in her room assisting her with care (3 hours and 15 minutes earlier). The resident's husband reported he typically visited the resident twice a day and was usually there for two or two and a half hours for every lunch and dinner meal. He denied the staff would come in and check the resident or offer to change her when he was there. There had been times he noted the resident to have an odor to her and he would have to go out and tell the staff he thought she may need checked for incontinence. On 05/06/25 at 1:30 P.M., an interview with CNA #335 revealed Resident #21 was incontinent. She denied the resident knew when she was incontinent and was supposed to be on a check and change schedule every two hours. She reported the aides working on that side of the building all helped one another, but she was not the CNA assigned to the resident's room that day. She covered the back half of the hall the resident resided on. She denied she had been in the resident's room to change her that day and indicated CNA #400 was assigned to the resident's room. She had seen him in there earlier that morning, but was not sure of the time. On 05/06/25 at 1:31 P.M., an interview with CNA #400 revealed Resident #21 was incontinent of her bladder at all times. He denied she was able to alert them when she was incontinent or when she needed to use the bathroom. The last time he provided care to her was around 9:00 A.M., when he was in there to get her up for the day. They would check and change her again after lunch. He indicated they tried to check and change her every two hours. He acknowledged, with the last time he checked and provided care to the resident at around 9:00 A.M., it had been four and a half hours since the resident was last checked and changed. He further acknowledged they were not following the resident's plan of care to be a check and change every two hours. The facility's Administrator denied they had a policy specific to completing rounds or assisting incontinent resident's with incontinence care. She provided a policy on Briefs/ Underpads, but that was the procedure that should be followed on how to change briefs/ underpads and not the frequency in which that should be done. 47985 2. Record review revealed Resident #1 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, muscle weakness, and hypertension. Review of a care plan revised on 11/07/18 revealed Resident #1 had or was at risk for an unavoidable decline in ADL self-care performance related to dementia, fatigue and limited range of motion. The goal was to maintain current level of function through the review date with interventions including but not limited to one staff assist for bathing. There was no indication of level of assistance needed for personal hygiene. Review of an MDS completed on 04/03/25 revealed Resident #1 had severely impaired cognition, no behaviors, and was dependent on staff for bathing and personal hygiene. Observation on 05/05/25 at 1:42 P.M. revealed Resident #1 had short, stubbly gray hairs covering her chin. Observation on 05/06/25 at 8:41 A.M. and 1:53 P.M. revealed Resident #1 continued to have short, stubbly gray hair covering her chin. Interview on 05/06/25 at 2:47 P.M. with CNA #168 revealed Resident #1 is usually shaved by night shift because they get her up and ready for the day every morning, but if Resident #1 were to need shaving, she would do it. CNA #168 stated Resident #1's hair does grow fast but it can be hard to see due to the angle she keeps her head while sitting in her chair. Observation and interview on 05/06/25 at 3:12 P.M. with CNA #168 confirmed Resident #1's chin was covered in hair. CNA #168 asked Resident #1 if she would like her chin shaved, and Resident #1 stated yes.

Based on record review, observation, and interview, the facility failed to ensure a resident was properly positioned when up in a specialized wheelchair and another resident received appropriate intervention when they went without a bowel movement for six days. This affected one (Resident #28) of two residents reviewed for positioning and one (Resident #8) of two residents reviewed for nutrition. The facility census was 40. Findings include: 1. Review of Resident #28's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included Parkinson's disease, neurocognitive disorder with Lewy Bodies, dementia with psychotic disturbance and agitation, muscle wasting and atrophy, restlessness and agitation, muscle weakness, rheumatoid arthritis, abnormalities of gait and mobility, and a history of falls. Review of Resident #28's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had unclear speech. He was rarely/ never able to make himself understood and was rarely/ never able to understand others. He had short and long term memory impairment and his cognitive skills for daily decision making was severely impaired. He was not indicated to have any functional limitations in his range of motion and a wheelchair was the only mobility device he was known to use. He was dependent on staff for chair/ bed to chair transfers and was dependent on staff for wheelchair mobility using manual wheelchair. Review of Resident #28's active care plans revealed he had a care plan in place for having or being at risk for an unavoidable decline in activities of daily living (ADL) self-care related to dementia and fatigue. The interventions included the use of a two person Hoyer lift transfer as needed and the need of a wheelchair for locomotion. The care plan was not specific in regard to the type of wheelchair to be used. Review of Resident #28's physician's orders revealed the resident was to be a Hoyer lift for all transfers as needed. He was also indicated to need a cushion when in his wheelchair, but the physician's orders did not specify the type of wheelchair to be used. On 05/05/25 at 10:53 A.M., an observation of Resident #28 revealed he was sitting up in a tilt space wheelchair in his room. The tilt space wheelchair was reclined back and left his legs/ feet dangling and not in contact with the floor. His tilt space wheelchair was not noted to have any leg rests or any other type of device to help support his legs. Ongoing observations of Resident #28 on 05/06/25 at 8:21 A.M. and again on 05/07/25 at 8:20 A.M. noted the resident to be sitting up in his tilt space wheelchair in his room. He continued to have his legs/ feet dangling over the seat of the wheelchair, as he was reclined back. His feet were between two and six inches off the floor when the three separate observations were made. On 05/07/25 at 10:32 A.M., an interview with Certified Occupational Therapist Assistant (COTA) #215 revealed she had worked with Resident #28 in the past. The last time she worked with the resident was about six or seven months ago and she was working with him for feeding assistance and transfers to the toilet. They had worked with him a little for positioning, but was not sure if that was this past time or the time before. They worked on core strength when they were working on his positioning and not wheelchair management. She denied the resident was able to self propel himself in the wheelchair and had not been able to do that using his arms in a long time. They had worked on positioning in the wheelchair in the past. She confirmed he had the use of a tilt space wheelchair. She was not certain where the wheelchair came from and indicated it may have came from their wheelchair representative. She recalled they were checking into him paying privately for a new wheelchair. She was not sure if that happened or not. She reported the resident would occasionally use his legs to propel the wheelchair, but it was sporadic and was not purposeful movement. He was not capable of that due to his cognitive impairment. She was asked to accompany the surveyor to the resident's room. She confirmed the resident's wheelchair was tilted back in a way that it raised his feet off the floor. She confirmed his legs/ feet were dangling and there were not any footrests on his wheelchair to support his legs. She reported he should not be positioned like that and he either needed to be tilted more forward to allow his feet to come into contact with the floor or they needed to have footrests on his wheelchair to support his legs. She stated leaving him in that position without his legs properly supported or his feet in contact with the floor would result in pressure to the back of his knees. She had seen him with footrests on his wheelchair last week. She searched his room and found them in his wardrobe. She attempted to put them on the wheelchair, but they were too short for his size and he was not able to comfortably bend his knees to get his feet on the foot pedals. She stated she would have to see if they could adjust them or get him a longer pair. On 05/07/25 at 10:52 A.M., an interview with Rehab. Director #275 revealed Resident #28 was utilizing a re-purposed wheelchair. It belonged to another resident who had had passed away and was donated it to the facility. He reported the resident's wife did not want to pursue the purchase of a new wheelchair for the resident so they started to use that one. 47985 2. Record review revealed Resident #8 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of cervix uteri, hyperlipidemia, and dementia. Review of orders revealed an order dated 04/01/25 for Resident #8 to receive Miralax 17 grams (GM) give one scoop by mouth every 24 hours as needed for constipation. Review of an MDS dated [DATE] revealed Resident #8 had moderately impaired cognition, required moderate assistance for toileting hygiene, and was occasionally incontinent of bowel. Review of orders revealed an order dated 04/15/25 for Resident #8 to receive hemmorex-HC rectal suppository insert one application rectally as needed for hemmoroids. Review of bowel elimination records revealed Resident #8 did not have a bowel movement from 04/27/25 through 05/02/25. Review of the medication administration records for April and May 2025 revealed no as needed stool softeners or laxatives were administered to Resident #8 from 04/27/25 through 05/02/25. Interview on 05/08/25 at approximately 2 P.M. with Director of Nursing (DON) confirmed Resident #8 had gone six days without a bowel movement and no as needed medications were administered to alleviate constipation. Additionally, DON revealed the facility does not have a bowel protocol in place.

Based on record review, observation, and interview, and facility policy review, the facility failed to ensure a resident, who had a history and was at risk for falls, had their fall prevention interventions implemented as per their plan of care. This affected one (Resident #21) of three residents reviewed for falls. The facility census was 40. Findings include: Review of Resident #21's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, vascular dementia, major depressive disorder, heart failure, osteoarthritis, chronic kidney disease (Stage II (mild), and irritable bowel syndrome. Review of Resident #21's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any speech and was rarely/ never able to make herself understood and was rarely/ never able to understand others. Her vision was highly impaired without the use of corrective lenses. She had short and long term memory impairment and her cognitive skills for daily decision making was severely impaired. She was known to have physical behaviors directed at others, but was not known to reject care. She was dependent on staff for bed mobility, transfers, and toileting hygiene. The resident was always incontinent of her bowel and bladder and not on a toileting program. Review of Resident #21's active care plans revealed she had a care plan in place for being at risk for falls related to confusion and incontinence. She was indicated to be unaware of her safety needs and also had an unsteady gait. The goal was for her to have a minimal risk for falls. The interventions included the need for her bed to be maintained in the lowest position while she was in bed. That intervention was added on 09/16/24. Review of Resident # 21's physician's orders revealed the resident had an order in place for her to be in a low bed at all times. The physician's order was dated 08/04/23. On 05/06/25 08:36 AM, an observation of Resident #21 noted her to be in bed with the head of her bed (HOB) raised at a 45 degree angle. Her bed was not noted to be in it's lowest position, but she did have fall mats on the floor at the bedside. She was awake and was looking around her room. There were no staff present with the resident when the observation was made. On 05/06/25 at 8:50 A.M., an interview with Certified Nursing Assistant (CNA) #335 revealed she had been in Resident #21's room that morning when assisting her with her breakfast. She stated she left the resident's HOB elevated to help her digest her food. She confirmed she did not lower the resident's bed to it's lowest position, when she left the resident unattended in her room. She stated it was around 8:00 A.M. when she finished feeding the resident and left the room. At the time of the interview, the resident's bed had been placed in it's lowest position. She denied that she re-entered the resident's room to lower her bed, but one of the other aides (CNA #400) had been in there, after the resident was assisted with her breakfast and may have lowered the bed to it's lowest position. On 05/06/25 at 9:01 A.M., an interview with CNA #400 confirmed he had been in Resident #21's room, after she was assisted with her breakfast by another aide. He indicated he was in the resident's room sometime around 8:45 A.M. and lowered the resident's HOB and the height of her bed to it's lowest position. He noted the resident's bed was not in it's lowest position, as it should have been, when he was walking down the hall and looked into her room. He further confirmed keeping the resident's bed in it's lowest position was one of her fall prevention interventions. Review of the facility's policy on Managing Falls and Fall Risk from Nursing Services Policy and Procedure Manual for Long-Term Care copyrighted in 2001 revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input from the attending physician, would implement a resident- centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If interventions have been successful in preventing falling, staff would continue the interventions or reconsider whether those measures were still needed if a problem that required the intervention had resolved.

