Every finding on record at Jamestowne Rehabilitation

Based on record review, observation, staff and resident interview, review of the guidelines from the National Pressure Injury Advisory Panel (NPIAP), and policy review, the facility failed to thoroughly assess a resident's skin and timely identify pressure ulcers (injuries to skin and underlying tissue caused by prolonged pressure, friction, or shear, usually over bony areas like the hips, heels, or tailbone) until they had reached an advanced stage. Actual Harm occurred on 08/03/26 when Resident #40, who was at risk for developing pressure ulcers, developed a facility acquired stage III pressure ulcer (full-thickness skin loss in which adipose [fat] is visible and granulation tissue [new tissue] and epibole [rolled wound edges] are often present. Slough [a soft, moist, yellow or white devitalized tissue comprised of dead cells, fibrin, and bacteria that forms in the wound bed, acting as a significant barrier to healing by stalling the inflammatory phase] and/or eschar [a thick, dry, black or brown layer of dead tissue that forms over deep wounds] may be visible along with undermining [tissue under the edges of the wound becomes eroded] and tunneling [narrow passageways or channels extending deep beneath the skin's surface into subcutaneous tissue or muscle may occur]) which was not identified until it had reached an advanced stage. This affected one (Resident #40) of two residents reviewed for pressure ulcers. The facility census was 27.Findings include:Review of the medical record revealed Resident #40 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.Review of the Minimum Data Set (MDS) assessment, dated 07/16/26, revealed Resident #40 was cognitively impaired. Resident #40 was dependent on staff for toileting and required substantial/maximal assistance with showering. He required substantial/moderate assistance for rolling left and right and sitting to stand. He was dependent for bed mobility and transfers. Resident #40 had an indwelling catheter and was always incontinent of bowel. Review of the care plan dated 06/24/26 revealed Resident #40 was at risk for potential skin breakdown related to diabetes, left side weakness, and decreased mobility. Interventions included assisting with turning every two hours, nurse to notify physician of changes in skin integrity, and observe resident every shift and as needed for any red, irritated, open or discolored areas.Review of the Braden Scale for Predicting Pressure Sore Risk dated 07/12/26 revealed Resident #40 was at risk for developing pressure ulcers.Review of the progress note dated 07/12/26 at 12:30 A.M. revealed Resident #40 had been readmitted from the hospital. Resident #40 had a new skin issue located on the coccyx that was described as redness. There was also another new skin issue on the peri-anal area that was described as redness.Review of the notes from the wound care visit on 07/13/26 revealed Resident #40 admitted to the facility with partial thickness areas of moisture associated skin damage scattered on the bilateral buttocks and intragluteal cleft.Review of the skin assessment for Resident #40 dated 07/24/26 revealed no new skin concerns were documented.Review of the progress note dated 07/28/26 at 4:43 P.M. revealed Resident #40 was being sent to the hospital for an evaluation after abnormal ultrasound results. Resident #40 returned to the facility on [DATE] at 3:40 A.M.Review of the medical record revealed there was no documentation of a skin evaluation being completed after Resident #40 returned from the hospital.Review of the notes from the wound care visit dated 08/03/26 revealed Resident #40 recently readmitted from the hospital with a stage III pressure ulcer over the sacrum that extends over to the left buttocks measuring 1.5 centimeter (cm) by 6.0 cm by 0.1 cm.During an interview on 08/04/26 at 12:55 P.M., Resident #40 said he was aware he had a pressure ulcer and stated that it occurred sometime between going to the hospital and now. He was unsure when the pressure ulcer developed but stated that it caused him pain. He said the staff only come and reposition him when he calls and asks them to do so. During an interview on 08/04/26 at 3:11 P.M., Director of Nursing (DON) #101 stated Resident #40 was being followed by wound care due to having some moisture related redness and concerns about skin integrity. The Wound Nurse Practitioner (WNP) #676 saw Resident #40 on 08/03/26 as a follow up and that was when the facility first discovered the pressure ulcer. DON #101 verified no new skin concerns were noted for Resident #40 prior to the wound care visit on 08/03/26.During an interview on 08/05/26 at 8:29 A.M., WNP #676 stated she had not been alerted to any new or worsening skin issues for Resident #40 prior to seeing him on 08/03/26. She believed Resident #40 had developed the pressure ulcer around 07/29/26 when he spent several hours in the emergency room and that it may have been missed when he returned to the facility. WNP #676 stated that she would expect the facility to notify her of any skin changes and for skin assessments to be completed daily due to Resident #40 having a history of poor skin integrity.During an interview on 08/05/26 at 10:20 A.M., MDS Specialist #19 stated she rounds with the wound care nurse, and she was present for the rounds on 08/03/26. She stated staff alerted her of any skin concerns, or she will review medical records before she does wound care rounds with the provider to add residents that need to be seen to the list. She stated she had not been alerted to any new or worsening skin issues for Resident #40 prior to 08/03/26. He was being seen for skin moisture and Resident #40 had been complaining about pain on his bottom. She verified Resident #40 did not have a skin assessment completed after his visit to the emergency room on [DATE] since he was never discharged from the facility. She did not know the date of the development of the pressure ulcer but that it was considered in-house acquired.During an observation on 08/05/26 at 10:53 A.M., Resident #40 had an oblong open area on his sacrum extending to the left buttock, approximately 1.5 cm by 6.0 cm by 0.1 cm. The wound tissue was bright red on the sacrum with pale yellow tissue at the borders of wound.Review of the facility policy titled, Skin Check Protocol, dated 10/27/25, revealed if a new or worsening area is identified, a treatment order should be implemented and to notify the MDS specialist to place the resident on the wound care nurse's list and to tell them what interventions have been started/ordered.Review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, dated 2014, pages 70-71, at (https://npiap.com/general/custom.asp?page=2014Guidelines), revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. The NPIAP Pressure Injury Stages revealed if necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage III or Stage IV).This deficiency represents non-compliance investigated under Complaint Number 3076038.

Based on observation, interviews, and policy review the facility failed to ensure food was prepared, stored, and served in a safe and sanitary manner to prevent the potential of a foodborne illness. This had the potential to affect 25 of 25 residents who eat food prepared in the facility kitchen. The facility identified two (Resident #1 and #61) residents who do not eat food from the facility kitchen. The facility census was 27. Findings Include:Observation of the dish machine temperature log on 08/03/26 at 9:30 A.M. revealed the breakfast and lunch temperatures had already been recorded for 08/03/26.Interview on 08/03/26 at 9:32 A.M., with Lead [NAME] #82 verified she had written a lunch temperature on the dish machine temperature log and lunch had not occurred yet for the day.Interview on 08/03/26 at 9:34 A.M., with Senior Director of Culinary (SDC) #382 verified the dish machine temperature log was inaccurate as it had a temperature logged for lunch when lunch had not occurred yet.Observation and interview on 08/03/26 at 9:41 A.M. of the clean storage rack revealed two metal pans that were stacked while wet and a metal pan that still had a date sticker on it. Interview with SDC #382 verified pans should be fully air dried prior to stacking and that a pan with a sticker still on it is not considered clean and should not have been stored on the clean dish rack.Observation and interview on 08/03/26 at 9:45 A.M. revealed a bucket of sanitizer and a bucket of dish detergent being stored on the preparation sink. Interview with SDC #382 verified chemicals are supposed to be stored under food contact surfaces.Observation and interview on 08/06/26 at 9:50 A.M. revealed a black substance on the white guard in the ice machine. Further observation revealed that when the black substance was wiped with a white cloth, the cloth turned black. Interview with SDC #382 verified the ice machine was unclean.Observation and interview on 08/03/26 at 9:57 A.M. revealed there was build up on the can opener blade. Interview with SDC #382 verified the can opener was unclean.Observation and interview on 08/03/26 at 10:01 A.M. revealed the gasket on the preparation cooler door was torn and a black substance was observed on the gasket. Interview with SDC #382 verified the gasket was in disrepair and unclean.Observation and interview on 08/03/26 at 10:01 A.M. revealed stacks of worn plate lids stacked above the preparation cooler. Interview with SDC #382 verified the lids were in use and once the lids get too worn, they should be replaced. He verified there were 25 lids stacked and 20 of them were worn enough that they should have been replaced.Observation and interview on 08/03/26 at 10:05 A.M. of the kitchen freezer revealed a bag of bratwurst, ravioli, and salami that were covered in ice crystals. Interview with SDC #382 verified the food products showed signs of freezer burn and should have been discarded.Observation and interview on 08/03/26 at 10:10 A.M. revealed bulk containers of flour and rice without a date. Interview with SDC #382 verified the containers should have been dated when the product was opened and placed into the containers.Observation and interview on 08/03/26 at 10:22 A.M. revealed eight bags of chicken and six loaves of bread with ice crystals being stored in the freezer. Interview with SDC #382 verified the food showed signs of freezer burn and should have been discarded.Observation and interview on 08/06/26 at 11:29 A.M. revealed the Director of Culinary (DC) #600 taking temperature of the food on the tray line. Observation of the ham salad revealed it was 42 degrees F, chicken salad was 42.6 degrees F, and the egg salad was 56 degrees F. DC #600 verified the temperature and stated cold food holding should be below 41 degrees F.Observation on 08/06/26 at 11:31 A.M. revealed SDC #382 instructed staff to discard the cold food that was above 41 degrees F.Observation on 08/06/26 at 11:47 A.M. revealed Line [NAME] #21 removed French fries from the oven and placed them on the service line for hot holding.Observation on 08/06/26 at 11:49 A.M. revealed Lead [NAME] #18 entered the kitchen, wash his hands, put on an apron, don gloves and then begin serving food. Lead [NAME] #18 was observed serving French fries to residents.Interview on 08/06/26 at 11:50 A.M., with Lead [NAME] #18 verified he had not washed his hands after putting on his apron. Lead [NAME] #18 verified his hands should have been washed. Lead [NAME] #18 verified he did not know the temperature of the French fries prior to serving to residents.Interview on 08/06/26 at 11:51 A.M., with DC #600 verified the temperature of the French fries was not taken prior to serving. DC #600 verified staff should wash their hands after putting on an apron.Observation on 08/06/26 at 12:03 P.M. revealed three residents had been served chicken salad sandwiches.Interview on 08/06/26 at 12:03 P.M., with Dietary Manager #816 verified the chicken salad was not discarded after it was discovered to be above 41 degrees F.Observation on 08/06/26 at 12:16 P.M. revealed Lead [NAME] #21 prepare and serve an egg salad sandwich for a resident.Interview on 08/06/26 at 12:19 P.M., with DM #816 verified a resident was served the same egg salad that was supposed to be discarded. DM #816 took the temperature of the egg salad and verified that it was at 52 degrees F.Observation and interview on 08/06/26 at 12:50 P.M. revealed an egg salad sandwich had been plated to be served to a resident. Interview with DM #816 verified that another egg salad sandwich had been made to serve to a resident, that it was the same egg salad as before and currently was at a temperature of 58 degrees F.Review of the facility policy titled Resident Meal Service, dated January 2024 revealed the facility will provide each resident with a nourishing, palatable, well-balanced, attractive meal, at a safe and appetizing temperature that meets their daily nutritional needs.

