Every finding on record at Home at Taylor's Pointe

Based on observations, staff interviews, and facility policy review, the facility failed to maintain a sanitary kitchen to prevent cross contamination of food. This affected 81 residents who received food from the kitchen. The facility identified 10 residents who do not receive food from the kitchen. The facility total census was 91. Findings include: 1. Observation and interview on 03/17/25 at 7:53 A.M. of the kitchen with Dietary Manager (DM) #140 revealed there were 15 individually packaged desserts, one opened beef base container, nine opened containers of liquids, and approximately 30 hard boiled eggs stored undated. There was a large tray of cooked sausage patties which were stored uncovered in the refrigerator. There was an opened undated container of jelly stored in the dry storage room with a label to refrigerate after opening. DM #140 verified the undated and uncovered food in the refrigerators and unrefrigerated items. 2. Observation on 03/19/25 from 7:30 A.M. through 8:15 A.M. revealed Dietary Manager (DM) #140 with approximately 20 rope-like strands of hair hanging out of DM #140's knitted cap he was wearing. The strands of hair were approximately six inches long that was hanging out of the knitted cap. DM #140 was assisting with breakfast food preparation. Interview on 03/19/25 at 8:15 A.M. with DM #140 verified his hair extended beyond the hair cap and was not contained. DM #140 verified all hair should be contained completely under the hair restraint. Interview on 03/20/25 at 9:55 A.M. with Registered Dietitian (RD) #695 verified all hair should be contained under the hair covering. 3. Observation on 03/19/25 at 9:10 A.M. on the 300 unit nursing station revealed the resident refrigerator had two insulated bags of food unlabeled. There were two bags of fast food unlabeled. There were two partially used and opened gallon containers of liquids which were undated. Interview on 03/19/25 at 9:10 A.M. with Admission Director (AR) #190 verified the refrigerator was for storage of resident foods only and all foods should be labeled and dated. AR #190 stated the unlabeled insulated bags of foods were employee's food containers and should have been stored in the employee breakroom. AR #190 verified the two bags of foods were not labeled with a name or dated. The two gallons of liquid were undated with a opened date. 4. Observation on 03/19/25 at 9:17 A.M. on the 200 unit nursing station revealed the resident refrigerator had a sign all foods should be dated. There was a bag of foods labeled with a name but had no date. There was a Styrofoam container with no label of contents or a date. There were two opened gallon containers of liquids with no open dates. There was as partially used pitcher of liquids with no label or date. Interview on 03/19/25 at 9:17 A.M. with Social Service Designee (SSD) #700 verified the refrigerator was for storage of resident foods only and all foods should be labeled and dated. SSD #700 verified there were no dates on the open containers of liquids and no date on the bag of identified resident's food. Review of the facility policy titled Food Storage Labeling and Dating dated 2017 revealed all items must be dated after opening with an open and a use by date.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure care conferences were held quarterly for residents and their representatives. This affected five (Residents #5, #9, #50, #51, and #63) of five residents reviewed for care conferences. The facility census was 91. Findings include: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of chronic ischemic heart disease, hypertension, vascular dementia, diabetes mellitus type II, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had no cognitive impairment and was always incontinent of bowel and bladder. Resident #5 required supervision with eating, moderate assistance with oral hygiene, dependent on staff for toileting, dressing and transfers and maximal assistance with bathing, personal hygiene and bed mobility. Review of the Care Conference Meeting Summary documents, as supplied by the Administrator, revealed Resident #5 did not have documented care conferences in the second quarter (April, May and June) and fourth quarter (October, November and December) of 2024. Interview on 03/20/25 at 9:50 A.M. with Resident #5 stated she could not remember the last time she had a care conference. Interview on 03/20/25 at 2:10 P.M. with Social Services Designee #132 verified the facility did not provide a care conference for Resident #95 in the second and fourth quarters of 2024. 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of quadriplegia status-post motor vehicle accident, neuromuscular dysfunction of bladder, diabetes mellitus type II, major depressive disorder and moderate protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had intact cognition and had a suprapubic catheter and was always incontinent of bowel. The resident was dependent on staff for eating, oral and personal hygiene, toileting, bathing, dressing, bed mobility, and transfers. Review of the Care Conference Meeting Summary documents, as provided by the facility Administrator, revealed Resident #9 did not have documented care conferences in the first quarter (January, February and March) of 2024. Interview on 03/20/25 at 10:00 A.M. with Resident #9 stated they have no recollection of quarterly care conferences. Interview on 03/20/25 at 2:10 P.M. with Social Services Designee #132 verified the facility did not provide a care conference for Resident #9 in the first quarter of 2024. 3. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses of quadriplegia, end-stage renal disease with dependence on renal dialysis and neuromuscular dysfunction of bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had moderate cognitive impairment and had an indwelling urinary catheter and was always incontinent of bowel. The resident was dependent on staff for eating, oral and personal hygiene, toileting, bathing, dressing, bed mobility, and transfers. Review of the Care Conference Meeting Summary documents, as supplied by the Administrator, revealed Resident #50 did not have documented care conferences in the first quarter (January, February and March) and third quarter (July, August and September) of 2024. Interview on 03/20/25 at 2:10 P.M. with Social Services Designee #132 verified the facility did not provide a care conference for Resident #50 in the first and third quarters of 2024. 4. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses of dementia, major depressive disorder, anxiety disorder and diabetes mellitus type II. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had intact cognition and was always continent of bowel and bladder. The resident required supervision with eating, oral and personal hygiene, toileting, dressing and transfers, moderate assistance with bathing and set up assistance with bed mobility. Review of the Care Conference Meeting Summary documents, as provided by the Administrator, revealed Resident #51 did not have documented care conferences in the first quarter (January, February and March), second quarter (April, May and June) and fourth quarter (October, November and December) of 2024. Interview on 03/20/25 at 10:10 A.M. with Resident #51 stated they have no recollection of the last care conference she had with the facility. Interview on 03/20/25 at 2:10 P.M. with Social Services Designee #132 verified the facility did not provide a care conference for Resident #9 in the first, second, and fourth quarters of 2024. 5. Review of the medical record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, diabetes mellitus type II, chronic obstructive pulmonary disease, post-traumatic stress disorder and anxiety. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #63 had intact cognition and was always continent of bowel and bladder. The resident required supervision with eating, oral and personal hygiene, toileting, dressing, bed mobility and transfers and moderate assistance with bathing. Review of the Care Conference Meeting Summary documents, as supplied by the Administrator, revealed Resident #63 did not have documented care conferences in the first quarter (January, February and March) and second quarter (April, May and June) of 2024. Interview on 03/20/25 at 10:10 A.M. with Resident #63 stated they have no recollection of the last care conference she had with the facility. Interview on 03/20/25 at 2:10 P.M. with Social Services Designee #132 verified the facility did not provide a care conference for Resident #9 in the first and second quarters of 2024. Review of the policy titled Care Conference, revised 03/20/24, revealed a purpose to provide the resident and, if applicable, the resident representative of the right to participate in the resident's plan of care in a manner that facilitates his/her participation. The facility's interdisciplinary team shall periodically review the resident's care plan and make necessary revisions based on the goals, preferences and needs of the resident.

Based on observations, staff interviews, and record reviews, the facility failed to ensure resident's had a dignified meal experience in the dining room. This affected two (Residents #32 and #191) of 15 residents in the 300 memory care unit dining room. The facility census was 91. Findings Include: Record review of Resident #191 revealed the resident was admitted to the facility on [DATE]. Diagnoses included anxiety, dementia, multiple sclerosis, and psychotic disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #191 had impaired cognition and required supervision with feeding assistance. Record review of Resident #32 revealed the resident was admitted to the facility on [DATE] . Diagnoses included cerebral infarction, aphasia, anxiety, depressive disorder, and dementia with behavioral disturbance. Review of the MDS assessment dated [DATE] revealed Resident #32 had impaired cognition. The resident received a regular, puree consistency diet. Record review of Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, anxiety, and mood disorder. Review of the MDS assessment dated [DATE] revealed Resident #27 had impaired cognition. The resident received a regular mechanical soft consistency diet. Observations on 03/19/25 at 12:12 P.M. revealed in the 300 memory care unit dining room, Resident #27 was seated in a wheelchair at a dining room table with Residents #32 and #191. Resident #27 was being fed the meal by Certified Nursing Assistant (CNA) #196. Observation on 03/19/25 at 12:30 P.M. revealed Resident #191 rocked back and forth in her wheelchair. Residents #191 and #32 had not received their lunch meal trays. CNA #178 attempted to calm Resident #191 by talking with her and told her the food was coming, which did not appear to calm Resident #191. Interview on 03/19/25 at 12:32 P.M. with CNA #178 verified Resident #191 appeared to be getting anxious by watching Resident #27 eat her lunch meal and Resident #27 should have been fed at a separate table so not to have Resident's #191 and #32 watch and become anxious. Observation on 03/19/25 at 12:40 P.M. revealed Resident #27 had completed her meal. At 12:44 P.M., Residents #191 and #32 received their lunch meal trays. Interview on 03/19/25 at 12:40 P.M. with Assistant Director of Nursing (ADON) #100 verified Resident #27 needed feeding assistance and received her meal first, then the other residents' received their meal trays. ADON #100 verified Resident #27 was fed while Residents #191 and #32 watched and became anxious. ADON #100 stated Residents #191 and #32 should have received their meals when Resident #27 received her meal. This deficiency represents non-compliance investigated under Complaint Numbers OH00153044 and OH00161555.

Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure medications were administered according to physician's order, resulting in a medication error rate rate which exceeded five percent (%). 35 opportunities were observed with four medication errors, resulting in a 11.43% error rate. This affected one (Resident #71) of four residents reviewed for medication administration. The facility census was 91. Findings include: Review of the medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II (DM), chronic obstructive pulmonary disease and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had intact cognition. Review of the physician orders revealed Resident #71 had the following orders: an order dated 02/07/25 for Novolog pen-injector 100 unit per milliliter (ml) (Insulin Aspart), inject 10 unit subcutaneously before meals for DM, hold for finger-stick blood sugar less than 150; an order dated 04/11/23 for Metoclopramide 10 milligrams (mg) give one tablet by mouth before meals and at bedtime for hiccups; an order dated 09/12/22 for Sucralfate one gram (gm), give one tablet by mouth before meals and at bedtime related to other symbolic dysfunctions; and an order dated 05/28/22 Simethicone tablet 80 mg, give one tablet by mouth before meals and at bedtime for gastro-esophageal reflux disease. Observation on 03/19/25 at 8:40 A.M. revealed Resident #71 had completed eating his breakfast meal in his room prior to receiving his morning medications. Observation of medication administration on 03/19/25 at 8:40 A.M. revealed Registered Nurse (RN) #164 administered Resident #71 four medications that had physician orders to be administered before eating breakfast. RN #164 administered Novolog insulin 10 units subcutaneously, Metoclopimide 10 mg by mouth, Sucralfate one gm by mouth, and Simethicone 80 mg by mouth. Interview on 03/19/25 at 8:50 A.M. with RN #164 verified the Novolog insulin, Metoclopramide, Sucralfate and Simethicone should have been administered before Resident #71 consumed his breakfast. Interview on 03/19/25 at 8:52 A.M. with Assistant Director of Nursing (ADON) #114 verified Resident #71 did not receive Novolog insulin, Metoclopramide, Sucralfate, and Simethicone per the physician order which stated to be administered before breakfast. Interview on 03/19/25 at 10:19 A.M. with the Director of Nursing (DON) verified nurses are to administer medications as ordered by the physician. She verified medications ordered to be administered before breakfast should be administered before the resident consumed breakfast. Review of the policy titled General Guidelines for Medication Administration dated 06/21/17 revealed medications will be administered by legally authorized and trained persons in accordance to applicable State, Local and Federal laws and consistent with accepted standards of practice.

Based on observations, staff interviews, review of facility policy, and record reviews, the facility failed to ensure hand sanitation was performed during meal service. This affected three residents (#71, #85 and #61) observed during meal service. The facility census was 91. Findings include: 1. Record review of Resident #61 revealed the resident was admitted to the facility on [DATE]. Diagnoses included sepsis and ileostomy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had severely impaired cognition. The resident had a physician order for contact isolation. Observation on 03/19/25 at 8:40 A.M. revealed there was a sign on a Resident #61's room door. The signage revealed the resident was in contact precautions and everyone must clean their hands, including before entering and when leaving the room. Certified Nursing Assistant (CNA) #117 donned gloves and gown and entered Resident #61's room with the breakfast meal tray. CNA #117 was observed to assist the resident in bed and touched other items in the room to assist in positioning the resident in bed. CNA #117 doffed the gown and gloves and did not wash or hand sanitize her hands prior to or after leaving the room. Interview on 03/19/25 at 8:45 A.M. with CNA #117 verified she had assisted Resident #61 in bed and stated she should have performed hand hygiene. She verified she did not wash her hands or use hand sanitizer when she doffed the gloves when exiting Resident #61's room. Interview on 03/19/25 at 2:40 P.M. with the Director of Nursing (DON) verified the staff should hand sanitize prior to and after delivery of meal trays. Interview on 03/20/25 at 9:30 A.M. with Unit Nurse Manager #114 verified the CNAs should be performing hand hygiene after exiting resident's rooms with contact precautions, including Resident #61's room. 2. Observations on 03/19/25 at 8:33 A.M. revealed Certified Nursing Assistant (CNA) #123 delivered a breakfast tray to Resident #19. CNA #123 was observed to touch items and assist Resident #19 in bed. CNA #123 exited the room and did not wash or sanitize her hands. CNA #123 obtained Resident #71's meal tray. CNA #123 delivered and assisted Resident #71 with the meal tray. CNA #123 exited Resident #71's room and did not wash or sanitize her hands and proceeded to obtain Resident #85's meal tray. CNA #123 delivered the meal tray and assisted Resident #85 with the meal set up and touching items in the room. CNA #123 exited the room. CNA #123 did not perform hand sanitizing or hand washing between assisting the residents and delivery of meal trays to the residents. Interview on 03/19/25 at 8:35 A.M. with CNA #123 verified she had touched items in the rooms of Residents #19, #71, and #85 and had not performed hand sanitization prior to or after delivery of the meal trays to Residents #19, #71 and #85. CNA #123 verified she should have performed hand sanitation after touching items in a resident's room and delivery of meal trays. Interview on 03/19/25 at 2:40 P.M. with the Director of Nursing (DON) verified the staff should hand sanitize prior to and after delivery of meal trays. Review of the facility policy titled Infection Control Policy dated 2010 revealed all staff perform hand hygiene after handling contaminated objects.

Based on observations, staff interviews, medical record review, review of guidance from the Centers for Disease Control and Prevention (CDC), and review of the policy, the facility failed to implement effective and recommended infection source control practices to prevent the spread of Coronavirus 2019 (COVID-19). This affected four (#75, #77, #81, and #85) of four Residents who tested positive for COVID-19 and had the potential to affect all fourteen (#74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, and #88) residents that resided on the unit. The facility census was 87. Findings included: 1. Review of the medical record for Resident #75 revealed an admitted [DATE]. Her diagnoses included Alzheimer's disease, anxiety disorder, major depressive disorder, COVID-19, and mood disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 99. This resident was assessed to require supervision with eating and transfers, dependent with toileting, bathing, and moderate assistance with dressing. Review of physician's order 10/26/23 revealed Resident #75 was ordered to maintain contact and droplet precautions every shift for 10 days for COVID -19. Room door may remain open as needed for supervision and as requested by resident for psychosocial or physical well-being. 2. Review of the medical record for Resident #77 revealed an admitted [DATE]. Her diagnoses included Alzheimer's disease, COVID-19, major depressive disorder, generalized anxiety disorder, and type two diabetes mellitus (DM II). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three. This resident was assessed to require two-person extensive assistance with transfers, toileting, and bathing, one-person extensive assistance with dressing, and one-person limited assistance with eating. Review of the physician order dated 10/26/23 revealed Resident #77 was ordered to maintain contact and droplet precautions every shift for 10 days for COVID -19. Room door may remain open as needed for supervision and as requested by resident for psychosocial or physical well-being. 3. Review of the medical record for Resident #81 revealed an admitted [DATE]. Diagnoses included frontal lobe function deficit following cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, type two diabetes mellitus (DM II), and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. This resident was assessed to require set-up for eating, partial assistance with toileting, bathing, dressing, and transfers. Review of the physician order dated 10/31/23 revealed Resident #81 was ordered to maintain contact and droplet precautions every shift for 10 days for COVID -19. Room door may remain open as needed for supervision and as requested by resident for psychosocial or physical well-being. 4. Review of the medical record for Resident #85 revealed she was admitted to the facility on [DATE]. Her diagnoses included type two diabetes mellitus (DM II), chronic pulmonary edema, chronic obstructive pulmonary disease (COPD), and dementia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three. This resident was assessed to require supervision with transfers, dressing, eating, toileting, and bathing. Review of the nurse's progress notes, dated 10/25/2023, revealed Resident #85 tested positive for COVID-19. Observation during the tour of the unit revealed four Residents (#75, #77, #81, and #84) who tested positive for COVID-19 were housed in a room with four Residents (#76, #78, #80, #84) who tested negative for COVID-19. Interview on 10/31/23 at 10:32 A.M., with Infection Preventionist Nurse (IPN) #215, who was standing outside the glass doors looking into the dining room of Rooms #301-#309, confirmed a sign was hanging advising someone prior to entering until to don a gown, N95, gloves. IPN #215 stated the sign was hanging on the glass door and next to it was a container with gowns, gloves, N95, however, it was just up to remind visitors to wear PPE. Interview and observation on 10/31/23 at 10:33 A.M., with Licensed Practical Nurse (LPN) #189 as she stood at the nurse's cart outside the open dining room. LPN#189 confirmed she had a surgical mask with a N95 over top of it. LPN #189 confirmed Resident #85 tested positive for COVID-19 and was seated in the open dining room with her surgical mask down and coughing. LPN #189 confirmed two of the Residents #81, and #85 were COVID-19 positive and were escorted by staff to attend an activity with the following Residents (#76, #80, #85, and #86) who tested negative for COVID-19. Interview on 10/31/23 at 10:44 A.M., with Registered Nurse (RN) #211 stated she is going onto the unit now to fix it. RN #211 confirmed the staff escorted the two COVID-19 positive Residents # 88 and #80 out to activities in an open dining room with Residents (#76, #80, #85, #86). However, RN #211 confirmed the COVID-19 positive Residents should remain isolated in their room to prevent the spread of COVID-19. Review of the CDC guidelines for Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/23, revealed Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If Cohorting, only patients with the same respiratory pathogen should be housed in the same room. MDRO colonization status and/or presence of other communicable disease should also be taken into consideration during the Cohorting process. Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection. Limit transport and movement of the patient outside of the room to medically essential purposes. Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other healthcare facilities. Review of the policy titled, COVID-19 Prevention, Response, and Reporting, dated 05/11/23, stated the facility will ensure that appropriate interventions are implemented to prevent the spread of COVID -19 infections. COVID-19 information will be reported through proper channels as per federal, state, and/or local health authority guidance. Further review of the policy confirmed, Residents with symptoms of COVID-19 should not be cohorted with residents with confirmed COVID-19 unless they have confirmed to have COVID-19 through testing. This deficiency represent the noncompliance discovered during the investigation of Master Complaint Number OH00147795 and Complaint Numbers OH00147744 and OH00146945.

