Every finding on record at Kenton Nursing and Rehabilitation Center

Based on observations, resident and staff interviews, and policy review, the facility failed to maintain comfortable temperatures throughout the building for Residents #2, #5, #24, #28 and #47. The facility census was 91.Findings include:Observation and interview on 05/05/26 at 2:27 P.M. revealed Residents #5, #24, and #28 were complaining it was cold in the dining area. Maintenance #166 checked the room temperature of the dining area with a digital thermometer with a result of 64.1 degrees Fahrenheit (F). Maintenance #166 verified the dining area's room temperature was 64.1 F. Interviews with Residents #5, #24, and #28 revealed all three residents were cold, even with two layers of clothing on in the dining area. Resident #5 was wearing a coat as well.Interview on 05/07/26 at 8:04 A.M. revealed Resident #47 stopped this surveyor and Director of Nursing (DON) stating the facility was so cold. Resident #47 was in the entry common area with a sweater on and a blanket.Observations and interview on 05/07/26 from 9:00 A.M. to 9:25 A.M. with the Administrator revealed room temperatures were obtained with the following results: the entry common area was at 67.5 degrees F, conference room was at 65.7 degrees F, lobby area was at 69.8 degrees F, service hall with entry to the dining room and activities was at 67.1 degrees F, 300 and 400 hallway common area was at 69 degrees F (Wall thermostat showed area at 69 degrees F with heat on at 73 degrees F), 400 hallway was at 68.4 degrees F, 200 common area was at 68.5 degrees F, 100 hallway was at 68.5 degrees F, and 100 hallway common area was at 70 degrees F. The Administrator confirmed the facility was not maintaining comfortable temperatures between 71 degrees to 81 degrees F. The current weather was cloudy at 41 degrees F.Interview on 05/07/26 at 9:21 A.M. revealed Resident #2 was cold in the entry common area with a sweater and two blankets in place.Interview on 05/07/26 at 10:16 A.M. revealed Licensed Practical Nurse (LPN) #161 was cold and unable to get warm. LPN #161 was in the 200 common area.Review of the facility policy titled, Quality of Life - Homelike Environment, revealed residents were to be provided with a safe, clean, comfortable, and homelike environment. This deficiency represents non-compliance investigated under Complaint Number 2986430.

Based on observations and staff interview, the facility failed to ensure the walls in resident rooms were maintained in a functional and comfortable manner. This affected five (#2, #8, #41, #50, and #82) of 25 residents reviewed for physical environment. The facility census was 91.Findings include:Observation on 05/06/26 at 2:30 P.M. of Resident #2's room revealed pieces of drywall missing from the wall which appeared clawed out by the resident.Observation on 05/06/26 at 2:32 P.M. of Resident #41's room revealed scrapes up and down the wall consistent with damage from the bed being repeatedly raised and lowered against the wall.Observation on 05/06/26 at 2:33 P.M. of Resident #8's room revealed pieces of drywall coming off the wall behind the resident's chair.Observation on 05/06/26 at 2:34 P.M. of Resident #82's room revealed wallpaper torn off the wall.Observation on 05/06/26 at 2:35 P.M. of Resident #50's room revealed drywall missing from the wall beside the resident's bed.Interview on 05/06/26 at 2:46 P.M. with Maintenance Director #166 confirmed the drywall and wallpaper damage identified in Resident #2, #41, #8, #82 and #50's rooms. Maintenance Director #166 stated the facility was aware some beds were positioned too close to the walls causing wall damage and confirmed the facility was working on implementing spacers to prevent additional damage but the spacers had not been implemented at the time of the observation.This deficiency represents non-compliance investigated under Complaint Number 2986430.

