Every finding on record at Independence House

Based on medical record review, review of the facility's fall investigations, staff interview and review of the facility policy, the facility failed to ensure a complete and thorough fall investigation for one (#8) resident and further failed to ensure post fall monitoring was completed for two (#8 and #13) residents. This affected two (#8 and #13) of three residents reviewed for falls. The facility census was 29. Finding include:1. Review of the medical record for Resident #8 revealed an admission date of 01/01/25. Diagnoses included peripheral vascular disease (PVD), diabetes mellitus with foot ulcers, congestive heart failure (CHF), hypertension (high blood pressure), and non-pressure chronic ulcer of the right heel and midfoot. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and had no falls during the assessment period.Review of the care plan, revised April 2026, revealed Resident #8 was care planned for falls due to deconditioning. Interventions included anticipate and meet needs, call light in reach, educate the resident/family/caregivers about safety reminders, ensure appropriate footwear was in place, follow fall protocol, review information on past falls and attempt to determine cause of fall and record possible root cause, and the most recent intervention was ROHO (type of air filled pockets of cushion to prevent wounds) to be removed from the recliner when resident was in the recliner.Review of the nursing progress note dated 03/28/26 at 6:31 P.M. revealed Resident #8 was found sitting on the floor in front of his recliner. The resident denied injury. Resident #8 stated he slid out of the chair. Vital signs taken.Review of the facility incident report dated 03/28/26, related to Resident #8's fall, revealed the incident report was not completed. The areas on the incident report that were left incomplete included the areas titled predisposing environmental factors, predisposing situational factors, and predisposing physiological factors. Further review of the incident report for Resident #8's fall revealed the only documentation on the form was vital signs, a statement of findings at the time of the fall, and notifications.Review of the Post Fall Monitoring Form for Resident #8 revealed the top section of the form was dedicated for initiation of neurological checks following a fall. The section was crossed off and there was no documentation of immediate neurological monitoring following the resident's fall. Further review revealed the 72-hour post monitoring was to be done for six shifts, every eight hours. The assessment was not completed on the midnight shifts on 03/29/26 and 04/01/26. Further review of Resident #8's medical record revealed an updated fall risk assessment was not completed until 04/05/26, eight days following the resident's fall on 03/28/26. Interview on 04/27/26 at 4:37 P.M. with the Director of Nursing (DON) and Regional Clinical Nurse (RCN) #400 revealed the facility had a fall packet where staff documented their findings at the time of the fall and further investigation was conducted from the staff statements of the events at the time of the fall.A follow-up interview on 04/27/26 at 5:03 P.M. with the DON verified Resident #8's fall on 03/28/26 was unwitnessed and neurological checks should have been implemented and they were not.A follow-up interview on 04/27/26 at 5:09 P.M. with RCN #400 verified the incident report dated 03/28/26 for Resident #8's fall was not completely filled out for a thorough investigation to be completed following the fall for the resident.Interview on 04/28/26 at 10:15 A.M. with RCN #400 verified the post fall assessments were not completed on the midnight shifts on 03/29/26 and 04/01/26 and further confirmed the fall risk assessment should have been completed immediately after Resident #8's fall on 03/28/26 and was not completed until 04/05/26, eight days after the resident's fall. 2. Review of the medical record for Resident #13 revealed an admission date of 06/30/21. Diagnoses included difficulty in walking, deep vein thrombosis (blood clot) of right lower leg, dementia, general weakness, diabetes mellitus, and wheelchair dependence.Review of the quarterly MDS assessment dated [DATE] revealed Resident #13 was cognitively intact and had one fall during the last assessment period that resulted in no injury.Review of the care plan, revised April 2026, revealed Resident #13 was care planned for falls due to deconditioning. Interventions included Dycem (special mat that prevents slipping) to chair, appropriate footwear-shoes or gripper socks, call light in reach, ensure items within reach, and custom wheelchair.Review of the nursing progress note dated 04/13/26 at 7:32 P.M. revealed Resident #13 was found sitting upright, leaning against the bed, facing the door with right arm resting on the recliner cushion. The left leg was bent up with his foot flat on the floor, shoes were on. The wheelchair was tipped over and resting on the left side.Review of the Post Fall Monitoring Form for Resident #13 revealed the top section of the form was dedicated for initiation of neurological checks following a fall. The section was crossed off and there was no documentation for immediate neurological monitoring following the fall. Interview on 04/27/26 at 5:15 P.M. with the Administrator revealed the facility expectation was for neurological checks to be initiated for any unwitnessed fall. A follow-up interview on 04/28/26 at 12:50 P.M. with the Administrator verified Resident #13's fall was unwitnessed and neurological checks were not completed and should have been implemented. Review of the facility policy titled, Standard for Falls, undated, revealed the purpose was to ensure resident safety from fall-related injury. Unwitnessed falls, if patient was alert and oriented to person, place, and thing (x3), then ask the patient if they hit their head or face during the fall, if patient admitted to hitting their head or face, document the patient's statement and follow head injury protocol. If the patient denied hitting their head or face, document the patient's statement, perform physical assessment and follow general procedure. General procedure was to place patient on 24 hour report and monitor the resident for the next 72 hours.Review of the facility policy titled, Fall Prevention and Management Policy, revised August 2024, revealed each resident would be assessed for fall risk on admission, quarterly, after any fall and as needed. In the event of a fall, the resident would be assessed by the licensed nurse, physician or Nurse Practitioner (NP) and interventions aimed to prevent further falls would be implemented. Details of the fall would be gathered and documentation completed as indicated. Falls would be reviewed by the Interdisciplinary Team. This review would include, but not limited to, new interventions that were identified/implemented, results of the new fall risk assessment, discussion with the resident and/or witness as to potential contributing factors, review of the environment where the fall occurred and discussion as to any new interventions that my help prevent any further falls.This deficiency represents non-compliance investigated under Complaint Number 2784759.