Based on record review and interview, the facility failed to ensure residents with post-traumatic stress disorder (PTSD) were provided with trauma-informed care. This affected one (#12) of one resident reviewed for PTSD. The facility census was 40. Findings include: Record review revealed Resident #12 admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic obstructive pulmonary disease, and major depression. Review of assessments revealed a Trauma-Informed Screen was completed on 06/06/23 and Resident #12 denied a history of trauma. Review of a nursing note dated 10/03/23 at 6:27 A.M. revealed while administering medications, Resident #12 because talking about having dreams of a gunfight and he ran out of bullets, and he had no control over the outcome. Resident #12 confessed to a bad marriage that ended poorly after being abused by his spouse. Resident #12 did not get to know his children and his parents turned their backs on him. Resident #12 stated he was a functioning alcoholic to alleviate his struggles before admission to the facility. Resident #12 requested to speak to someone about his mental health. Provider was notified and gave orders for a referral for counseling and requested a male provider, no females. Review of orders revealed an order dated 11/10/23 for Resident #12 to receive prazosin oral capsule 1 milligrams by mouth one time a day for PTSD. Review of a minimum data set (MDS) dated [DATE] revealed Resident #12's cognition remained intact, he had no behaviors, and he had a diagnosis of PTSD. Review of a care plan last updated 04/30/25 revealed no evidence of a care plan or interventions related to PTSD. Interview on 05/06/25 at 3:01 P.M. with Certified Nursing Assistant (CNA) #168 revealed Resident #12 does seem to be always anxious because he messes with his hair and the way he interacts with her make her feel like Resident #12 is anxious. CNA #168 stated she was unsure if Resident #12 had PTSD but he doesn't say much, and she does not know what triggers his anxiety, he just is anxious every time she walks in the room. Interview on 05/06/25 at 3:16 P.M. with CNA #400 revealed Resident #12 does have anxiety but he was not sure what about. CNA #400 stated he was unaware of Resident #12 having a history of trauma. Interview on 05/07/25 at 10:12 A.M. with Director of Resident Services (DRS) #300 revealed she did not have any copies of recent psych notes for Resident #12 and she was not sure how often he was seen by psych. DRS #300 stated the mental health providers usually speak with nursing staff who will then relay orders to the primary care provider but she is not sure how the information is passed down to CNAs. DRS #300 confirmed there is no specific plan of care in place to address Resident #12's history of PTSD, triggers, or interventions.

Based on interview and medical record review the facility failed to address pharmacy recommendations timely for Resident #2 and Resident #9. This effected two (Resident #2 and Resident #9) of five residents reviewed for unnecessary medications. The facility census was 40. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses including hepatic encephalopathy, diabetes mellitus type two, dementia without behavioral disturbance, psychotic disturbance or anxiety, bipolar disorder, asthma, chronic pain, gastrointestinal reflux disorder (GERD) and major depressive disorder. Review of the Medication Administration Record (MAR) for 05/25 revealed Resident #9 received the following medications: Aldactone (diuretic) 75 milligrams (mg) by mouth daily for edema, Zoloft 25 mg by mouth daily for depression, Lactulose oral solution 10 grams (gm) per 15 milliliters (ml) give 60 ml by mouth three times daily for hepatic encephalopathy, Lantus Solostar subcutaneous solution pen-injector 100 units per ml inject five units subcutaneous daily at bedtime for diabetes mellitus type two, memantine hydrochloride 10 mg by mouth two times daily for dementia, donepezil hydrochloride 10 mg by mouth daily for dementia, metformin hydrochloride 1000 mg by mouth daily for diabetes mellitus type two, famotidine 20 mg by mouth daily for GERD, Lidocaine topical patch four percent apply to right shoulder daily and remove per schedule for pain, multivitamin by mouth daily as supplement, acetaminophen 650 mg by mouth two times per day for pain and memantine 10 mg by mouth two times per day for dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively impaired and had behaviors directed towards others. Resident #9 had no impaired range of motion and was independent with eating meals, personal hygiene and transfers. Resident #9 required substantial assistance from the staff for showers and bathing. The assessment indicated Resident #9 received seven insulin injections, an antidepressant, diuretic and hypoglycemic medications. Review of the nursing progress notes revealed documentation of adverse behaviors throughout. Review of the monthly medication review by the pharmacy revealed recommendations made on 05/31/24 to change Cyclobenzaprine five mg by mouth daily to as needed. The pharmacy recommendation was reviewed, approved and signed by the physician on 07/01/24. A pharmacy recommendation dated 12/20/24 to consider discontinuing the as needed Hydrocodone-acetaminophen used two times in the last 30 days. The pharmacy recommendations was reviewed, approved, and signed by the physician on 03/25/25. An interview on 05/07/25 at 10:17 A.M. with the Director of Nursing (DON) revealed the DON received the pharmacy recommendations via email on the same day the pharmacist completed the monthly review. The DON would print the recommendations, keep a copy for the facility, place a copy in the medical record of the resident, and emailed a copy to the primary care provider. The primary care provider would return the recommendation after reviewing and signing. If any changes made to the medications an order would be written and provided to the floor nurse. The DON stated the facility did not have a policy related to pharmacy recommendations however the facility followed regulations provided by the state that stated the pharmacy recommendations should be addressed timely. The DON confirmed the pharmacy recommendation for Resident #9 dated 12/20/24 and addressed and signed by the physician on 03/25/25 was not timely. The DON also confirmed the pharmacy recommendation for Resident #9 dated 05/31/24 and addressed and signed by the physician on 07/01/24 was not timely. 47985 2. Record review revealed Resident #2 admitted to the facility on [DATE] with diagnoses including dementia, anemia, and depression. Review of a care plan dated 11/18/24 revealed Resident #2 had chronic pain related to arthritis and a history of fractures. Goals included to not have an interruption in normal activities due to pain through the review date. Interventions included attempt non-pharmacological interventions to assist with pain management, monitor and report any complaints of pain or requests of pain treatment, report any change in usual activity patterns related to signs and symptoms of pain, and administer analgesics as ordered. Review of an MDS completed 12/18/24 revealed Resident #2 had severely impaired cognition, had vocal complaints of pain, and facial expressions indicating pain for one to two days of the observation period. Review of a pharmacy recommendation dated 12/20/24 revealed an order for Lidocaine 5% needed clarified due to being prescription strength but it is noted in the electronic record house stock Lidocaine patches are used which would be over-the-counter strength of 4%. The pharmacy recommendation was not completed until 02/12/25. Review of a pharmacy recommendation fated 12/20/24 revealed Resident #2 received a Lidocaine patch daily since admission but was also receiving 325 milligrams of Tylenol once daily. The medications needed re-evaluated to determine if Lidocaine patch would be discontinued and the Tylenol dose to be increased. The pharmacy recommendation was not completed until 03/25/25. Interview on 05/08/25 with Director of Nursing (DON) confirmed the pharmacy recommendations for Resident #2 were not completed timely and were dated as completed on 02/12/25 and 03/25/25 despite the recommendations being made 12/20/24.

Based on record review, interview and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed within the 14 day allotted time period following the assessment reference date (ARD). This affected seven residents (#6, #7, #10, #13, #19, #22, #32) of 25 sampled residents. The facility census was 35. Findings Include: 1. Review of the medical record for Resident #10 revealed an initial admitted [DATE] with the latest readmission of 12/18/20 with diagnoses including diabetes mellitus, major depressive disorder, anxiety disorder, hypertension, morbid obesity, obstructive sleep apnea, hyperlipidemia, osteoarthritis, chronic pain and congestive heart failure. Review of the resident's MDS list revealed a quarterly MDS assessment with the ARD date of 07/24/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed by the required completion date. 2. Review of the medical record for Resident #13 revealed an initial admitted [DATE] with the diagnoses including calcaneal spur, hypertension, hyperlipidemia, hypothyroidism, gastro-esophageal reflux disease and vitamin D deficiency. Review of the resident's MDS list revealed a comprehensive MDS assessment with the ARD date of 07/12/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed by the required completion date. 3. Review of the medical record for Resident #19 revealed an initial admitted [DATE] with the latest readmission of 11/03/22 with diagnoses including vascular dementia, depression, hypertension, hyperlipidemia, hypothyroidism, gastro-esophageal reflux disease and hearing loss. Review of the resident's MDS list revealed a quarterly MDS assessment with the ARD date of 08/07/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed by the required completion date. 4. Review of the medical record for Resident #32 revealed an initial admitted [DATE] with diagnoses including acute and chronic respiratory failure, cerebral infarction, chronic kidney disease, hypertension, hyperlipidemia, osteoarthritis, anxiety disorder, atrial fibrillation, COVID-19 and edema. Review of the resident's MDS list revealed a quarterly MDS assessment with the ARD date of 07/30/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed by the required completion date. 5. Review of the medical record for Resident #7 revealed an initial admitted [DATE] with the diagnoses including generalized muscle weakness, repeated falls, depressive disorder, vertigo, dizziness and giddiness, presence of cardiac pacemaker, hypertension, hypothyroidism, hyperlipidemia, rheumatoid arthritis and muscle wasting and atrophy. Review of the resident's MDS list revealed a comprehensive MDS assessment with ARD 08/25/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed by the required completion date. 6. Review of the medical record for Resident #22 revealed an initial admitted [DATE] with the latest readmission of 08/30/23 with the diagnoses including traumatic subdural hemorrhage, COVID-19, vascular dementia with anxiety and mood disorder, diabetes mellitus, acute and chronic respiratory failure, hypertension, hyperlipidemia, heart failure, hypothyroidism, chronic obstructive pulmonary disease, asthma, gastro-esophageal reflux disease and old myocardial infarction. Review of the resident's MDS assessment list revealed a quarterly MDS assessment with an assessment reference date of 08/25/23 still in progress and incomplete. Review of the resident's MDS assessment list revealed a discharge assessment with ARD date of 08/28/23 still in progress and incomplete Review of the resident's MDS assessment list revealed an entry MDS assessment with the ARD of 08/30/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed by the required completion date. 7. Review of the medical record for Resident #6 revealed an initial admitted [DATE] with the most recent readmission of 01/11/23 with the diagnoses including COVID-19, pneumonia, acute and chronic respiratory failure, dysphagia, generalized muscle weakness, acute pulmonary edema, major depressive disorder, diabetes mellitus, hypertension, retention of urine, angina pectoris, hypertension, gout, hypothyroidism and disorders of bladder. Review of the resident's MDS list revealed a quarterly MDS assessment with ARD 07/27/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed by the required completion date. Review of the facility policy titled, MDS Completion and Submission Timeframes, dated 07/17 revealed the facility will conduct and submit resident assessments in accordance with current and federal and state submission timeframes.

Based on record review, interview and facility policy review, the facility failed to ensure one resident's quarterly Minimum Data Set (MDS) assessment was transmitted to the required state agency. This affected one resident (#17) of 25 sampled residents. The facility census was 35. Findings Include: Review of the medical record for Resident #17 revealed an initial admitted [DATE] with the diagnoses including hyperlipidemia, anemia, pain, gastro-esophageal reflux disease and [NAME] cell carcinoma. Review of the resident's MDS list revealed a quarterly MDS assessment with the ARD date of 07/14/23 not transmitted to the required state agency. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not transmitted to the state agency as required. Review of the facility policy titled, MDS Completion and Submission Timeframes, dated 07/17 revealed the facility will conduct and submit resident assessments in accordance with current and federal and state submission timeframes.

Based on interview and record review the facility failed to provide a resident with timely dental care and services. This affected one resident (#27) of one resident reviewed for dental services. The facility census was 35. Findings include: Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses including urinary retention, obstructive and reflux uropathy, type two diabetes mellitus and congestive heart failure. Review of the admission nursing assessment dated [DATE] revealed Resident #27 had his own teeth with caries and broken teeth. Review of the nursing progress notes revealed on 08/24/22 nurse documented Resident #27 went to dentist appointment this A.M. The resident returned with a referral to an oral surgeon related to pacemaker and high risk for complications. The referral was sent to a Facial Surgeon. Review of the plan of care dated 09/08/22 revealed Resident #27 had oral and or dental health problems. The interventions included to coordinate arrangements for dental care and transportation as needed or ordered, provide oral and dental care two times daily and as needed, administer medication as ordered, and monitor for and document any side effects and effectiveness of the medication. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had slightly cognitive impairment with a Brief Interview Mental Status of 12. Resident #27 required assistance with all activities of daily living. Resident #27 had problems with chewing and no mouth or facial pain. A note dated 10/19/22 at 12:06 P.M. a referral was faxed to the University of Cincinnati Oral Surgery and an appointment was scheduled on 01/23/23 at 2:00 P.M. at [NAME] Hospital in Cincinnati. A note dated 01/23/23 at 1:18 P.M. revealed Resident #27 had appointment scheduled at [NAME] Hospital in Cincinnati for consult for teeth extraction. Transport services was to arrive at 11:00 A.M. for a 2:00 P.M. appointment however, did not arrive until 11:30 A.M. At 12:05 P.M. a staff member from the transport services messaged the facility requesting the facility to call [NAME] Hospital and ensure resident would be seen with a 2:30 P.M. arrival time. The hospital stated they would accommodate Resident #27 with a 2:30 P.M. arrival time. The transport services dispatch was notified of the accomodation, and called [NAME] Hospital stating Resident #27 would not be arriving until around 3:00 P.M. At that time [NAME] Hospital was not able to accommodate the late arrival time and and the transport was canceled. [NAME] Hospital dental office called the facility to reschedule the appointment for 02/09/23 at 10:00 A.M. A note dated 02/09/23 at 7:05 A.M. the resident left the facility via Medcare transportation and returned at 1:50 P.M. with follow up appointment scheduled for 06/23/23. A note dated 06/22/23 at 1:33 P.M. the facility had called transport company on 06/16/23 to schedule pick up for appointment. Medcare (transport company) stated they could not transport that early in the morning. Another transport service, Portsmouth Ambulance, was called and stated they did not have a truck in that area that could do the transport. On 06/20/23 the facility contacted Medcare transport who stated they could do the transport with a pick up of 10:00 A.M. The facility contacted [NAME] Hospital and the appointment could not be moved due to being fully booked. The dental appointment for extraction was rescheduled for 11/15/23 at 1:30 P.M. at [NAME] Hospital in Cincinnati. No documentation related to transport for service scheduled 11/15/23 at 1:30 P.M. Review of the physician orders September 2023 indicated Resident #27 had an appointment on 11/15/23 at 1:30 P.M. with [NAME] Hospital in Cincinnati. Review of the documentation by the State tested Nursing Assistants (STNA) in the medical record revealed Resident #27 received oral care two times daily but refused at times. An observation on 09/11/23 at 1:22 P.M. of Resident #27 revealed he had poor dental hygiene with caries noted. An interview on 09/11/23 at 1:22 P.M. with Resident #27 revealed he had oral pain at times and was not sure when he last saw a dentist. An interview on 09/14/23 at 12:00 P.M. with the Director of Nursing (DON) revealed the facility had a van for transportation and outings, however, Resident #27 was not able to go far away in the van as he needed ambulance transport due to his medical conditions. Review of the facility policy titled Dental Services dated 12/16 did not address timeliness of care and services or transportation.