Based on record review, staff interviews, and policy review, the facility failed to ensure that Pre-admission Screening and Resident Review (PASARR) were updated when residents received new mental health diagnoses. This affected four (#3, #11, #14 and #87) of five residents reviewed for PASARRs. The facility census was 91.Findings include:1. Review of the medical record for Resident #3 revealed an admission date of 09/16/25. Diagnoses included post-traumatic stress disorder (PTSD) (10/30/25) and bipolar disorder (09/16/25).Review of the PASARR dated 09/05/25 revealed Resident #3 did not have any diagnoses of any mental disorders. Interview on 05/06/26 at 1:13 P.M. with Social Work Designee (SWD) #144 verified Resident #3 did not have the appropriate PASARR completed. SWD #144 confirmed Resident #3 had newly diagnosed mental health diagnoses which should have triggered completion of a new PASARR.2. Review of the medical record for Resident #87 revealed an admission date of 12/01/23. Diagnoses included post-traumatic stress disorder (PTSD) (01/14/25), bipolar disorder (03/19/24) , major depressive disorder (01/19/23), borderline personality disorder (03/27/24), anxiety disorder (02/05/23), and bipolar two disorder (10/03/23).Review of the physician orders revealed orders included for Depakote sprinkles 125 milligrams (mg) four capsules three times a day, hydroxyzine 25 mg daily, Risperdal one mg twice daily for schizoaffective disorder, and trazodone 50 mg daily.Review of the PASARR dated 12/01/23 revealed no diagnoses of any mental disorders and stated Resident #87 was not taking any psychotropic medication.Interview on 05/06/26 at 1:13 P.M. with Social Work Designee (SWD) #144 verified Resident #87 did not have the appropriate PASARR completed. SWD #144 confirmed Resident #87 had newly diagnosed mental health diagnoses which should have triggered completion of a new PASARR.3. Review of the medical record for Resident #11 revealed an admission date of 06/18/09 with re-entry on 12/18/23. Diagnoses included schizoaffective disorder, bipolar disorder, paranoid schizophrenia, panic disorder, anxiety disorder, and hallucinations.Review of ViaQuest documentation revealed Resident #11 was involuntarily hospitalized ( pink slipped) on 07/14/2025 due to acute psychosis with paranoid and grandiose delusions, impaired insight and judgment, refusal of psychiatric medications, and behaviors creating a grave and imminent risk to self or others. Review of the PASARR provided by the Director of Nursing (DON) on 05/06/26 at 8:27 A.M. verified the only PASARR completed for Resident #11 was the original PASARR completed in 2009. The PASARR dated 2009 did not include newly mental health diagnoses including schizoaffective disorder, bipolar type dated 12/18/23 and manic episode dated 05/17/24. There was no updated PASARR in Resident #11's medical record.Interview on 05/06/2026 at 1:03 P.M. with Social Worker Designee (SWD) #144, revealed Resident #11 did not have the appropriate PASARR completed. SWD #144 confirmed the resident had newly diagnosed mental health diagnoses which should have triggered completion of a new PASARR. 4. Review of the medical record for Resident #14 revealed an admission date of 08/02/22 with re-entry on 10/28/22. Diagnoses included schizoaffective disorder, bipolar type, major depressive disorder with psychotic symptoms, and hallucinations.Review of the PASARR provided by the Director of Nursing (DON) on 05/06/26 at 8:28 A.M. verified the only PASARR completed for Resident #14 was the original PASARR completed in 2022. The PASARR dated 2022 did not include newly diagnoses schizoaffective disorder, bipolar type dated 04/23/25. There was no updated PASARR in Resident #14's medical record. Interview on 05/06/26 at 1:03 P.M. with SWD #144, revealed Resident #14 did not have the appropriate PASARR completed. SWD #144 confirmed the resident had newly diagnosed mental health diagnoses which should have triggered completion of a new PASARR.Review of the facility policy titled, PASRR Statutes, revealed that nursing facilities must promptly notify the State mental health authority or State developmental disability authority after a significant change in a resident's physical or mental condition, including new mental health diagnoses for residents who are mentally ill or intellectually disabled. A new PASRR assessment and determination is required promptly upon such notification to evaluate whether the resident requires the level of services provided by a nursing facility or specialized services for mental illness. Failure to complete the required review can result in denial of Medicaid payment for nursing facility services.

Based on record review, staff interview, and policy review, the facility failed to ensure a level two Pre-admission Assessment and Resident Review (PASARR) was completed for Resident #3. This affected one (#3) of five residents reviewed for PASARR. The facility census was 91.Findings include:Review of the medical record for Resident #3 revealed an admission date of 09/16/25. Diagnoses included post-traumatic stress disorder (PTSD) and bipolar disorder.Review of the PASARR dated 09/05/25 revealed Resident #3 did not have any diagnoses of any mental disorders. Resident was taking antidepressants and antianxiety medications, had an intellectual disability than manifested before the individual's 22nd birthday, and was likely to continue indefinitely. The individual has indications of substantial functional impairments in any of the major life activity areas. The individual currently receives, or they have previously received services from a county board of developmental disability (DD). The individual has indications of DD. Level 2 evaluation was recommended. There was no Level two evaluation in Resident #3's medical record.Interview on 05/06/26 at 1:13 P.M. with Social Work Designee (SWD) #144 verified Resident #3 did not have a level two PASARR determination completed that the facility could locate. Review of the policy undated titled PASRR Statutes revealed long term residents not requiring nursing facility services, but requiring specialized services for mental illness or [intellectual disability], and who has continuously a resident in a nursing facility for at least 30 months before the date of determination, the state must, in consultation with the resident's family or representative and care givers inform the resident of the institutional and noninstitutional alternatives covered under the state plan for the resident, offer the resident the choice of remaining in the facility or of receiving covered services in an alternative appropriate institutional or noninstitutional setting, clarify the effect on eligibility for services under the state plan if the resident chooses to leave the facility (including its effect on readmission to the facility), and regardless of the residents choice, provide for or arrange for the provision of such specialized services for the mental illness or [intellectual disability].