Based on medical record review, review of wound clinic notes, staff interview and review of the facility policy, the facility failed to ensure non-pressure ulcer wound treatments were completed according to physician orders and further failed to monitor ongoing effectiveness of wound treatments by not conducting ongoing assessments of the wounds. This affected one (#8) of four residents reviewed for wound care. The facility census was 29.Findings include:Review of the medical record for Resident #8 revealed he was admitted on [DATE]. Diagnoses included diabetes mellitus Type II with foot ulcers, need for personal assistance, congestive heart failure (CHF), hypertension, peripheral vascular disease (PVD) and non-pressure chronic ulcer of the right heel and midfoot.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and required the application of ointments or medications.Review of the care plan revised April 2026 revealed Resident #8 was care planned for venous statis ulcer of bilateral (both) lower extremity related to PVD. Interventions included documentation of location of wound, amount of drainage, peri-wound (around) area, pain, edema (swelling), evaluate the wound for size, depth, sinuses, undermining, exudate (drainage), granulation (healthy tissue), infection, necrosis (dead tissue), and gangrene. Document in wound healing on an ongoing basis and notify the physician as indicated, treatments per order, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and drainage and any notable changes or observations.Review of the February 2026 physician orders revealed Resident #8 had a treatment ordered placed to wash the right heel with soap and water, apply triple antibiotic ointment, and cover with mepilex (type of adhesive dressing) every morning on Monday, Wednesday and Friday and an order for bilateral lower leg wounds to cleanse with soap and water, pat dry, apply triple antibiotic ointment to wound and cover with mepilex border every Monday, Thursday, and Saturday for wound care three times per week and as needed. Further review of the April 2026 physician orders revealed a treatment order for the right fourth tip of toe to paint the tip of the toe with betadine and cover with a band-aid daily until healed.Review of the Treatment Administration Record (TAR) for February 2026 revealed no evidence the right heel treatment was completed on 02/02/26 and 02/04/26. Further review revealed no evidence the bilateral lower leg treatment was completed on 02/02/26. Lastly, review of the April 2026 TAR revealed no evidence treatment was completed on 04/10/26 and 04/24/26. Further review of the medical record revealed Resident #8 had received wound care at a community wound clinic, with visits on 12/02/25, 12/23/25, 01/07/26, 01/21/26, 02/11/26, and 03/11/26 for management of wounds to the bilateral lower extremities and right heel. The wound clinic notes included wound measurements and treatment updates and any changes to wound care treatments.Additional review of Resident #8's medical record revealed no evidence of wound monitoring from the last documented community wound clinic visit on 03/11/26 through 04/28/26. An interview on 04/27/26 at 4:02 P.M. with Regional Clinical Nurse (RCN) #400 and the Director of Nursing (DON) verified there was no evidence the facility completed any skin and wound grids for Resident #8 other than what was completed during visits to the community wound clinic.Interview on 04/28/26 at 12:55 P.M. RCN #400 verified the missing initials, indicating treatments were not completed, on the TAR for Resident #8 for the five missing treatments. Review of the facility policy titled, Assessment Schedule, undated, revealed pressure and non-pressure grids were required to be completed for all wounds upon discovery and then weekly.Review of the facility policy titled, Wound Treatment Management, dated December 2021, revealed to promote wound healing of various types of wounds, it was the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The effectiveness of treatments would be monitored through ongoing assessment of the wound and take into consideration progression towards healing, change in wound, and changes in resident's goals and preferences, such as end of life.This deficiency represents non-compliance investigated under Master Complaint Number 2787800, Complaint Number 2784759, and Complaint Number 2742748.

Based on record review, interview, and policy review, the facility failed to ensure physician orders were followed as ordered. This affected one (#33) of three residents reviewed for physician orders. The facility census was 32.Findings include:Review of medical record for Resident #33 revealed an admission date of 12/05/25 and discharge date of 01/07/26 with diagnoses including but not limited to atrial fibrillation, psoas muscle abscess, heart failure, chronic gout, bacteremia, osteomyelitis of vertebra lumbar region, neoplasm of uncertain behavior of cerebral meninges, type two diabetes, non-pressure chronic ulcer of other part of right foot with fat layer exposed and hypertension.Review of minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact.Review of the hospital discharge orders dated 12/05/25 revealed ergocalciferol 50,000 units by mouth weekly.Review of physician orders dated 12/05/25 revealed ergocalciferol tablet give 5,000 units by mouth weekly on Monday for vitamin D deficiency, daily weights first thing in the morning if weight is up three pounds in 24 hours, or five pounds in one week notify the physician, cyclobenzaprine 5 milligrams (mg) twice daily for muscle relaxer until 12/15/25, gabapentin 400 mg by mouth four times daily.Review of medication administration record (MAR) for December 2025 revealed ergocalciferol 5000 units was given on Mondays (not the 50,000 as documented in hospital discharge paperwork), daily weights were not obtained on 12/06/25, 12/08/25 through 12/13/25, 12/15/25 through 12/18/25, 12/20/25, and 12/23/25, cyclobenzaprine was not administered on 12/05/25 in the evening, gabapentin 400 mg was not signed off as administered on 12/05/25 in the evening.Interview on 02/12/26 at 3:40 P.M. with the Administrator revealed the daily weights were not obtained on the above dates. The Administrator verified the ergocalciferol order was transcribed incorrectly on 12/05/25 and the resident received three doses weekly since admission. The Administrator verified that cyclobenzaprine and gabapentin was not signed off on 12/05/25 for the evening shift.Review of policy titled, Medication Administration, revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection and sign the MAR after medication is administered.