Based on record review and interview the facility failed to provide an appropriate diagnosis for the use of an antipsychotic medication. This affected one resident (#3) of five residents reviewed for unnecessary medications. The facility census was 35. Findings include: Record review of Resident #3 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: human metapneumovirus, muscle weakness, difficult ambulation, anxiety, depression, atherosclerosis, asthma, OA, sepsis, unspecified dementia with psychotic disturbance, sepsis, hypertension, hyperlipidemia, and constipation. This resident is currently alert to name only with a Brief Interview for Mental status(BIMS) score of three on the most recent Minimum Data Set(MDS) assessment completed on 05/08/23, indicating severe cognitive impairment. Review of physician orders revealed this resident is receiving the following medications: Seroquel 25mg 1 tablet by mouth daily for unspecified dementia with psychotic disturbance. Review of the FDA Black Box Warning for the medication Seroquel revealed elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk for death. Seroquel is not approved for the treatment of patients with dementia-related psychosis. Interview with the Administrator on 09/13/23 at 11:12 A.M. verified that an inappropriate diagnosis of unspecified dementia with psychotic disorder is being used for the use of Seroquel.

Based on record review, pharmacy recommendation review, interview, and facility policy review, the facility failed to ensure two residents (#5, #18) pharmacy recommendations were addressed by the physician. This affected two of five residents reviewed for unnecessary medications. The facility census was 35. Findings include: 1. Review of the medical record for Resident #5 revealed an initial admitted [DATE] with the latest readmission of 04/10/23 with the diagnoses including COVID-19, hypertension, pneumonia, major depressive disorder, major depressive disorder, suicidal ideations, traumatic subdural hemorrhage, frontal lobe and executive function deficit following cerebral infarction, seizures, atrial fibrillation, hyperlipidemia, benign prostatic hyperplasia, gastro-esophageal reflux disease (GERD) and arthritis. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the plan of care dated 10/14/22 revealed the resident had GERD related to medication use. Interventions included give medications as ordered, monitor/document side effects and effectiveness, avoid lying down for at least one hour after eating, keep head of bed elevated, encourage to stand/sit upright after meals, monitor vital signs as ordered and record and obtain and monitor lab/diagnostic work as ordered, report results to physician and follow up as indicated. Review of the pharmacy recommendation dated 07/27/23 revealed the pharmacist recommended tapering the medication Reglan 5 mg twice daily with an end goal to discontinue the medication. Further review of the recommendation revealed the physician had not addressed the recommendation. Review of the monthly physician orders for September 2023 identified orders dated 01/24/23 Omeprazole 20 mg by mouth daily for GERD, 01/31/23 Reglan 5 mg by mouth before meals and at bedtime for gastroparesis. On 09/14/23 2:49 P.M., interview with the Director of Nursing (DON) verified the recommendation had not been addressed by the physician. 2. Review of the medical record for Resident #18 revealed an initial admitted [DATE] with the latest readmission of 08/09/22 with diagnoses including low back pain, hypothyroidism, hypertension, urinary incontinence, major depressive disorder, chronic pulmonary edema, diabetes mellitus, gastro-esophageal reflux disease, COVID-19, acute and chronic respiratory failure, dependence on supplemental oxygen, zoster, dysphagia, delusion disorder, mood disorder, dementia, bipolar disorder, chronic obstructive pulmonary disease, cervical disc degeneration, absolute glaucoma, heart failure, cardiomegaly, constipation and osteoarthritis. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the plan of care dated 10/29/17 revealed the resident used psychotropic medications related to major depressive disorder, paranoia, delusions, bipolar disorder and dementia. Interventions included administer medications as ordered, monitor/document for side effects and effectiveness, consult with pharmacy, and/or physician to consider dosage reduction when clinically appropriate and provide non-pharmacological interventions. Review of the monthly physician orders for September 2023 identified orders dated 10/13/22 Risperdal 0.25 mg by mouth daily. Review of the pharmacy recommendation dated 11/15/22 revealed the pharmacist recommended a fasting lipid panel (FLP) due to no record of one on the resident's chart in the past 12 months. The recommendation was not signed or reviewed by the physician. Review of the medical record revealed the FLP had not been obtained. On 09/13/23 at 1:01 P.M., interview with the Director of Nursing (DON) verified the pharmacy recommendation for the FLP was not addressed as well as the FLP not being completed. Review of the facility policy titled, Medication Regimen Review, last revised 08/17/23 revealed the facility should encourage the physician or other responsible parties receiving the medication regimen review (MRR) and the Director of Nursing to act upon the recommendation contained in the MRR. The attending physician should document in the resident's health record that the identified irregularity has been reviewed and what, if any action has been taken to address it.

Based on medical record review and interview, the facility failed to ensure one resident's (#5) antihypertensive medications were held when the resident's pulse was below the physician ordered parameter. This affected one of five residents reviewed for unnecessary medications. The facility census was 35. Findings Include: Review of the medical record for Resident #5 revealed an initial admitted [DATE] with the latest readmission of 04/10/23 with the diagnoses including COVID-19, hypertension, pneumonia, major depressive disorder, major depressive disorder, suicidal ideations, traumatic subdural hemorrhage, frontal lobe and executive function deficit following cerebral infarction, seizures, atrial fibrillation, hyperlipidemia, benign prostatic hyperplasia, gastro-esophageal reflux disease and arthritis. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the plan of care dated 10/07/22 revealed the resident had an altered cardiovascular status related to atrial fibrillation, hypertension, hyperlipidemia, edema and orthostatic hypotension. Interventions included administer medications as ordered, encourage low fat, low salt intake, monitor edema, monitor blood pressure via orthostatic blood pressure method per orders and monitor vital signs as ordered, notify the physician of any abnormal findings. Review of the monthly physician orders for September 2023 identified orders dated 01/24/23 for Metoprolol Tartrate 25 mg with the special instructions to give one tablet by mouth twice daily for hypertension and hold if systolic blood pressure (SBP) is less than 110 or pulse less than 60. Review of the resident's Medication Administration Record (MAR) for June 2023 revealed on 06/05/23, 06/12/23, 06/15/23 and 06/28/23 the resident was administered the medication Metoprolol 25 mg by mouth despite the fact the resident's pulse was less than 60. Review of the resident's Medication Administration Record (MAR) for July 2023 revealed on 07/07/23, 07/08/23, 07/09/23, 07/11/23 and 07/12/23 the resident was administered the medication Metoprolol 25 mg by mouth despite the fact the resident's pulse was less than 60. Review of the resident's Medication Administration Record (MAR) for September 2023 revealed on 09/08/23 the resident was administered the medication Metoprolol 25 mg by mouth despite the fact the resident's pulse was less than 60. On 09/14/23 at 8:52 A.M., interview with the Director of Nursing (DON) verified the medication was administered despite the fact the resident's pulse was below the physician ordered parameter of 60.