Based on observation, review of the dish machine temperature log, review of an email correspondence, staff interview, and policy review, the facility failed to ensure the dish machine was maintained in a safe operating condition. This had the potential to affect 25 of 25 residents who received their food from the facility kitchen. The facility identified two (Resident #1 and #61) residents who did not eat from the facility kitchen. The facility census was 27. Findings Include:Observation on 08/03/26 at 9:34 A.M. revealed Senior Director of Culinary (SDC) #382 testing the dish machine. The thermometer was observed broken and a plate thermometer was used to test the temperature inside the dish machine which read 157 degrees Fahrenheit (F).Observation on 8/03/26 at 9:37 A.M. revealed SDC #382 ran the dish machine for a second cycle and the plate thermometer read 159 degrees F. Interview on 08/03/26 at 9:39 A.M., with SDC #382 verified the plate thermometer needed to reach 160 degrees F to properly sanitize. SDC #382 verified the thermometer outside the dish machine was not functioning properly and he was unaware of how long it has been like that. Observation on 08/03/26 at 9:42 A.M. revealed the plate thermometer was 159.8 degrees F. Observation on 08/03/2026 at 9:44 A.M. revealed the plate thermometer was 160.5 degrees F.Interview on 08/03/2026 at 9:45 A.M. with SDC #382 verified that it took 4 cycles for the dish machine to reach the proper sanitizing temperature. He stated that the if the dish machine sits for about 30 minutes, it needed to be ran for multiple cycles before it reached temperature. SDC #382 verified that he was aware of the dish machine not functioning properly and that you should not have to run it for multiple cycles to reach temperature each time you use it.Review of a facility email correspondence dated 04/17/26 revealed the facility was notified that the current dish machine was only connected to a cold water source and that typically they are required to be connected to hot and cold water to work properly.Review of the dish machine temperature logs revealed the wash cycle minimum is 160 degrees F and final rinse temperature minimum is 180 degrees F. Further review revealed a corrective action was needed if the wash temperature is below 150 degrees F, final rinse is below 180 degrees F, or the plate thermometer is not 160 degrees F or higher.Review of the dish machine logs for June 2026 revealed the dish machine temperature was logged three times for each day. Further review revealed the dish machine did not reach the required temperature 30 times and no corrective actions were listed.Review of the dish machine logs for July 2026 revealed the dish machine did not reach the required temperatures 48 times and had no corrective actions listed.Interview on 08/04/26 at 9:34 A.M. with SDC #382 verified the dish machine logs for June and July 2026 had multiple days where the required temperature was not met and no corrective action was documented as being completed. Interview on 08/05/26 at 11:40 A.M., with Administrator #201 verified that the facility had no documentation of the dish machine being repaired.Review of the facility policy titled Dish machine Temperatures, dated January 2024 revealed the policy is for the dish machine to be at the proper temperature for cleaning and sanitizing all equipment, and utensils, and is clean and in good working condition.

Based on record review, observation, resident and staff interview, and policy review, the facility failed to provide food at a palatable temperature to residents. This affected one (Resident #13) of 25 residents who received food and drink from facility kitchen. The facility census was 27.Findings include: Review of the medical record for Resident #13 revealed an admission date of 07/17/26. Diagnoses included streptococcal infection, diabetes mellitus type II, and chronic kidney disease.Review of the minimum data set (MDS) dated [DATE] revealed Resident #13 to be cognitively intact, utilized a wheelchair for mobility, required setup or clean-up assistance with eating and oral hygiene. Review of an order dated 07/17/26 for Resident #13 revealed the resident was ordered a cardiac and diabetic diet, two gram sodium and no concentrated sweets.Interview on 08/03/26 at 12:45 P.M., with Resident #13 revealed she was concerned about being the last room served meals because her food was frequently cold. Observation on 08/04/26 at 12:58 P.M. revealed Resident #13 had a serving of French fries on her lunch plate that were untouched.Interview on 08/04/26 at 12:58 P.M., with Resident #13 revealed the hamburger she had for lunch was only lukewarm, and the French fries were cold.Observation on 08/06/26 at 12:45 P.M., revealed the Director of Culinary #600 took the temperature of a cheeseburger flatbread and it was 112 degrees Fahrenheit. A taste test of the cheeseburger flatbread revealed it was cold.Interview on 08/06/26 at 12:46 P.M., with Senior Director of Culinary #382 verified the temperature was 112 degrees Fahrenheit. Senior Director of Culinary #382 confirmed the cheeseburger flatbread tasted cold.Review of facility policy titled Policies undated revealed food and drinks are palatable, attractive, and served at a safe and appetizing temperature to ensure resident satisfaction.

Based on record review, observation, and staff interview, the facility failed to ensure a resident received care of a pressure ulcers consistent with professional standards of practice to prevent infection and failed to follow enhanced barrier precautions to help prevent the transmission of communicable infections. This affected one (Resident #40) of three residents reviewed for infection control, enhanced barrier precautions. The facility census was 27.Findings include:Review of the medical record for Resident #40 revealed admission date of 07/11/26 with diagnoses including: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, diabetes mellitus type II, cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery.Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #40 utilized a wheelchair for mobility, had an indwelling urinary catheter, was always incontinent of bowel, required partial/moderate assistance with oral hygiene and wheelchair mobility, required substantial/maximal assistance with; shower/bathing, dressing upper body, rolling left and right from lying on back and return to lying position. Resident #40 was dependent for toileting hygiene, moving from side of bed to lying flat on bed, ability to move from lying on back to sitting on side of bed, and ability to transfer from bed to chair or wheelchair.Review of an order dated 07/25/26 for Resident #40 revealed place patient in Enhanced Barrier Precautions (EBP). Gown and glove during high contact activities, such as: dressing, bathing/showering, transferring, providing hygiene, changing linens, toileting/brief change, device care, or wound care.Review of an order dated 08/03/26 for Resident #40 revealed a wound treatment to the sacrum/Left buttock to cleanse pressure ulcer over the sacrum extending to the left buttock with normal saline, pat dry, apply a betadine moistened gauze with an army battle dressing (ABD) pad covering twice daily and as needed (PRN).Observation on 08/05/26 at 10:53 A.M. revealed Licensed Practical Nurse (LPN) #97 provided wound care to a pressure ulcer on Resident #40's sacrum/left buttock. Upon removal of resident's incontinence brief, Resident #40 was observed to be incontinent of bowel movement with fecal matter on bilateral buttocks. LPN #97 then removed pressure wound dressing and provided wound care to pressure ulcer before cleaning resident of fecal incontinence. Interview on 08/05/26 at 11:10 A.M., with LPN #97 confirmed fecal incontinence was approximately four inches from stage III pressure ulcer. LPN #97 confirmed she removed the dressing from pressure ulcer and applied the new dressing before cleaning resident of fecal incontinence.Interview on 08/05/26 at 12:06 P.M., with Infection Control Nurse #262 revealed incontinence care should be provided to residents before changing a sacral wound dressing to prevent infection.Observation on 08/05/26 at 10:53 A.M. revealed Physical Therapy Assistant (PTA) #13 entered Resident #40's room to assist rolling Resident #40 to his right side for wound care and incontinence care. PTA #13 had not donned a gown before assisting the resident to his side while wound care and incontinence care were provided.Interview on 08/05/26 at 11:07 A.M. with PTA #13 confirmed she did not wear a gown while assisting Resident #40 with bed mobility during wound care and incontinence care.Observation on 08/05/26 at 11:05 A.M. revealed LPN #97 removed her gown after providing wound care to Resident #40 and then proceeded to provide incontinence care to Resident #40 without wearing a protective gown.Interview on 08/05/26 at 11:10 A.M. with LPN #97 confirmed she did remove her gown after providing wound care to Resident #40. Further interview confirmed LPN #97 provided incontinence care without wearing a protective gown. LPN #97 confirmed an active order for Resident #40 to be on enhanced barrier precautions. LPN #97 confirmed she should have donned a gown before providing incontinence care to Resident #40.Review of facility policy titled Pressure Ulcer Treatment Stage III & IV & Unstageable, undated revealed the prevention of infection to be an objective of policy.Review of facility policy titled Clean Dressing Change, revealed the purpose of a dressing change is to prevent infection in a wound and the spread of infection to others.Review of facility policy titled Infection Control: Enhanced Barrier Precautions dated 8/2026 revealed staff will don gloves and gown prior to the following high-contact care activities including; dressing, providing hygiene, changing briefs, and wound care.