Based on review of facility documents and staff interview, the facility failed to ensure the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days per week. This had the potential to affect all 83 residents residing in the facility. The census was 83. Findings include: Review of staffing schedules revealed the facility did not have an RN scheduled on the following dates: 10/16/22, 10/22/22, 10/29/22, 10/30/22. Interview on 11/12/22 at 2:40 P.M. with Assistant Administrator (AA) #100 confirmed the facility did not have RN working on the following dates: 10/16/22, 10/22/22, 10/29/22, 10/30/22. AA #100 confirmed the facility did not have a staffing policy. This deficiency represents non-compliance investigated under Complaint Number OH 015.

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to administer medications under direct supervision. This affected one resident (#31) out of four residents reviewed for medication administration. The facility census was 87. Findings include: Review of the medical record for Resident #31 revealed an admitted on 10/02/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the minimum data set (MDS) dated [DATE] for Resident #31 revealed intact cognition. Resident #31 required extensive assistance with bed mobility, and toilet use. Resident #31 required total assistance for transfers and supervision for eating. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 09/28/22 at 3:14 P.M. revealed Resident #31 lying on her bed with a medication administration cup on the bed side table in front of the resident. Inside the medication cup was one small white tablet. Corporate Registered Nurse (RN) #212 was also present at the time of the observation. No facility staff were present at the time of the observation. Interview on 09/28/22 at 3:19 P.M., with Resident #31 stated the nurse just brought the medication in for her and she had not taken it yet. Interview on 09/28/22 at 3:25 P.M., with Corporate RN #212 and RN #127 verified medication should not be left at the bedside unsupervised. The nurse should stay in the room until the medication was administered. RN #127 verified she had not waited until Resident #31 took the medication before leaving the room. Review of facility policy titled Medication Administration, dated 06/21/2017 revealed the nurse should remain with the resident while the medication is swallowed. Never leave a medication in a residents room without an order to do so.

Based on medical record review, staff, resident, and pharmacist interview, observations, review of the quick reference guide for the fasting glucose monitoring system, and policy review, the facility failed to document a physician's order for a fasting glucose device on the medication administration record and document every fourteen days the need to change to subcutaneous sensor. This affected one resident (#47) out of two residents reviewed for medication administration documentation related to the application and monitoring of a fasting glucose monitoring system. The facility census was 87. Findings include: Medical review for Resident #47 revealed an admitted d on 01/31/22 with diagnoses including [CONDITION(S)], depression, chronic [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], chronic sinusitis, [CONDITION(S)] C, hypertension, and type two diabetes. Review of the Minimum Data Set (MDS) dated [DATE] for Resident #47 revealed intact cognition. Resident #47 required extensive assistance for bed mobility and transfers. Resident #47 required supervision for eating and toilet use. Resident #47 received insulin during the look back period. Review of the plan of care for Resident #47 dated 03/20/22 revealed the resident was at risk for elevated blood glucose. Interventions included insulin as ordered, monitor blood sugars as ordered and rotate the injection sites. Review of the active physician's orders for Resident #47 revealed there was no order for the application of fasting glucose monitoring systems Review of the progress notes for Resident #47 dated 07/28/22 through 09/28/22 revealed there was no documentation related to the application of the fasting glucose monitoring system. Observation on 09/26/22 at 4:10 P.M. of Resident #47 revealed a glucose monitoring system attached to the right upper back arm. Interview on 09/26/22 at 4:10 P.M., Resident #47 stated the sensor fell off a few days ago and she advised the nurse of the incident. Resident #47 stated she went for three days without her glucose sensor before it was replaced. Resident #47 stated the nurses had to do blood sugar testing using my fingers until they got the sensor reordered from the pharmacy. Resident #47 states she has had the device in use since her admission to the facility. Interview on 09/28/22 at 11:48 A.M., with Registered Nurse (RN) #127 verified there were no orders regarding the free Style Libre blood glucose monitoring system and there should be. Review of the Freestyle Libre 2 quick reference guide dated 2018 through 2022 revealed the sensor will alarm when a replacement is needed, this will occur about every fourteen days. Review of the pharmacy label for Resident #47 on the box for the FreeStyle Libre 2 reader revealed an order date of 09/01/22. Interview on 09/28/22 at 12:16 P.M., with the Pharmacist #211 at the pharmacy utilized by the facility for Resident #47 verified the pharmacy had sent 16 glucose monitoring units to the facility for FreeStyle Libre 2 system for Resident #47. Interview on 09/28/22 at 12:30 P.M., with the Director of Nursing stated the facility was completing an audit to ensure that no other residents had the same situation. The DON verified the facility should have an order for the glucose monitoring system on the medication administration record and did not. Review of facility policy titled Medication Administration, dated 06/21/17 revealed when a new non medication order does not appear on the medication administration record the nurse should send a copy to the pharmacy to ensure it is in the pharmacy's system.

Based on medical record review, observations, staff and resident interview, and policy review, the facility failed to apply a resting hand splint per the plan of care. This affected one resident (#31) out of two residents reviewed for application of assistive devices. The facility census was 87. Findings included: Review of the medical record for Resident #31 revealed an admitted on 10/02/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #31 had intact cognition. Resident #31 was not coded with rejections of care of behaviors. Resident #31 required extensive assistance for bed mobility, toilet use, and personal hygiene. Review of the plan of care for Resident #31 dated 12/17/21 revealed the resident required assistance with activities of daily living (ADL). Factors that place her at risk for decline and complications included decreased mobility, dementia with behaviors, left [CONDITION(S)], following a stroke, incontinence, [CONDITION(S)], anxiety, depression, [CONDITION(S)] disorder, [CONDITION(S)] type, coronary artery disease, hypertension, [CONDITION(S)], and use of [CONDITION(S)] medications. Resident's self-performance and assistance needed may fluctuate throughout the course of the day; self-performance and assistance needed may fluctuate related to disease processes. Interventions included a left hand carrot splint placed in morning and removed at night, resident can donn and doff independently, and required cues to encourage wearing of splint. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident could donn and doff independently, required cues to wear splint. Observation on 09/26/22 at 10:19 A.M. of resident sitting in bed, revealed a contracted left hand where Resident #31's fingers were touching the palm of her hand. Interview on 09/26/22 at 10:19 A.M., with Resident #31 stated she had a stroke several years ago and was unable to fully open her left hand. Resident #31 states she was unable to use her hand at all. Resident #31 states she used to have a splint, but staff has not offered it to her to use for a long time. Further stated she does not even know where the splint was. Interview on 09/28/22 03:03 P.M., with the State tested Nursing Assistant (STNA) #71 stated she had not attempted to place the splint on Resident #31 today and she was not sure where the splint was and would have to look for it. Interview on 09/28/22 at 3:19 P.M., with Registered Nurse (RN) #127 verified the splint was not in place at the time of observation. Review of facility policy titled Range of Motion, dated 08/2016 revealed number three states the nursing personnel may provide services needed to maintain or improve the resident's ability including splint/brace assistance.

Based on record review, staff interviews, resident interviews and facility policy, the facility failed to report an allegation of abuse to the state agency. This affected one resident (#57) out of three residents reviewed for abuse. The facility census was 74. Findings include: Review of the medical record for Resident #57 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment for Resident #57, dated 02/21/22, revealed the resident had impaired cognition. No hallucinations, delusions, or rejection of care was noted. The resident required extensive assistance for all activities of daily living (ADL's) except for eating where supervision was needed. No other behaviors were noted. Review of the nursing notes for Resident #57 dated 05/03/22 at 6:17 P.M. stated the resident had a room change. Review of the nursing notes for Resident #57 dated 05/03/22 at 6:20 P.M. revealed writer was made aware that resident was laying in bed and his roommate came over being sexually inappropriate. The roommate then was redirected by the aide and removed back to his side of the room. Review of the nursing notes for Resident #57 dated 05/04/22 at 9:09 A.M. revealed Licensed Social Worker (LSW) met with resident regarding 05/03/22's incident involving peer/roommate. Resident appeared pleasantly confused, social, and easily engaged. He reports he does not recall any issues or concerns with prior roommate. He reports feeling safe without fears or concerns. No noted decline in psychosocial mood/well-being. LSW will continue to monitor and offer support. Review of the nursing notes for Resident #57 dated 05/04/22 at 1:32 P.M. revealed Interdisciplinary Team (IDT) met on 05/04/22 regarding the incident that occurred on 05/03/22. Resident unable to recall any details of the incident. Resident was immediately brought to the common area for closer observation at the time of the incident. Room changed and he is adjusting to his new surroundings. MD and family aware. Review of the nursing notes for Resident #57 dated 05/05/22 at 6:28 P.M. revealed LSW met with resident as to monitor his mood/well-being. Resident appears alert and pleasantly confused. No noted increase in mood/behavior. No noted/observed decline in psychosocial mood/well-being. Interview on 05/05/22 at 4:15 P.M. with Resident #57 revealed the resident was unaware if he had a roommate. He didn't remember any problems with his old roommate. Resident #57 stated that he had never been physically or sexually abused. He also stated that he never had to report anything like this to staff members. Observations on 05/05/22 at 4:15 P.M. of Resident #57 revealed the resident was resting quietly in his wheelchair. The surveyor spoke briefly to the resident regarding the incident on 05/03/22. Resident #57 had no recollection of the incident. There was no nervousness noted from Resident #57. The resident was able to have a normal, calm conversation with the surveyor but was noted as being pleasantly confused. Interview on 05/05/22 at 5:40 P.M. with LSW #111 revealed he talked with Resident #57 and #64 regarding the incident on 05/03/22. Both residents are pleasantly confused. When speaking with Resident #57, LSW #111 noted no changes in behavior from the incident. The social worker stated that the resident was worried where his roommate was. LSW #111 stated that Resident #64 denied any inappropriate sexual behaviors towards Resident #57. The social worker noted that the residents had known each other for a long time and Resident #64 would always attempt to help or advocate for Resident #57. When asked if Resident #64 had previous history of this behavior, the social worker stated that he did not. LSW #111 mentioned that Resident #64 would walk around with loose fitting pants and would have to hold his pants up with hand. Review of the witness statement dated 05/03/22 written by Assistant Director of Nursing (ADON) #310 revealed she was notified that Resident #64 was noted by State tested Nursing Assistant (STNA) #17 to be standing near the bed of Resident #57 with his penis exposed. STNA #17 redirected Resident #64 to his side of the room and brought Resident #57 out of the room to the common area for closer evaluation. Resident #64 was educated by staff. The Director of Nursing (DON) was notified by ADON #310 at this time. Review of the facility investigation dated 05/03/22 at 6:30 P.M. revealed that the DON was notified of the incident between Resident #57 and #64 by floor staff and management staff. The residents were checked out by staff members with no concerns. Resident #57 was immediately brought out of the room and relocated to a different room. Resident #57 had no recollection of the incident. The doctor and families were called and notified of the incident. Interventions put into place for Resident #64 were 15-minute checks, order for psych evaluation, and a UA C&S. The DON also notified the Administrator at this time of the incident between Resident #57 and #64. Interview on 05/05/22 at 4:50 P.M. with the DON confirmed she notified the Administrator within two hours of the incident which had occurred around 6:00 P.M. on 05/03/22 between Residents #57 and #64. No SRI was created regarding the event occurring on 05/03/22 between Residents #57 and #64. Interview on 05/05/22 at 5:00 P.M. with the Administrator confirmed there was no SRI created for the event occurring between Resident #57 and #64 on 05/03/22. The Administrator confirmed he was notified of the incident on 05/03/22 in the evening. Review of facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property dated 11/21/16, revealed the facility did not implement the policy regarding the allegation. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: report the results of all investigation to the administrator or his or her designated representative and to the other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident. This deficiency substantiates Complaint Number OH 447.