Based on record review, interview, and policy review, the facility failed to ensure physician orders were followed regarding wound care. This affected one (#33) of three residents reviewed for wounds. The facility census was 32.Findings include:Review of medical record for Resident #33 revealed an admission date of 12/05/25 and discharge date of 01/07/26 with diagnoses including but not limited to atrial fibrillation, psoas muscle abscess, heart failure, chronic gout, bacteremia, osteomyelitis of vertebra lumbar region, neoplasm of uncertain behavior of cerebral meninges, type two diabetes, non-pressure chronic ulcer of other part of right foot with fat layer exposed and hypertension.Review of minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact.Review of physician orders revealed treatment to coccyx triad cream with optifoam daily ordered from 12/06/25 through 12/12/25, sacrum wound cleanse with normal saline (NS) apply Santyl nickel thick, calcium alginate and apply silicone border foam dressing from 12/12/25 through 12/19/25, and mid thoracic back wound treatment cleanse with NS, apply silver alginate cover with ABD and secure with tape daily from 12/12/25 through 12/24/25, back incision cleanse with NS cover with gauze and ABD pad secure with tape daily from 12/06/25 through 12/10/25, sacrum wound cleanse with NS apply Santyl nickel thick, calcium alginate, xtrasorb and cover with tape daily from 12/20/25 through 12/24/25, miconazole external powder two percent (%) apply to affected skin areas topically twice daily for skin rash, bilateral heels apply derma prep and cover with mepilex every three days from (12/09/25 through/ 12/24/25, and right heel wound cleanse with NS apply skin prep and cover with silicone bordered foam dressing on Tuesday, Thursday, and Saturday daily.Review of treatment administration record (TAR) for December 2025 revealed the treatment to coccyx triad cream cover with optifoam was not signed off on 12/11/25, treatment to sacrum was not signed off for 12/16/25, mid thoracic back wound treatment was not signed off on 12/16/25 and 12/18/25, miconazole external powder two % twice daily was not signed off at bedtime on 12/11/25 and 12/12/25 and upon rising on 12/16/25, right heel wound cleanse with NS apply skin prep and cover with silicone bordered foam dressing on Tuesday, Thursday, Saturday was not signed off on 12/16/25, back incision cleanse with NS cover with gauze and ABD pads secure with tape daily was not signed off on 12/11/25, and bilateral heels apply derma prep and cover with mepilex every three days was not signed off on 12/11/25.Review of after visit summary dated 01/03/26 revealed orders to pack coccyx wound with Dakin's soaked kerlix and then apply sacral foam border to hold in place, paint bilateral heels with iodine and place mepilex over unstageable wounds daily, and back incision dressing check operative dressing at least once a shift and change dressings postoperative day three and then as needed moving forward. Postoperative day three is 01/05/26.Review of physician orders for January 2026 revealed heel inspection twice daily from 01/03/25 through 01/08/26, Dakin's soaked kerlix one quarter strength to sacral wound daily from 01/07/26 through 01/20/26, left heel paint with betadine cover with mepilex daily start date of 01/08/26 and discharge date of 01/08/26. No order was noted for monitoring the back incision every shift or to change the postoperative dressing until 01/06/26. No sacral treatment noted from 01/03/26 through 01/07/26.Review of TAR for January 2026 revealed heel inspection twice daily was not signed off on 01/05/26, left heel paint with betadine cover with mepilex daily was started on 01/08/26 after discharge. Review of wound documentation for 12/11/25 and 12/18/25 revealed the wounds to the mid thoracic, sacrum, and bilateral heels were improving from admission.Interview on 02/12/26 at 3:08 P.M. with the Administrator revealed they verified the discharge orders for 01/03/26 was to paint bilateral heels with iodine and place mepilex over the unstageable wounds daily and back incision dressing check operative dressing at least once per shift and change the dressing postoperative day three and then as needed moving forward, sacral wound was pack with Dakin's soaked kerlix daily. administrator verified there was no order to change the postoperative dressing on 01/05/26 or an order to monitor the dressing once a shift. Administrator located a physician order placed under other to apply ABD to back incision on 01/06/26 and it did not show up on the physician order due to not needing any documentation. Verified there was no order for sacral wound until 01/07/26 or paint bilateral heels upon discharge on [DATE] and no order in place until 01/08/26. Administrator verified the treatments not signed off in December as listed above.Review of policy titled Wound Treatment Management dated 12/01/2021 revealed to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.This deficiency represents non-compliance investigated under Complaint Number 2705856.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident's care plan was revised for advanced directive orders. This affected one (#12) of 13 residents reviewed for care planning. The facility census was 37. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE]. Diagnoses included end stage renal disease, polyneuropathy, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition. Review of the plan of care, initiated 10/12/23 and revised on 10/26/23, revealed Resident #12 had elected a full code (cardiopulmonary resuscitation) status. Review of the physician orders revealed dated 08/15/24 revealed the resident's code status orders were changed from Full Code to Do Not Resuscitate Comfort Care (DNRCC). Review of a DNR order form dated 08/15/24 revealed Resident #12 had elected DNRCC. Review of a nurse's note dated 08/14/24 at 9:04 A.M., revealed Resident #12 had changed her code status from full code to DNRCC. Interview on 09/04/24 at 12:49 P.M. with Licensed Practical Nurse (LPN) #212 verified Resident #12's care plan had not reflected the code status changed from full code to DNRCC. Review of the facility policy titled Care Plan -- Comprehensive dated 05/15/15 revealed the care plan would be updated when there was a significant change in resident condition, when a desired outcome was not met, when the resident had been readmitted to the facility from a hospital stay and at least quarterly.

Based on medical record review, resident and staff interviews, observations, and policy review, the facility failed to timely obtain physician orders for a wound dressing change and complete wound dressing changes as physician ordered. This affected one (#23) of one resident reviewed for skin conditions. The facility census was 37. Findings include: Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included hypertension, chronic obstructive pulmonary disease, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had impaired cognition. Review of a nursing progress note dated 08/22/24 at 12:05 P.M., revealed dietary staff reported Resident #23 got bit by something in the dining room during lunch. The resident's left forearm was noted to have a raised reddened area. The physician was notified and gave a verbal order for Benadryl 25 milligrams every six hours as needed. Review of a nurse's note dated 09/02/24 at 5:11 P.M. revealed the physician was notified of a new skin issue on left forearm. Awaiting response. Review of a wound assessment dated [DATE] revealed the resident had drainage from a wound on her left forearm. Review of a wound assessment dated [DATE] revealed the resident had a skin tear on her left forearm. Observation and interview on 09/03/24 at 8:39 A.M. revealed Resident #23 had a gauze dressing applied to her left forearm. Resident #23 slid the dressing down and there was a nonadherent dressing underneath covering a wound with two steri-strips in place. The dressing was not dated. Resident #23 stated she thought she got bit by a bug and the facility had been placing a dressing on her left forearm for three to four days. Review of the physician orders on 09/03/24 at 1:00 P.M. revealed there were no orders in place for the dressing to Resident #23's left forearm. Review of the treatment administration record (TAR) revealed no documentation of the dressing applied to the wound. Review of a physician order dated 09/03/24 at 3:00 P.M. revealed an order for antibacterial ointment to the left arm wound and tear topically two times a day for wound care. Observation on 09/04/24 at 7:41 A.M., revealed Resident #23 told Licensed Practical Nurse (LPN) #200 the wound dressing to her left arm was too tight. LPN #200 unwrapped a layer of self-adherent wrap then a layer of gauze wrap from around the left forearm revealing a nonadherent dressing covering a skin tear closed with two steri-strips. LPN #200 then cleansed the wound with normal saline, applied a new nonadherent dressing before wrapping the wound with new gauze and a self-adherent wrap. Interview on 09/04/24 at 7:53 A.M. with LPN #200 verified she had removed an undated wound dressing from Resident #23's left forearm. LPN #200 verified she had not checked for a physician order prior to applying the dressing. LPN #200 then checked the physician orders and verified there was no order in place for a wound dressing to the resident's left forearm. LPN #200 verified there was an order for antibacterial ointment to be applied to the wound. LPN #200 verified she had not applied the ordered antibacterial ointment. LPN #200 revealed she would call the physician for an order for the wound dressing. Interview on 09/05/24 at 7:02 A.M. with the Director of Nursing (DON) revealed she called the physician last night and clarified orders for the wound dressing. The DON stated a nurse had received wound care orders from the physician but forgot to enter the orders. The DON revealed the nurses applying the resident's wound dressing should have first ensure there was an order in place before changing the wound dressing and they should have documented the completion of the wound dressing change. Review of the policy titled Skin Care and Ulcer Prevention dated 05/11/21 revealed the physician would be notified to obtain treatment orders for skin impairments. Daily monitoring of the wound dressing and site around wound as well as the wound if visible would be completed.