Based on observation, record review, facility policy and procedure review and interview the facility failed to provide adequate and necessary care and services to prevent the development of hand contractures for two residents (#5 and #25). Actual harm occurred when Resident #25 who was severely cognitively impaired was not provided range of motion services or the application of splint/ orthotic devices resulting in the development of bilateral hand contractures. Actual Harm also occurred for Resident #5 when the facility failed to provide range of motion and/or hand roll/splinting care for the resident's left hand to prevent a decline in range of motion and development of a contracture to the hand. This affected two residents (#5 and #25) of three residents reviewed for positioning/ mobility. Findings include: 1. A review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's diagnoses list was updated to reflect a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #25's nursing admission assessment completed on 06/24/20 revealed no indication of any contracture or limitations to range of motion at the time of her admission. A review of Resident #25's Occupational Therapy (OT) Recertification/ Progress Report/ Updated Therapy Plan for a certification period of 02/08/21 to 03/08/21 revealed the resident's diagnoses included muscle wasting and atrophy, [CONDITION(S)], abnormal posture, stiffness of an unspecified joint, muscle weakness and abnormalities of gait and mobility. Contractures were not included in the resident's diagnoses at that time. The goals for the resident's treatment were to increase her bilateral upper extremity (BUE) strength and to improve her activities of daily living (ADL) self care ability and her ability to perform self dressing of her upper and lower extremities. The assessment did not include anything about limitations in range of motion (ROM) or the resident having any known contractures. A review of Resident #25's OT Discharge Summary, for date of service of 01/12/21 to 03/19/21 revealed the resident's discharge recommendations included a restorative ROM program. The ROM program established/ training included bilateral upper extremity (BUE) ROM in all planes three times a week as tolerated. A review of Resident #25's OT Recertification/ Progress Report/ Updated Therapy Plan for a certification period of 03/15/21 to 04/13/21 revealed the resident was having issues with her ring finger (fourth digit) of her right hand. Listed diagnoses did not include contractures as one of the resident's diagnoses for treatment. The resident was assessed to be experiencing deficits in ROM and strength. The short term goal was for the resident to increase her right ring finger metacarpophalangeal (MCP)/ proximal interphalangeal (PIP) joint extension to -15 degrees to increase her grasp for self feeding. A review of Resident #25's physician's progress note, dated 06/24/21 revealed the resident was noted to have bilateral hand contractures. The physician's plan for the bilateral hand contractures was for her to have occupational therapy. A review of Resident #25's OT Recertification/ Progress Report/ Updated Therapy Plan for a certification period of 06/23/21 to 07/21/21 revealed the resident's diagnoses added contractures of the right and left hand that were not previously identified. The onset date of the contractures were noted to be 06/23/21. The reason for the OT referral was for BUE digit contractures increasing the resident's risk for skin breakdown. Her right upper extremity (RUE) and left upper extremity (LUE) ROM was noted to be impaired. An assessment of the RUE and LUE ROM revealed the resident's wrists, hands, middle finger, ring finger and little fingers were impaired. Recommendations were made for the resident to use hand rolls to decrease her risk for skin breakdown and to assist with extension of her digits (fingers). A review of Resident #25's OT Discharge Summary for date of service of 06/23/21 to 08/19/21 revealed discharge recommendations included the use of hand rolls to the resident's BUE and a hand roll schedule to decrease the resident's risk for skin breakdown. Restorative programs recommended by OT were a restorative splint and brace program. The resident was to wear hand rolls in her BUE four hours on and four hours off to decrease the risk for skin breakdown. A review of a Therapy to Restorative Nursing Communication form, dated 08/20/21 revealed the resident had been discharged from physical therapy (PT) and OT. OT recommendations included BUE hand stretching/ passive range of motion (PROM) in all planes daily as tolerated. Adaptive equipment/ orthotic devices issued with schedule included BUE hand rolls four hours on/ four hours off daily as tolerated. A review of Resident #25's most recent quarterly Minimum Data Set (MDS) assessment, dated 07/09/21 revealed the resident did not have any communication issues but her cognition was severely impaired. She was not known to display any behaviors during the assessment reference period (seven days) but was known to reject care one to three days during the seven day assessment period. The resident was totally dependent on two for transfers and an extensive assist of two staff for dressing. Ambulation did not occur. The resident had functional limitations in range of motion on both sides of her upper and lower extremities. Contracture of the right hand was listed as an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #25's active care plans revealed she did not have a care plan in place to address her contractures. There was no indication in the care plans the resident was to receive any type of restorative nursing program for ROM/ hand stretching or the use of BUE hand rolls/ splints to help prevent contractures. A review of Resident #25's Kardex, used by the State tested Nursing Assistants (STNAs) to identify a resident's care needs, revealed there was no indication the resident was to receive any type of ROM programming. The Kardex also failed to include the use of hand rolls that had been recommended by OT, to be on for four hours and off for four hours (per schedule). A review of Resident #25's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25's electronic health record was absent for any evidence of her receiving any type of restorative nursing services as part of a program to provide her with PROM exercises. It also did not include evidence of hand rolls being used on the on for four hours/ off for four hours schedule recommended by OT. On 10/12/21 and 10/13/21 ongoing observations at various times each day, including specific observations on 10/12/21 at 10:38 A.M. and 10/13/21 at 9:37 A.M., 10:55 A.M. and 1:42 P.M. revealed no evidence of Resident #25 having any hand rolls in place to her bilateral hands. Contractures were noted to her bilateral hands. It was not until 10/14/21, when the facility was asked to provide information on the resident's development of her contractures, that she was observed to have hand rolls put in place. An observation on 10/14/21 at 8:45 A.M., was the first observation in the previous three days of the resident having hand rolls in place. The hand rolls had Velcro straps wrapped around the resident's posterior hands to hold them in place. On 10/14/21 at 8:59 A.M. interview with STNA #145 revealed Resident #25 required extensive assistance/total dependence from staff for personal care. The STNA initially reported the resident had full ROM to her arms and legs and then reported the resident's legs had limited ROM. The STNA was then asked about the resident's hands and indicated staff were putting hand rolls in them. The STNA revealed they had black hand rolls to use that were given to them by therapy. The STNA reported staff (the STNAs) knew what the care needs of each resident were based on the kardex they had for reference. The STNA was not aware the resident's kardex did not include the need for ROM to be provided or the use of hand rolls for the resident. She stated she knew the resident needed those things but could not speak to whether or not the other staff would know as well. She reported she had been off work the past couple of days and last worked with the resident this past Saturday. On 10/14/21 at 9:10 A.M. interview with the Director of Nursing (DON) revealed the facility did have a restorative nursing program but not all programs were being implemented by a restorative aide. She stated if the need arose, the facility might pull the restorative aide to work the floor due to a call-off. The DON revealed things like ROM would still be provided during a resident's bath or during other personal care. She reported, if ROM was provided as part of a restorative program, it should be documented in the electronic health record under the task tab so the minutes provided could be recorded. She denied ROM or the use of hand rolls would be in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON acknowledged Resident #25's plan of care did not address her contractures as there was not a care plan in place for it and the Kardex that was used by the STNAs to direct the resident's care did not include the need to provide range of motion or use of hand rolls to prevent worsening of her existing contractures. The DON was not able to explain why that information was not included on the Kardex or why a care plan had not been developed. The DON revealed this must have been missed. She acknowledged without it being included on the Kardex and no documented evidence range of motion and hand rolls were being used, it was hard to show staff were providing the care and services to prevent the resident's contractures from developing. She agreed contractures were considered avoidable, if those types of interventions weren't being implemented on a routine basis. 2. Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment, dated 07/07/20 for Resident #5 revealed no impairment with range of motion to the left upper extremity including the shoulder, elbow, wrist and hand. Review of the Occupational Therapy (OT) notes and OT plan of care revealed Resident #5 received OT services from 07/07/20 through 08/04/20 to increase bilateral upper extremity strength to facilitate participation in activities of daily living. The assessment, dated 07/07/20 revealed the resident had range of motion within functional limits to left hand with no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the OT services provided 01/11/21 through 02/08/21 revealed the resident was seen to increase bilateral upper extremity strength to facilitate participation in activities of daily living/self care tasks and to increase metacarpophalangeal joint of the hand extension to increase functional abilities. The assessment, dated 01/11/21 revealed the resident had range of motion within functional limits to the left hand and no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the OT services provided 05/26/21 through 07/22/21 revealed the resident was seen to increase active range of motion to left middle finger and left ring finger to improve dexterity skills and improve function grasp/release skills. The OT notes revealed the resident would safely wear a hand roll on the left fingers and hand for up to four hours daily. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment dated [DATE] revealed the resident had impaired range of motion to left hand. Review of the annual MDS 3.0 assessment, dated 07/14/21 revealed Resident #5 was cognitively impaired and was totally dependent on staff for personal hygiene needs and bathing. The resident was receiving occupational therapy services three to five times per week and was not identified to have limited range of motion to bilateral upper extremities including shoulder, elbow, wrist or hand. Review of a Restorative Nursing Communication form for Resident #5 dated 07/22/21 recommended left upper extremity hand roll, four hours on, four hours off as tolerated. Review of the 10/2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 10/12/21 and 10/13/21 at various times including on 10/12/21 at 11:05 A.M. and 2:03 P.M. and on 10/13/21 at 8:01 A.M. and 11:15 A.M. revealed the resident's left hand was contracted with very limited range of motion. The resident was not observed with a hand splint, hand roll or device in place to prevent further decline during any of the observations made. On 10/12/21 at 12:48 P.M. interview with the Assistant Director of Nursing (ADON) revealed the communication form from therapy for restorative nursing care would be given to the ADON, who would write the order and inform the restorative STNA of the orders. The ADON confirmed there was no order in Resident #5's medical record for restorative nursing care or splint to left hand. An interview on 10/13/21 at 8:07 A.M. with Licensed Practical Nurse (LPN) # 102 confirmed Resident #5's left hand was contracted and the resident did not have a splint, hand roll or device in place to prevent further decline. An interview on 10/13/21 at 8:18 A.M. with Occupational Therapist (OT) #164 revealed the resident was discharged from therapy approximately two months ago and was placed on a restorative program for a hand roll to be in place every four hours as tolerated. OT #164 confirmed the resident did not have a contracture of the left hand upon admission to the facility but had subsequently developed the contracture. On 10/13/21 at 10:35 A.M. interview with STNA #145 revealed Resident #5 was to receive restorative care daily including range of motion to hands and apply a left hand splint/brace. However, the STNA could not find a hand roll or splint in the resident's room at that time. A review of the facility's policy on Restorative Nursing Services, revised July 2017 revealed residents would receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consisted of nursing interventions that may or may not be accompanied by formalized rehabilitation services (e.g., physical, occupational or speech therapies). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives were individualized and resident-centered, and were outlined in the resident's plan of care. Restorative goals may include supporting and assisting the resident in developing, maintaining, or strengthening his/ her physiological and psychological resources.

Based on observation, record review, facility policy and procedure review and interview the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #10. Actual harm occurred on 10/07/21 when Resident #10, who was severely cognitively impaired was identified to have a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer to the ball of his left foot. There was no evidence the facility had adequate interventions in place to prevent the development of the ulcer and to promote healing once the ulcer was identified. The facility failed to ensure the pressure ulcer was timely identified prior to being found as a Stage III and failed to ensure a treatment was initiated at the time the ulcer was first identified. This affected one resident (#10) of four residents reviewed for pressure ulcers. Findings include: Review of Resident #10's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician's orders, revealed an order dated 04/09/21 for a pressure reduction mattress to bed, cushion to wheelchair, body audit weekly every Monday, encourage to turn and reposition every two hours and as needed, barrier cream to buttocks every shift and as needed for prevention and incontinence care every two hours and as needed. Review of the plan of care, dated 04/15/21 revealed the resident was at risk for pressure ulcer development or skin integrity complications. Interventions included skin prep to bilateral heels twice daily and as needed, encourage to turn every two hours, barrier cream to buttocks every shift as needed, foam cushion to my chair of choice, nurse to provide complete body audit weekly, shower twice weekly as needed and pressure reduction mattress to bed. Review of the resident's Braden Scale dated 07/13/21 revealed a score of 15 indicating a low risk for skin breakdown. Review of the resident's Minimum Data Set (MDS) 3.0 assessment, dated 07/17/21 revealed the resident had clear speech, understood others, made himself understood and had a severe cognitive deficit as indicated by a BIMS score of three. The assessment revealed the resident was independent with bed mobility, transfers and ambulation. The resident was identified as being at risk for skin breakdown and had no unhealed skin breakdown at that time. The MDS identified the facility implemented a pressure reducing device to bed/chair and applications of ointments/medications other than to feet. Review of the resident's skin profile document, dated 10/07/21 revealed the resident acquired a Stage III pressure ulcer to his left outer foot (the ball of the left foot) measuring 2.0 centimeters (cm) in length by 2.0 cm width with 0.1 cm depth and yellow slough to the wound bed. Comments included: Weekly wound assessment complete. No odor present at this time. Denies any pain to area. Tolerated assessment and dressing change well. On 10/07/21 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care, dated 10/12/21 revealed the resident had an actual Stage III pressure area on his left foot related to history of ulcers (the resident had been admitted with a pressure ulcer to the buttocks that had healed after admission). Interventions included assess wound, record/monitor status weekly and don't put shoes on left foot. On 10/12/21 at 2:28 P.M. observation of the resident revealed he was positioned on his left side with the Stage III pressure ulcer directly on the bed. The resident was very thin in appearance and there was no evidence of any type of pressure reduction to the resident's feet. On 10/13/21 (six days after the pressure ulcer was first identified) an order was obtained to cleanse wound to left foot with wound cleanser, pat dry, apply [MEDICATION(S)] and cover with an Allevyn. Review of the resident's October 2021 Treatment Administration Record (TAR) revealed no treatment was documented to have been completed until 10/13/21. Review of the resident's progress noted failed to provide evidence a treatment was administered for the pressure ulcer from 10/07/21 until 10/13/21. On 10/13/21 at 9:23 A.M. observation of the resident revealed he was positioned on his back with his left foot resting directly on the foot board of the bed. There was no evidence of any type of pressure reduction to the resident's feet. Although, the MDS from July 2021 identified the resident was independent with bed mobility and ambulation, the resident was not observed during any observations on 10/12/21 or 10/13/21 to be out of bed and was not observed to be able to reposition himself in bed. At multiple times the ball of the resident's left foot was observed either directly pressing against the foot board of the bed or resting on his right foot. The resident was tall and appeared to be too long for the bed with the foot board which created additional pressure to the ball of the left foot when it pressed again the foot board and resulted in the pressure ulcer development. On 10/13/21 at 2:25 P.M. observation of Licensed Practical Nurse (LPN) #128 provide the physician ordered treatment to the Stage III pressure ulcer to the ball of the left foot revealed the resident was positioned on his left side with the ball of his left foot resting on his right foot. The LPN entered the room in personal protective equipment (PPE) and set-up the required supplies on a barrier on the resident's bedside table. The LPN had to assist the resident to position on his back at which time the resident's foot rested against the foot board of the bed. The LPN then exited the room to obtain wound cleanser. The LPN entered the room with PPE, washed her hands and applied gloves. She cleansed the wound with wound cleanser and four by four dressing. The LPN then placed [MEDICATION(S)] on the wound and covered the pressure ulcer with an Allevyn patch. She placed a pillow over the resident's right leg but the left foot continued to touch the resident's right foot. The LPN verified the current pressure ulcer interventions were ineffective and the Stage III pressure ulcer continued to have direct pressure to it. On 10/13/21 at 4:12 P.M. interview with the Director of Nursing (DON) revealed she believed a pressure ulcer treatment had been ordered on 10/07/21 at the time the ulcer was discovered but the order was not put in the resident's electronic medical record. The DON verified the resident's medical record contained no evidence of a treatment until 10/13/21. Review of the facility policy titled, Prevention of Pressure Ulcers, dated 04/2020 revealed the purpose of the procedure was to provide information regarding identification of pressure injury risk factions and interventions for specific factors. Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living and reposition resident as indicated on the care plan.