Based on observation, staff interview, review of facility documents, and review of online resources per the Center for Medicare and Medicaid Services (CMS) and the Centers for Disease Control (CDC), the facility failed to ensure staff wore appropriate eye protection and/or an appropriate facemask in resident care areas to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 71 residents residing in the facility. The facility also failed to ensure staff performed appropriate hand hygiene which had the potential to affect Residents #69 and #70. The census was 71. Findings include: 1. Observations on 12/29/21 during initial tour revealed the following staff were in resident care areas and were not wearing eye protection: State tested Nursing Assistant (STNA) #100 at 6:09 A.M., STNA #150 at 6:15 A.M., STNA #200 at 6:23 A.M., STNA #275 at 6:36 A.M. and Registered Nurse (RN) #125 at 6:41 A.M. Interviews on 12/29/21 with the following staff confirmed there were working in resident care areas and were not wearing eye protection: STNA #100 at 6:09 A.M., STNA #150 at 6:15 A.M., STNA #200 at 6:38 A.M., STNA #275 at 6:36 A.M., Registered Nurse (RN) #125 at 6:41 A.M. Interview on 12/29/21 at 6:45 A.M. with the Director of Nursing (DON) confirmed staff should wear eye protection in resident care areas based on the high positivity rate for the county in which the facility was situated. Review of facility policy titled Novel Coronavirus Response dated 03/19/21 revealed the facility would educate staff on appropriate use of personal protective equipment (PPE) including eye protection. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/covid-19/covid-19-nursing-home-data revealed the county in which the facility was situated was experiencing a high spread (red) of COVID 19 with a positivity rate of 15.9 % for the week ending in 12/27/21. Review of an online resource per the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. 2. Observation on 12/29/21 at 6:09 A.M. of STNA #100 revealed the aide was wearing a cloth mask in the resident care area. Interview on 12/29/21 at 6:09 A.M. with STNA #100 confirmed she was wearing a cloth mask which she had brought from home and she had worn the cloth mask during her entire shift which had started on 12/28/21 at 7:00 P.M. Interview on 12/29/21 at 6:45 A.M. with the DON confirmed staff should wear surgical masks or N-95 masks in resident care areas depending on the task and the facility status. DON further confirmed cloth masks were not considered personal protective equipment (PPE) and were not appropriate for resident care. Review of facility policy titled Novel Coronavirus Response dated 03/19/21 revealed interventions to prevent the introduction of COVID-19 into the facility included implementation of staff wearing face masks in accordance with regulatory requirements. Review of online resource at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html revealed the following guidance regarding facemasks: ensure all healthcare care personnel (HCP) wear a facemask while in the facility. Cloth face coverings are not considered personal protective equipment (PPE) because their capability to protect HCP is unknown. 3. Observation on 12/29/21 at 6:23 A.M. of STNA #200 revealed aide entered the resident unit pushing a Hoyer lift down the hall and was wearing disposable gloves. STNA #200 entered the unit and touched the entry door/area with her gloved hand and knocked on the door of Resident #69 and #70's room with her gloved hand. STNA #200 then opened the door with her gloved hand, pushed the Hoyer lift inside the room and did not exit the room until 6:38 A.M. When STNA #200 exited the room, she was pushing the Hoyer lift down the hall with gloved hands. Interview on 12/29/21 at 6:38 A.M. with STNA #200 confirmed she washed her hands with soap and water and donned clean gloves before she got the Hoyer lift to use to provide care for Residents #69 and #70. STNA #200 further confirmed when entered the room she removed her gloves and donned a pair of clean gloves and cared for Resident #69. Then she removed her gloves and donned a pair of gloves and care for Resident #70. Then she removed those gloves and donned another pair of gloves and exited the room. STNA #200 confirmed the last time she had performed hand hygiene either by hand washing or use of sanitizer was prior to retrieving the Hoyer lift and entering the floor to care for Residents #69 and #70. STNA #200 further confirmed she thought it was not necessary for her to wash or sanitize her hands because she changed her gloves between residents. Review of the facility policy titled Novel Coronavirus Response dated 03/19/21 revealed the facility would support proper hand hygiene by making sure soap, paper towels, and alcohol-based hand rubs were available. Review of the facility policy titled Hand Hygiene dated 11/28/17 revealed staff should perform hand hygiene even if gloves are used in the following situations: before and after contact with the resident, after removing PPE such as gloves, after contact with blood, body fluids, or visibly contaminated surfaces or other objects and surfaces in the resident's environment. Review of CMS policy memo QSO-20-14-NH revised 3/13/20 titled, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes, revealed facilities were to Increase the availability and accessibility of alcohol-based hand rubs, and to reinforce strong hand-hygiene practices. This deficiency substantiates Complaint Number OH 059, Complaint Number OH 190 and Complaint Number OH 088.

Based on medical record review, observation, review of the facility's policy, staff interviews, and review of the National Pressure Injury Advisory Panel (NPIAP) resource, the facility failed to monitor two pressure ulcers routinely from 05/03/21 to 06/08/21. This resulted in Actual Harm to one resident (#105) when the facility staff did not complete timely monitoring of Resident #105's left outer ankle and right heel pressure ulcers including measuring/staging the wound and Resident #105's left outer ankle and right heel wound subsequently deteriorated into Unstageable pressure ulcers (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar). This affected one (#105) of three residents reviewed for pressure ulcers. The facility identified eight residents who had pressure ulcers. The facility census was 75. Findings include: Review of the medical record for Resident #105 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 04/13/21, revealed the resident had impaired cognition. The resident required extensive assistance from staff for bed mobility and was totally dependent on staff for transfers. The assessment indicated the resident had a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle). Review of the nurse's notes, dated 04/27/21 at 1:42 P.M. for Resident #105, revealed a Stage IV pressure ulcer on the coccyx, stage three pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed) to the left ankle, and a Deep Tissue Injury (DTI) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue) to the right heel upon return from a stay at a local hospital. Review of the Braden Scale assessment, dated 04/27/21, revealed Resident #105 was at a moderate risk for the development of pressure ulcers. Review of the physician orders, dated 04/27/21, revealed a treatment to the left outer ankle: Cleanse area with normal saline and pat dry. Cover area with foam dressing every three days and as needed. There was a treatment order to the right heel: Cleanse area with normal saline and pat dry. Cover area with foam dressing every three days and as needed. The treatment orders to the left outer ankle and the right heel did not change from 04/27/21 through 06/08/21. Review of the wound assessment by Wound Nurse #500, dated 04/27/21 for Resident #105, revealed the right heel wound was labeled as a DTI. The wound measured 5.0 centimeters (cm.) in length by 5.0 cm. wide. Black eschar was noted on the wound bed. The left outer ankle was labeled as a Stage II pressure ulcer (Partial Thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough). The wound measured 1.5 cm. by 1.0 cm. by 0.2 cm. depth. A small amount of serosanguinous drainage was noted with a pink wound bed. Review of the hospital paperwork for Resident #105, dated 05/02/21, revealed on 04/30/21, the pressure ulcer to the right heel measured 5.0 cm. by 4.0 cm. and the pressure ulcer to the left outer ankle measured 1.0 cm. by 1.3 cm. by 0.2 cm. depth. Review of the plan of care, dated 05/06/21, revealed the resident was at risk for alteration in skin integrity related to decreased mobility, decreased cognition, and fluctuating moods. One of the goals included for the wounds to stabilize as evidence by no increase in size, drainage, etc. Interventions included completing skin assessments per facility policy, body checks weekly and as needed, low air loss mattress to bed as ordered, and notifying the physician and family of any changes as needed. Review of weekly wound assessments for Resident #105 revealed the wound nurse or other facility staff members were not monitoring the wounds to the left outer ankle and right heel from 05/03/21 to 06/08/21. The wounds to the right heel and left outer ankle were noted on 04/27/21 with a treatment order put into place. No further weekly assessments were completed for the right heel or the left outer ankle. Treatments that were put into place on 04/27/21 continued to be completed as written. Interview on 06/08/21 at 11:45 A.M. with Licensed Practical Nurse (LPN) #70 stated she was the facility's wound nurse as of the beginning of May 2021. She stated she was not notified Resident #105 had pressure ulcers from Wound Nurse #500 when she took over the wound nurse role. She confirmed there were no weekly assessments completed for the pressure ulcers on the left outer ankle and right heel. LPN #70 also stated she had no idea Resident #105 had wounds to the right heel and left outer ankle. Observation on 06/08/21 at 2:50 P.M. with LPN #70 of the treatment to Resident #105's pressure ulcers on her right heel and left outer ankle revealed a previously completed treatment dated 06/05/21 to both areas. The treatment to the left outer ankle was completed first and the LPN measured the wound to be 2.0 cm. by 1.5 cm. by 0.1 cm. The wound bed contained slough. There was a scant amount of serosanguinous drainage with no odor noted by LPN #70. The LPN measured the right heel as 4.0 cm. by 4.5 cm. by 0.1 cm. and the LPN described the wound bed to the right heel was at least 75% eschar. A moderate amount of serosanguinous drainage was noted with no odor. LPN #70 stated the left outer ankle and right heel were both Unstageable pressure ulcers (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar). Interview on 06/08/21 at 3:10 P.M. with LPN #70 confirmed the wounds to Resident #105's right heel and left outer ankle appeared to be like the measurements from 04/27/21 at the facility and the measurements taken at the hospital on 04/30/21. LPN #70 stated it would be difficult to say if the wounds got worse without seeing what they looked like on 04/27/21. Interview on 06/10/21 at 10:30 A.M. with Nurse Practitioner (NP) #100 revealed she was not aware of the pressure ulcers to the left outer ankle and right heel until 06/09/21. NP #100 stated she ordered new treatments along with a diagnostic study. NP #100 was unable to determine if the wound got worse since 04/27/21 as she had not seen the wounds. Review of the facility's policy titled Skin Assessment, dated 09/2017, revealed the facility should provide the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. The procedure included if areas of alteration in skin are present, or which developed subsequently to admission, are treated according to medical direction, and are conscientiously followed and on a weekly basis, an assessment of the area(s) is performed and recorded in the resident record. The resident's response to preventive efforts and treatment interventions is monitored and approaches are revised as appropriate. Review of the information from the NPIAP at https://npiap.com/ revealed facilities should develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. If the risk is from malnutrition, address those problems. Staff should inspect the skin at least daily for signs of pressure injury, especially nonblanchable [CONDITION(S)]. Further review revealed a Stage III pressure ulcer is full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury This deficiency substantiates Complaint Number OH 664. This deficiency is an example of continued non-compliance from the surveys dated 05/13/21 and 03/23/21.