Based on observations, record reviews, resident and staff interviews, and policy review, the facility failed to ensure the residents right to privacy was maintained. This affected two (#25 and #82) of two residents reviewed for privacy. The facility census was 91.Findings include:1. Review of medical record for Resident #82 revealed an admission date of 01/16/26. Diagnoses included cerebral palsy, severe intellectual disabilities, blindness right and left eye category three, and restlessness and agitation.Review of the care plan dated 01/16/26 revealed Resident #82 had a behavior problem including pinching, scratching, grabbing at staff, pulls on his own genitals, hits walls and wheelchair, removes clothes and briefs, plays in bowel movements, moans and yells, refuses to eat meals and fluids, pulls and claws at electrical outlets, pulls call light cord out of wall, and crawls around on the floor to play related to developmental disabilities. Interventions included caregivers to provide for positive interaction, attention, stop and talk with the resident as passing by, and explain all procedures before starting and intervene as necessary.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had severe cognitive impairment. Resident #82 was dependent on staff for all activities of daily living.Observation on 05/04/26 at 9:19 A.M. revealed Resident #82 was lying on the floor on a black mat with no clothes on. Resident #82's door was open and the resident was visible from the hallway. Resident #82 was moaning and yelling out. Three residents were observed at the tables across the hall from the residents' room.Observation on 05/05/26 at 2:59 P.M. revealed Resident #82 was lying naked on the floor in the fetal position with door open, no curtain drawn and a resident in the doorway watching him. Resident #82's testicles were exposed to a resident sitting in a wheelchair in the doorway watching the resident for approximately five minutes.Observation on 05/06/26 at 8:24 A.M. revealed Resident #82 was in his room moaning. Resident #82 was observed lying on the black mat on the floor naked with genitals exposed. No residents were observed in the hallway at the time. Door to room was open and the resident was visible from the hallway.Observation and Interview on 05/05/26 at 3:00 P.M. with Registered Nurse (RN) #111 revealed Resident #82 typically lays on the floor. RN #111 observed going into the room and stating yeah and closed the door and covered the resident with a blanket before opening the door. RN #111 stated the staff would round every time they pass the room but could not give an exact time of how often but stating they round at least every two hours. N #111 verified there was a resident sitting watching Resident #82 while she was sitting at the nursing station across from the resident's room and did not redirect or close the curtain.Interview on 05/06/26 at 8:30 A.M. with Certified Nursing Assistant (CNA) #191 revealed Resident #82 was often removing his clothes and briefs. CNA #191 stated it was hard to keep Resident #82 covered. CNA #191 verified Resident #82 was visible from the hallway and anyone who walks past his room could see him naked.2. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included sequel dislocated left hip, neuromuscular dysfunction of bladder, and paraplegia.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition. Resident #6 was dependent on staff with toileting, bathing and dressing and had a indwelling catheter in place.Review of the care plan dated 02/20/26 revealed Resident #6 had a behavior problem and refuses to get out of bed. Observation on 05/04/26 at 9:49 A.M. revealed Resident #25 lying in bed A, her legs were spread open, indwelling catheter in place and bag hanging on the bedrail, brief in place, and shirt pulled up to breast. The door was opened all the way with no privacy curtain pulled and was visible from the hallway.Interview on 05/04/26 at 9:49 A.M. with Resident #25 revealed Resident #25 would prefer the door to be open but the privacy curtain pulled halfway at all times so no one in the hallways could see her.Interview on 05/04/26 at 9:52 A.M. with License Practical Nurse (LPN) #132 verified Resident #25's door was open and privacy curtain was not pulled and Resident #25 was exposed to everyone passing by her room.Interview on 05/07/26 at 10:05 A.M. with Director of Nursing (DON) revealed a signed paper from the Social Services #144 stating Resident #26 does not want her door closed or curtains pulled due to claustrophobic.Interview on 05/07/25 at 10:45 A.M. with Resident #25 revealed Resident #25 does not want her door closed or the curtain pulled all around her. Resident #25 would like the curtain to be pull so no one in the hallway was able to see her.Review of the facility's policy titled Resident Rights, revised December 2016, revealed residents have the right to privacy and confidentiality.