Based on medical record review, observation, resident interview, staff interview, review of the facility policy, and review of online guidance per the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure residents with pain from pressure ulcers were assessed and medicated for pain before, during and after wound care. Actual Harm occurred for Resident #142 when staff failed to assess Resident #142 for pain prior to wound care. Resident #142 reported she was experiencing severe pain prior to wound care and during wound care and the resident moaned and grimaced during the treatment while staff failed to assess for pain and/or offer pain medication or to pause the treatment. This affected one (Resident #142) of three residents reviewed for pain. The facility identified 16 residents (#03, #06, #10, #20, #23, #30, #142 #143, #144, #145, #194, #195, #198, #200, #201, #202) with orders for pain medication. The facility census was 29 residents. Findings include: Review of the medical record for Resident #142 revealed an admitted [DATE] with diagnoses including aftercare following a joint replacement surgery, need for personal care assistance, emphysema, chronic obstructive pulmonary obstruction, and osteoarthritis to the left hip. Review of the care plan for Resident #142 dated 10/14/24 revealed the resident had the potential for alteration in comfort. Interventions included staff were to administer medications to promote comfort/reduce pain per physician orders and to observe for effectiveness and side effects. Review of the pain assessment for Resident #142 dated 10/14/24 revealed the resident had experienced frequent pain in the last five days which made it hard for her to sleep, to participate in therapy, and limited the resident's day-to-day activities. Resident #142 rated her worst pain as a 6 out of 10 on a scale of 1 to 10 with 10 being the worst pain. Review of the admission Minimum Data Set (MDS) assessment for Resident #142 dated 10/20/24 revealed the resident was cognitively intact, had impairment on one side for the upper and lower extremity, used a walker and a wheelchair for mobility, and required assistance from staff with toileting, bed mobility, and transfers. Review of physician's orders for Resident #142 revealed an order dated 10/22/24 for oxycodone five milligrams (mg) routinely at 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M. and to give oxycodone 5 mg as needed twice a day for moderate to severe break-through pain. Further review of physician's orders for Resident #142 revealed an order dated 10/22/24 to cleanse right and left buttock with warm soapy water, allow to dry fully, apply Triad paste and leave open to air and to offer pain medications prior to wound care for deep tissue injury (DTI), a type of pressure ulcer that occurs when the soft tissue beneath the skin is damaged by pressure or shear forces. Review of the Medication Administration Record (MAR) for Resident #142 dated 10/28/24 revealed the resident received routine oxycodone at 9:00 A.M. and 1:00 P.M. but did not receive any as-needed oxycodone on 10/28/24. Interview on 10/28/24 at 2:51 P.M with Resident #142 confirmed she complained of pain on her bottom while sitting in her wheelchair in her room which she rated as 8 on a scale of 1 to 10 with 10 being the worst pain. Resident #142 confirmed her bottom hurt badly and the staff had given her pain medicine at 9:00 A.M. and 1:00 P.M., but it didn't help. Resident #142 confirmed she had requested additional pain medicine but didn't hear back from anyone about it. Observation of the wound treatment to the DTI on the resident's buttocks on 10/28/24 at 2:55 P.M. per Licensed Practical Nurse (LPN) #55 revealed the nurse did not assess the resident for pain prior to starting the wound treatment. Observation revealed as LPN #55 washed the resident's buttocks the resident moaned and grimaced and tightened her buttocks when the nurse touched the excoriated closed wound. As LPN #55 applied Triad paste to Resident #142's buttocks he told the resident she would be okay and then the nurse pulled up the resident's incontinence brief and rolled the resident onto her back while the resident continued to grimace and moan in pain. LPN #55 did not assess Resident #142's pain upon completion of the treatment nor did the nurse offer to stop during the treatment or offer pain medications. Interview on 10/28/24 at 4:31 P.M. with Resident #142 confirmed she was in severe pain during the wound treatment performed by LPN #55 especially when the nurse cleansed her bottom. Resident #142 confirmed she was still having pain to her bottom even after the treatment and she rated her pain as 7 on a scale of 1 to 10 with 10 being the worst pain. Resident #142 confirmed she didn't receive any pain medication after the treatment had been done at approximately 3:00 P.M. on 10/28/24. Interview on 10/28/24 at 4:32 P.M with LPN #55 confirmed he was focused on getting the treatment completed for Resident #142 and had failed to ensure the resident was assessed and medicated for pain before, during, and after the treatment. Review of the facility policy entitled Pain Assessment and Management dated 09/25/23 revealed the staff would identify pain in the resident and would develop interventions that were consistent with the resident's goals and needs and that addressed the underlying causes of pain. Review of online guidance per the NPUAP at chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://cdn.ymaws.com/npiap.com/resource/resmgr/2014_guideline.pdf on page 161 revealed nursing staff should manage pressure ulcer pain by organizing care delivery to ensure that it is coordinated with pain medication administration and that minimal interruptions follow. Proper pain management included performing care after administration of pain medication to minimize pain experienced and interruptions to comfort for the individual and for staff to encourage individuals to request a 'time out' during any procedure that causes pain.