Based on observation, record review, interview and policy review the facility failed to timely identify weight loss and implement nutritional intervention to prevent weight loss for residents. Actual harm occurred to Resident #9 when she experienced a 39 pound, 25.3% weight loss in three months from 05/07/18 to 08/13/18 without evidence of adequate interventions being initiated to prevent the weight loss or promote weight gain. Actual harm occurred for Resident #17 when she experienced a 15.6 pound, 10.7% significant weight loss in six months from 145.6 pounds to 130 pounds on 08/08/18 without evidence of adequate interventions being initiated to prevent the weight loss or promote weight gain. Actual harm occurred to Resident #64 when she experienced an unplanned severe weight loss of 15.6% (14.6 pounds) in six weeks between 07/09/18 and 08/20/18 with limited nutritional interventions implemented. Actual harm occurred to Resident #12 when she lost 19.4 pounds in six months representing a 13.5 % severe weight loss between 02/26/28 and 08/14/18 with limited nutritional interventions and lack of monitoring of acceptance of a nutritional supplement. This affected four of six sampled residents reviewed for nutrition (Resident #9. #12, #17 and #64). The facility identified nine residents with significant unplanned weight loss. The facility census was 64. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) 3.0 assessment completed 05/10/18 revealed the resident was independent with eating except for set up help. No further MDS had been completed. Observations on 08/20/18 at 11:24 A.M. revealed an unheated lunch meal tray cart was delivered to(NAME)Plaza hall where Resident #9 resided. State tested Nursing Assistant (STNA) #77 was observed passing all of the lunch meal trays on(NAME)Plaza. All of the trays were removed from the tray cart by 11:40 A.M. Observations at 11:56 A.M. revealed Resident #9's meal tray was sitting at the bedside untouched. Resident #9 was observed laying in bed on her right side facing the wall with the lunch meal tray on a table behind her. At 12:11 P.M. Resident #9's lunch meal tray was still at the bedside untouched . At 12:21 P.M. (57 minutes after the tray was delivered to the unit) STNA #68 went into Resident #9's room and asked her if she wanted to eat. STNA #68 began feeding Resident #9. STNA #68 stated she did not know how long Resident #9's tray had been sitting at the bedside since she did not pass the lunch trays. She stated the resident had been declining lately and was unable to feed herself. At 12:49 P.M. STNA #68 left Resident #9's room and stated she was concerned with the resident's ability to chew. At 12:53 P.M. STNA #68 returned and continued to feed Resident #9. At 12:56 P.M. the speech therapist entered the room to evaluate the resident. Resident #9 had only taken a few bites of the meal at this point. Interview with STNA #77 on 08/20/18 at 12:56 P.M. revealed she had placed Resident #9's meal tray at her bedside but then had to answer call lights and did not assist the resident to eat. Interview with STNA #77 on 08/23/18 at 7:30 A.M. revealed STNA #68 was on her lunch break on 08/20/18 at 11:24 A.M. when she passed the lunch meal trays by herself. She confirmed she was the only staff that passed lunch trays on 08/20/18 on(NAME)Plaza hall. She stated that she either had to assist residents with eating or answer call lights. STNA #77 stated that when STNA #68 returned from her lunch break, STNA #77 had to go assist in the dining room. This left one STNA on(NAME)Plaza again during the lunch meal. Review of the speech therapy plan of care dated 08/21/18 revealed Resident #9 was referred to speech therapy due to increased difficulty with oral intake. It indicated speech therapy was required for dysphagia treatment to decrease aspiration risk. Notes revealed the resident was on a regular diet. Speech therapy was to be provided three times a week for two weeks. The goal was for the resident to tolerate a pureed diet. A physician's orders [REDACTED]. Observations on 08/22/18 at 7:26 A.M. revealed STNA #67 feeding Resident #9 breakfast. The resident had a regular consistency egg croissant sandwich. The diet card on the tray said regular diet. The resident had not eaten any of the croissant. STNA #67 said the resident did not want to eat. Interview with Dietary Manager #142 on 08/22/18 at 10:21 A.M. confirmed Resident #9 was to be on a pureed diet as of 08/21/18. She confirmed the kitchen did not receive the diet order change in time to serve the pureed diet for breakfast. Interview with the Director of Nursing on 08/22/18 at 10:45 A.M. revealed speech therapy had recommended a pureed diet due to swallowing difficulties on 08/21/18 for Resident #9. She confirmed she should have received a pureed diet for breakfast on 08/22/18. Interview with MDS Registered Nurse #118 on 08/23/18 at 9:04 A.M. confirmed Resident #9 now needed assistance from staff with eating and was unable to feed herself on some days. Review of the medical record revealed Resident #9 weighed 154 pounds on 05/07/18. On 08/13/18 Resident #8 weighed 115 pounds, indicating a 39 pound, 25.3% weight loss since admission as follows: On 05/07/18 weight records indicated the resident weighed 154 pounds. On 05/13/18 the resident weighed 143.4 pounds indicating a 10.6 pound, 6.9% significant weight loss in one week. Review of the admission nutrition assessment of 05/16/18 revealed the resident was on a regular diet. The assessment stated the dietician met with the resident in her room and family was present. The resident was asleep. Not eating well. No recommendations were made due to no extra items were desired per family. There was no evidence of any changes in nutritional interventions after the 10.6 pound weight loss in one week. Interview with the Dietician #125 on 08/22/18 at 11:16 A.M. revealed she did not know what family member she talked to on 05/16/18 but did not make any nutritional recommendations because they did not want anything added to her diet. Interview with the Medical Director on 08/29/18 at 9:45 A.M. revealed Resident #9 was under the care of adult protective services due to family members trying to take money and other things from her. On 05/24/18 dietary progress notes indicated a weight of 144.8 pounds and not eating well. A liquid nutritional supplement (ensure plus) was recommended daily. On 06/03/18 the resident weighed 136.6 pounds which represented a 17.4 pound, 11.3 % significant weight loss since admission. On 06/06/18 a dietary progress note indicated the resident's weight was decreasing and that ensure plus was offered. A recommendation for a super milkshake and a medication, [MEDICATION NAME] used for treatment of [REDACTED]. There was no evidence the physician responded to the recommendations made on 06/06/18 until 06/13/18, seven days later and no evidence a physician's orders [REDACTED]. The [MEDICATION NAME] was not started. Instead, an order was obtained for an appetite stimulant, [MEDICATION NAME] which was started on 06/16/18, ten days after the recommendation). Interview with dietician #125 on 08/22/18 at 11:16 A.M. revealed she visits the facility one time per week. She stated she emails her recommendations to the physician. She confirmed the physician did not respond to the recommendations she made on 06/06/18 until 06/13/18. She confirmed the order for the milkshake was not written until 06/15/18 and the appetite stimulant was not started until 06/16/18. The dietician confirmed 9-10 days was too long to get a response from the physician and get recommendations implemented for weight loss. Review of weight records revealed that during the time the facility was waiting for the physician to review the dietary recommendations made on 06/06/18, the resident lost an additional 2.4 pounds. A weight on 06/10/18 was 133 pounds. On 06/26/18 there was a physician's orders [REDACTED]. A dietary progress note on 07/08/18 revealed there was a recent order for consult. The note indicated labs and diet were reviewed, received ensure plus, [MEDICATION NAME], and supershake. No recommendations for changes. On 07/13/18 the resident weighed 128.8 pounds, representing a 25.2 pound, 16.4 % significant weight loss since admission. On 07/18/18 a dietary progress note revealed a recommendation for ensure plus three times per day. The order was obtained on 07/18/18. There was no evidence of another weight until 08/13/18. The resident weighed 115 pounds. This represented a 39 pound, 25.3% significant weight loss since admission and a 13.8 pound, 10.7% loss in one month. On 08/19/18 a dietary progress note revealed recommendations for ice cream with lunch and supper and carnation instant breakfast daily. Interview with Dietary Manager #142 on 08/22/18 at 10:21 A.M. revealed the physician had not yet responded to the recommendations made by the dietician on 08/19/18. Interview with Assistant Director of Nursing #75 on 08/22/18 at 10:35 A.M. confirmed weekly weights were not done after ordered 06/26/18. She stated only monthly weights were done. Interview with the Director of Nursing on 08/22/18 at 4:30 P.M. revealed the facility did not have a policy which addressed how quickly recommendations from the dietician were to be followed up on. Observations revealed the resident's lunch meal tray sat for 57 minutes before the resident was fed by staff. The resident was fed a regular diet instead of pureed as ordered at the time of the observation. In addition, there was a nine day delay in the physician approving recommendations for supplements made by the dietician on 06/06/18. Monthly, not weekly weights were completed, when weekly weights were ordered. Current recommendations from the dietician on 08/19/18 had not been responded to by the physician as of 08/22/18 2. Review of the medical record for Resident #17 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a MDS 3.0 assessment completed 01/27/18 revealed the resident had severe cognitive impairment, required extensive assistance from staff with eating. A MDS completed on 05/22/18 indicated the resident required supervision with set up help only for eating. Review of weight records revealed the resident weighed 133.8 pounds on admission on 01/20/18. On 01/24/18 the resident weighed 132.6 pounds. A dietary progress note on 01/24/18 indicated recent admission, full assessment to follow. A recommendation was made for magic cup with all meals and bedtime. The physician ordered the magic cup on 01/25/18. The admission nutritional assessment was not completed until 01/31/18. It indicated the resident was on a regular diet, had a magic cup supplement, and was total assistance with eating. The assessment did not include a height, body mass index (BMI), usual body weight, or ideal body weight. It stated the weight status (BMI) was normal. No recommendations were made. Observations on 08/20/18 at 5:54 P.M. revealed Resident #17 in the dining room for supper and staff were feeding the resident a pureed diet. At 6:28 P.M. the resident had eaten a few bites of mashed potatoes and meat and had eaten half of a magic cup and half of her ensure plus. Observations at breakfast on 08/22/18 at 8:17 A.M. revealed staff feeding the resident. The resident ate a few bites of eggs and oats, 1/2 of applesauce, 1/2 ensure plus, none of magic cup (about 25% overall). Interview with dietician #125 on 08/24/18 at 3:04 P.M. revealed she did not have the resident's height, which was required to determine BMI and ideal body weight, at the time of the initial nutritional assessment. She stated if she does not fill in an item, the assessment will not let her go on, so she enters something (weight status/BMI normal) so she can go on with the nutritional assessment. Review of weight records revealed Resident #17's weight went up to 148.8 pounds on 03/28/18. On 04/04/18 the resident weighed 142.8 pounds. On 07/13/18 the resident weighed 136.8 pounds. On 07/27/18 ensure plus three times per day with meals was ordered. On 07/30/18 a pureed diet was ordered. On 08/08/18 the resident weighed 130 pounds. This represented a 15.6 pound, 10.7% significant weight loss in six months. A nutritional progress note on 08/08/18 revealed the resident's weight was 130 pounds and was decreasing. Supercalorie mashed potatoes was recommended and ordered at lunch. On 08/13/18 the resident weighed 128.2 pounds. This represented an 8.6 pound, 6.3% significant weight loss in one month. A nutritional progress note on 08/20/18 indicated the resident weighed 128.2 pounds. The note stated the resident was not taking the supplements well (0-25%). There were no recommendations made. The note said will continue to follow. There was no evidence the resident was weighed after 08/13/18 and no evidence any changes were made to nutritional interventions after an 8.6 pound, 6.3% significant weight loss in one month was identified. A nutritional progress note on 08/21/18 stated the possibility of hospice was discussed with the resident's daughter and the daughter would get back in touch. Resident #17 weighed 125.8 pounds on 08/24/18 after a request for a weight was made. This was an additional 2.4 pound weight loss. Interview with dietician #125 on 08/24/18 at 2:37 P.M. revealed that it just depends on each person if weekly weights were recommended after a significant weight loss. She stated she was waiting on the family to decide on Hospice services. She confirmed the resident had not been weighed since 08/13/18. Interview with MDS Coordinator #118 on 08/24/18 at 2:42 P.M. revealed the resident's daughter had told her the day before that she did not want Hospice and she was going to bring in food from home. A nutrition progress note on 08/24/18 revealed the resident's weight continued to decrease. Super milkshakes twice per day between meals was recommended. The note stated the resident was expected to decline in weight with intakes and current status. Interview with dietician #125 on 08/27/18 at 2:13 P.M. revealed the recommendation made on 08/24/18 for super milkshakes was not approved by the physician and ordered until 08/27/18. She stated she did not know why it took three days for the recommendation to be followed up on. She further confirmed there was no evidence of re-weights when the resident lost greater than five pounds. The dietician stated staff were to re-weigh residents when they showed a weight loss of greater than five pounds. She stated that if residents have dementia, they know they are going to decline. Based on the investigation completed, the resident was not weighed after 08/13/18 until requested by the surveyor on 08/24/18. The resident weighed 125.8 pounds on 08/24/18. There were no changes in nutritional interventions from 08/13/18 until 08/24/18. 3. Review of the medical record revealed Resident #64 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #64's laboratory values revealed on 07/10/18 her [MEDICATION NAME] was 12.9 (normal range 20.0-40.0), total protein 5.5 (normal range 6.3-8.2), and her [MEDICATION NAME] 2.1 (normal range 3.5-5.0), indicating compromised nutritional status. Resident #64's wound notes revealed the resident was admitted with a Stage III pressure ulcer to the coccyx area. Review of Resident #64's admission MDS 3.0 assessment, dated 07/12/18 revealed her speech was unclear, she sometimes understood, usually understands, had short and long-term memory problems, no recall and severely impaired decision making with indicators of [MEDICAL CONDITION]. Resident #64 did not reject care. Resident #64 was dependent on one staff to eat and had no swallowing problems. No height was recorded, weight was 93 pounds, had no weight change and received a mechanically altered diet. Review of Resident #64's 14-day Medicare MDS 3.0 assessment, dated 07/18/18 revealed the resident's weight was 84 pounds, a 9.8% weight loss in one week. The MDS did not identify Resident #64 had a severe weight loss. Review of Resident #64's nutrition profile dated 07/15/18 revealed she received a puree diet, had increased protein needs and her body mass index (BMI) was normal. Resident #64's needs were met by a regular diet. The recommendation from this assessment was to offer a frozen nutritional assessment (magic cup) twice daily. However, the magic cup twice daily was not ordered. Review of Resident # 64's dietary notes, dated 07/25/18 revealed her weight was reviewed with the team and weekly weights were to continue. The note documented the resident's weight was 83.8 pounds and was stable from last week. The dietary note indicated Resident #64 was eating well for her. A recommendation for a supplement to promote wound healing, Juven twice daily and supercal potatoes daily was made. The dietary note dated 08/08/18 revealed Resident #64's current weight was 79 pounds and was stable from 7/30/18, the resident's BMI reflected underweight, she was fed meals as needed, on a regular puree diet and supercal potatoes were offered. Resident #64's [MEDICATION NAME] was low, skin status reviewed, Juven in place, poor oral intakes, and will continue to monitor. The dietary note dated 8/20/18 revealed Resident #64's current body weight was 78.4 pounds which was a decrease from 80 pounds last week, continues with Juven and supercal potatoes regular puree diet, fed meals, will ask to offer magic cup daily. Review of Resident # 64 physician's orders [REDACTED]. On 07/27/18 supercal potatoes and Juven were ordered. On 08/23/18 a magic cup one time a day was ordered. Review of Resident #64's weights revealed on 07/09/18 the resident weighed 93 pounds and on 08/20/18 the resident weighed 78.4 pounds representing a severe 15.6%, 14.6 pounds weight loss in six weeks. Review of Resident #64's plan of care revealed the resident had nutritional problems. Staff were to monitor for signs/symptoms of malnutrition including significant weight loss (identified to be three pounds in one week, five percent in one month, seven and half percent in three months, and ten percent in six months). Review of Resident #64's meal intakes revealed for July, (YEAR) she averaged 60% with 60% acceptance of the supercal potatoes. For (MONTH) (YEAR) her average intake was 61% with 63% acceptance of the supercal potatoes once daily. Observation of Resident #64 during the breakfast meal on 08/23/18 at 7:59 A.M. revealed she ate 62% of her meal. The resident was observed with 1% milk on her tray. Interview with Licensed Practical Nurse (LPN) #105 on 08/23/18 at 8:50 A.M. revealed Resident #64 never had an order for [REDACTED].>Interview with STNA #105 on 08/23/18 at 7:59 A.M. revealed if you take your time Resident #64 eats well, but it takes a long time. Interview with STNA #77 on 08/24/18 at 2:30 P.M. revealed Resident #64 will eat well but it takes a long time to feed her. Interview with dietician #125 on 08/24/18 at 3:04 P.M. revealed her initial assessment reflected Resident #64's BMI was normal as she did not have the resident's height, and she had to fill the question in, so she could complete the assessment. She stated the program would not let her continue if she left it blank. She just entered normal BMI. RD #125 further stated she would not recommend extra protein at meals if the resident was not eating well. She stated she does not recommend protein supplements as they don't taste good and residents would not take them. She was not aware the recommendation for magic cup twice daily was not implemented and gave no reason for 1% milk being provided. RD#125 stated she did not identify the weight loss on the 14-day MDS because it was not 30 days. 4. Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. On 08/15/18 [MEDICATION NAME] capsule 2.5 milligrams two times a day for appetite stimulant was ordered. Review of Resident #12's quarterly MDS 3.0 assessment, dated 05/15/18 revealed the resident had severe cognitive impairment. Resident #12 was independent with set up help to eat, and had significant unplanned weight loss. Review of Resident #12's 04/11/18 dietary note revealed the resident was reviewed with the team, her weight was 136 pounds, which was a decrease that week. Recommendations were to add supercal potatoes to lunch and supper. On 05/21/18 the dietary note recommended to offer ice cream twice daily. The dietary note dated 07/25/18 recommend adding a liquid nutritional supplement (Boost) daily. On 08/05/18 the notes reflected the recommendation of super cereal at breakfast. On 08/08/18 Resident #12 declined super cereal, as she preferred cheerios, the super cereal was discontinued. On 02/26/18 Resident #12 weighed 142.8 pounds, on 08/14/18 she weighed 123.4 pounds which reflected a 13.5 % severe weight loss of 19.4 pounds in six months. Observation on 08/22/18 at 7:46 A.M. revealed Resident #12 received chocolate milk and cheerios and ate 33% of her meal. Interview with STNA #135 at the time of the observation revealed Resident #12 did not eat well for breakfast and did better at lunch. Review of Resident #12's tray card revealed it called for 1% milk. Observation on 08/23/18 at 9:58 A.M. revealed Resident #12 was in bed asleep and the boost supplement was observed full on the bedside table out of the resident's reach. At 11:22 A.M. the Boost supplement remained in the same location and was full. Review of Resident #12's (MONTH) (YEAR) medication administration records revealed on 08/23/18 the Boost was signed off as being administered. The actual percentage of intake of the Boost was not documented as there was no space to document it on the form. Interview with LPN #129 on 08/23/18 at 12:40 P.M. revealed when she signed off on the Boost it meant the resident consumed it. She stated if the resident took less than 100% then she marked the intake percentage. The LPN was showed and confirmed Resident #12's Boost was full in her room at that time. LPN #129 stated she thought she had taken it. Interview with STNA #86 on 08/23/18 at 2:34 P.M. revealed some days Resident #12 eats better than others. STNA #86 stated the resident was hit and miss with the Boost and today she did not want it at all. Interview with RD #125 on 08/23/18 at 4:00 P.M. revealed Resident #12 did not want the super-cereal and she did not replace it with other food that was nutritionally dense at breakfast. RD #125 stated the resident only gets a morning snack and did not add an afternoon or evening snack. RD #125 stated Resident #12 gained and lost weight in the past. Interview with Assistant Director of Nursing #75 on 08/23/18 at 4:30 P.M. confirmed there should have been a percentage for the Boost consumed and there was not. She also confirmed Resident #12 only received a morning snack. Interview of Dietary Manager #142 on 08/24/18 at 7:43 A.M. confirmed Resident # 12 received 1% milk, that she liked chocolate milk and she did not get between meal snacks except for the 9:30 AM Boost supplement. Review of the facility's weight protocol policy revised 06/01/18 revealed STNA staff would provide resident weights to the nurse. The nurse was to compare weight to the last weight obtained. If there was a variance of +/- three pounds in a resident weighing less than 100 pounds or +/- 5 pounds in a resident over 100 pounds the nurse was to assist the STNA to re-weigh the resident during the same shift. If the variance remained significant the nurse was to notify the physician, and responsible party and a nursing note documenting the weight variance and the responsible party and physician were notified. The unit manager reviewed and submitted significant weight change list to the dietitian.