Based on record review, staff interview, and policy review, the facility failed to ensure Resident #7 had a discharge plan of care. This affected one (#7) of 25 residents reviewed for care plans. The facility census was 91.Findings include:Review of the medical record for Resident #7 revealed an admission date of 04/06/24 with diagnoses including osteoarthritis of right and left knee, bipolar disorder, and chronic kidney disease stage 3B.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact.Review of the care plan dated 03/17/25 revealed there was no care plan addressing discharge plan or goals.Interview on 05/04/26 at 9:30 A.M. with Resident #7 revealed the facility had not discussed any discharge planning with her.Interview on 05/07/26 at 10:14 A.M. with MDS Nurse #161 verified there was no discharge plan of care for Resident #7.Review of the policy titled Care Plans, Comprehensive Person-Centered revised March 2022 revealed the comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, which included the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.

Based on record reviews, staff interviews, observations, and policy review, the facility failed to ensure residents who were at risk for falls had the care planned fall interventions in place. This affected two (#29 and #82) of three residents reviewed for falls. The facility census was 91.Findings include:1. Review of the medical record for Resident #29 revealed an admission date of 02/12/26. Diagnoses included fracture of left femur, psychosis, anxiety, repeated falls, restlessness and agitation, and irritability and anger. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had moderately impaired cognition and had no behaviors during the seven day look back period.Review of Resident #29's physician orders dated 02/12/26 revealed an order to place dycem (non-slip material used to secure objects) to wheelchair every shift for fall prevention.Review of the care plan dated 04/19/26 revealed Resident #29 was at risk for falls related to history of falls, poor balance, seizure disorder, and decreased safety awareness. Interventions included dycem to wheelchair. Observation on 05/06/26 at 8:15 A.M. revealed Resident #29 was lying in bed sleeping. A wheelchair was observed beside the resident's bed with no dycem in the wheelchair.Observation on 05/06/26 at 11:09 A.M. revealed Resident #29 was sitting in her wheelchair in the front common area with his feet elevated on his wheelchair. There was no dycem observed in the wheelchair.Interview on 05/06/26 at 11:10 A.M. with Activities Personnel #138 verified there was no dycem in Resident #29's wheelchair.Interview on 05/06/26 at 3:44 P.M. with the Director of Nursing (DON) verified the care plan for Resident #29 indicated that dycem to the wheelchair was a fall intervention. The DON stated the resident was noncompliant and takes the dycem from the wheelchair.Interview on 05/06/26 at 4:23 P.M. with Registered Nurse (RN) #111 revealed Resident #29 was noncompliant with the dycem and will take it out of the wheelchair. RN #111 stated when Resident #21 walked with restorative therapy in the morning, the dycem was in the wheelchair.2. Review of the medical record for Resident #82 revealed an admission date of 01/16/26. Diagnoses included cerebral palsy, restlessness and agitation, severe intellectual disabilities, and convulsions.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had severe cognitive impairment and was dependent on staff for activities of daily living.Review of the care plan dated 01/16/26 revealed Resident #82 was at risk for falls related to poor balance and decreased safety awareness. Interventions included padding to be placed between the bed and wall to prevent injury to resident, right side of bed against the wall, fall mat to left side of the bed, and mattress to floor.Observation on 05/05/26 at 9:33 A.M. revealed Resident #82 was lying in bed with his face against the wall. There was no padding observed between the wall and the bed.Observation on 05/06/26 at 8:18 A.M. revealed Resident #82 was lying in bed in the fetal position. There was no padding observed between the wall and the bed.Interview on 05/06/26 at 3:47 P.M. with the Director of Nursing (DON) verified the care plan for falls included padding between the wall and bed to prevent injury. The DON verified there was no padding between the wall and the bed for Resident #82. The DON stated the padding had been ordered but had not arrived yet. The DON stated the intervention for the padding should not have been under the falls care plan and should not have been care planned until it had come in and was in place.Review of the policy titled Accidents and Supervision not dated revealed the resident's environment will remain as free of accident hazards as is possible. The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. Resident-directed approaches may include implementing specific interventions as part of the plan of care, supervising staff and residents, and facility records document the implementation of these interventions. Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new interventions.This deficiency represents noncompliance investigated under Complaint Number 2986430.