Based on observation, staff interview, and review of online resources from the Center of Disease Control (CDC), the facility failed to ensure staff wore facemasks in an appropriate manner to potentially prevent the spread of COVID-19. This had the potential to affect all 80 residents at the facility. Findings include: Observation on 05/04/21 at 7:20 A.M. of the facility's long-term and skilled-care hallways revealed multiple staff were observed improperly wearing masks. Observation of State tested Nursing Assistant (STNA) #21 revealed the STNA was wearing an N95 mask, however the bottom strap of the mask was hanging loose under her chin. The STNA confirmed the bottom strap was hanging loose under chin at the time of the observation. Observation of one Housekeeping Staff (HK) #26 revealed the HK was walking toward the nurse's station with her housekeeping cart and did not have any mask on. STNAs #31, #61, and #51 were walking from resident rooms with surgical masks only covering their chins. At the time of the observation STNA #31 confirmed her face mask was only covering her chin. Licensed Practical Nurse (LPN) #20 was wearing her surgical mask dangling from one ear walking toward the nurse's station from resident rooms. Interview on 05/04/21 at 7:45 A.M. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #100 revealed the expectation of the facility was all staff were required to wear an N95 in resident care areas. ADON #100 confirmed the staff were not compliant with the facility's expectation of wearing an N95 in resident care areas. The ADON #100 confirmed the staff were observed not properly wearing the masks. Interview with HK #26 at 8:10 A.M. on 05/04/21 confirmed she was not wearing any mask. HK #26 revealed she left her mask in the room she was previously cleaning. Review of the online resource from the CDC at https://www.cdc.gov/Coronavirus/2019-ncov/hcp/long-term-care-strategies.html revealed the following guidance regarding facemasks: ensure all healthcare personnel (HCP) wear a facemask for source control while in the facility. Review of the CDC website at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html revealed social distancing should be practiced in combination with other everyday preventive actions to reduce the spread of COVID-19, including wearing masks. This deficiency is an example of the continued non-compliance from the survey dated 03/23/21.

Based on medical record review, review of hospital records, facility staff interview, hospital staff interview, and facility policy review, the facility failed to complete ordered weekly skin checks and failed to provide appropriate and timely wound care per physician orders. This affected two Residents (#55 and #6) of three reviewed for pressure wounds. The facility census was 80. Findings include: 1. Review of Resident #55's medical record revealed an original admitted [DATE]. the resident went out to the hospital on 04/19/21 and returned to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's physician orders dated 05/17/19 revealed an order to complete a head to toe skin check on every Friday. Review of the Resident #55's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. The resident required total dependence for all activities of daily living (ADLs). The assessment revealed the resident had a pressure ulcer or injury over a bony prominence. The MDS revealed the resident had applications of ointments and medications to the feet. Review of Resident #55's current plan of care revealed the resident was at risk for alteration in skin integrity related to altered sensation, chronic progressive disease, circulation impairment, and [CONDITION(S)]. Interventions included weekly body checks and to notify the physician and family of changes. Review of Resident #55's medical record revealed there was no evidence the weekly head to toe skin check was completed on 04/16/21. Interview with Resident #55's Power of Attorney (POA) for Healthcare revealed she had not been notified of any skin concerns prior to the resident's hospitalization on [DATE]. The resident's POA revealed the hospital advised her of the pressure wound and skin concerns when the resident was admitted on [DATE]. Interview on 05/05/21 at 12:12 P.M. with the Corporate Clinical Registered Nurse (CCRN) # 500 confirmed the nurse had not completed the skin check for Resident #55 on 04/16/21 as ordered by the physician. Interview on 05/04/21 at 2:11 P.M. with the Assistant Director of Nursing (ADON) #100 revealed Resident #55's wounds were not facility acquired wounds. The ADON # 100 stated the wounds were not present until after the resident returned from a hospitalization on [DATE]. Review of Resident #55's hospital documentation dated 04/19/21 revealed the following skin issues were found on arrival to the ER: 1. Left heal deep tissue injury, measured at seven centimeters (cm) in length by six cm in width. The deep tissue injury was described as a blood filled blister. Surrounding skin, dry and flakey. 2. Sacrum Right-Left Stage II (shallow with a reddish base) pressure injury, active. No measurements were documented. 3. Ischium Left. Pressure injury pink intact skin. 4. Ischium Right. Pressure injury pink intact skin. 5. Right hip Stage II. No measurement documented. Interview on 05/06/21 at 7:56 A.M. with Hospital Registered Nurse (HRN) #300 revealed Resident #55 was assessed in the emergency room (ER) upon admission to the hospital on 04/19/21 and was found to have multiple skin integrity concerns. She revealed the resident was admitted with wounds on his heel, sacrum, right and left ischium, and right hip. Review of the facility policy titled, Skin Assessments, dated 12/02/21 revealed the resident was to receive a weekly skin integrity check performed by licensed personnel. 2. Medical record review revealed Resident #6 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive decline. The resident was noted with a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often includes undermining and tunneling) on admission. Interventions included pressure reducing device for the bed, application of nonsurgical dressings, application of ointment and medication. Review of the Resident #6's current plan of care revealed the resident had alteration in skin integrity as evidenced by a pressure ulcer present at the right buttock. Interventions included to assess condition of skin and dressing, assess for pain, and provide treatment per physician order. Review of Resident #6's physician order dated 04/16/21 revealed to refer the resident to wound clinic. Review of Resident #6's physician's order dated 04/20/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Pack wound with Dakins-soaked gauze and cover with abdominal pad and secure with tape twice daily. Review of the April 2021 and May 2021 Treatment Administration Record (TAR) revealed the treatment was completed as ordered on 04/20/21 through 05/08/21. Interview on 05/09/21 at 1:45 P.M. with Resident #6's daughter and power of attorney (POA) revealed the resident went to the wound clinic on 05/04/21 via facility transportation. The daughter revealed the wound clinic changed the treatment to the resident's right buttock wound on 05/04/21. The daughter revealed the paperwork from the wound clinic was given to the facility driver by the Wound Clinic. Resident #6's daughter revealed the facility continued to treat her mother's wound with the previous order dated 04/20/21. Interview on 05/09/21 at 1:55 P.M. with the Assistant Director Of Nursing (ADON) #100 revealed he was not aware Resident #6 had gone to the Wound Clinic on 05/04/21. The ADON #100 reviewed the resident's electronic charting and the hard-chart and was not able to provide documentation of the resident's appointment at the wound clinic. Interview on 05/09/21 at 3:45 P.M. with the ADON #100 confirmed Resident #6 had not timely received the new treatment order written on 05/04/21. The ADON #100 confirmed the order from the wound clinic was dated 05/04/21, however was not implemented until 05/09/21. This deficiency substantiates Complaint Numbers OH 180, OH 837, and is an example of the continued non-complaince from the survey dated 03/23/21.