Based on kitchen record review, observation, staff interview, review of the facility policy, and medical record review, the facility failed to prepare foods as planned by the Registered Dietitian (RD). This had the potential to affect all of the residents residing in the facility. The facility census was 29 residents. Findings include: 1.Review of the resident diet roster dated 10/30/24 revealed there were 28 residents with physician orders for regular, no added salt or no concentrated sweet diets. Review of the lunch diet spreadsheet dated 10/30/24 revealed the residents with regular, no added salt or no concentrated sweet diets were to receive a beef French sandwich. The recipe included two ounces of beef served on a roll, submarine roll or hoagie bun and one quarter cup of broth for dipping. Observation on 10/30/24 at 12:06 P.M revealed [NAME] #70 served a tong of beef slices onto one slice of bread with a ladle of gravy. The ladle was unlabeled for the serving size. Interview on 10/30/24 at 12:06 P.M. with [NAME] #70 confirmed she did not review the recipe book or spreadsheet to know the portion of the beef, bread or gravy. Interview on 10/30/24 at 1:37 with Registered Dietary Manager (RDM) #90 confirmed the beef sandwich was not served as a beef French dip sandwich as planned by the RD. The sandwich should have included two slices of bread with one-quarter cup of broth on the side. RDM #90 confirmed the gravy ladle portion was not listed on the ladle. RDM #90 confirmed [NAME] #70 should have reviewed the recipe book and spreadsheet for the sandwich portions. Review of the facility policy Resident Meal Service dated 2024 revealed staff should utilize diet spreadsheets during meal service to ensure meal accuracy. 2. Review of the medical record for Resident #202 revealed an admitted [DATE] with diagnoses including dysphagia, cervicalgia, and neoplasm of right breast. Review of the Minimum Data Set (MDS) assessment for Resident #202 dated 10/24/24 revealed the resident had intact cognition and required moderate assistance with activities of daily living (ADLs). Review of the physician's orders for Resident #202 revealed an order dated 10/24/24 for regular diet with puree consistency. Review of the menu spreadsheet of the lunch meal dated 10/30/24 revealed the lunch included four ounces of pureed broccoli, four ounces vanilla ice cream and four ounces of puree beef French dip sandwich. The recipe revealed the sandwich was to include a bun. Observation on 10/30/24 at 10:59 A.M. revealed [NAME] #70 did not puree any bread or bun as listed on the recipe and spreadsheet. Observation on 10/30/24 at 11:59 A.M. revealed the [NAME] #70 served the Resident #202 two and two-thirds ounces of broccoli with a number 12 scoop portion, four ounces of frozen supplement and a four-ounce portion of beef. The resident received no puree bread and did not receive the full portion of broccoli as listed on the spreadsheet. Interview on 10/30/24 at 12:20 P.M. with [NAME] #70 confirmed Resident #202 should have received four ounces of puree broccoli and four ounces of a beef sandwich which should have included bread. [NAME] #70 confirmed Resident #202 should have received four ounces of ice cream instead of four ounces of frozen supplement. [NAME] #70 stated she had not read the spreadsheet and had not followed the recipe instructions to prepare the pureed broccoli and the sandwich to include bread. Interview on 10/30/24 at 1:37 P.M. with Dietary Manager (DM) #80 and RDM #90 confirmed Resident #202 should have received pureed broccoli and pureed bread with the beef. DM #80 also verified [NAME] #70 did not have access to the pureed spreadsheet or pureed recipes to prepared the pureed food items. The pureed recipe instructions for pureed food preparation had not been available for any of the pureed consistency meals served to the residents. Review of facility policy titled Modified Texture Foods dated 2023 revealed the pureed consistency foods would be prepared by the menu diet spreads and portions will be provided in the proper amounts according to the menu and diet spreadsheet.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure staff performed appropriate hand hygiene during meal service. This affected seven (Residents #13, #20, #141, #145, #146, #199, #200) of eight residents observed for meal service. The facility also failed to store, label and serve food under sanitary conditions and had the potential to affect all of the residents residing in the facility. The facility census was 29 residents. Findings include: 1.Observation on 10/28/2024 at 11:59 A.M. revealed Dietary Aide (DA) #70 delivered meal trays to Resident #145, #141, and #199's rooms and did not perform hand hygiene after leaving each resident's room or before handling each resident's tray. Interview on 10/28/24 at 12:03 P.M. with DA #70 confirmed she did not perform hand hygiene before delivering room trays to Residents #141, #145, and #199 and she did not perform hand hygiene between residents. Observation on 10/28/24 at 12:27 P.M. revealed Dietary Aide #70 wore gloves as she prepared and loaded lunch trays into meal cart then propelled the cart to the 200 hall. DA #70 did not remove her gloves or perform hand hygiene before she delivered a meal tray to Resident #20. DA#70 did not remove gloves or perform hand hygiene before she returned to the cart, took out a meal tray, and delivered the tray to Resident # 200. DA #70 set up the tray on bedside table, adjusted height of tray table, and placed the table in front of Resident #200. DA#70 adjusted the head of bed to the resident's preference, left the room, and returned to meal cart without removing her gloves or performing hand hygiene. DA #70 took a meal tray out of cart and delivered it to Resident #146 and exited the room without removing her gloves or sanitizing her hands. Interview on 10/28/2024 at 12:38 P.M. with DA #70 confirmed she did not remove her gloves or sanitize her hands when delivering meals to Residents #20, #146, or #200 . DA #70 confirmed she did not normally wear gloveds when she delivered trays, but she put them on because she was nervous. DA #70 stated she was not sure how frequently she was supposed to doff gloves, but she knew she was supposed to sanitize her hands after removing gloves. Review of the facility policy titled Infection Control Hand Hygiene policy dated 07/03/23 revealed staff should perform appropriate hand hygiene to prevent the spread of infection. Staff should perform hand hygiene between contact with different residents. Review of the facility policy titled Meal Service dated 2004 revealed staff should sanitize hands after touching a resident. 44083 2. Observations on 10/28/24 at 8:50 A.M. revealed the following kitchen sanitation concerns: -The reach-in refrigerator contained an open undated container of cottage cheese and a covered pan of food with no label or date. -The ceiling in the dish area where clean dishes were stored had two incoming air vents with black debris to the edges. The ceiling above the food preparation sink had an incoming air vent with a dark brown substance on the edges. -There were two large unlabeled food storage bins with the food scoop stored on top of the food. -There were two uncovered trash containers in the kitchen full of trash without lids. -The reach in freezer contained three open packages of frozen foods which were not dated upon opening and were not properly sealed, allowing the food to be open to air. There was no thermometer inside the freezer and there was food debris on the bottom shelf. -The dry storage area contained 25 large food cans with no dates of delivery and a rotation schedule was unable to be determined. There were three opened containers of oats with no open date. -- The ice machine scoop was stored in an undrainable pan with the scoop bowl stored in undrainable position. Interview on 10/30/24 at 1:37 P.M. with Dietary Manager (DM) # 80 confirmed the kitchen violations including opened undated foods, unlabeled foods, dirty air vents in the kitchen, food scoops stored in the food bins, debris in the freezer, improperly Review of the facility policy titled Food Service and Nutrition dated September 2022 revealed the facility prepared and served food under sanitary conditions in a manner that protects against spoilage and contamination. Review of the facility policy titled Food and Supply Storage dated 2024 revealed open foods are to be covered, labeled and dated, and unopened foods are to be dated and rotated. Foods stored in bins are to be labeled and the scoop stored in scoop holder. 3. Review of the refrigerator and freezer temperature monitoring logs for October 2024 revealed there were no temperatures recorded for the refrigerator or freezer from 10/19/24 through 10/28/24. Interview on 10/30/24 at 1:37 P.M. with DM #80 confirmed there were no recorded temperatures for the refrigerator or freezer temperature logs from 10/19/24 to 10/28/24 and confirmed temperatures should be recorded every shift. 4. Review of the dishwasher temperature logs dated October 2024 revealed there were no recorded dishwasher temperatures for three meals on the following dates: 10/19/24, 10/20/24, 10/21/24, 10/22/24, 10/23/24, 10/24/24, 10/25/24, 10/26/24, 10/27/24. Interview on 10/30/24 at 1:37 P.M. with DM #80 confirmed there were no recorded temperatures for the dishwasher on the following dates: 10/19/24, 10/20/24, 10/21/24, 10/22/24, 10/23/24, 10/24/24, 10/25/24, 10/26/24, 10/27/24. Review of the facility policy titled Dishwasher Temperatures dated 2024 revealed dishwasher temperatures were recorded during each period of use. Once a day, a dishwasher temperature strip was used to verify the temperature. The Director was to review and verify the temperature log weekly. 5. Review of the food temperature log dated October 2024 revealed there were no food temperatures recorded for all three meals from dates of 10/20/24 through 10/28/24. Interview on 10/30/24 at 1:37 P.M. with DM #80 confirmed there were no recorded food temperatures for all three meals dated 10/20/24 to 10/28/24. 6. Observations on 10/28/24 through 10/30/24 revealed DM #80, Regional Dietary Manager (RDM) #90, [NAME] #70 and [NAME] #75 were in the kitchen and did not have their facial hair contained with beard coverings. Interview on 10/30/24 at 1:37 P.M. with DM #80 confirmed neither her nor RDM #90, [NAME] #70 and [NAME] #75 wore beard coverings while in the kitchen in the food preparation area. Review of the facility policy titled Meal Service dated 2004 revealed employees' hair should be pulled away from food when handling foods. 7. Observation on 10/30/24 at 11:15 A.M. revealed [NAME] #70 washed the blender used for pureed foods with gloved hands. [NAME] #70 reassembled the washed blender blade into the blender with the same gloved hands used to operate the dishwasher. The blender blade immediately came into contact with the next food during the pureeing process. Interview on 10/30/24 at 12:06 P.M. with [NAME] #70 confirmed she should have changed gloves prior to reassembling the blender blade and sanitized the food thermometer between food temperatures. 8. Observation on 10/30/24 at 11:20 P.M. [NAME] #70 obtained the temperature of the four pans of food served to residents without sanitizing the thermometer between the food items. Interview on 10/30/24 at 12:06 P.M. with [NAME] #70 confirmed she should have sanitized the food thermometer between food temperatures. Review of the facility policy titled Policies undated revealed food thermometers were to be sanitized between food items with sanitizer wipes. 9.Observation on 10/30/24 at 11:51 A.M. revealed [NAME] #75 prepared the lunch meal wearing gloves and touched the food cart, the food lids, the serving counter and utensils and then assembled sandwiches, and pizza toppings with the same gloved hand. [NAME] #75 continued touching items and returning to prepare foods without changing gloves and washing hands. [NAME] #70 handled the inside of insulated lids placed over top of residents' meal plates with ungloved hands. Interview on 10/30/24 at 12:06 P.M. with [NAME] #75 confirmed he should have changed gloves or used a utensil to prepare sandwiches and pizza toppings. [NAME] #70 confirmed she should not have touched the inside of a resident plate covering lid with the hand. [NAME] #70 verified she should have changed gloves prior to reassembling the blender blade.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff administered medications in a sanitary manner. This affected one (Resident #142) of three residents reviewed for medication administration. The facility also failed ensure residents with wounds were placed in enhanced barrier precautions (EBP.) This affected nine (Residents #10, #146, #142, #200, #201, #198, #144, #202, and #199) of ten facility-identified residents with wounds. The facility also failed to ensure staff performed proper hand hygiene after blood glucose monitoring. This affected one (Resident #30) of one resident reviewed for blood glucose monitoring. The facility also failed to proper hand hygiene was performed during and after wound care. This affected one (Resident #142) of one resident reviewed for wound care. The facility census was 29 residents. Findings include: 1. Review of the medical record for Resident #142 revealed an admitted [DATE] with diagnoses including aftercare following joint replacement surgery, emphysema, and unspecified chronic obstructive pulmonary disorder. Review of the physician's orders for Resident #142 revealed an order dated 10/14/24 for oxycodone 5 milligrams (mg) by mouth four times daily. Review of the Minimum Data Set (MDS) assessment for Resident #142 dated 10/20/24 revealed the resident was cognitively intact. Observation of medication administration on 10/29/2024 at 8:39 A.M. per Licensed Practical Nurse (LPN) #55 for Resident #142 revealed LPN #55 unlocked the medication cart, removed the resident's oxycodone card from the locked narcotic drawer, pushed one pill through the back of the card into his hand, and placed the pill into the medication cup. Interview on 10/29/2024 at 8:39 A.M. with LPN #55 confirmed he dispensed the oxycodone 5 mg tablet into his had before placing the pill in the medication cup. LPN #55 further confirmed he was not supposed to touch resident medications with his hands. Review of the facility policy titled Administration of Medications: Administration of Tablets and Capsules dated September 2022 revealed tablets and capsules were to be handled so that fingers did not touch them. 2a. Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses including unspecified fracture to the neck of the left femur, type II diabetes, and unspecified depression. Review of the care plan for Resident #10 dated 10/28/24 revealed the resident had potential for infection related to surgical wound to the left hip related to left hip hemiarthroplasty. Interventions included to follow up with surgeon orders, observe surgical wounds for infection, and provide treatments as ordered. Review of the medical record for Resident #10 revealed the resident did not have physician's orders for Enhanced Barrier Precautions (EBP). 2b. Review of the care plan for Resident #10 dated 10/14/24 revealed the resident had the potential for had infection related to surgical wound: left hip after conversion to left total hip arthroplasty. Interventions included administer medications/treatments as ordered, keep surgical dressing in place until follow up with ortho, observe wound for signs of infection. Review of the medical record for Resident #142 revealed the resident did not have physician's orders for EBP. 2c. Review of the medical record for Resident #146 revealed an admitted [DATE] with diagnoses including unspecified fracture to the neck of the right femur, chronic combined heart failure, chronic obstructive pulmonary disease, and chronic kidney disease with dependence on dialysis. Review of care plan for Resident #146 dated 10/14/2024 revealed the resident had potential for infection related to surgical wound to the right hip. Interventions included keep surgical dressing in place until follow up with surgeon, and observe surgical wound for symptoms of infection. Review of the medical record for Resident #146 revealed the resident did not have physician's orders for EBP. 2d. Review of the medical record for Resident #200 revealed an admitted [DATE] with diagnoses including unspecified acute kidney failure, unspecified fracture to the neck of the right femur, and major depressive disorder. Review of care plan for Resident #200 dated 10/24/24 revealed the resident had potential for infection related to surgical wound to right hip. Interventions included follow up with surgeon as ordered, keep surgical dressing in place until follow up with surgeon, monitor surgical incision to right hip for signs of infection, remove staples/suture as per order, and complete treatments as ordered. Review of the medical record for Resident #200 revealed the resident did not have physician's orders for EBP. 2e. Review of the medical record for Resident #201 revealed an admitted [DATE] with diagnoses including morbid obesity, type two diabetes, unspecified kidney disease, and aftercare following right knee joint replacement surgery. Review of care plan for Resident #201 dated 10/22/24 revealed the resident had potential for infection related to surgical wound to the right knee. Interventions included complete treatments as ordered, follow up with surgeon as ordered, and monitor surgical wound for signs of infection. Review of the medical record for Resident #201 revealed the resident did not have physician's orders for EBP. 2f. Review of the medical record for Resident #198 revealed and admitted [DATE] with diagnoses including displaced fracture of the base of the neck of the right femur, acute posthemorrhagic anemia, hyperlipidemia, and hypothyroidism. Review of care plan for Resident #198 dated 10/20/24 revealed the resident had potential for infection related to surgical wound to the right hip. Interventions included follow up with surgeon as ordered, remove staples/suture as ordered, and observe surgical wound for symptoms of infection. Review of the medical record for Resident #198 revealed the resident did not have physician's orders for EBP. 2g. Review of the medical record for Resident #144 revealed an admitted [DATE] with diagnoses including aftercare following joint replacement surgery, type II diabetes, mixed hyperlipidemia, major depressive disorder, and generalized anxiety disorder. Review of care plan for Resident #144 dated 10/20/2024 revealed the resident had potential for infection related to surgical wound. Interventions included follow up with surgeon, remove ace wraps within 24-48 hours, keep dressing in place until follow-up appointment, and observe surgical wound for signs of infection. Review of the medical record for Resident #144 revealed the resident did not have physician's orders for EBP. 2h. Review of the medical record for Resident #202 revealed an admitted [DATE] with diagnoses including localized edema, malignant neoplasm to the right breast, unspecified pressure ulcer of the sacral region, and prediabetes. Review of care plan for Resident #202 dated 10/24/24 revealed the resident was admitted with compromised skin issues to the left buttock and left heel. Interventions included assisting with turning/repositioning every 2 hours, provide incontinence care as needed, pressure relieving devices as ordered, and weekly skin evaluations. Review of the medical record for Resident #202 revealed the resident did not have physician's orders for EBP. 2i. Review of the medical record for Resident #199 revealed an admitted [DATE] with diagnoses including cellulitis of right lower limb, chronic obstructive pulmonary disease, chronic kidney disease, chronic diastolic heart failure, and schizoaffective disorder bipolar type. Review of care plan for Resident #199 dated 10/10/24 revealed the resident had the potential for skin breakdown related to catheter tubing in use, admitted with compromised area to left shin, and venous ulcer to left lower extremity. Interventions included assisting with turning ad repositioning every two hours, assisting with peri-care after incontinent episodes, treatments as ordered, and pressure reducing devices as ordered. Review of the medical record for Resident #199 revealed the resident did not have physician's orders for EBP. Observations on 10/30/2024 at 12:20 P.M. revealed Residents #10, #146, #142, #200, #201, #198, #144, #202, and #199 had no signs posted on the door to each residents' room which notified staff or visitors of EBP. There was no personal protective equipment (PPE) available outside of each residents' room. Interview on 10/30/2024 at 12:25 P.M. with Infection Control Preventionist (ICP) Registered Nurse #10 confirmed residents with surgical wounds (Resident # 10, Resident # 146 , Resident # 142, Resident # 200, Resident # 201, Resident # 198, Resident # 144), pressure wounds (Resident #202), and other ulcers (Resident #199) had not been placed in EBP. Review of the facility policy titled Infection Control: Enhanced Barrier Precautions dated 10/25/22 revealed the facility instituted EBP for any resident with wounds regardless of colonization or infection status according to the Centers for Disease Control and Prevention (CDC) guidelines. 3. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus, idiopathic chronic gout, and phantom limb syndrome with pain. Review of MDS assessment for Resident #30 dated 10/03/24 revealed the resident was cognitively intact. Review of care plan for Resident #30 dated 09/30/24 revealed the resident had the potential for glucose imbalance related to the diagnosis of type two diabetes. Observation of blood glucose monitoring on 10/29/24 at 4:12 P.M. per LPN #64 for Resident #30 revealed after checking the resident's blood sugar, the nurse doffed his gloves and left the room without performing hand hygiene and then opened the medication cart and obtained medications. Interview on 10/29/2024 at 4:17 P.M. with LPN #64 confirmed he did not perform hand hygiene after checking Resident #30's blood sugar and doffing gloves. Review of the facility policy titled Infection Control Hand Hygiene Policy dated 07/20/23 revealed at minimum, employees were required to perform hand hygiene in circumstances including before direct contact with a resident, before handling food, immediately after touching body substances, after handling potentially contaminated objects, between direct contact with different residents, and after removing gloves. 34291 4. Review of the medical record for Resident #142 revealed an admitted [DATE] with diagnoses including aftercare following a joint replacement surgery, need for personal care assistance, emphysema, chronic obstructive pulmonary obstruction, and osteoarthritis to the left hip. Review of the MDS assessment for Resident #142 dated 10/20/24 revealed the resident was cognitively intact, had impairment on one side for the upper and lower extremity, used a walker and wheelchair for mobility, and required staff assisting with toileting, bed mobility, and partial/moderate assistance for transfers. Observation on 10/28/24 at 2:55 P.M. of wound care for Resident #142 per LPN #55 revealed the nurse donned gloves, assisted the resident into bed, turned the resident over to the right side, closed the blinds, turned on the lights, put water into a basin and then removed his gloves and applied new gloves. LPN #142 cleansed Resident #142's buttocks, removed his gloves and applied new gloves without washing his hands. LPN #142 applied Triad paste to the area and then removed his gloves and left the room. Interview on 10/28/24 at 3:16 P.M. with LPN #55 confirmed he should have washed his hands after doffing gloves and before leaving the Resident #142's room