Based on record reviews, staff interviews, and facility policy review, the facility failed to identify and care plan trauma triggers and post-traumatic stress disorder (PTSD) related interventions for the residents. This affected three (Residents #3, #22, and #87) of three residents reviewed for trauma-informed care. The facility census was 91. Findings include:1. Review of the medical record for Resident #22 revealed an admission date of 04/09/26. Diagnoses included PTSD. The five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had intact cognition.Review of the Trauma Informed Care Evaluation, dated 04/10/26, revealed no indication of trauma triggers, nightmares, avoidance behaviors, or interventions related to PTSD.Review of the care plan for Resident #22 revealed no interventions, approaches, or identified triggers related to PTSD. Review further revealed the only reference to PTSD within the care plan was under nutritional risk.Review of Mental and Behavioral Health #500's documentation dated 04/30/26 revealed Resident #22 endorsed occupational trauma exposure accrued during a career as a paramedic. Documentation further revealed Resident #22 reported recurrent nightmares, avoidance of interpersonal contacts associated with triggering personality characteristics, a history of interpersonal trauma with associated nightmares, chronic hyperarousal, persistent racing thoughts, and sleep-maintenance difficulty consistent with PTSD presentation.Interview on 05/06/26 at 1:03 P.M. with Social Worker Designee (SWD) #144, revealed Resident #22 answered no to trauma questions during the trauma assessment and confirmed she was only asking yes or no questions on the trauma assessment. SWD #144 confirmed Mental and Behavioral Health #500's documentation contained information related to the resident's PTSD symptoms, trauma history, nightmares, avoidance behaviors, and hyperarousal symptoms.Interview on 05/06/26 at 2:02 P.M. with SWD #144 confirmed she had not completed any care planning related to PTSD for Resident #22 and stated MDS Nurse #135 had been handling care plans while she adjusted to the role.Interview on 05/06/26 at 2:04 P.M. with MDS Nurse #135 confirmed she had not completed care plan interventions related to PTSD for residents in the facility and confirmed Resident #22 did not have PTSD-related interventions or identified triggers included in the care plan.2. Review of the medical record for Resident #3 revealed an admission date of 09/16/25 with diagnoses including PTSD. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had moderate cognitive impairment with no behaviors.Review of Mental and Behavioral Health #500's note dated 03/12/26 revealed Resident #3 had diagnosis of PTSD due to history of incarceration with exposure to traumatic experiences. Resident #3 reported nightmares related to past trauma. Resident #3 with avoidance of certain triggers (closed places with lots of people). Resident #3 had hyperarousal symptoms such as anxiety in crowds and waking tense from nightmares. Sleep disturbances associated with trauma memories.Review of the care plan dated 03/17/26 for Resident #3 revealed there was no care plan for PTSD to include the trauma type and triggers with interventions.Interview on 05/06/26 at 2:02 P.M. with Social Worker Designee (SWD) #144 confirmed she had not completed any care planning related to PTSD for Resident #3 and stated MDS Nurse #135 had been handling care plans while she adjusted to the role.Interview on 05/06/26 at 2:04 P.M. with MDS #135 confirmed she has not completed anything related to PTSD in the care plans for any residents in the facility and confirmed Resident #3 did not have a PTSD-related care plan with interventions and identified triggers included in the care plan.3. Review of the medical record for Resident #87 revealed an admission date of 12/01/23 with diagnoses including PTSD. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was cognitively intact.Review of the care plan for Resident #87 dated 04/13/26 revealed there was no care plan for PTSD to include the trauma type and triggers with interventions.Interview on 05/05/26 at 9:28 A.M. with Resident #87 revealed the resident sees people, talks to herself, and they were raped as a child. Resident #87 denied any real triggers that they could think of currently.Interview on 05/06/26 at 2:02 P.M. with Social Worker Designee (SWD) #144 confirmed she had not completed any care planning related to PTSD for Resident #87 and stated MDS Nurse #135 had been handling care plans while she adjusted to the role.Interview on 05/06/26 at 2:04 P.M. with MDS #135 confirmed she has not completed anything related to PTSD in the care plans for any residents in the facility and confirmed Resident #87 did not have a PTSD-related care plan with interventions and identified triggers included in the care plan.Review of the policy titled Trauma Informed Care not dated revealed the facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission assessment, the history and physical, the social history/assessment, and others. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident care plan. Trauma-specific care plan interventions will recognize the interrelation between the trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery.