Based on medical record review, observation, and staff interview, the facility failed to properly position the resident for meals. This affected one Resident (#6) of three residents reviewed for positioning during meals. The facility census was 80. Findings include: Review of Resident #6's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive decline. The resident required supervision with set-up for eating. Review of the Resident #6's plan of care with a revision date 03/26/21, revealed the resident had potential for alteration in nutrition and hydration related to due to the resident's need for a therapeutic diet of low concentrated sweets and no added salt. The interventions also included a magic cup to aid with wound healing. Interventions included to assist with meals as needed, monitor for reflux, and elevate head of bed as ordered. Review of Resident #6's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 05/09/21 at 12:30 P.M. of Resident #6 eating lunch revealed the resident was in bed with the head of the bed elevated at approximately thirty percent. The resident's eye level was at the level of the breakfast tray, making it difficult to see what was on her lunch tray. Observation of the meal tray revealed the resident only had eating the roast beef that was closest to the edge closest to the resident. None of the meal on the far side of the tray appeared to have been eaten. Observation and interview on 05/09/21 at 12:39 P.M. with the Director of Nursing (DON) confirmed the Resident #6 was not positioned appropriately in order for the resident to remain safe and comfortably eat her lunch. This deficiency substantiates Master Complaint Number OH 214 and Complaint Number OH 180.

Based on medical record review, staff interview, family interview, and facility policy review, the facility failed to timely notify a resident's representative of a significant change in health conditions. This affected one Resident (#55) of three reviewed for notification of change. The facility census was 80. Findings include: Review of Resident #55's medical record revealed an original admitted [DATE], and a recent re-admission from the hospital on 04/26/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #55's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required total dependence for all activities of daily living (ADLs). Review of Resident #55's plan of care dated 04/15/21 revealed the resident was dependent on staff to complete his personal hygiene, monitor for skin redness and irritation, monitor and provide hydration. Interventions included to notify the physician and the family of changes as needed. Review of Resident #55's progress note dated 04/19/21 at 10:15 A.M. revealed the resident had an onset of labored breathing. Breaths were documented at 28 breaths per minute (bpm), an increased heart rate of 107 bpm. The physician was notified and advised the staff to continue to monitor. There was no evidence the resident's spouse was notified of the change in condition. At 4:38 P.M., Resident #55's spouse was at the facility and was advised the resident had a temperature of 102 degrees Fahrenheit (F), heartrate of 110 bpm, labored breathing at 28 bpm. The Resident's spouse requested the resident be transferred to the hospital. Review of Resident #55's dietary progress note dated 05/05/21 at 10:25 A.M. revealed Dietitian #300 documented a significant weight gain. The Dietitian also documented a supplement Prostat AWC of 45 milliliters (ml.) would be ordered for wound healing. The Dietitian #300 documented the MD and family were notified of the weight change. Interview on 05/05/21 at 3:32 P.M. with Resident #55's wife revealed she was not notified her husband had an onset of respiratory distress until she arrived at the facility on 04/19/21 at around 4:00 P.M. She further revealed she had not been advised of any skin integrity concerns for her husband until she was advised by the emergency room (ER) nurses when he was assessed on 04/19/21 at the hospital. Additionally, the residents's spouse revealed she had not been notified of her husband's weight gain, or the supplement being added to aid in wound healing. Telephone interview on 05/06/21 at 9:30 A.M. with the Dietitian #300 revealed her dietary note was written on 05/05/21 in error. The Dietitian #300 confirmed she had not contacted the family on 05/05/21 as documented. The Dietitian #300 stated she had intended to call Resident #55's family to update on the significant weight change, however she had been distracted and not made the phone call as she had previously documented. Review of the facility policy titled, Change of Condition, dated 10/18/01, revealed a change of condition is defined as a deterioration in health of a resident related to a life threatening condition, alteration in treatment or a change in the clinical condition or status. The Unit Supervisor or Charge Nurse will notify the resident, physician and guardian/interested family member of all changes as stated above and of any other situations requiring notification. The person doing the notification may document all notifications. This deficiency substantiates Complaint Number OH 837, and is an example of continued non-compliance from the survey dated 03/23/21.