Based on observation, record review and interview the facility failed to ensure residents were provided with timely, appropriate and adequate perineal care and catheter care to prevent urinary infections. Actual harm occurred when Resident #23 experienced decreased appetite, vomiting, urgency, burning of urine, and/or confusion while being treated five times for urinary tract infections from (MONTH) (YEAR) to (MONTH) (YEAR). Four of the urinary tract infections were Escherichia Coli (E coli) bacteria and the fifth was not cultured. Seven different antibiotics were used and the last two urine cultures were Extended spectrum beta Lactamase (ESBL) positive. E coli is bacteria commonly found in the bowel and ESBL are germs that break down several types of antibiotics and make infections harder to treat. Actual harm occurred when Resident #17 experienced lethargy, decreased food and fluid intake, a fall, and low blood pressure while being treated five times for urinary tract infections from (MONTH) (YEAR) to (MONTH) (YEAR). Two of the urinary tract infections were E coli. The last culture was Extended spectrum beta Lactamase (ESBL) positive. E coli is bacteria commonly found in the bowel and ESBL are germs that break down several types of antibiotics and make infections harder to treat. Actual harm occurred when Resident #48 experienced low back pain, dysuria, confusion, burning around the catheter, and verbal aggression while being treated six times for urinary tract infections from (MONTH) (YEAR) to (MONTH) (YEAR). Five of the six urinary tract infections were E coli. Actual harm occurred when Resident #14 experienced an elevated temperature of 102.1, decreased appetite, and loose stool while being treated five times for urinary tract infections from (MONTH) (YEAR) to (MONTH) (YEAR). Actual harm occurred when Resident #12, who was dependent on staff for personal hygiene, developed three urinary tract infections between 05/15/18 and 08/08/18, the resident experienced falls and pain as result of the infections. This affected seven residents (Resident #12, #14, #17, #23, #32, #48 and #64) of eight residents reviewed for urinary tract infections. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of nurse's notes on 01/07/18 at 7:10 P.M. revealed 30 milliliters from post void was obtained for urinalysis and culture. There was nothing documented to say why the urine was sent for testing. A urinalysis result from the lab on 01/08/18 indicated the test was positive for [MEDICATION NAME], bacteria, and a trace of blood. However, it stated it did not meet the accepted criteria for culture. Nurse's notes on 01/10/18 at 3:47 P.M. revealed staff spoke with the physician about the urinalysis results. A new order was received for antibiotic, [MEDICATION NAME] every day for 10 days. Review of nurse's notes on 01/19/18 at 6:01 P.M. revealed the resident was still complaining of urgency and burning and stated she felt like she had a urinary tract infection. Resident #23 completed the last dose of [MEDICATION NAME] that morning. Called lab to follow up on last urinalysis and culture obtained on 01/07/18. The lab stated they did not run a culture since it did not specify obtained via cath on the lab order form. Physician notified and order to obtain another urinalysis and culture via straight cath. On 01/20/18 at 5:58 P.M. it was noted the physician reviewed the urinalysis results and ordered an antibiotic, [MEDICATION NAME] 100 milligrams twice per day for 10 days. The final urine culture results were obtained on 01/22/18 which showed >100,000 Escherichia coli organisms (Escherichia coli (E coli) are bacteria commonly found in the bowel) that were Extended spectrum beta Lactamase (ESBL) negative. ESBL are germs that break down several types of antibiotics and make infections harder to treat. The E coli was not sensitive to [MEDICATION NAME] (the antibiotic previously ordered based on the urinalysis on 01/07/18) but was sensitive to the [MEDICATION NAME] so it was continued. Review of nurse's notes on 02/03/18 at 1:58 P.M. revealed an order was received from the physician for a stat urinalysis and culture for urgency and pain to rule out urinary tract infection. On 02/03/18 at 6:36 P.M. it was noted the urinalysis results were given to the physician (which were positive for [MEDICATION NAME] and 2+ bacteria). An antibiotic, [MEDICATION NAME] one gram intramuscularly (IM) for three days was ordered. The urine culture results of 02/06/18 showed >100,000 E coli bacteria which was ESBL negative. It was sensitive to [MEDICATION NAME] so the physician ordered for it to be continued for ten days IM. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment completed on 06/05/18 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. It stated the resident required limited assistance from staff with toileting and personal hygiene and identified the resident to be continent of bladder. A plan of care dated 06/05/18 stated the resident was at risk for urinary tract infections with a goal to decrease frequency of urinary incontinence. The care plan stated staff were to wash, rinse, and dry perineum using soap and water when the resident was incontinent. Nurse's notes on 07/07/18 at 10:47 A.M. revealed a urinalysis and culture was ordered due to increased confusion. On 07/08/18 at 11:50 P.M. nurse's notes stated new orders were received for an antibiotic, Keflex 500 milligrams three times per day for ten days for urinary tract infection. The final urine culture results of 07/09/18 showed >100,000 E coli and was now ESBL positive. The E coli was not sensitive to the Keflex ordered on [DATE] so on 07/09/18 it was changed to the antibiotic [MEDICATION NAME] for urinary tract infection. Review of nurse's notes on 08/18/18 at 6:18 P.M. revealed the resident told the nurse she was having a decreased appetite and showed concerns of having a urinary tract infection due to previously having one and this being one of the symptoms. The physician was notified and ordered a urinalysis and culture. On 08/23/18 at 5:04 P.M., five days after the urine culture was ordered, nurse's notes stated orders were received from the physician to recollect the urinalysis and culture and then start an antibiotic, [MEDICATION NAME] one gram IM for three days. Notes did not indicate why it was necessary to recollect the urine. Urine culture results of 08/25/18 showed >100,000 E coli that was ESBL positive. It continued to be sensitive to only 7 of 15 antibiotics listed on the culture. It was resistant to the [MEDICATION NAME] that was started on 08/23/18 so the antibiotic was changed to [MEDICATION NAME] per nurses noted of 08/25/18 at 10:55 P.M. for urinary tract infection. Observations on 08/28/18 at 7:43 A.M. revealed Resident #23 in bed in her room. Her breakfast tray was sitting on the table in front of her with very little eaten. She stated she was not feeling good and could not eat. She stated if she takes a bite she gags. When asked what was wrong, she stated she had a urinary tract infection. She stated she had experienced at least four urinary tract infections since being admitted and had never had them before being admitted . She stated she didn't usually have typical symptoms like burning on urination. She stated they test her urine when she starts feeling bad and won't eat. She stated the staff does perineal care for her. Interview with State tested Nursing Assistant (STNA) #104 on 08/28/18 at 8:54 A.M. revealed Resident #23 did have incontinent episodes at times and staff also assist her to the toilet. She stated staff does provide perineal care for the resident after incontinent episodes and also sometimes have to clean her after she used the toilet. She stated the resident did not eat well the day before and complained of her stomach hurting. She stated she was not aware if the resident had experienced very many urinary tract infections. Interview with Assistant Director of Nursing (ADON) #75 on 08/28/18 at 10:44 A.M. revealed a urine culture was not done on 01/07/18 because it had 6-10 epithilials which indicated possible contamination. She stated the physician just treated it as a urinary tract infection. In addition, interview with ADON #75 on 08/28/18 at 10:44 A.M. revealed the urine on 08/18/18 did not show any susceptibility so it was reordered on [DATE]. She further stated it was probably necessary to have staff observe Resident #23 wiping herself since she sometimes does this for herself to see if she was doing it properly. She confirmed there was no evidence this had been done. 2. Review of the medical record for Resident #17 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of nurse's notes revealed on 01/26/18 at 1:02 P.M. Resident #17 was found on the floor at bedside. Notes further stated the resident's daughter wanted the resident sent to the hospital related to not eating/drinking and changes in overall mentation and health. The resident was sent to the hospital for evaluation and returned on 01/26/18 at 7:12 P.M. with orders for an intravenous antibiotic, [MEDICATION NAME], for five days for a urinary tract infection. Review of a urine culture result on 03/11/18 revealed Resident #17 had >100,000 [DIAGNOSES REDACTED] pneumoniae. The nurse's notes were silent to the reason the culture was obtained. On 03/13/18 at 1:44 P.M. nurse's notes documented the resident continued on antibiotics for a urinary tract infection. Nurse's notes on 04/28/18 at 5:28 P.M. revealed Resident #17 was extremely lethargic, cool and clammy to touch. Her pulse was 101 and oxygen saturation was 87%. Oxygen was administered. The physician was notified and lab tests were ordered including a urinalysis and culture. Urine culture results on 05/02/18 showed >100,000 E coli. Nurse's notes on 05/02/18 at 3:18 P.M. stated the resident was started on an antibiotic, Keflex 500 mg, three times per day for 10 days based on the urine culture results. Review of the MDS 3.0 assessment, completed 05/22/18 revealed the resident had a BIMS score of three, indicating severe cognitive impairment. The resident required extensive assistance from staff with dressing, toileting, and personal hygiene. The MDS indicated the resident was always incontinent of bowel and bladder. Nurse's notes on 07/22/18 at 7:11 P.M. stated the Resident #17 was extremely lethargic for the last couple days. Difficult to arouse. Unable to take medications. The physician was notified and lab tests were ordered including a urinalysis and culture. On 07/23/18 the resident was started on the antibiotic, [MEDICATION NAME] one gram IM for five days, for a urinary tract infection. An intravenous line was also started with fluids administered. The urine culture results on 07/26/18 showed >100,000 E coli. Nurse's notes on 08/07/18 at 10:38 A.M. indicated the resident was up in therapy, awake and alert. Resident #17 had poor food intake the last few days, however she was taking fluids. The physician was notified and lab tests were ordered including urinalysis and culture. The urine culture results on 08/09/18 showed >100,000 [DIAGNOSES REDACTED] pneumoniae that was ESBL positive. IV antibiotics were ordered for 10 days. On 08/24/18 at 8:20 A.M. STNA #119 was observed providing perineal care for Resident #17. STNA #119 applied gloves and obtained a basin of water which she sat on the bedside table with no barrier. She put soap on a washcloth. STNA #119 wiped down each side of the labia and then down the middle using the same part of the washcloth. STNA #119 laid the soiled washcloth on the bedside table. She then wiped down each side of the labia and then down the middle using the same part of a second washcloth. This washcloth had visible bowel movement on it when she was done. She laid this washcloth on the bedside table with no barrier. The resident's water pitcher was sitting nearby on the bedside table. STNA #119 then rinsed the residents perineal area and laid the washcloth on the bedside table. She then dried the resident's perineal area and laid the towel on the bedside table. She then rolled the resident over and cleansed bowel movement off the rectal area. STNA #119 then laid the washcloth soiled with bowel movement on the bedside table. STNA #119 then got a trash bag out of her pocket and put the linens in the bag. She poured the basin full of water down the sink in the resident's bathroom. STNA #119 then wiped off the bedside table with a wet brown paper towel from the resident's bathroom. 