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents were treated with dignity and respect. This affected one (Resident #142) of 13 residents sampled. The facility census was 29 residents. Findings include: Review of the medical record for Resident #142 revealed an admitted [DATE] with diagnoses including aftercare following a joint replacement surgery, need for personal care assistance, emphysema, chronic obstructive pulmonary obstruction, and osteoarthritis to the left hip. Review of the admission Minimum Data Set (MDS) assessment for Resident #142 dated 10/20/24 revealed the resident was cognitively intact, had impairment on one side for the upper and lower extremity, used a walker and a wheelchair mobility, and required staff assistance with toileting, bed mobility, and transfers. Review of physical therapy (PT) note for Resident #142 dated 10/27/24 revealed the resident required moderate assistance and safety cues for transfers. Review of occupational therapy (OT) note for Resident #142 dated 10/28/24 revealed the resident required contact guard assistance with toileting, moderate assistance with lower body dressing, and stand by assistance with getting out of bed. Interview on 10/28/24 at 2:40 P.M. with Resident #142 confirmed she had an incontinent accident on 10/28/24 at approximately 4:30 A.M. which soiled the bed. Resident #142 confirmed she rang the call light and Licensed Practical Nurse (LPN) #52 answered the call light. Resident #142 confirmed she told LPN #52 she had an accident and needed the aide to help her get cleaned up and change her bed and that she was cold and didn't want to get out of bed. Resident #142 confirmed LPN #52 told her Certified Nursing Assistant (CNA) #33 had stated the resident needed to change her own brief because the aide wasn't going to turn in bed. Resident #142 confirmed LPN #52 also said STNA #33 had said the aide wouldn't change the resident's bed until the aide changed her own brief. Resident #142 confirmed the interaction made her feel terrible and she tried to do most of her activities of daily living (ADL) independently, but wanted the aide help her because it was her job to help her. Resident #142 confirmed she did what she was told and got up out of bed and changed her brief herself and CNA #33 came in and changed her bed. She stated she didn't want this aide to take care of her again. Review of a witness statement per Social Service Coordinator (SSC) #29 dated 10/28/24 revealed the SSC interviewed Resident #142. Further review of the statement revealed Resident #142 reported that on 10/28/24 at 4:30 A.M. the resident said she was wet, and LPN #52 said CNA #33 wouldn't change her unless she got out of bed, because she didn't want to roll her side to side. Further review of the statement revealed Resident #142's sheets were wet and the resident was cold didn't want to get out of bed. Interview on 10/28/24 at 3:43 P.M. with CNA #33 confirmed she did not tell LPN #52 to tell the resident to change her brief before she would change the bed. Interview on 10/29/24 at 10:41 A.M. with LPN #52 confirmed on 10/28/24 at 4:30 A.M. Resident #142 asked for the aide to come in and change her and the bed. LPN #52 confirmed CNA #33 said the nurse should tell the resident to change her own brief because it would be easier to change the linens and she wouldn't have to roll the resident from side to side since the resident had a recent hip surgery. LPN #52 confirmed the resident was incontinent of urine on 10/28/24 at approximately 4:30 A.M. and required staff assistance with incontinence care. LPN #52 further confirmed the nurse did not assist the resident because the nurse was getting ready to make her final rounds of the night. Interview on 10/29/24 at 12:57 P.M. with Activity Director (AD) #9 on 10/29/24 confirmed Resident #142 was upset in the morning of 10/28/24 and reported after having an accident in the aide said if the resident didn't get up and change herself, the aide wasn't going to change her bed. Interview on 10/29/24 at 1:29 P.M. with Therapy Manager (TM) #12 confirmed Resident #52 required hands on staff assistance with toileting, with bed mobility and with getting out of bed. Review of the facility policy titled Resident Rights dated 10/14/22 revealed the facility would treat each resident/patient with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure intravenous (IV) therapy was administered in accordance with professional standards of practice. This affected one (Resident #143) of two facility identified residents receiving IV therapy. The facility census was 29 residents. Finding include: Review of the medical record review for Resident #143 revealed an admitted [DATE] with a diagnosis of left knee prosthetic infection. Review of the physician's orders for Resident #143 revealed an order dated 10/04/24 to change the dressing to the resident's central line dressing (for administration of IV therapy) once a week on Thursday. Review of the care plan for Resident #143 dated 10/06/24 revealed the resident required IV therapy for treatment of an acute infection to the left knee. Review of the Minimum Data Set (MDS) for Resident #143 dated 10/11/24 revealed the resident was cognitively intact. Observation on 10/28/24 at 11:55 A.M. of Resident #143 revealed the dressing to the resident's central line was not dated. Interview on 10/28/24 at 12:20 P.M. with Licensed Practical Nurse (LPN) #55 confirmed Resident #143's central line dressing wasn't dated and should have been. LPN #55 confirmed Resident #143 had an order to have the dressing changed once weekly and was unsure when the dressing had been changed last. Review of the facility policy titled Central Line Dressing Changes dated 08/11/16 revealed the facility provided a standard for central line dressing changes that prevented infection and prevented migration of the catheter. Central line dressings should be changed every seven days and as needed.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure oxygen tubing was dated. This affected two (Residents #145 and 143) of three facility-identified residents who required oxygen routinely. This facility census was 29 residents. Findings include: Review of the medical record for Resident #145 revealed an admitted [DATE] with diagnoses including traumatic brain dysfunction, coronary artery disease, and hypertension. Review of admission Minimum Data Set (MDS) for Resident #145 dated 09/01/24 revealed the resident was cognitively intact. Review of care plan for Resident #145 dated 10/23/24 revealed resident had the potential for skin breakdown related to oxygen tubing in use. Review of physician's orders for Resident #145 revealed an order dated 10/23/24 for oxygen 0-4 liters per minute per nasal cannula to keep oxygen saturation level at or above 92 percent (%.) Observation on 10/28/24 at 2:22 P.M. of Resident #145 revealed the resident's oxygen tubing was undated. Interview on 10/28/24 at 10:21 A.M. with Licensed Practical Nurse (LPN) #71 confirmed Resident #145's oxygen tubing wasn't dated. LPN #71 confirmed oxygen tubing should be changed once weekly, and she was unsure when Resident #145's oxygen tubing had last been changed. 2. Review of medical record for Resident #143 revealed an admitted [DATE] with medical diagnoses included left knee prosthetic infection. Review of physician's orders for Resident #143 revealed an order dated 10/04/24 for oxygen 0-4 liters titrate oxygen per nasal cannula to keep saturation at or above 92%. Review of care plan for Resident #143 dated 10/06/24 revealed the resident has the potential for skin breakdown related to oxygen tubing in use. Review of the MDS for Resident #143 dated 10/11/24 revealed the resident was cognitively intact. Observation on 10/28/24 at 11:55 A.M. of Resident #143 on 10/28/24 at 11:55 A.M. revealed there was no date on the oxygen tubing. Interview on 10/28/24 at 12:20 P.M. with LPN #55 confirmed the oxygen tubing wasn't dated and should have been. Review of the facility policy titled Oxygen Administration dated 09/25/23 revealed oxygen tubing should be dated/initialed and should be changed once weekly on night shift.