Based on medical record review, observations and staff interview, the facility failed to ensure Resident #12 received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. This resulted in actual harm when Resident #12 experienced a decrease in range of motion to his hands/wrists due to staff failing to apply a splint device per Occupational Therapy (OT) recommendations. Additionally, the facility failed to ensure Resident #10's palm protectors were applied as recommended by OT which placed the resident at risk for more than minimal harm. This affected two (#12 and #10) out three residents reviewed for range of motion. Facility census was 81. Findings include: 1. Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's OT discharge summary by Occupational Therapist, Registered (OTR) #449 dated 11/17/20 revealed the resident was able to tolerating wearing splints to both of his hands for four to six hours on discharge. The therapist documented in the discharge summary the resident has made substantial functional gains in response to skilled interventions. OTR #449 noted the resident has made significant gains in increasing ROM to both upper extremities and is not able to wear his splints once again to prevent progression of contracture's. The therapist documented that on discharge the resident was able to actively participate in hand strengthening and squeezing activities to increase bilateral grip strength. OTR #449 noted that staff have been educated on the importance of placing the splints on the resident to maintain functional gains. The therapist documented the resident's splints were to worn to both upper extremities daily to maintain functional gains and prevent progression of contracture's. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment, dated 02/03/21, revealed the resident could not be interviewed, but staff identified the resident as having adequate short and long term memory, and recall. The resident was dependent on two staff for bed mobility and transferring, and one staff for toilet use, personal hygiene, and eating. The resident was assessed was having functional limitations in both upper and lower extremities. Review of the resident's current comprehensive plan of care revealed a plan of care to for the problem/need of having self care deficits which included the problem of having contracture's to both upper and lower extremities. The care planned interventions did not include the application of splints or other devices to improve the contracture's or prevent decline. Review of the resident's OT evaluation by OTR #450 dated 02/24/21 by revealed the therapist documented the resident had contracture's of both hands, and the resident was not tolerating wearing the resting hand splints due to lack of carryover to splint application. OTR #450 noted under the clinical impressions in the evaluation the resident was referred for skilled OT services to address bilateral hand contracture's and splint program. The therapist documented the resident presented with worsening bilateral shoulder, elbow, hand/wrist contracture's in fixed position with rigid tone in movement. OTR #450 documented the resident is unable to actively move his upper extremities and passive ROM is difficult/impaired at his baseline. Further review of Resident #12's Kardex failed to reveal any interventions for staff to follow regarding the application of hand splints, palm protectors etc. Under the devices/equipment section of the Kardex there was no mention of any devices for the resident's contracture's. Observation of Resident #12 on 03/16/21 at 4:55 P.M., 03/16/21 at 8:36 P.M., 03/17/21 at 11:38 A.M., and on 03/17/21 at 12:22 P.M. revealed the resident appeared to have severe contracture's of both hands/wrists and was not wearing any devices to improve his range of motion (ROM) his his hands, prevent further contracture's, or to provide comfort/protection to his palms. Interview with State tested Nursing Assistant (STNA) #51 on 03/16/21 at 4:55 P.M. confirmed Resident #12 was not wearing any devices in either of his hands while she was feeding the resident. STNA #51 stated the resident did not have any splints on, but she thinks he has some. Interview with the Director of Nursing (DON) on 03/18/21 at 11:05 A.M. confirmed Resident #12's hands were very contracted, and she was not sure what interventions were in place for him. Interview with STNA #86 on 03/18/21 at 11:10 A.M. confirmed Resident #12 was not wearing any hand splints, and was unsure if the resident was supposed to be wearing any splints or not. She stated she would need to check the resident's Kardex (care planned interventions). Interview with the Director of Rehabilitation Services, Certified Occupational Therapy Assistant (COTA) #412 on 03/18/21 at 9:25 A.M. revealed Resident #12 was currently receiving OT, and had also received services in the past. He stated the resident has bilateral hand splints that should be on in the morning, and removed in the evening. COTA #412 reported that he had just recently been picked back up for therapy services as there has been a decline in his contracture's; range of motion. She specified that he started receiving OT again on 02/24/21, and that he did have splints prior to 02/24/21 and that therapy was working with the same splints he was using before. Interview with the MDS nurse, LPN #75 on 03/22/21 at 2:18 P.M. confirmed Resident #12's comprehensive plan of care did not include the use of resting hands splints, and subsequently would not have been evident on the resident's information sheets (Kardex) that nurse aides use when providing care to residents. 2. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #10's quarterly MDS assessment, dated 01/20/21, revealed the resident's cognitive status was not assessed, but review of a 11/06/20 quarterly MDS assessment identified the resident as having moderate cognitive impairment. The 01/20/21 MDS assessment identified the resident as requiring physical assistance of two staff to transfer, one staff for locomotion in her wheel chair, the resident did not walk, and being totally dependent on one staff person to eat. The MDS identified the resident as having limited range of motion to both upper extremities. Review of Resident #10's comprehensive plan of care failed to reveal any mention of the resident's limited range of motion in both upper extremities, or the use of any splints or other devices to improve the contracture's or prevent decline. Review of an OT discharge summary by OTR #449 dated 01/21/21 revealed on discharge the resident was unable to open her hands fully but was able to pinch and grasp small finger food items with supervision. OTR #449 documented the resident was unable to tolerate resting hand splints, and was now wearing palm protectors. The therapist discharge recommendations included the resident using palm protectors to maintain skin integrity. However, there was no mention in the recommendation evident regarding a wearing schedule for the palm protectors. Observation of Resident #10 on 03/15/21 at 12:31 P.M. revealed the resident appeared to have significant contracture's of both of her hands. She was not assisting in eating or drinking her meal, although adaptive equipment was provided. The resident was not wearing any splints, palm protectors, or other devices in her hands at the time. STNA #69 was spoon feeding the resident at the time of the observation. Observation of Resident #10 on 03/15/21 at 4:25 P.M. revealed the resident lying in bed. She was alert with confusion. The resident appear to have significant contracture's of both hands, and was not wearing any devices to her hands to manage the contracture's. Registered Nurse (RN) #07 was asked to come to the resident's room at that time. RN #07 confirmed the resident was not wearing any splints or palm protectors and stated she had never seen anything in her hands. Interview with STNA #100 on 03/16/21 at 3:44 P.M. revealed the nurse aide was aware the resident had splints, one gray and one blue, but confirmed she was not wearing them now. STNA #100 stated the staff put the splints on in the morning. STNA #100 confirmed the resident was not wearing any splints, palm protectors, or other devices to her contracted hands at that time. Interview with the Director of Rehabilitation Services COTA #412 on 03/18/21 at 9:25 A.M. confirmed Resident #10 had bilateral hand contracture's, and resting hand splints to both hands were initiated a few months ago. He stated the resident could not tolerated the splints and facility staff were to be using sheep's wool palm protectors that Velcroed on and protected the resident's hand. COTA #412 was not able to locate a wearing schedule for the palm protectors. Interview with the MDS nurse, LPN #75 on 03/22/21 at 2:18 P.M. confirmed the resident's comprehensive plan of care did not include the use of palm protectors, and subsequently would not have been evident on the resident's information sheets (Kardex) that nurse aides use when providing care to residents. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, medical record review, and staff and resident interview, the facility failed to ensure that each resident dependent on staff to complete activities of daily living (ADL's) received the necessary services to maintain good personal hygiene. This affected three residents (#12, #16 and #18) of four residents reviewed for ADL's. The facility census was 81. Findings include: 1. Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #16's Minimum Data Set (MDS) assessment (MDS), dated [DATE], revealed the resident had intact cognitive skills with good memory and recall. The assessment identified the resident as requiring the physical assistance of one staff person to completed bed mobility, transferring, personal hygiene, and bathing. The resident was also assessed as requiring two staff persons for toilet use and always being incontinent of bladder and bowel. Review of the resident's current plan of care, with a target date of 04/08/21, revealed a plan of care of address the resident's problem/need related to incontinence of bowel and bladder, with a goal that the resident would be clean, dry and odor free. The interventions included providing incontinence care as needed. Interview with Resident #16 on 03/15/21 at 12:21 P.M. revealed the resident was reporting she had been wet all night, and had not been change since last night. She stated she had put her call light on several times about getting changed and a shower, and a nurse was questioning her why she was so wet, but nothing has been done about it. The resident then showed this surveyor that her that portions of her sheets were wet. Interview with a State tested Nurse Aide (STNA) #115, who was working on the same unit as the resident, was interviewed on 03/15/21 at 12:26 P.M. STNA #115 stated the resident was not on her assignment, that a different nurse aide was caring for the resident. Interview with non-state tested nurse aide (NA) #29 on 03/15/21 at 12:28 P.M., who was working on the same unit as Resident #16, revealed she was not assigned to care for the resident that STNA #69 was assigned to care for the resident, but she was feeding a different resident at that time, STNA #69 then stated she would provide the resident with incontinence care. Interview with NA #29 on 03/15/21 at 12:44 P.M., after she provided the resident with incontinence care, confirmed the resident was soaked with urine. She stated the resident's under pad and sheets were all soaked through with urine, and that her adult diaper was heavy with urine. Interview with STNA #68 on 03/15/21 at 1:11 P.M. revealed she was not assigned to care for the residents, but had answered her call light when she was asking about getting a shower. She confirmed she had not provided the resident with any care that morning, stating that NA #29 was assigned to care for the resident during the shift (7:00 A.M. through 7:00 P.M.). All three nurse aides assigned to the unit where Resident #16 was located, all reported that they were been assigned to care for the resident, and care had not been provided during the morning hours of 03/15/21 until care was provided by NA #29 at 12:28 P.M. Review of task documentation by the nurse aides in the resident's electronic health record on 03/16/21, after the resident reported she had not received care on 03/16/21 at 12:21 P.M., revealed the last documentation regarding urinary incontinence was on 03/15/21 at 12:25 A.M. 2. Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #12 quarterly MDS assessment, dated 02/03/21 revealed the resident could not be interviewed, but staff identified the resident as having adequate short and long term memory, and recall. The resident was dependent on two staff for bed mobility and transferring, and one staff for toilet use, personal hygiene, and eating. The resident was assessed was having functional limitations in both upper and lower extremities. On 03/15/21 at 4:16 P.M., Resident #12's covered meal tray was observed sitting on the ledge of the 200 unit nursing station. The tray continued to sit at the nursing station at 4:23 P.M., and 4:37 P.M. At 4:38 P.M., Registered Nurse (RN) #07 who was passing the nursing station, stopped and confirmed the tray belonged to Resident #12. The tray remained at the 200 unit nursing station at 4:46 P.M., at which time Assistant Director of Nursing (ADON) #83 was made aware the tray had been sitting there since 4:16 P.M. At that time, ADON #83 confirmed the tray was Resident #12's evening meal tray, and then instructed a nurse aide take the tray to the resident's room to feed the resident. ADON #83 did not dispose of the tray, and ask the kitchen for a new tray of food for the resident. Observation of the resident eating his evening meal on 03/16/21 at 4:55 P.M. revealed the resident was totally dependent on staff to set-up his meal tray and feed him. The resident appeared to have severe contracture's of both hands/wrists, had limited communication skills, and was being spoon fed by STNA #51. 3. Review of the medical record for Resident #18 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the most recent MDS assessment for Resident #18 revealed was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL's). Review of the care plan for Resident #18 dated 12/10/19 revealed resident required assistance with ADL's. Interventions included the following: assist resident with grooming including nail care, provide assistance for ADL's based on residents needs/abilities. Review of the shower sheets for Resident #18 revealed resident's nails were trimmed on 03/03/21. Review of shower sheets for Resident #18 for the following dates revealed resident's nails were not trimmed on the following shower dates: 03/05/21, 03/06/21, 03/07/21, 03/09/21, 03/11/21, 03/14/21. Observation of Resident #18 on 03/18/21 at 11:14 A.M. with the Director of Nursing (DON) revealed resident's fingernails were long, jagged, and had debris underneath them. Interview with the DON on 03/18/21 at 11:16 A.M. confirmed Resident #18's fingernails were long, jagged, and had debris under them. DON further confirmed the STNA's should trim resident nails on their shower days and as needed. DON confirmed the facility did not have a nail care policy, but the shower sheets completed by the STNA's had a space to indicate if nails were trimmed or not trimmed on the shower day. This deficiency substantiates Complaint Number OH 867.

Based on observation, medical record review, staff and resident representative interview, and policy review, the facility failed to notify each resident's physician and family/representative when there was a significant change in the resident's clinical condition. This affected two (#78 and #12) out of four resident's reviewed for notification of change. Facility census was 81. Findings include: 1. Review of Resident #78's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment, dated 12/12/20, revealed the resident had significant cognitive impairment, required the physical assistance of one staff person for be mobility and transfer, did not walk, and was able to eat with supervision with the assistance of one staff person. The resident was assessed as being 5'1 tall and weighing 135 pounds (#) with no known weight loss. Review of the resident's current physician orders revealed the resident was on a regular mechanical soft diet with thin liquids. On 03/10/21 the physician ordered the resident to received 120 milliters (ml's) of the house supplement twice daily. Review of an assessment of the resident's nutritional status by Registered Dietitian (RD) #345 dated 12/10/20 revealed the resident's body weight was documented as 134.5# with a body mass index of 25.4 which was within normal limits for the resident's age. RD #345 assessed the resident's needs based on current body weight and documented the resident's current diet was appropriate to meet the resident's nutritional needs at the time. She documented the resident had full upper dentures and natural bottom teeth, with no issued noted with the current consistency of her diet. RD #345 noted the resident required supervision, limited assistance, and set-up at meals. She also identified the resident was receiving hospice services. The RD documented she would continued to monitor the resident's nutrition related issued as indicated, with a goal for the resident to maintain her weight without any significant weight changes, to consume greater than 75% of meals and snacks, and provide nutrition and hydration to promote comfort care and dignity. RD #345 also noted the resident was receiving hospice services. The resident's recorded weight history was as follows: 134.5# on 12/10/20; 129.6# on 12/31/20; No January 2020 weight was recorded; 117.8# on 02/05/21; and 116.8# on 03/02/21. The resident experience an unplanned significant weight loss of 16.7# or 12.4% of her total body weight within two months, and a total of 13.2% within a three month period. Review of nutrition progress notes revealed no documentation in nutrition or nursing notes regarding the resident's significant weight loss on 02/05/21, or notification of the resident's family or physician regarding the weight loss. Review of a nutrition progress note by RD #345, dated 03/10/21, revealed the dietitian noted the resident's significant weight loss over a three month period at that time. She documented the resident continues with hospice services, and had full upper dentures and natural bottom teeth with no issued noted on the current mechanical soft consistency diet. RD #345 noted the resident required supervision/limited assistance/set-up at meal. She recommended to add 120 ml's of the house supplement twice daily to aide with weight maintenance, and would updated the plan of care. Review of the resident's March 2021 Medication Administration Record [REDACTED]. Nursing staff documented the resident was offered the supplement as ordered twice daily since that time, and routinely consumed 25% to 100% of the 120 ml's offered. Interview with RD #345 on 03/17/21 at 12:45 P.M. confirmed the dietitian was not aware of the resident's significant weight loss on 02/05/21, and did not plan any new interventions to improve the resident's weight status or prevent further decline until 03/10/21 when she was first aware of the resident's significant weight loss. She affirmed there was no documentation to support the resident's family/representative or physician were notified in February regarding the weight loss as she was not aware of the loss on 02/05/21. Review of the facility policy titled Weight Change Protocol revealed that when a significant weight loss is identified that the nurse responsible for the resident would notify the physician family/representative, dietary manager and the MDS nurse and document these notification in the nurse's noted. The procedure specified the dietitian would be notified per facility policy by nursing or the dietary manager. Review of the facility policy titled Change in Condition dated April 2013 revealed that a significant change in the resident's clinical condition or status included unplanned weight loss (5% in 30 days; 10% in 180 days). The procedure specified that the unit supervisor or charge nurse would notify the resident, physician, and family/guardian of all changes, and the person doing the notification would document al notifications. 2. Review of the medical record for Resident #12 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the most recent MDS assessment for Resident #12 dated 02/03/21 revealed resident was cognitively impaired, was totally dependent on the assistance of two staff with activities of daily living and was coded as negative for refusing care. Review of the nurse progress note for Resident #12 dated 03/16/21 per the Director of Nursing (DON) revealed the nurse practitioner (NP) who works with the resident's attending physician was contacted and an order for [REDACTED].#12's underarms prior to 03/16/21. Review of the March 2021 physician orders for Resident #12 revealed an order dated 03/16/21 for [MEDICATION NAME] powder to bilateral armpits four times daily for yeast infection. Review of the March 2021 Medication Administration Record [REDACTED].M. Interview on 03/18/21 at 11:25 A.M. with the DON confirmed staff reported to her on 03/16/21 that resident needed a treatment order due to reddened and malodorous areas to bilateral underarms. DON confirmed she did not visualize the area, but she notified the NP on 03/16/21 of the concern for possible yeast infection to Resident #12's underarms. DON further confirmed she notified Resident Representative (RR) #300 by telephone of the new order and RR #300 confirmed she had seen the area when she visited resident on 03/14/21. Interview on 03/18/21 at 12:23 P.M. with Licensed Practical Nurse (LPN) #78 confirmed he observed Resident #12's underarms to be reddened and presenting with what looked like a fungal infection to him on 03/12/21. LPN #78 confirmed he was not the nurse assigned to Resident #12 on 03/12/21 but the assigned nurse had asked him to look at the reddened areas to resident's underarms. LPN #78 confirmed he did not notify Resident #12's physician or resident's representative of resident's impaired skin integrity which he noted on 03/12/21. Observation on 03/18/21 at 12:25 P.M. with LPN #54 of Resident #12's underarms revealed the skin was reddened and irritated. Interview on 03/18/21 at 12:30 P.M. with LPN #54 confirmed she had first observed the skin to Resident #12's underarms on Sunday, 03/14/21 when RR #300 brought it to her attention. LPN #54 confirmed resident's underarms were still reddened but they appeared to be improving somewhat since the [MEDICATION NAME] powder was initiated on 03/16/21. LPN #54 confirmed she did not notify Resident #12's physician of Resident #12's impaired skin integrity noted on 03/14/21. Interview on 03/18/21 at 4:13 P.M. with RR #300 confirmed visited Resident #12 on 03/14/21 and observed his underarms had a very foul odor and were extremely red and she brought the concerns to LPN #54 immediately. RR #300 confirmed the DON called her on 03/16/21 to notify her of the [MEDICATION NAME] order and RR #300 told DON she had identified the area on 03/14/21 and brought it to staff's attention at the time. RR #300 confirmed DON told her she learned of the reddened areas to Resident #12's underarms on 03/16/21. Review of the facility policy titled Change in Condition dated April 2013 revealed the facility would ensure resident's attending physician and resident's representatives were notified of new skin conditions and need to commence a new medication or treatment. This deficiency substantiates Complaint Number OH 867.