Based on medical record reviews, observations, staff interviews, the Center of Disease Control (CDC) guidelines and review of the facility list of COVID-19 positive residents, the facility failed to adhere recommended infection control practices for preventing the spread of COVID-19 and failed to ensure there was dedicated nursing staff working solely on the COVID-19 unit (Buckland). This affected 16 residents (#3, #4, #5, #6, #8, #9, #12, #13, #14, #15, #18, #19, #20, #33, #34 and #38) who resided on the non-COVID-19 unit (Mott Hall). The facility failed to ensure dietary staff had eye protection in place when delivering food carts to a resident care area. This affected 17 residents (#1, #2, #7, #10, #11, #17, #21, #22, #23, #24, #26, #28, #30, #31, #32, #37 and #39) who resided on Schoettley Hall. The facility failed to ensure a resident who tested negative for COVID-19 was not cohorted with COVID-19 positive residents on the COVID-19 unit. This affected Resident #35 who tested negative for COVID-19 and was placed on the COVID-19 unit. The facility census was 39. Findings include: 1. Observation on 11/17/20 at 12:00 P.M. of the COVID-19 (Buckland Hall) unit revealed one staff person on the unit, State tested Nursing Assistant (STNA) #402. During interview on 11/17/20 at 12:15 P.M., STNA #402 stated Registered Nurse (RN) #224 had also been working the COVID-19 unit and had been on and off the unit through out the shift. During interview on 11/17/20 at 2:00 P.M., RN #224 verified she had been working the COVID-19 unit (Buckland) and non-COVID-19 unit (Mott hall). RN #224 stated she had completed medication administration for the residents on the COVID-19 unit in the morning and lunch and will return to the unit for evening medication administration. RN #224 verified she had been back and forth from the COVID-19 and non-COVID units. RN #224 denied having a staffing shortage. Review of nursing schedule dated 11/17/20 revealed RN #224 and Licensed Practical Nurse (LPN) #340 were scheduled on day shift. RN #224 was listed on the schedule as working the COVID-19 unit (Buckland Hall) and Mott Hall. 2. During observation on 11/17/20 at 8:10 A.M.,the dining room had two residents sitting at separate tables. Two dietary employees were in the dining room with only surgical masks in place. The dietary employees were not wearing eye protection. During observation on 11/17/20 at 11:45 A.M., Dietary employees #521 and #523 delivered the lunch meal cart to a non-COVID-19 (Schoettley) unit. Dietary employees #521 and #523 were wearing surgical masks and gloves, but were not wearing eye protection. The carts were transported through the hallway to the dining room. The dietary employees then handed disposable food containers to STNA's to deliver to the residents in the dining room. During interview on 11/17/20 at 9:35 A.M., the Administrator stated dietary employees do not have to wear a N95 respirator or eye protection if they aren't in direct contact with residents. 3. Review of the facility census and facility floor plan for 11/17/20 revealed four residents (Resident #27, #29, #35 and #36) resided on the COVID-19 unit. Review of Resident #27's COVID-19 laboratory result dated 11/02/20 revealed the resident was COVID-19 positive. Review of Resident #36's COVID-19 laboratory result dated 11/04/20 revealed the resident was COVID-19 positive. Review of Resident #29's COVID-19 laboratory result dated 11/04/20 revealed the resident was COVID-19 positive. Review Resident #35's medical record revealed the resident did not have any signs or symptoms of COVID-19. Review of the facility census dated 11/17/20 listed Resident #35 in room [ROOM NUMBER] on the COVID-19 unit. Review of Resident #35's COVID-19 laboratory results dated [DATE], 11/07/20, 11/11/20, and 11/15/20 revealed negative test results. Observation on 11/17/20 at 12:00 P.M. of the COVID-19 unit revealed Resident #35 resided in room [ROOM NUMBER]. During interview on 11/17/20 at 8:30 A.M., the Administrator stated Resident #35 had been testing negative for COVID-19 and resided on the COVID-19 unit due to her exposure to her roommate, Resident #27, who had tested positive for COVID-19. During interview on 11/17/20 at 11:00 A.M. , RN #226, the Infection Control Preventionist, stated Resident #35 and Resident #27 had been roommates. Resident #27 was COVID-19 positive during routine testing and did not have symptoms. Resident #35 tested negative for COVID-19 and did not have symptoms. RN #226 stated both Resident #27 and Resident #35 were moved to the COVID-19 unit. Review of the CDC website (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes responding.html), dated 04/30/20, revealed facilities will need to create a plan for managing new admission and readmission whose COVID-19 status is unknown. All recommended COVID-19 personal protective equipment (PPE) should be worn during care of residents under observation, which includes the use of an N95 or higher-level respirator (or facemask if respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible,should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit).

Based on review of the employee screening log, review of the facility COVID-19 Implementation Plan, staff interviews, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to properly screen staff for signs and symptoms of Coronavirus Disease 2019 (COVID-19). This affected seven staff review for screening and had the potential to affect all 38 residents residing in the facility. Facility census was 38. Findings include: Review of the employee screening log dated 08/09/20 through 09/10/20 revealed there was no documentation of the absence of fever and/or COVID-19 symptoms prior to starting work for two nurses, four nursing assistants and one housekeeper. Further review of the employee screening forms dated 08/09/20 through 09/10/20 revealed there was no documentation the following employees were screened for COVID-19 symptoms: Registered Nurse (RN) #300 on 08/14/20; Licensed Practical Nurse (LPN) #200 on 08/11/20, 08/13/20, 08/18/20, 08/19/20, 08/20/20, 08/22/20, 08/23/20 and 09/10/20; State tested Nursing Assistant (STNA) #100 on 08/15/20, 08/21/20 and 09/10/20; STNA #101 on 08/21/20 and 08/24/20; STNA #102 on 08/23/20 and 09/09/20 and Housekeeper #98 on 08/12/20. Additionally, STNA #103 had no documented temperature recorded on 09/09/20. Review of the information revealed the facility has three halls: Mott, Schoettley and Buckland. Housekeeper #98 worked Mott and Schoettley Halls. LPN #200, STNA #100, STNA #102 and STNA #103 worked Schoettley Hall. STNA #101 worked Buckland Hall. RN #300 was identified as the facilities Infection Control Nurse. Interview on 09/14/20 at 12:25 P.M., the Administrator verified the missing screening documentation for RN #300, LPN #200, STNA #100, STNA #101, STNA #102, STNA #103 and Housekeeper #98. Interview on 09/14/20 at 12:32 P.M., the Director of Nursing (DON) stated the employee screenings were completed and it was a documentation issue. The facility confirmed this had the potential to affect all 38 residents residing in the facility as the different staff identified as not being properly screened worked in different halls in the facility. Interview on 09/14/20 at 12:48 P.M., LPN #200 revealed she had not answered the screening question about signs and symptoms of COVID-19 because she normally had signs and symptoms unrelated to COVID-19. LPN #200 revealed staff were not appropriately educated on how to answer the questions. Review of the facility policy COVID-19 Implementation Plan dated 09/01/20 revealed all staff would have a temperature screening upon entering the building. Further review of the policy revealed there were no guidelines for screening staff for the signs and symptoms of COVID-19. Furthermore, there were no guidelines for documenting employee temperatures or the absence of signs and symptoms of COVID-19 on the employee screening log. Review of the CDC website (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) updated 06/25/20, Infection Control for Nursing Homes revealed to evaluate and screen all HCP (Healthcare Personnel) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19.