Based on record review, observation, resident and staff interview, and review of the facility policy, the facility failed to timely assess and treat a [CONDITION(S)]. This affected one (#29) of five facility identified residents with impaired skin integrity to the feet. The census was 27. Findings include: Review of the medical record for Resident #29 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the hospital continuity of care form for Resident #29 revealed resident had diabetic foot ulcers. Review of the admission nursing assessment for Resident #29 dated 10/15/21 revealed resident had open [CONDITION(S)] to the left great toe and left second toe. Resident's right leg had been amputated above the knee. Review of the baseline care plan for Resident #29 dated 10/15/21 revealed resident should receive wound care. Review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse progress notes for Resident #29 dated 10/15/21, 10/16/21, 10/17/21 revealed the record contained no documentation regarding a further description of the [CONDITION(S)] to residents' left foot and any treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician orders for Resident #29 revealed an order dated 10/18/21 to cleanse left great toe and left second toe with normal saline and apply [MEDICATION(S)]. Review of the wound nurse practitioner (NP) note for Resident #29 dated 10/19/21 revealed nurse was asked by the facility to evaluate diabetic ulcers to the resident's left great toe and resident's left second toe both of which were present upon admission. The wound nurse note described the wound to Resident #29's great toe as follows: a diabetic ulcer measuring 1.1 centimeters (cm) in length by 0.7 cm in width by 0.1 cm in depth without tunneling or undermining, scant amount of sanguineous drainage noted which has no odor. The wound nurse note described the wound to Resident #29's second toe as follows: a diabetic ulcer measuring 3.0 cm in length by 1.3 cm in width by zero cm in depth, without tunneling or undermining, no drainage noted, wound bed has 76-100 percent (%) eschar. Review of the physician orders for Resident #29 revealed an order dated 10/19/21 to cleanse left great toe and left second toe with normal saline and apply [MEDICATION(S)] and cover with a dry dressing twice daily Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/20/21 at 8:13 A.M. of wound care for Resident #29 per Licensed Practical Nurse (LPN) #200 revealed the resident had an undated dressing to his left great toe and left second toe. LPN #200 removed the dressing and performed the treatment as ordered. Resident #29 had open areas to the top of his left great toe and left second toe. Interview on 10/20/21 at 8:20 A.M. with LPN #200 confirmed the treatment to Resident #29's left great toe and left second toe was put in place on 10/19/21. Interview on 10/20/21 at 8:21 A.M. with Resident #29 confirmed he was admitted to the facility with ulcers to his left great toe and left second toe. Resident #29 further confirmed the facility began the treatment to his foot ulcers on 10/19/21 after he was seen by the wound NP. Interview on 10/20/21 at 3:30 P.M. with the Director of Nursing (DON) confirmed Resident #29 was admitted on [DATE] with diabetic ulcers to his left great toe and left second toe. The admission assessment for Resident #29 did not include an assessment/description of the wounds and the treatment order to the ulcers on the resident's toes was not initiated until 10/19/21. Review of facility policy titled Wound Treatment Protocol dated 11/2020 revealed the wound NP should be contacted if no orders for wounds have been provided by the hospital upon resident's admission. Further review of the policy revealed nurses should describe the wound thoroughly (wound bed, drainage, peri wound) in the skin assessment upon admission. This deficiency substantiates Complaint Number OH 518.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure resident oxygen orders included a rate (liters per minute) prescribed by the physician. This affected one (#30) of three facility-identified residents with oxygen orders. The census was 27. Findings include: Review of the medical record for Resident #30 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #30 dated 09/21/21 revealed resident was cognitively intact and required extensive assistance of two staff with activities of daily living (ADL's). Review of the care plan for Resident #30 dated 09/26/21 revealed resident had impaired gas exchange. Interventions included administer oxygen as prescribed. Review of physician's orders for Resident #30 revealed an order dated 09/15/21 for oxygen per nasal cannula to maintain oxygen saturation level at or above 92 percent (%). The order did not include a rate of administration. Review of the September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the October 2021 MAR for Resident #30 revealed resident was administered oxygen at varying rates each day including two LPM, four LPM, four and a half (4.5) LPM, and six LPM. Interview on 10/20/21 at 3:30 P.M. with the Director of Nursing (DON) confirmed Resident #30's oxygen order did not include directions regarding the flow rates of oxygen resident should receive. The DON confirmed Resident #30 received oxygen at rates ranging from two LPM to seven LPM. Review of the facility policy titled Oxygen Therapy dated 10/04/21 revealed physician orders for oxygen therapy shall include liter flow rate for the oxygen administration. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview and review of facility policy, the facility failed to implement a pharmacy recommendation by ensuring an antidepressant was decreased timely when approved by the physician. This affected one resident (#118) of three residents reviewed for unnecessary medication. The facility census was 36. Findings include: Medical record review for Resident #118 revealed an admitted on 08/04/21. Diagnoses include [CONDITION(S)] and [CONDITION(S)] following a stroke, [CONDITION(S)], pneumonia, wedge compression fracture, anxiety, major depressive disorder, abdominal pain, hypertension, [CONDITION(S)] (BPH), [CONDITION(S)], kidney failure, urine retention, depression and contracture of right thigh. Review of admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #118 revealed an impaired cognition. Resident required supervision for bed mobility, limited assist for transfers and toileting and supervision for eating. Resident is always continent for bowel an bladder. Resident was coded as having a diagnosis of depression and received antidepressant daily during the assessment period. Review of the plan of care for Resident #118 dated 08/06/21 revealed resident was at risk for alteration in mood and psychosocial wellbeing related to restrictions to the facility due to Coronavirus Disease 2019 (COVID-19) pandemic. Interventions included observe for any mood or behavioral changes and notify physician as indicated, provide for expression of feelings related to situational stressor and provide psychologist consults as needed. Review of the care area assessment (CAA) completed for Resident #118 and dated 08/19/21 revealed resident was receiving antidepressant for depression and anxiety. CAA refers to gradual dose reduction in chart. Further stated resident is being closely monitored for adverse reactions and ill effects of medication. Review of pharmacy recommendations for Resident #118 dated 08/06/21 revealed a recommendation for the reduction of [MEDICATION(S)] 40 milligrams (mg) one time a day to [MEDICATION(S)] 20 mg one time a day. Review of physician recommendations for Resident #118 dated 08/06/21 revealed the physician agreed with the pharmacy recommendations to decrease [MEDICATION(S)] 40 mg daily to [MEDICATION(S)] 20 mg daily. The physician signed the document 08/10/21. Review of physician orders for Resident #118 revealed an order dated 08/05/21 [MEDICATION(S)] oral tablet 40 mg one time a day related to major depressive disorder Review of the medication Administration record for August 2021 for Resident #118 revealed the resident received [MEDICATION(S)] 40 mg daily since 08/05/21. Interview on 08/19/21 11:24 A.M. with Registered Nurse (RN) #4 verified Resident #118's [MEDICATION(S)] should have been decreased when the physician order was returned on 08/10/21 on the pharmacy recommendation was received Review of facility policy titled Pharmacy Formulary, dated 09/04/16, revealed medication orders will be transmitted to the pharmacy by a facsimile copy of the practitioner orders as soon as possible after it is written.