Based on observation, record review, staff interview, facility policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff performed proper hand hygiene when utilizing gloves and donned appropriate personal protective equipment (PPE) during high contact resident care activities for residents in enhanced barrier precautions (EBP). This affected two (#6 and #77) of three residents reviewed for infection control. The facility census was 91.Findings include:1. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included sepsis due to methicillin resistant staphylococcus aureus (MRSA), nephropathy, absence of left above knee, and diabetes mellitus type two.Review of the care plan dated 04/09/26 revealed Resident #6 required EBP related to a wound.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition.Observation on 05/04/26 at 9:09 A.M. revealed Licensed Practical Nurse (LPN) #132 was observed entering Resident #6's room to access Resident #6's peripherally inserted central catheter (PICC). LPN #132 did not perform hand hygiene prior to donning gloves. LPN #132 also did not don an isolation gown before accessing the PICC line. LPN #132 then attached a Daptomycin-Sodium Chloride intravenous solution(antibiotic) to Resident #6's PICC line, removed gloves, and did not perform hand hygiene. LPN #132 then grabbed Resident #1's medication out of the medication cart and administered the medication to Resident #1. No hand hygiene was completed.Interview on 05/04/26 at 9:09 A.M. with LPN #132 verified they forgot to place a gown on and asked the surveyor were gowns were kept. LPN #132 verified they did not perform hand hygiene prior to donning gloves for Resident #6's intravenous medication and did not perform hand hygiene after removal of gloves and prior to administering Resident #1's medications.Interview on 05/04/26 at 11:00 A.M. with Director of Nursing (DON) revealed DON thought the facility policy stated EBP were not needed for a PICC line resident.2. Review of the medical record for Resident #77 revealed an admission date of 01/20/26. Diagnoses included uninhibited neuropathic bladder, functional urinary incontinence, presence of urogenital implants, retention of urine, and neuromuscular dysfunction of bladder. Review of the current physician orders for 05/07/26 revealed an order for EBP due to an indwelling urinary catheter. Observation on 05/07/26 at 9:50 A.M. revealed Certified Nursing Aides (CNAs) #190 and #191 were going to provide catheter care for Resident #77. There was a sign on Resident #77's door starting the resident was on EBP. CNAs #190 and #191 did not don gowns when providing catheter care for Resident #77.Interviews on 05/07/26 at 10:02 A.M. with CNAs #190 and #191 verified they did not don gowns prior to providing catheter care for Resident #77. CNA #191 verified Resident #77 was in EBP and gowns should have been worn.Review of the facility's policy titled Enhanced Barrier Precautions dated 2001 revealed a resident is not known to be infected or colonized with any Multidrug-resistant Organisms (MDRO), has a wound or indwelling medical devices is to be in EBP.Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Under frequently asked question about enhanced barrier precautions in Nursing Homes, dated 06/28/24 revealed question #22 stated an example of indwelling medical device included peripherally inserted central catheters (PICCs).Review of CDC guidance titled Clinical Safety: Hand Hygiene for Healthcare Workers found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html and dated 02/27/24 revealed hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of deadly germs to patients. Recommendations included on know when to wear (and change) gloves stated gloves are not a substitute for hand hygiene. If your tasks requires gloves, perform hand hygiene before donning gloves and touching the patient or the patients surroundings; always clean your hands after removing gloves. When to change gloves and clean hands included if gloves become soiled with blood or body fluids after a task, if moving from work on a soiled body site to a clean body site on the same patient or if clinical indication for hand hygiene occurs, and before exiting a patient room.

Based on staff interview, record review, and personnel file review, the facility failed to hire a qualified worker to fill the social work role with the facilities capacity being 125. This had the potential to affect all 91 residents residing in the facility. Findings include:Review of Social Worker Designee (SWD) #144 personnel file revealed prior work history included Certified Nursing Assistant (CNA) positions, kitchen employment, and Activity Director experience beginning in April 2019. SWC had no qualifying degree in social work or human services and no prior social work experience. SWD #144's start date in the Social Worker Designee role was 03/25/26.Interview on 05/06/26 at 1:33 P.M. with SWD #144 revealed she was not a social worker and did not have prior social work experience before assuming the position. SWD #144 confirmed the regional social worker had not been in the building since she was hired approximately two and a half weeks prior and stated she had only participated in one virtual meeting with the regional social worker.Interview on 05/06/26 at 1:49 P.M. with Regional Nurse #300 revealed the regional social worker only provided training and did not oversee staff within the facility. Regional Nurse #300 confirmed the facility had been attempting to lower its bed capacity due to difficulty locating a qualified social worker in the rural area. Regional Nurse #300 further confirmed the facility had an active job posting for the position and provided census documentation to present which revealed the highest resident census from the last annual to current was 104 residents.Review of the summary of qualifications for the role at the facility revealed the position required a Master's degree in a related field, possess a valid Ohio State Driver's License and have transportation available for job related travel, a desire to assist the elderly, and must meet health assessment requirements, including a two-stage Mantoux skin test.