Based on medical record review and staff interview, the facility failed to update a resident's plan of care, when the resident repeatedly displayed aggressive behaviors toward staff and residents. This affected one (Resident #2) of three residents who had care plans reviewed. The facility census was 43. Findings include: Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set 3.0 assessment, dated 09/12/19, revealed the resident had no cognitive deficits, no abnormal behaviors or rejection of care. The resident required supervision for all activities of daily living and received antidepressants. Review of the progress note, dated 07/01/19, revealed Resident #2 was very mean and rude. It revealed the resident was observed yelling at another resident who was not near the resident and then later the same day Resident #2 attempted to hit another resident who opened the door to Resident #2's room. Attempts were made to redirect Resident #2 but she remained very angry and spiteful toward staff and other residents. The progress note further revealed staff got all other residents into bed or at least into their rooms to Resident #2 would have less stimulation from them and the television. Review of the progress notes, dated 07/06/19 at 12:34 P.M., revealed Resident #2 was scheduled to receive a shower. It further revealed Resident #2 made the comment if staff tried to give her a bath she would kill them. Review of the progress note, dated 08/29/19 at 5:48 P.M., revealed Resident #2 was calling staff and other residents foul names. The notes revealed staff attempted to redirect and the resident continued to escalate with staff, calling names, hitting, throwing things and attempting to run staff and residents over with her walker. Review of the plan of care for Resident #2, dated 07/03/19, revealed the resident did have cognitive function issues and used [MEDICAL CONDITION] medication for wandering. The plan of care did not address resident aggression towards staff or other residents, factors known to cause aggression and interventions to de-escalate any resident's aggressive behavior. Interview with the Administrator on 09/23/19 at 4:00 P.M. verified the plan of care for Resident #2 was not updated to include the resident's aggressive behavior toward staff and residents, nor interventions to assist staff when the resident displayed this behavior. Interviews with State tested Nursing Assistants #20 and #65 and Licensed Practical Nurse #70 on 09/23/19 between 9:30 [NAME]M. and 4:00 P.M. revealed they had witnessed Resident #2 being aggressive with staff and residents. This deficiency substantiates Master Complaint Number OH 953.

Based on review of a Legionella environmental assessment form, staff interviews and policy review, the facility failed to complete a Legionella risk assessment and failed to implement a water management program with defined control measures and testing protocols based on standards from the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) and the Centers for Disease Control and Prevention (CDC) tool kit, Developing a Water management Program to Reduce Legionella Growth and Spread in Buildings, dated 06/05/17. This had the potential to affect all 40 residents residing in the facility. Findings include Review of a Centers for Disease Control and Prevention (CDC) questionnaire for Legionella Environmental Assessment Form, dated 06/2015, utilized by the facility revealed no diagram of the water system outlining all areas of risk for Legionella. Further review of the form revealed the facility also had not specified control measures and testing protocols for Legionella based on standards from the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) and the CDC tool kit Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings dated 06/05/17. Interview on 06/14/19 at 2:15 P.M. with the Administrator revealed the facility had not conducted a Legionella risk assessment using the CDC tool kit. The Administrator revealed the facility had used a CDC Legionella Environmental Assessment Form from (YEAR). Interview on 06/13/19 at 3:45 P.M. with the Director of Maintenance (DOM) #120 revealed the facility had not diagrammed the water supply and identified all areas at risk using the CDC tool kit. DOM #112 revealed the facility checked the water temperatures around the building each month. DOM #112 further revealed the facility pool was tested when used. DOM #112 also revealed the water was flushed in rooms or areas not used. Review of the facility policy Maintenance and Monitoring of Water Systems, last reviewed 08/02/16, revealed the facility would perform a clinical and environmental risk assessment to determine if culturing should be performed. Further review of the policy revealed no guidelines for implementing a water management program. Further interview on 06/14/19 at 2:15 P.M. with the Administrator verified the facility policy was last reviewed in (YEAR).

Based on medical record review and staff interview, the facility failed to obtained laboratory values as ordered by the physician. This affected one (#4) of five residents reviewed for unnecessary medications with potential to affect 31 residents identified by the facility with orders to obtain laboratory values. The facility census was 40. Findings include: Review of Resident #4's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician order, dated 02/16/19, revealed Resident #4 was ordered to have a complete blood count (CBC) laboratory test, which was a laboratory test to determine the overall health of a person's blood, obtained every six months with the months of (MONTH) and (MONTH) as the intended months to obtain Resident #4's blood. Review of the most recently obtained CBC laboratory values for Resident #4 revealed the laboratory values were obtained on 10/31/18. There were no further CBC laboratory values in the medical record for Resident #4 since 10/31/18. Interview on 06/13/19 at 10:36 A.M., with Director of Nursing (DON) #1 verified the laboratory values from 10/31/18 were the most recently collected CBC laboratory values for Resident #4. DON #1 stated Resident #4 should have had a CBC laboratory value obtained in (MONTH) 2019, and verified it was done done as ordered.

Based on medical record review and staff interview, the facility failed to provide documentation of a rationale and an extended timeframe for extending the use of an as needed [MEDICAL CONDITION] medication beyond 14 days. This affected one (#1) of five residents reviewed for unnecessary medications with potential to affect nine residents identified by the facility with orders for as needed [MEDICAL CONDITION] medications. The facility census was 40. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician order, dated 08/27/18, revealed Resident #1 was ordered the anti-anxiety medication [MEDICATION NAME] 0.5 milligrams (mg.) by mouth every 12 hours as needed for anxiety. The physician order [REDACTED]. Review of a physician recommendation form, dated 09/17/18, revealed the facility pharmacy recommended the physician evaluate and update Resident #1's chart with documentation to extend the initial order for as needed [MEDICATION NAME] beyond 14 days. The physician response to the recommendation was marked as other with a written notation of noted and signed by the physician on 09/21/18. There was no further instructions or orders provided on the physician recommendation form, as well as no additional physician recommendation forms related to Resident #1's order for as needed [MEDICATION NAME]. Review of Resident #1's entire medical record including nursing and physician progress notes [REDACTED].#1's as needed [MEDICATION NAME] beyond the initial 14 days when it was ordered on [DATE], as well as no timeframe documented for how long the order would be extended. Interview on 06/13/19 at 10:42 A.M. with Director of Nursing (DON) #1 verified Resident #1 had an active order for an as needed anti-anxiety medication since 08/27/19, and verified the medical record contained no documented rationale for extending the physician order [REDACTED].