Based on medical record review, staff and hospital staff interview, observations and facility policy review, the facility failed to ensure a resident was free from unnecessary medications when the staff failed to monitor lab levels as ordered. This affected two (#118 and #125) of five residents reviewed for medication monitoring. The facility census was 36. Findings included: 1. Medical record review for Resident #118 revealed an admitted on 08/04/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #118 revealed an impaired cognition. Resident required supervision for bed mobility, limited assist for transfers and toileting and supervision for eating. Resident was coded as receiving anticoagulant medication all seven days of the look back period. Review of the plan of care for Resident #118 dated 08/06/21 revealed resident was at risk for adverse effects of medication due to anticoagulants usage. Interventions included avoid massaging legs, handle resident carefully to avoid bruising, monitor for deep vein thromboses, localized heat redness and pain, obtained laboratory tests as ordered. Review of active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of laboratory results for Resident #118 contained no documentation for laboratory tests conducted on 08/17/21 as ordered. Observation on 08/18/21 at 9:51 A.M. of Resident #118 revealed multiple small areas of varying degree of blue and black discolorations on right arm. Interview on 08/18/21 at 2:42 P.M. with hospital laboratory staff #70 stated the facility staff input the laboratory tests to be collected into an electronic web-based system. Laboratory Staff #70 verified no laboratory tests were placed into the system for Resident #118 for 08/17/21, further stated the laboratory did not miss the test as it was not ordered for us to draw the blood sample. Interview on 08/19/21 10:53 A.M. with Registered Nurse (RN) #4 verified the INR was not collected on the 08/17/21 as it should was ordered. Interview with Director of Nursing on 08/19/21 at 3:30 P.M. stated the laboratory test for Resident #118's INR was missed on 08/17/21 when the lab came to draw the samples that morning. 2. Medical record review for Resident #125 revealed an admitted on 08/05/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE] revealed the resident had intact cognition. Resident #125 required extensive assist of two staff members for bed mobility, transfers, and toileting. Resident requires supervision for eating. Resident was coded as receiving anticoagulants for three days during the look back period. Review of the plan of care for Resident #125 dated 08/06/21 revealed resident was at risk for adverse effects of medication due to anticoagulants usage. Intervention included avoid massaging legs, handle resident carefully to avoid bruising, monitor for deep vein thromboses, localized heat redness and pain, obtained laboratory tests as ordered. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of laboratory results for Monday 08/09/21 for Resident #125 contained no documentation for completion of ordered laboratory tests as ordered. Review of nursing progress notes' dated 08/10/21 at 6:11 P.M. for Resident #125 revealed an order to hold [MEDICATION(S)], INR 3.3 today, repeat daily INR until resident is Therapeutic between 2.0 and 3.0 and report changes to physician or nurse practitioner. Review of [MEDICATION(S)] Flow sheet for Resident #125 revealed an entry dated 08/06/21 indicating the next INR was scheduled on 08/09/21. Handwritten in the edge of the document near the date 08/09/21 with the initials belonging to RN #17 stated unavailable. The next line on the document was dated 08/10/19 indicating an INR was collected and continued to be abnormal. Review of hospital laboratory documents dated 08/09/21 revealed Resident #125 was not listed on the schedule for blood collection for an INR on 08/09/21. Interview with 08/18/21 at 2:42 P.M. with hospital laboratory staff #70 stated the facility staff input the laboratory that we draw into an electronic web-based system. Laboratory Staff #70 verified no laboratory tests were placed into the system for Resident #125 for 08/09/21, further stated the laboratory did not miss the test as it was not ordered for us to draw the blood sample. Interview on 08/19/21 at 3:19 P.M. with Registered Nurse (RN) #17 stated she called the nurse schedule on 08/17/21 and was told the laboratory did not have enough blood to complete the INR on 08/09/21. Interview on 08/19/21 at 4:04 P.M. with RN #75 (working on 08/17/21) stated she was not able to confirm an INR was collected for Resident #125 or if it was for another resident on 08/09/21. RN #75 was not able to recall the laboratory staff notifying RN of the lack of blood needed to complete the INR as ordered. Review of facility policy titled Laboratory, Radiology and other Diagnostic, dated 11/28/16, revealed the facility failed to implement the policy in regards to the allegation. Letter A states the facility is responsible for the quality and timeliness of the services.

Based on record review, observation, staff and resident interview, and review of facility policy, the facility failed to administer insulin as ordered by the physician resulting in a significant medication error. This affected one (#175) of three residents reviewed for medication administration. The census was 36. Findings include: Review of record for Resident #175 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the mental status evaluation for Resident #175 dated 08/10/21 revealed resident was cognitively intact. Review of the care plan for Resident #175 dated 08/12/21 revealed resident had unstable blood glucose levels. Intervention included: administer medications as prescribed, educate resident/representative on preparation and administration of insulin injection, educate resident/representative regarding fluid & dietary restrictions, educate resident/ representative regarding prescribed treatment plan to manage blood sugars, evaluate blood glucose level per ordered frequency, monitor for signs/symptoms of [CONDITION(S)], [CONDITION(S)], monitor medication effectiveness for management of blood glucose level. Review of the August 2021 physician orders for Resident #175 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] = three units; 201 to 250 = four units; 251 to 300 = six units; 301 to 350 = 12 units; 351 to 400 = 15 units; 401 to 450 = 18 units, subcutaneously before meals related to DM. Review of the breakfast tray ticket for Resident #175 dated 08/18/21 revealed resident was served a tray in her room, a low fat/low cholesterol regular texture diet. Observation on 08/18/21 at 8:15 A.M. revealed Licensed Practical Nurse (LPN) #55 obtained Resident #175's blood sugar and it was 496. LPN #55 administered 18 units of insulin per sliding scale to resident. Interview on 08/18/21 at 8:15 A.M. with Resident #175 confirmed she was served breakfast at approximately 7:45 A.M. and was supposed to have her blood sugar taken and insulin administered before breakfast. Interview on 08/18/21 at 8:20 A.M. with LPN #55 confirmed Resident #175's blood sugar was 496 on 08/18/21 at approximately 8:15 A.M. LPN #55 further confirmed the resident's physician had ordered for insulin to be administered per sliding scale before meals and blood sugar was obtained and insulin administered after resident had already consumed breakfast. Review of the facility policy titled Administration of Medications dated 02/01/21 revealed medications were to be given at the time ordered and as directed by the physician.

Based on record review, observation, staff interview, review of facility policy, and review of online resources per the Centers for Disease Control (CDC) and the Center for Medicare and Medicaid Services (CMS), the facility failed to ensure staff wore appropriate eye protection to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). Additionally, the facility failed to ensure staff used proper infection control practices during medication administration. This affected one (#175) of three residents observed for medication administration. The census was 36. Findings include: Review of the medical record for Resident #175 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician orders for Resident #175 revealed an order dated 08/10/21 for [MEDICATION(S)] extended release 120 milligram (mg) capsule by mouth. Observation on 08/18/21 at 7:50 A.M. revealed Licensed Practical Nurse (LPN) #55 prepared and administered medications to Resident #175. LPN #55 was not wearing eye protection. LPN #55 opened resident's [MEDICATION(S)] capsule and it dropped on the top of the medication cart. LPN #55 picked up [MEDICATION(S)] capsule with her bare hands and dropped it in the cup for administration to the resident. Interview on 08/18/21 at 8:20 A.M. with LPN #55 confirmed she was not wearing eye protection during medication administration to Resident #175 and further confirmed she touched Resident #175's medication with her bare hand prior to preparing for administration. Interview on 08/18/21 at 2:59 P.M. with Registered Nurse (RN) #60, the facility's Infection Preventionist (IP) confirmed based on the current positivity rate of COVID-19 for the county in which the facility is situated, all staff should wear eye protection at all times in resident areas. Review of facility policy titled Administration of Medications dated 02/01/21 revealed tablets and capsules should be handled so that the fingers do not touch the medication. Review of the facility policy titled COVID-19 Preparedness Response and Plan dated 07/23/20 revealed in times of sustained community transmission (county positivity rate is over five percent), face shield or lab style goggles must be worn in all resident care areas. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data-Test-Positivity-Rates/q5r5-gjyu/ revealed the county in which the facility was situated was experiencing a moderate spread of COVID 19 with a positivity rate of 8.7 percent and was identified as a color of yellow for the week ending in 08/10/21. Review of an online resource per the CDC 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.

Based on resident and staff interviews, observations and review of facility policy, the facility failed to post the results of the most recent survey and ensure residents were made aware of the availability of survey results. This had the potential to affect all 36 residents residing in the facility. The census was 36. Findings include: Interviews on 08/18/21 at 10:21 A.M. with Resident #119 and at 10:38 A.M. with Resident #120 confirmed they were not aware of the availability of recent survey results. Observation on 08/18/21 at 10:40 A.M. with Activity Director (AD) #2 revealed the facility had survey binders in the common area of the facility but they did not include the results of all recent surveys since the facility's last standard survey in 2019. Interview on 08/18/21 at 10:46 A.M. with the Director of Nursing (DON) confirmed the survey binder did not include the results of all recent surveys since the facility's last standard survey in 2019. Review of facility policy titled Residents' Rights dated 10/01/20 revealed the facility should post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility and post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.

Based on observations and staff interview, the facility failed to post the daily staffing in the facility. This had the potential to affect all residents residing in the facility. The census was 36. Findings include: Observation on 08/18/21 at 10:45 A.M. of the daily staffing posting for the Coast and Prairie units revealed the staffing posting was dated 08/16/21. Interview on 08/18/21 at 10:45 A.M. with Registered Nurse (RN) #50 confirmed the daily staffing posting for the Coast and Prairie unit did not reflect the correct date. Observation on 08/18/21 at 10:50 A.M. of the daily staffing posting for the Mountain and Forest units revealed there was no daily staffing posting for that side of the facility. Interview on 08/18/21 at 10:50 A.M. with State tested Nursing Assistant (STNA) #7 confirmed there was no daily staffing posting in the holder where the posting should be displayed.