Based on observations, staff and resident interviews and policy review the facility failed to ensure the facility environment temperatures were maintained at a comfortable level. This had the potential to affect 24 (#113, #68, #109, #18, #83, #58, #25, #17, #39, #80, #96, #50, #27, #48, #33, #42, #63, #12, #89, #93, #61, #21, #86 and #91) residents residing on the 300 hall. The census was 106 Findings include: Observation and interview on 06/17/24 at 12:06 P.M. with Resident #12 revealed the resident stated her room was too be hot and stuffy. The lighted clock on her wall revealed a temperature reading of 86 degrees Fahrenheit (F). Observations and interview on 06/17/24 at 12:12 revealed the Administrator had taken an infrared temperature in the 300 hall which was 80.4 degrees F and the temperature in Resident #12's room was between 84 degrees F to 86 degrees F. The Administrator confirmed the air conditioning unit had been out for sometime, but stated the facility was scheduled to get a new roof tip air conditioning unit the next day. The Administrator verified the temperature was elevated in the hall and pointed to two portable air conditioning units which were placed on each side of the hallway. The Administrator stated the air conditioning unit had not been functioning for greater then one year. Interview on 06/17/24 at 12:54 P.M. with Maintenance Supervisor #106 revealed the left side of the air conditioning condenser unit had been out for two years. Interview and observation on 06/17/24 at 2:38 P.M. with Resident #17 revealed the room was hot and stuffy. Resident #17 stated his room had been hot all day and he had asked maintenance for a fan earlier in the day, but no one brought one in for him. Interview and observations on 06/17/24 at 2:46 P.M. with Maintenance Staff #124 revealed he was unaware Resident #17 had requested a fan. He agreed to use the infrared temperature readings for intermittent rooms on the 300 hall. Maintenance Staff #124 pointed the infrared thermometer at chair level into the rooms to obtain the temperatures. room [ROOM NUMBER] was 86 degrees F, room [ROOM NUMBER] was 86.9 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 86.7 degrees F, room [ROOM NUMBER] was 82.2 degrees F, room [ROOM NUMBER] was 83.7 degrees F, room [ROOM NUMBER] was 79.2 degrees F and room [ROOM NUMBER] was 82.9 degrees F. Interview on 06/17/24 at 3:12 P.M. with the Administrator and Director of Nursing (DON) revealed they were unaware any resident had requested a fan and were unsure of which residents had fans in their rooms. They did state they had staff offering cool wash cloths, ice water and Gatorade. Interview on 06/18/24 at 9:12 A.M. with the Administrator revealed the air conditioner contractors were at the facility to repair the air conditioner. The Administrator supplied the requested square footage coverage for the two portable units previously placed on the 300 hall. Portable air conditioner number one was 13,000 British Thermal Units (BTU) with a 650 square (sq) foot (ft) coverage and the second unit was 10,000 BTU with a 500 sq. ft. coverage. The Administrator confirmed the 300 hall was 6,144 sq. ft so the portable air conditioning units were not enough to cool the unit. The facility confirmed there are 24 (#113, #68, #109, #18, #83, #58, #25, #17, #39, #80, #96, #50, #27, #48, #33, #42, #63, #12, #89, #93, #61, #21, #86 and #91) residents residing on the 300 hall that could potentially be affected. Review of the undated policy, Room Temperatures revealed the room temperatures were to be between 71 degrees F and 81 degrees F. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, observations and staff interview, the facility failed to ensure dietary orders were followed. This affected one (#16) of three residents reviewed for dietary preferences. The facility census was 106. Findings include: Review of medical record for Resident #16 revealed admitted [DATE]. The resident was admitted with diagnoses including arthritis, Congestive Heart Failure, and depression. The resident remained in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she/he had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He required set up assistance for eating, moderate assistance for toileting hygiene, bed mobility and was dependent for transfers. Review of the physician orders revealed a diet order for a Controlled Carb diet, Regular texture, Regular consistency with double protein with a start date of 09/13/23. Observation on 06/18/24 at 12:20 P.M. of the meal ticket for Resident #16 revealed the meal should be double protein. Observation of his lunch tray revealed the ravioli was not double portioned. Interview and observation on 06/18/24 at 12:25 P.M. with Regional Dietary Manager #113 verified Resident #16's lunch meal did not match the ticket. This deficiency represents non-compliance investigated under Complaint Numbers OH00154512 and OH00154409.