Based on observation, staff interview and record review, the facility failed to ensure a resident who was dependent on staff for fingernail care received adequate fingernail care as care planned. This affected one (#9) of one resident reviewed for activities of daily living. This had the potential to affect three residents identified by the facility who were dependent on staff assistance with personal hygiene. The facility census was 40. Findings include: Review of Resident #9's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 04/08/19, revealed Resident #9 had severely impaired cognition, did not reject any care during the look back period, and required an extensive two plus person physical assistance with personal hygiene. Review of an activities of daily living (ADL) self-care performance deficit revealed Resident #9 was to have her nail length checked, trimmed, and cleaned on bath day as necessary, and report any changes to the nurse. Review of a shower schedule for facility residents, dated 01/28/19, revealed Resident #9 was scheduled for showers on Mondays and Thursdays on second shift. Review of a shower sheet dated 06/10/19 (Monday) revealed Resident #9 was provided a shower with no concerns noted and no indication of fingernail care provided. Review of additional shower sheets from 05/30/19, 06/03/19, and 06/06/19 revealed Resident #9 received showers with no refusals of care. Review of nursing progress notes and nurse aide ADL documentation between 05/30/19 and 06/12/19 revealed no documentation of Resident #9 refusing care. Observation on 06/10/19 at 12:05 P.M. revealed a dried black substance underneath three fingernails (index, middle, and ring) on her left hand. Observations on 06/11/19 at 1:08 P.M. and 3:23 P.M., and on 06/12/19 at 10:07 A.M. revealed Resident #9's fingernails on her left hand continued to have a dried black substance underneath them. Interview on 06/12/19 3:29 P.M. with State tested Nurse Aide (STNA) #250 stated Resident #9 was an extensive to total care assist with personal hygiene, and stated Resident #9 would not be able to clean her fingernails on her own. STNA #250 stated the facility staff does provide Resident #9 with fingernail care when it is needed, and if the fingernails were dirty they would be cleaned right away. Observation on 06/12/19 at 3:47 P.M. with STNA #250 and STNA #275, revealed Resident #9 sitting in the common area of the secure unit with her hands under a blanket. When Resident #9 was asked, she lifted her left hand from under the blanket and revealed the dried black substance under her fingernails of her left hand. STNA #250 and STNA #275 verified the dried black substance under Resident #9's fingernails and stated they would clean them right away.

Based on observation, staff interview, and medical record review, the facility failed to provide a dignified dining experience while assisting a resident with eating. This affected one (#12) of 14 residents observed dining on the secured unit. The facility identified Resident #12 as the only resident on the secured unit who required feeding assistance. The facility census was 40. Findings include: Review of Resident #12's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an activities of daily living care plan dated 04/04/18 revealed Resident #12 required reminding, prompting, cueing, and assistance to eat. Review of the most recent Minimum Data Set (MDS) assessment, dated 04/04/19, revealed Resident #12 had short and long term memory issues with severely impaired cognitive skills for daily decision making. Resident #12 was assessed as requiring extensive one person physical assistance for eating. Observation on 06/10/19 at 11:45 A.M. of the lunch time meal revealed residents on the secured unit seated in the common dining area. On 06/10/19 at 11:48 A.M., State tested Nurse Aide (STNA) #215 was observed standing on the right side of Resident #12 and was noted to be placing food items on a spoon and lifting the spoon to Resident #12's mouth. STNA #215 was also observed lifting cups to Resident #12's lips to take drinks of fluids. The observation continued until 12:15 P.M. on 06/10/19 and STNA #215 was observed standing to assist Resident #12 during the lunch meal the entire observation. At no time did STNA #215 attempt to locate a chair to sit one once she began assisting Resident #12. Interview on 06/10/19 at 12:23 P.M. with STNA #215 verified she stood to assist Resident #12 throughout lunch, and stated she normally sits to assist residents with feeding. However, there were no additional chairs available for her to sit on.

Based on medical record review, review of facility policy and staff interview, the facility failed to remove alleged staff from resident care during an abuse investigation. This affected one (#1) of three residents reviewed for abuse. The facility census was 49. Findings include: Review of the medical record for the Resident #1 revealed the resident was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set 3.0 (MDS) assessment, dated 02/09/18, revealed the resident had unclear speech, usually understood and usually was understood. It further revealed the resident had moderate cognitive impairment. The MDS further revealed the resident required extensive assistance for bed mobility, transfers, dressing, toileting and hygiene and only supervision for eating. Review of a Self Reported Incident (SRI) report # 5 revealed on 02/20/18 at 6:00 P.M. Resident #1 made an allegation of State tested Nurse Aide #14 hitting her in the eye. Review of an investigation into the abuse allegation revealed the Assistant Director of Nursing (ADON) #15 documented a written statement which read on 02/20/18 at 6:18 P.M., Resident #1 reported STNA #14 hit her in the eye last night and that it was not an accident. The statement revealed the left eye was bloodshot and had no bruising or lacerations. The statement revealed STNA#14 would have her assignment moved to another hallway during the rest of the shift to avoid any contact with Resident #1 until other residents could be questioned. , Review of the nursing schedule for 02/20/18 revealed the STNA #14 worked from 10:00 P.M. on 2/20/18 until 6:00 A.M. on 02/21/18. Interview with STNA #4 on 03/04/18 at 8:20 P.M. revealed she was working in the dining room on 02/20/18 and Resident #1 called and stated some girl hit me in the eye last night. She further stated with further questioning, the resident informed her it was around 2:00 A.M. that morning. She reported it right away to ADON #15, who was right there. She then stated ADON #15 went and talked to the resident in the dining room, in front of everyone. She stated the ADON then went to STNA #14 and allowed STNA #14 to continue to work the remainder of the shift but moved her to another unit. Interview with the Administrator on 03/04/18 at 8:40 P.M. revealed Resident #1 had shared concern with STNA #4 that another STNA had hit her in the eye. The Administrator further stated she felt the investigation was completed quickly and there was no need to remove STNA #14 from resident care that night or from the upcoming schedule. Interview with STNA #14 on 03/04/18 at 9:50 P.M. revealed she had cared for Resident #1 the night on 02/20/18 and had come in at 6:00 P.M. on 02/19/18. STNA #14 stated the ADON spoke with her and informed her Resident #1 had said she hit her in the eye. STNA #14 stated she had been put on a different unit and told to stay away from the resident for a couple days. Interview with Director of Nursing on 03/05/18 at 1:00 A.M. verified STNA #14 was not removed from the schedule pending investigation but was placed on another unit during the investigation. She further verified the facility policy was to remove the alleged perpetrator from resident care and not just move them to another unit. Review of the facility policy Abuse, Neglect, and/or Misappropriation of Resident funds or Property Policy, dated 11/2008, revealed if a staff member was accused or suspected of abuse, mistreatment, neglect or misappropriation, the facility was to remove the staff member from direct resident contact until the investigation was complete and provide verbal counseling or a temporary suspension pending the result of the facility's investigation, based on the facility's investigation. This deficiency substantiates Complaint Number OH 558.