Based on medical record review, staff and resident representative (RR) interview, review of hospital records, review of a facility investigation report, review of medication error log, review of a vaccination card, review of facility policy and review of an online resource regarding Coronavirus Disease 2019 (COVID-19) vaccine errors, the facility failed to ensure a COVID-19 vaccine was administered to the correct resident resulting in a resident receiving a third dose of the vaccine and a significant medication error. This resulted in actual harm when Resident #29 began having side effects after receiving the third dose of the COVID-19 vaccine and was subsequently admitted to the hospital with an [CONDITION(S)] reaction. This affected one (#29) of three residents sampled. The census was 31. Findings include: Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #29 dated 02/02/21 revealed resident was cognitively impaired and required limited assistance of one staff with activities of daily living (ADL's). Review of the immunization record for Resident #29 revealed the resident had a COVID-19 vaccine on 01/22/21 in the community prior to his admission, and two additional separate COVID-19 vaccines on 02/25/21 for a total of three COVID-19 vaccines. Review of February 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. on 02/25/21 at the county fairgrounds vaccination site. Review of nurse progress note for Resident #29 dated 02/25/21 identified as a late entry, per Licensed Practical Nurse (LPN) #110 revealed the resident had signs and symptoms of respiratory distress, with an oxygen saturation level of 85 percent (%), a body temperature of 102.2 degrees Fahrenheit (F), and resident verbalized complaints of not feeling well and exhibited difficulty breathing. Further review of note revealed resident had a second dose of the COVID-19 vaccine earlier in the day and the physician gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurse progress note dated 02/25/21 identified as a late entry, per the Director of Nursing (DON) revealed the facility called the hospital to confirm a paramedic from the city where the facility is situated entered Resident #29's room on 02/25/21 and administered a COVID-19 vaccine to the resident. Further review of note revealed hospital staff removed Resident #29's facility identification bracelet used by the facility for medication administration upon resident's entry in the emergency department. Review of the nurse progress note dated 02/26/21 for Resident #29 revealed the resident was admitted to hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse progress note dated 02/26/21 for Resident #29 revealed the facility completed a report to the Vaccine Adverse Events Reporting System regarding resident's possible reaction to Moderna vaccine on 02/25/21. Review of the medical record for Resident #33 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the immunization record for Resident #33 revealed no record of resident receiving COVID-19 vaccine prior to admission or during stay at the facility. Review of the record for Resident #33 revealed he had the same first name as Resident #29. Further review of the hospital records for Resident #29 dated 02/25/21 at 6:47 P.M. revealed the record included a COVID-19 vaccine card with vaccinations recorded on 01/22/21 and 02/25/21 with Resident #33's full name and Resident #33's date of birth at the top of the card. Further review of the hospital records revealed Resident #29 received the second dose of the COVID-19 vaccine twice on 02/25/21. Resident #29 had the second dose at the county fairgrounds on 02/25/21 and later when resident returned to facility, he was given an additional dose of the vaccine by local fire department (two doses of vaccine in one day). Review of hospital record revealed resident was admitted due to an acute on chronic CHF/exacerbation of CHF, had multiple comorbidities, and had a possible adverse reaction to the COVID-19 vaccine. Review of the hospital records revealed Resident #29 caregiver states that this occurred similarly on his first vaccination. Resident #29 had a positive COVID-19 test three weeks ago. Review of hospital triage nurse note for Resident #29 dated 02/25/21 timed at 6:50 P.M. revealed resident arrived to the hospital per emergency medical service (EMS) for complaints of shortness of breath, EMS reported a fever of 103.0 degrees F, and possible concern due to receiving two doses of the second dose of the COVID-19 vaccine on 02/25/21. Review of hospital admission note for Resident #29 dated 02/25/21 timed at 7:28 P.M. revealed resident was brought to the hospital emergency room by emergency medical service (EMS) for complaints of shortness of breath, fever, and difficulty breathing following receiving COVID-19 vaccine. Further review of note revealed Resident #29 was admitted to the hospital with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital nurse progress note for Resident #29 dated 02/26/21 revealed RR #130 notified hospital staff that resident received the second dose of the COVID-19 vaccine twice. RR #130 set up second dose to be received at county fairgrounds on 02/25/21 in the morning and when resident returned to facility, he was given another dose of the COVID-19 vaccine by local fire department. Review of hospital cardiologist's progress note for Resident #29 dated 02/28/21 revealed the resident presented with shortness of breath after the COVID-19 vaccine and was later found to have volume overload and [CONDITION(S)] reaction after second COVID vaccine. Review of hospital internal medicine physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of note revealed resident was treated with an intravenous (IV) diuretic for fluid overload likely triggered by reaction from COVID-19 vaccine. Review of note revealed Resident #29's troponin level (blood test in which elevated levels can indicate stress or injury to the heart muscle) was elevated likely due to an [CONDITION(S)] reaction to the vaccine, resident had acute respiratory failure required oxygen therapy and had a fever which was also attributed to the vaccine. Interview on 03/05/21 at 12:40 P.M. with the Director of Nursing (DON) confirmed the facility had COVID-19 vaccine clinics administered per an outside pharmacy on the following dates: 12/21/20, 01/11/21, and 02/01/21. The DON further confirmed some residents chose to go outside to the county fairgrounds to be vaccinated, and some residents received vaccines per the local fire department coming into the facility to vaccinate residents. Interview on 03/05/21 at 3:45 P.M. with the Administrator and the DON confirmed Resident #29 received a second dose of the COVID-19 vaccine at approximately 11:30 A.M. on 02/25/21 at the county fairgrounds with transportation provided by the facility. Interview confirmed facility cameras showed Paramedic #120 from the local fire department entered the facility through a locked side entrance at approximately 3:30 P.M. on 02/25/21 and was permitted entrance to the facility per Registered Nurse (RN) #100. Interview confirmed cameras showed Paramedic #120 was not screened and was led to Resident #29's room per RN #100, paramedic was in the facility for a total of nine minutes and did not stop by the nurse's station, and RN #100 left the area after leading paramedic to Resident #29's room. Interview confirmed RN #100 was a nurse manager for the facility and was not the nurse assigned to Resident #29's care on 02/25/21. Resident #29's nurse was Licensed Practical Nurse (LPN) #110, but she was not seen in the area while the paramedic was in the building. Interview on 03/05/21 at 4:04 P.M. with LPN #110 confirmed Resident #29 went to the county fairgrounds on 02/25/21 transported by the facility. LPN #110 confirmed she found the resident in respiratory distress in the afternoon, notified the physician, and obtained an order to send resident to the hospital. LPN #110 confirmed she saw a COVID -19 vaccine card hanging in Resident #29's room on 02/25/21 but she did not inspect it closely to confirm the name on the top of the card. LPN #110 confirmed she had no knowledge at the time of Resident #29's transfer to the hospital of him receiving a dose of the COVID-19 vaccine per Paramedic #120 in the afternoon on 02/25/21. LPN #110 confirmed Resident #29 told the emergency personnel as he was being transferred to the hospital, he had received two COVID-19 vaccines on 02/25/21. Interview on 03/05/21 at 4:19 PM with RN #100 confirmed Paramedic #120 came to a locked side door on 02/25/21 at approximately 3:30 P.M. RN #100 confirmed Paramedic #120 said he had a vaccine for a resident, and he gave the first name of Resident #29 and Resident #33. RN #100 asked if the vaccine was intended for Resident #29 giving resident's first and last name. Paramedic #120 verbally confirmed the vaccine was for Resident #29 and RN #100 permitted paramedic entrance to the facility. RN #100 confirmed the conversation with Paramedic #120 occurred through a closed glass entry door. RN #100 stated there was no further conversation to verify Resident #29's identity was correct upon allowing Paramedic #120 into the facility. RN #100 stated she then led Paramedic #120 to Resident #29's room and left the area. RN #100 confirmed Paramedic #120 was not screened for signs or symptoms of COVID-19 and he did not stop at the nurses' station. RN #100 confirmed she did not notify LPN #110, Resident #29's nurse, Paramedic #120 had entered the facility to give a vaccine to Resident #29. RN #100 confirmed she did not return to Resident #29's room until LPN #110 alerted her resident was having respiratory distress and was going to the hospital. RN #100 confirmed she gave the COVID-19 vaccine card hanging in the resident's room to emergency personnel but did not inspect it closely to read the name on the top of the card. RN #100 confirmed Resident #29 told emergency personnel he received two doses of the COVID-19 vaccine on 02/25/21. Interview on 03/16/21 at 1:00 P.M. with RR #130 confirmed she arranged for Resident #29 to receive a second dose of the COVID-19 vaccine at the county fairgrounds with the facility providing transportation on 02/25/21. RR #130 further confirmed she spoke on the phone to Resident #29 on 02/25/21 at 1:30 P.M. approximately two hours after the resident had received the vaccine at the fairgrounds and confirmed resident complained of no adverse side effects. Interview on 03/16/21 at 1:26 P.M. with the DON confirmed Resident #29 was transported to the county fairgrounds at 11:30 A.M. on 02/25/21 per Driver #160. The DON further confirmed Driver #160 reported Resident #29 stayed at the fairgrounds for 15 minutes following the vaccine for monitoring. Driver #160 reported Resident #29 exhibited no adverse signs and symptoms during transport back to the facility. The DON confirmed the facility's internal investigation revealed Resident #29 exhibited no adverse signs and symptoms until approximately 6:30 P.M. on 02/25/21. Interview on 03/16/21 at 3:36 P.M. with RR #140 confirmed she took Resident #29's vaccine card to the facility approximately a week before the resident was to receive his second dose of the Moderna vaccine at 11:30 A.M. on 02/25/21 at the county fairgrounds. RR #140 confirmed when she brought the card to the facility the card indicated the resident had received one dose of the Moderna vaccine on 01/22/21. Further interview revealed RR #140 had sat at the hospital with Resident #29 on the evening of 02/25/21 and had located Resident #29's vaccine card a few days later when going through his belongings. RR #140 confirmed at that time the vaccine card showed Resident #29 had a second dose of the Moderna vaccine on 02/25/21. RR #140 confirmed she also took a photograph of the vaccine card in case it was misplaced. Review of a COVID-19 vaccination card revealed the vaccine card contained Resident #29's first and last name, correct date of birth, and documentation of administration of two Moderna vaccines, one on 01/22/21 and the other on 02/25/21. Review of the facility Medication Error log for January 2021 through February 2021 revealed there was a medication error on 02/25/21 for Resident #29. Review of the facility internal investigation initiated on 02/25/21 revealed the following timeline of events on 02/25/21 confirmed per facility camera footage: 3:44 P.M. Paramedic #120 is allowed into facility per RN #100; 3:45 P.M. Paramedic #120 enters Resident #29's room and RN #100 leaves the area; 3:54 .P.M. Paramedic #120 exits Resident #29's room; 3:59 P.M. Paramedic #120 exits the facility assisted by a therapy staff person. Further review of the facility investigation revealed on 02/25/21 at approximately 6:20 P.M. LPN #110 and RN #120 discover Resident #29 in respiratory distress and call EMS to take resident to the hospital. Review of facility document undated titled Medication Administration Competency revealed prior to administration of a medication the resident's identity should be verified and the label on the medication should be compared to the prescriber's order. Review of facility policy titled External Parties Administering Treatments or Medications in the Facility dated 03/01/21 revealed upon notification of an outside party entering facility to administer treatments or medications, the nurse manager will require external parties to provide work identification to verify their identity and will verify practitioner orders were in the resident's record for the treatment or medication. Further review of the policy revealed the nurse would accompany the individual to the room to witness to the identification process. Two identifiers, first and last name and date of birth, should be verified by the external administering party prior to the treatment or medication administration. Review of an online resource titled Learning from Errors with the New COVID-19 Vaccines dated 01/14/21 at https://ismp.org/ revealed there had been no reported errors of overdose with the Moderna vaccine which does not require dilution prior to administration but stronger adverse reactions had been reported with the Pfizer vaccine which does require dilution prior to administration. Further review of the resource revealed the addition of an insufficient amount of dilutant to a vaccine could possibly invoke stronger adverse effects due to an increased amount of the vaccine being administered. This deficiency substantiates Complaint Number OH 538.