3. Review of the medical record for Resident #48 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of nurse's notes revealed on 09/07/17 at 2:23 P.M. indicated Resident #48 complained of lower back pain and dysuria. Awaiting lab pickup for urinalysis and culture. A final urine culture result on 09/13/17 showed two bacteria: >100,000 E coli and >100,000 streptococcus agalactiae. The resident was started on antibiotics but the antibiotics had to be changed when the culture results were obtained due to not being sensitive to the bacteria. Nurse's notes on 10/11/17 indicated Resident #48's daughter approached and stated her mother was having increased confusion and some burning in the peri area surrounding the resident's Foley catheter. Urine with slight cloudiness. The physician was notified and an order was received for a urine culture. The urine culture results on 10/14/17 showed >100,000 E coli. The resident was started on an antibiotic. Nurse's notes on 01/07/18 at 3:18 P.M. revealed the resident was complaining of flank back pain and requested her urine be tested and stated usually when had this type of back pain she has a urinary tract infection. Urine culture results on 01/09/18 showed >100,000 E-Coli. The resident was started on an antibiotic for ten days. Nurse's notes on 02/23/18 at 12:44 A.M. indicated Resident #48 was complaining of increased flank back pain and an antibiotic was started on 02/23/18. Urine culture results on 02/25/18 showed >100,000 [DIAGNOSES REDACTED] pneumoniae. Nurse's notes on 07/06/18 noted awaiting urine culture results with no further symptoms or reason given. Urine culture results on 07/09/18 showed >100,000 E-Coli. The resident was started on antibiotics for the urinary tract infection. Review of the MDS 3.0 assessment, completed 07/17/18 revealed a BIMS score of 15, indicating the resident was cognitively intact. It indicated the resident had an indwelling Foley catheter and had not had a urinary tract infection in the past 30 days. Nurse's notes on 08/12/18 at 11:22 P.M. noted the resident to be very confused this shift with complaints of dysuria and burning at the catheter site. A urine culture was ordered. Urine culture results on 08/16/18 showed two organisms including >100,000 E-Coli and >100,000 Streptococcus agalactiae. The resident received two different antibiotics for the urinary tract infection. Interview with Resident #48 on 08/20/18 at 4:26 P.M. revealed she was currently being treated for [REDACTED]. She stated she had a catheter and wore a leg bag during the day. Interview with Registered Nurse #93 (the nurse caring for Resident #48) on 08/23/18 at 9:00 A.M. revealed she was not aware the resident did her own catheter care. On 08/23/18 at 9:20 A.M. Resident #48 was observed to be in the bathroom in her room sitting on the commode with a towel covering the toilet hole. STNA #68 was in the bathroom with the resident and stated the resident does her own catheter care every day. STNA #68 handed Resident #48 a washcloth which the resident used to wash her perineal area. The resident used the washcloth to go back and forth from the front of the perineal area to the back near the rectum repeatedly using the same area on the washcloth to wash with. The resident was noted to have an indwelling catheter. Resident #48 handed the washcloth to STNA #68, who was wearing gloves. STNA #68 then handed the resident another washcloth to rinse with. The resident used the washcloth to go back and forth from the front of the perineal area to the back near the rectum repeatedly using the same area on the washcloth to rinse with. The resident handed the washcloth to STNA #68. While cleansing herself, the resident did not cleanse the catheter tubing separately. The catheter tubing was just present as the resident moved the wash cloth from front to back then back to front repeatedly with the wash and rinse of her perineal area. STNA #68 did not say anything to the resident about how she was cleansing herself. STNA #68 then, wearing the same gloves, assisted the resident to put on her panty hose. STNA #68 wore the same gloves that she had handled the soiled wash cloths with to put the hose on. STNA #68 stood by the resident and held the catheter tubing above the level of Resident #48's bladder while she was sitting on the commode. STNA #68 then laid the catheter bag with urine in it on the bathroom floor. STNA #68 then disconnected the catheter bag from the catheter. STNA #68 then took a brown paper towel from the dispenser in the bathroom and wiped off the end of the catheter before attaching it to a new leg bag. Interview with the Director of Nursing on 08/24/18 at 2:55 P.M. revealed staff should not lay catheter bags on the floor, put the tubing above the level of the bladder, and should wash their hands before disconnecting the catheter from the collection bag. During the interview the DON revealed she had been aware for about three months that Resident #48 did her own catheter care, but she did not know how well she did it. She stated there was no evidence of any training for Resident #48 on how to do catheter care properly. 4. Review of the medical record for Resident #14 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of nurse's notes revealed on 10/27/17 at 6:55 A.M. the resident was started on an antibiotic for a urine culture result of >100,000 Proteus mirabilis. There was no documentation to indicate why the urine culture was done. Review of nurse's notes on 02/03/18 at 7:58 P.M. revealed the resident was started on antibiotics for a urinary tract infection. The urine culture results on 02/06/18 showed >100,000 Proteus mirabilis. The antibiotic was changed due to lack of sensitivity to the antibiotic used prior to the culture results. There was no documentation to indicate why the urine culture was done. Nurse's notes on 02/25/18 at 3:52 A.M. revealed the urine in the resident's Foley catheter tubing was noted to have a milky white/yellow consistency and some discharge from meatus. The physician was notified and ordered a urine culture after a catheter change. Urine culture results on 02/27/18 showed >100,000 [MEDICATION NAME] faecalis. The resident was started on antibiotics for the urinary tract infection. Review of a MDS 3.0 assessment, completed 05/15/18 revealed a BIMS score of 13 indicating the resident was cognitively intact. It indicated the resident had an indwelling catheter and required extensive assistance from staff with toileting and personal hygiene. The resident had physician's orders for an indwelling catheter with a leg bag during the day and catheter care every shift. Nurse's notes on 06/06/18 at 1:51 A.M. revealed the resident was started on antibiotics related to a urinary tract infection. There was no documentation of symptoms. A preliminary urine culture on 06/06/18 showed a mixed culture of three or more organism and recommended recollection of the specimen due to probable contamination. There was no documentation of how the specimen was collected. A note on the urine culture results indicated the physician gave an order to complete the antibiotic that was previously ordered and if symptomatic after completion, obtain another urine culture. Nurses notes on 07/07/18 at 1:11 P.M. revealed the catheter was leaking profusely with urine that was foul smelling and cloudy with sediment. The physician was notified and a urine culture was ordered. On 07/09/18 antibiotics were started for ten days related to the urine test results. Additional nurses notes on 07/09/18 indicated the resident had a temperature of 102.1 degrees with no change after [MEDICATION NAME]. The resident also had decreased appetite and one loose stool. On 07/09/18 at 8:05 P.M. the physician was notified of the urine culture results which showed >100,000 Proteus mirabilis. The urine culture indicated the antibiotic ordered previously ([MEDICATION NAME]) was not sensitive to the bacteria in the urine so the antibiotic was changed to Keflex 500 milligrams three times per day for ten days and also one gram of [MEDICATION NAME] IM one dose. 5. Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment, dated 05/15/18 revealed Resident #12 had severe cognitive impairment and required extensive assistance of one staff for personal hygiene. resident #12 was frequently incontinent of bladder and bowel. Review of Resident #12's nursing notes dated 05/10/18 revealed the resident fell and hit her head and sent out to the emergency room due to the fall. The resident returned with a [DIAGNOSES REDACTED]. The organism identified was E. Coli and the resident was treated with an antibiotic. On 07/08/18, 07/12/18, and 07/13/18 Resident #12 tried to self-transfer and fell . Resident #12 was tested for a urinary tract infection with the results showing the resident had a urinary tract infection and the organism was E. Coli. Review of nursing notes dated 08/06/18 revealed Resident #12 was out of bed with repeated statements I hurt while holding in between her legs and inner thigh. The resident was tested , and she was positive for a urinary tract infection and the results of 08/06/18 revealed it was gram negative bacilli. Interview with Licensed Practical Nurse (LPN) #88 on 08/24/18 at 8:23 A.M. revealed there was no reason for Resident #12's urinary tract infections, but she thought the resident was declining. LPN #88 stated she does not monitor the aides providing care to resident. 6. Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS 3.0 assessment revealed Resident #32 had severe cognitive impairment Resident #32 was dependent on staff for personal hygiene and incontinent of bowel and bladder. Review of Resident #32's nursing notes date 06/03/18 revealed the resident was more lethargic and was tested for urinary tract infection. The results were obtained on 06/06/18 and the resident was positive for E. coli. On 06/11/18 an antibiotic was ordered. The family did not want the facility administering intravenous antibiotics and Resident #32 was sent to the emergency room for treatment. On 07/19/18 Resident #32 was tested for a urinary tract infection. Results, dated 07/19/18 revealed she was positive for a urinary tract infection. However, she was not treated at that time. Interview with LPN #88 on 08/24/18 at 8:23 A.M. revealed there was no reason for Resident #32's urinary tract infections, although she believed the resident was declining. LPN #88 stated she does not monitor the aides providing care to resident. 7. On 08/23/18 at 10:30 A.M. STNA #77 was observed providing catheter care for Resident #64. The STNA applied gloves and obtained a basin of water. STNA #77 used the same area of the washcloth with soap to cleanse the perineal area from front to back twice and to cleanse the catheter tubing. She used the same area of the washcloth to rinse the perineal area from front to back twice. When she was finished, she poured the water from the basin down the sink in the resident's bathroom. STNA #77 then got another basin with water to cleanse the resident's rectal area after the resident was turned on her side. After using a washcloth to cleanse the rectal area, bowel movement was visible on the washcloth. STNA #77 laid the washcloth on the pad in the resident's bed. She then rolled up the washcloth in the pad and laid the pad on the back of the chair in the resident's room. STNA #77 laid the catheter bag containing urine on the resident's bed. While STNA #77 was adjusting the resident, the catheter bag fell on the floor. STNA #77 then poured the water in the basin used to clean up bowel movement down the sink in the resident's bathroom. STNA #77 then used a brown paper towel from the dispenser to wipe out the water basin. STNA #77 then used the same brown paper towel that she wiped out the basin with to wipe off the resident's bedside table. Based on the investigation of the above residents, review of the facility policy on Foley catheter care dated (MONTH) 1994 revealed it stated to wash hands, put on gloves, gently separate the labia on females and wipe from front to back. Using a clean wash cloth, soap and water wash catheter itself from front to back and rinse with a clean wash cloth. Review of the facility policy on perineal care dated (MONTH) 1994 revealed it stated to wash perineal area with soap and water or peri wash from pubis toward perineum to prevent contamination. The policy stated to discard linen in laundry barrel. The policies did not address where to lay linens or what to do with water when done with care. There was also no evidence the facility had a policy on changing from a catheter collection bag to a leg bag. Interview with the Director of Nursing on 08/24/18 at 2:55 P.M. revealed she was aware the policies were old and lacked the proper steps to complete catheter care and incontinence care. She confirmed staff should not lay catheter bags on the floor, put the tubing above the level of the bladder, and should wash their hands before disconnecting the catheter from the collection bag. She further stated staff are supposed to use trash bags to place linens in and not place on bedside table. She further stated germicidal wipes should be used to cleanse the bedside tables and water should not be poured down the sink. Interview with the Director of Nursing (DON) on 08/24/18 at 2:55 P.M. revealed the facility did not track urinary tract infections by resident, so a pattern was not identified for Resident #17, #23, #48, #14, #12 or #32 and there was no evidence of any interventions to prevent further urinary tract infections for these residents. Interview with the Medical Director on 08/29/18 at 10:40 A.M. revealed a different part of the wash cloth or a clean wash cloth should be used each time staff wipe from front to back to prevent urinary tract infections. She further stated that Escherichia coli bacteria in the urine is a sign of improper perineal or catheter care. 8. Review of the resident urinary tract infection [MEDICAL CONDITION] tracking records revealed four of seven UTIs in (MONTH) (YEAR) were Escherichia coli (E-Coli) infections. Five of eight UTIs in (MONTH) (YEAR) were E-Coli infections and six of ten UTIs in (MONTH) (YEAR) were E-Coli infections. Record review revealed a staff inservice record dated 02/15/18 contained staff training related to handwashing/peri care. Interview with the Director of Nursing on 08/28/18 at 1:25 P.M. revealed nursing assistants had not received any training on incontinence care since 02/15/18. She stated that, although multiple urinary tract infections from E-Coli were noted in the past three months, observations of staff providing incontinence care/catheter care had not been done to determine if care was proper. She further stated the facility did not track urinary tract infections by resident. Therefore, repeat urinary tract infections for Resident #12, #14, #17, #23, #32, #48, and #64 were previously not identified.