Based on medical record review, review of facility policies, and staff interview, the facility failed to timely notify the responsible party of a resident's allegation of staff abuse. This affected one (#1) of three residents reviewed for abuse. The facility census was 49. Findings include: Review of the medical record for the Resident #1 revealed the resident was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set 3.0 (MDS) assessment, dated 02/09/18, revealed the resident had unclear speech, usually understood and usually was understood. It further revealed the resident had moderate cognitive impairment. The MDS further revealed the resident required extensive assistance for bed mobility, transfers, dressing, toileting and hygiene and only supervision for eating. Review of Review of progress notes dated 02/21/18 at 7:56 A.M. revealed Resident #1 complained of pain in and around her left eye and rated the pain as a five on a zero to 10 scale. It further revealed the left eye was swollen around the outer edge of the eye socket and the eye was red and watery. Further notes dated 02/21/18 at 1:53 P.M. revealed a new order for eye drops had been obtained and the family was notified of eye drops. Review of an investigation into an allegation of abuse revealed the Assistant Director of Nursing (ADON) #15 documented a written statement which read on 02/20/18 at 6:18 P.M., Resident #1 reported to State tested Nursing Assistant (STNA) #4 that STNA #14 hit her in the eye last night and that it was not an accident. The statement revealed the left eye was bloodshot and had no bruising or lacerations, it looks like the resident may be developing pink eye and staff should be monitoring for drainage. Review of the timeline associated with the investigation of the abuse allegation revealed Resident #1's family was not notified of the resident's allegation of abuse by staff until 12/27/18. Review of the facility policy titled Notification of Changes to Physician, Resident and Family, dated 01/30/14, revealed an acute medical change defined as any sudden or serious change in a resident's condition manifested by a marked change in physical or mental status should be communicated to the physician and family prior to the end of an assigned shift but no later than 24 hours. Attempts to contact physician and exchanges with families was to be documented in the nurses' notes and include the name of the person spoken to, date and time of contact and signature and title of the individual making the entry. An unusual/unanticipated event was defined as an event that was not planned that may have an impact on the resident's physical or psychosocial well-being. If an event occurred that met the defined definition, determination of routine versus acute notification would be completed based on the seriousness of the event. Review of the facility policy titled Abuse, Neglect, and/or Misappropriation of Resident funds or Property Policy, dated 11/2008, revealed the nurse supervisor was to notify the resident's responsible party of the incident. Interview with Director of Nursing on 03/05/18 at 1:00 A.M. verified the family of Resident #1 was not notified regarding the allegations of abuse until 02/27/18. This deficiency substantiates Complaint Number OH 558.

Based on medical record review, review of facility policy and staff interview, the facility failed to follow their policy to remove alleged staff from resident care during an abuse investigation. This affected one (#1) of three residents reviewed for abuse. The facility census was 49. Findings include: Review of the medical record for the Resident #1 revealed the resident was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set 3.0 (MDS) assessment, dated 02/09/18, revealed the resident had unclear speech, usually understood and usually was understood. It further revealed the resident had moderate cognitive impairment. The MDS further revealed the resident required extensive assistance for bed mobility, transfers, dressing, toileting and hygiene and only supervision for eating. Review of a Self Reported Incident (SRI) report # 5 revealed on 02/20/18 at 6:00 P.M. Resident #1 made an allegation of State tested Nurse Aide #14 hitting her in the eye. Review of an investigation into the abuse allegation revealed the Assistant Director of Nursing (ADON) #15 documented a written statement which read on 02/20/18 at 6:18 P.M., Resident #1 reported STNA #14 hit her in the eye last night and that it was not an accident. The statement revealed the left eye was bloodshot and had no bruising or lacerations. The statement revealed STNA#14 would have her assignment moved to another hallway during the rest of the shift to avoid any contact with Resident #1 until other residents could be questioned. , Review of the nursing schedule for 02/20/18 revealed the STNA #14 worked from 10:00 P.M. on 2/20/18 until 6:00 A.M. on 02/21/18. Interview with STNA #4 on 03/04/18 at 8:20 P.M. revealed she was working in the dining room on 02/20/18 and Resident #1 called and stated some girl hit me in the eye last night. She further stated with further questioning, the resident informed her it was around 2:00 A.M. that morning. She reported it right away to ADON #15, who was right there. She then stated ADON #15 went and talked to the resident in the dining room, in front of everyone. She stated the ADON then went to STNA #14 and allowed STNA #14 to continue to work the remainder of the shift but moved her to another unit. Interview with the Administrator on 03/04/18 at 8:40 P.M. revealed Resident #1 had shared concern with STNA #4 that another STNA had hit her in the eye. The Administrator further stated she felt the investigation was completed quickly and there was no need to remove STNA #14 from resident care that night or from the upcoming schedule. Interview with STNA #14 on 03/04/18 at 9:50 P.M. revealed she had cared for Resident #1 the night on 02/20/18 and had come in at 6:00 P.M. on 02/19/18. STNA #14 stated the ADON spoke with her and informed her Resident #1 had said she hit her in the eye. STNA #14 stated she had been put on a different unit and told to stay away from the resident for a couple days. Interview with Director of Nursing on 03/05/18 at 1:00 A.M. verified STNA #14 was not removed from the schedule pending investigation but was placed on another unit during the investigation. She further verified the facility policy was to remove the alleged perpetrator from resident care and not just move them to another unit. Review of the facility policy Abuse, Neglect, and/or Misappropriation of Resident funds or Property Policy, dated 11/2008, revealed if a staff member was accused or suspected of abuse, mistreatment, neglect or misappropriation, the facility was to remove the staff member from direct resident contact until the investigation was complete and provide verbal counseling or a temporary suspension pending the result of the facility's investigation, based on the facility's investigation. This deficiency substantiates Complaint Number OH 558.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, physician and staff interviews, review of an employee personnel file, and review of in-service documentation, the facility failed to provide the necessary care and services when staff did not initiate Cardiopulmonary Resuscitation (CPR) for one (#40) resident who was found cold, without vital signs, and who was a Full Code status. This resulted in Immediate Jeopardy for one of three residents reviewed who required CPR in the event of a cardiopulmonary arrest. The facility identified a total of 13 residents who were a Full Code status. The facility census was 40. On [DATE] at 9:48 A.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 8:45 P.M., when Resident #40 was found cold, without vitals, and Licensed Practical Nurse (LPN) #41 and Registered Nurse (RN) #42 failed to initiate CPR or call 911. The Immediate Jeopardy was removed and the deficient practice was corrected on [DATE], when the facility implemented the following corrective actions: · On [DATE] at 1:30 P.M., the DON initiated disciplinary action and provided education on CPR procedures and Standards of Nursing Practice to LPN #41 and RN #42. · On [DATE] between 2:00 P.M. and 3:00 P.M., the DON educated all nurses who work for the facility on CPR and Full Code status procedures. · On [DATE] at 3:00 P.M., the DON reviewed all current residents charts to verify code status on all residents in the facility. · On [DATE] at 4:00 P.M., the DON added code status of all current residents onto a 24 hour nursing report for a quick reference for all nursing staff. The DON continues to monitor current and new admission code status. · On [DATE] at 4:00 P.M., interview with LPN #41 and on [DATE] at 8:50 A.M. to 9:00 A.M. interviews with LPN #51 and RN #52 revealed they were knowledgeable about where to check for a resident ' s code status and the procedure to follow to initiate CPR. Findings include: Review of Resident #40's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #40's Resuscitation Identification form dated [DATE], revealed her code status was handwritten on the upper right hand corner of this form as being a Full Code. Review of Resident #40's nurses notes dated [DATE] at 11:09 P.M., revealed the resident was found sitting on her toilet by State tested Nurse Aide (STNA) #53 who immediately called the LPN #41 and RN #42 to the room. The resident ' s skin was cold with no vital signs detectable. The note indicated Resident #40 was moved to her bed by staff. The documentation further revealed a call was placed to the DON, the son, and attending physician, who released the body. Interview with Physician #5 on [DATE] at 2:46 P.M. via telephone revealed he was the physician on call and was notified on [DATE] regarding Resident #40's death. Physician #5 stated LPN #41 informed him Resident #40 ' s vital signs were ceased and needed an order to release the body. Physician #5 stated he was unaware of the code status for Resident #40. Further interview on [DATE] at 10:00 A.M. revealed the physician stated if the resident was cold, without vital signs, and had a pacemaker he would not have expected the nurses to initiate life saving measures. Interview with the DON on [DATE] at 10:00 A.M., stated during a nursing skills in-service conducted on [DATE], which included CPR and code status; RN #42 and LPN #41 indicated Resident #40 had been found without vital signs and they had not initiated CPR when the resident was a Full Code. Interviews were attempted via telephone on [DATE] at 10:20 A.M. and 12:15 P.M. with RN #42. Both attempts were unsuccessful, messages were left and RN #42 did not return the calls. Review of RN #42 ' s personnel file revealed she resigned [DATE] due to scheduling issues. Interview on [DATE] at 2:07 P.M. with STNA #53, revealed she discovered Resident #40 in her personal bathroom slumped over, leaning on the attached handrail. The resident ' s face was pale and her lips were purple. She yelled to STNA #54 standing at the doorway to get a nurse immediately, and RN #42 responded. LPN #41 came into the bathroom and attempted to obtain the resident ' s vital signs. STNA #53 did not see anyone initiate CPR on Resident #40. The resident was lifted into a wheelchair and then put into her bed. Interview with the DON on [DATE] at 3:54 P.M., revealed LPN #41 notified her via telephone that Resident #40 had expired. She stated she did not ask what Resident #40 ' s code status was nor if CPR was initiated. Interview on [DATE] at 4:00 P.M. with LPN #41 revealed she responded to the resident ' s bathroom and upon entering the resident ' s bathroom observed Resident #40 sitting on the toilet, slumped over and leaning against the attached arm railing. The resident ' s skin was ash gray, cold, and dry. There were no vital signs, audible heart rate or respirations present. LPN #41 verified she did not know the residents code status, but felt she was gone and never thought to perform CPR. She further stated she not realize the resident was a Full Code until 20 minutes later when she reviewed the record. Review of one additional resident who was a Full Code status and found without a pulse and was unresponsive revealed the facility initiated CPR immediately. The facility identified there were no other residents with a Full Code status who had expired since [DATE]. The Ohio Board of Nursing Pronouncement of Death Publication, Number OBN - 102, revised on [DATE], indicates the pronouncement of death is a decision which could only be made by an individual holding a current certification to practice medicine or surgery or osteopathic medicine or surgery issued under section 4731 of the Ohio Revised Code.