Based on medical record review, observation and resident and staff interviews the facility failed to ensure a residents pain was effectively managed. This resulted in actual harm to Resident #125 who screamed and moaned during a pressure ulcer treatment. Staff did not stop the treatment timely to address the pain. This affected one Resident (#125) of three residents sampled for pressure ulcers. The facility identified five residents with pressure ulcers. The census was 83. Review of the medical record revealed Resident #125 was admitted to the facility on [DATE] with an unstageable pressure ulcer on her right heel. Pertinent [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #125 had a severe cognitive impairment, was non-ambulatory and required the extensive assistance of staff with her activities of daily living. Review of the skin grid dated 04/18/17 revealed Resident #125 had an unstageable pressure ulcer on her right heel. There was eschar present and the wound measured four centimeters (cm) by 4.5 cm. Review of Resident #125's care plans revealed she had a complaint of pain daily related to generalized pain and recent femur fracture. She had utilized as needed (PRN) pain medication during this assessment period. There was an intervention to utilize medications as ordered to manage pain. Review of the nursing notes dated 04/26/17 at 3:38 P.M. documented Resident #125 complained of severe pain to her right heel, especially during treatment change. Nonpharmacological interventions ineffective. PRN [MEDICATION NAME] (narcotic pain medication) given with positive results. Resident was alert and oriented with intermittent confusion. Some safety and care needs must be anticipated by staff. Nursing notes dated 04/28/17 at 6:19 P.M. documented Resident #125 complained of severe pain to her right heel, especially during treatment change. Nonpharmacological interventions ineffective. PRN [MEDICATION NAME] given with positive results. Nursing notes dated 04/29/17 at 1:37 P.M. documented Resident #125 complained of severe pain to her right heel, especially during treatment change. PRN [MEDICATION NAME] given with effective results, nonpharmacological interventions ineffective. Nursing notes dated 04/30/17 at 12:25 P.M. documented Resident #125 had a healed right femur fracture. Resident voiced pain to right heel with dressing change. Non pharmacological interventions ineffective, PRN pain medication given with effectiveness. On 05/02/17 at 5:30 P.M. Registered Nurse (RN) #133 was walking down the hall carrying dressing supplies for a dressing change for Resident #125. RN #133 agreed to be observed during the dressing change. The nurse washed her hands, donned gloves and removed the gauze dressing from the residents' right heel. Before she started the dressing change, she asked the resident if she was in pain. The resident replied not now. The nurse proceeded apply normal saline to the dressing in order to remove it. As she was cleansing the wound the resident cried out in pain. On 05/02/17 at 5:38 P.M. the resident was screaming and asked the nurse if the dressing was off. The nurse replied the dressing was not off. The resident said Good Lord, take it off. She screamed at the nurse to hurry up and to cut her foot off. The resident screamed Lord, have mercy on my soul. The nurse said the wound was probably pretty sore and she was sorry. The resident cried out and said she could not help it. The nurse measured the wound at 4.2 cm by 3.5 cm with eschar. The peri wound was red with a white callous. As she was cleansing the wound and removing the cream from the previous dressing change, the resident screamed, My God. On 05/02/17 at 5:44 P.M. the nurse asked the resident if she wanted pain medication and the resident replied Yes!. The nurse did not stop the dressing change and proceeded to apply Calcium Alginate to the wound. The resident screamed out in pain. The nurse applied the abdominal pad and wrapped the residents' foot in Kerlix. The nurse said to the resident, That hurts, sorry, Sweetheart. The resident moaned in pain and the nurse taped the dressing and re-applied the boot to the residents' right heel. On 05/02/17 at 5:48 P.M. an interview with RN #133 revealed she had not offered the resident pain medication, she only asked if she was in pain, prior to the dressing change. RN #133 said she usually offered pain medication prior to completing the dressing change, but forgot too. The nurse said the resident normally screamed all day but she had not heard her much today. The nurse said she thought she had given the resident pain medication earlier that day but a review of the Medication Administration Record [REDACTED].M. The resident had last received Tylenol for pain on 04/30/17 at 5:30 A.M. The resident had orders for [MEDICATION NAME] 5-325 milligrams (mg) to be given every four hours as needed for moderate to severe pain. She also had an order for [REDACTED]. RN #133 indicated she did not know why she did not stop the dressing change to administer pain medication after the resident began screaming in pain. Nursing notes dated 05/02/17 at 5:50 P.M. documented [MEDICATION NAME] Tablet 5-325 mg was administered. On 05/02/17 at 6:00 P.M. the resident was sitting in her wheelchair with her boot on the right foot. She said her foot was hurting, she was unable to rate her pain on a scale of one to 10. On 05/02/17 at 6:05 P.M. an interview was conducted with Licensed Practical Nurse (LPN) #37, she revealed she had changed the resident's pressure ulcer dressing every Wednesday and Thursday. LPN #37 said she ensured the resident had received pain medication 30 minutes prior to the dressing change. LPN #37 said if a resident was screaming out in pain during the dressing change, she would stop immediately and medicate the resident. She said if the resident did not have a pain medication ordered, she would call the physician for an order for [REDACTED].>On 05/03/17 at 4:20 P.M. an interview was conducted with the Director of Nursing (DON). The DON said she would expect a nurse to stop a dressing change and administer pain medication if a resident was screaming and moaning during a dressing change. She also verified they had changed Resident #125's pain medication to routine instead of PRN to see if it would cut down on the resident yelling out. The DON said the resident called out in pain even when she was not being touched. On 05/03/17 at 4:35 P.M. the resident was observed laying quietly in bed with her boot on her right lower extremity. However, her bed was raised and she had slid down and wanted to be repositioned. A State tested Nurse Aide (STNA) repositioned her. Resident #125 said she wanted the head of her bed lowered. On 05/04/17 at 8:00 A.M. an interview was conducted with RN #93. RN #93 said the resident had yelled out less since she was receiving pain medication routinely. She said the resident did not yell out on 05/03/17 and she had not yelled out yet this morning. On 05/04/17 at 8:03 A.M. the resident was eating her breakfast she had a boot on and her feet were resting on pillow with her heels off the bed. The resident said she was having pain in her foot. RN #93 said the resident just received pain medication and it probably had not kicked in yet. On 05/04/17 at 11:50 A.M. an interview was conducted with Nurse Practitioner (NP) #515 and LPN #37. NP #515 said if a resident was screaming out in pain during a dressing change, she would stop and attempt to divert her attention. If that was unsuccessful, she would immediately administer pain medication. She also verified with a history of screaming during a dressing change, it would have been a good idea to pre-medicate the resident prior to a dressing change.