Based on medical record review, fall investigation review, staff interview, review of manufacturer recommendations for use of a power wheelchair, and review of the facility's fall prevention policy, the facility failed to properly secure one resident (Resident #85) during a transport in the facility's van. Actual harm occurred on 05/26/18 when Resident #85 who was in her power wheelchair was placed in the facility van for transport. The wheelchair was positioned facing the wrong direction, and the resident was not secured as recommended with both a torso and pelvic seat belt. The resident slid out of the wheelchair onto the floor of the van and sustained a left distal femur fracture and a right ankle fracture. The facility also failed to ensure physician ordered fall prevention interventions were in place for one resident (Resident #30) resulting in fall with subsequent laceration of the right side of her head requiring sutures. This affected two of three residents reviewed for falls. Findings Include: 1. Review of Resident #85's medical record revealed an admission date of [DATE] with the latest readmission on 08/13/17. [DIAGNOSES REDACTED]. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had no cognitive deficit, was dependent on the staff for transfers and her primary mode of transportation was a wheelchair. The MDS also indicated the resident had not had any falls since the prior assessment. Review of the fall risk assessment dated [DATE] revealed a score of 15 indicating the resident was at high risk for fall. Review of the plan of care dated 02/02/13 revealed Resident #85 was at risk for falls due to gait and balance problems. Interventions included supervision and/or to be assisted at all times with transfers, ambulation and toileting. Review of physician orders [REDACTED]. Review of the fall investigation dated 05/26/18 at 5:00 P.M. revealed during transport in the facility van Resident #85 slid out of her power wheelchair onto the floor of the van. Review of the nurse's notes dated 05/26/18 at 6:24 P.M. by Registered Nurse (RN) #104 revealed he received a phone call informing him while the resident was being transported in the facility van she slid out of her power wheelchair. The progress note indicated 911 was dispatched and the resident was transported from the scene to the local emergency room (ER) via squad. Review of the nurse's note dated 05/26/18 at 9:31 P.M. by Licensed Practical Nurse (LPN) #105 revealed the local ER called the facility and informed her Resident #85 was admitted to the hospital with [REDACTED]. Review of the witness statement dated 05/27/18 by STNA #107, who was the driver of the facility van, revealed he placed the resident in her power wheelchair facing the lift and the lift door so all four hooks could be securely attached to the power wheelchair. The statement indicated the resident's lift pad slid from the wheelchair dragging the resident with it. The resident landed between the secured wheelchair and the lift on her hands and knees. STNA #107 pulled the facility van over to the side of the road and called the facility. The facility called 911 for assistance. The resident was then transported to the local ER. On 05/31/18 at 2:20 P.M. the Administrator and Director of Nursing (DON) verified Resident #85 was not properly secured in the power wheelchair with a restraint system including torso and pelvic seat belts and the wheelchair was not anchored in the correct position in the van. The resident should not have been facing the lift. Consequently during transport the resident slid out of the power wheelchair and sustained a left distal femur fracture and a right ankle fracture. On 05/31/18 at 3:10 P.M. STNA #107 verified Resident #85 was not secured in the power wheelchair with seat belts and the wheelchair was not positioned in the van correctly causing her to slide out of the wheelchair and onto the floor of the van. Review of the manufacturer recommendations for use of the power chair during transport revealed it is essential to use a complete wheelchair tie down and an occupant restraint system to secure the power chair to the vehicle and to provide the power chair occupant with a properly designed and tested safety restraint system. A restraint system with both pelvic and upper torso belts must be used to protect the power chair occupant and minimize the likelihood of injury. 2. Review of Resident #34's medical record revealed an admission date of [DATE] with the admitting [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS dated [DATE] indicated the resident was severely cognitively impaired. The resident required extensive assistance of two staff members for transfers and locomotion with a wheelchair, and had no falls since the previous assessment was completed. Review of Resident #34's care plan related to risk for falls (dated 11/03/15) revealed the resident was unaware of safety needs. Interventions included to anticipate and meet her needs, ensure the call light was within reach, encourage her to wear gripper socks at all times and keep a floor mat on the left side of the bed. Review of Resident #34's physician's orders [REDACTED]. Review of the falls root cause analysis guide dated 05/28/18 revealed Resident #34 fell out of her recliner onto the floor. The resident was unable to explain what happened and the fall was unwitnessed. The facility implemented the intervention of adding Dycem to the seat of the recliner. Review of the progress note dated 05/28/18 at 3:00 P.M. revealed the nurse responded to a groaning noise coming from the resident's room. Upon entry to the room Resident #34 was found in a prone position (face down) on the floor in front of her recliner with the foot rest of the recliner extended. A moderate amount of blood was noted coming from a laceration to the right side of her head. A call was placed to 911 and the resident was transported to the local ER. On 05/31/18 at 2:50 P.M. the DON verified Resident #34 had an order dated 10/31/17 for Dycem to the seat of her recliner to be used for fall prevention. The Dycem was not in place at the time of the fall on 05/28/18. Review of the facility's fall prevention policy and procedure dated 08/17 revealed it is the facility's policy to assess each resident's risk for falls and to prevent resident falls. This deficiency substantiates Complaint Number OH 209.