Based on observations, staff interview, and review of facility policy, the facility failed to ensure the residents soiled laundry was being handled in a sanitary manner to prevent infection. This affected 40 of 40 residents who reside in the facility. Findings include: Observations of Housekeeper (HK) #45 on 01/07/16 at 8:19 A.M., revealed she was wearing gloves while handling items in the dirty laundry side of the laundry room. Housekeeper #45 took off the soiled gloves and began handling items on the clean side of the laundry room. She was not observed to wash her hands between the two tasks. Interview at the time of the observation with Housekeeper #45, verified she should have washed her hands upon removal of the gloves and before moving to the clean side. Observations of HK #45 on 01/07/16 at 9:17 A.M., revealed she placed clean rags on top of a bin in the dirty laundry area and then took them out to the floor to be put away. Interview with HK #45 at the time of observation, verified she always does it by taking the clean items through the dirty laundry area to save steps. She further stated she could go out the other door and pointed toward the clean laundry side but was concerned that it would take extra time. Observation of HK #45 on 01/07/16 at 11:34 A.M., revealed she was collecting personal clothing items on the units. She collected soiled personal clothing from the shower room and proceeded to remove soiled laundry items from one bin and placed them in another laundry bin she had in the hallway. Housekeeper #45 was wearing gloves with no other protective garments, such as a gown. Housekeeper #45 then pulled the door closed with her gloved hand without removing the soiled gloves. Interview with Housekeeper #45 at the time of the observation, verified she did not remove the soiled gloves nor was she wearing any protective garment when handling dirty laundry. Interview with Assistant Administrator #57 on 01/07/16 at 1:33 P.M., revealed staff were to use standard universal precautions to prevent the spread of infection and follow nursing standards of practice for infection control. She further verified there was no infection control policy related to laundry.

Base on medical record review and staff interview, the facility failed to ensure one (Close Record CR #2) resident received medications in accordance with physician orders. This affected one (CR #2) of three residents reviewed for medications. The facility identified a total of 44 residents as currently receiving medications. Findings include: Review of Closed Record (CR) #2 revealed the resident was admitted on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Review of the admission physician orders [REDACTED]. Review of the hospital discharge medication record, revealed the resident was due to receive her evening doses of the Lumigan, Cosopt, Zantac, Lodine, and Zantac on 03/30/14. Review of the Medication Administration Record [REDACTED]. In addition, the Director of Nursing (DON) verified the resident failed to receive the following physician ordered medications on 03/31/14, Lumigan 0.01% eye drop, Lodine 200 mg tablets, Zantac 150 mg tablet, Cosopt 2-0.05% eye drop and Zyrtec 10 mg tablet. Interview with the DON on 04/16/14 at 1:57 P.M., verified CR #2 was admitted on [DATE] at approximately 3:00 P.M. She verified the resident did not receive several of her physician ordered medications for the evening of 03/30/14 and throughout the day of 03/31/14. She verified on 03/30/14, the resident failed to receive her Lumigan 0.01% eye drops, Lodine 200 milligram (mg) tablet, Zantac 150 mg tablet, and Cosopt 2-0.5% eye drops. In addition, the DON verified the resident failed to receive the following physician ordered medications on 03/31/14, Lumigan 0.01% eye drop, Lodine 200 mg tablets, Zantac 150 mg tablet, Cosopt 2-0.05% eye drop and Zyrtec 10 mg tablet. The DON stated the facility does not receive medication supplies from the pharmacies on Sundays. She states the pharmacy will only "drop ship" medications if the pharmacy deems them to be emergency medications. She stated the medications CR #2 failed to receive were not available in the facility's contingency supply box. In addition, she verified the facility does not have written policies on on pharmaceutical supply/availability.