Based on review of the daily staffing posting, staff interview, and facility policy review, the facility failed to post current nurse staffing information. This had the potential to affect all residents who reside in the facility. The facility census was 100. Findings include: Observation on 07/24/23 at 4:22 P.M. revealed four daily staff postings for 05/12/23, 05/13/23, 05/14/23, and 05/15/23 posted on the window next to the main entrance of the facility. Observation on 07/25/23 at 8:01 A.M. revealed the daily staff postings for 05/12/23, 05/13/23, 05/14/23, and 05/15/23 remained in place. Interview on 07/25/23 at 10:24 A.M. with the Director of Nursing (DON) verified the facility posted staffing information on the door to the main entrance. The DON verified the staff postings of 05/12/23, 05/13/23, 05/14/23, and 05/15/23 were outdated and needed to be updated. Review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, revised August 2006, revealed the facility will post the number of nursing personnel responsible for providing direct care to residents on a daily basis.

Based on observation, medical record review, staff interviews, and review of facility policy, the facility failed to develop accurate care plans to reflect residents' current status. This affected two (Residents #40 and #34) of three reviewed for care planning. The facility census was 100. Findings include: 1. Review of the medical record for Resident #40 revealed an admitted [DATE]. The resident was admitted with diagnoses including end stage renal disease, dependence on dialysis, type two diabetes mellitus, depression, and Rheumatoid Arthritis. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 had a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. The resident was independent with Activities of Daily Living (ADLs). Further review revealed Resident #40 had likely cavity or broken teeth. Additionally, the resident was documented as having pain. Review of the dental note dated 05/05/23 revealed Resident #40 had tooth decay and was referred to an orthodontist for removal. Review of Resident #40's most recent care plan revealed no goals or interventions in place for dental needs or pain. Interview on 07/24/23 at 3:19 P.M. with Resident #40 revealed she needed her teeth repaired and left wrist pain, in which she received pain medication as needed. Interview on 07/27/23 at 9:41 A.M. with MDS coordinator #239 verified dental needs and pain were documented areas of concern on Resident #40's MDS and were not included in the resident's care plan. 47988 2. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included convulsions, cerebrovascular disease, myoneural disorder, muscle weakness, dementia, epilepsy, cognitive communication deficit, convulsions, anxiety, and depression. Review of Resident #34's Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of nine, indicating cognitive impairment. Further review revealed the resident required extensive two-person assistance for bed mobility, dressing, personal hygiene, and toileting with incontinence of bowel and bladder. Review of Resident #34's care plan dated 05/21/22 revealed no goals or interventions in place for the use of physical restraints. Observation and interview on 7/24/23 at 11:32 A.M. revealed Resident #34 was observed in her room sitting in a Broda chair with a large plastic tray in front of the resident's lap covering both arm rests. The tray was connected to the Broda chair with a strap that wrapped around to the back of Resident 34's Broda chair and fastened using a plastic buckle clip. Resident #34 stated she was unable to remove the tray, grabbing the tray and shaking the tray with the attempt to move the tray and was unable to remove tray from her lap. Interview on 07/24/23 at 11:43 A.M. with State tested Nurse Aide (STNA) #236 revealed Resident #34 was not able to remove the tray attached to her Broda chair herself and proceeded to show the plastic buckle clipped in the back of the Broda chair, with Resident #34 was sitting in the chair. Interview on 07/26/23 at 11:27 A.M. with Licensed Practical Nurse (LPN) #229 revealed Resident #34 used the tray table all the time while up in the Broda chair and was unable to remove the tray herself. Observation on 07/26/23 at 5:00 P.M. revealed Resident #34 sitting in her Broda chair with the tray table across her lap and buckled behind the Broda chair while in her room. Interview on 7/27/23 at 2:16 P.M. with the Director of Nursing (DON) verified Resident #34's care plan did not include the use of physical restraints. Review of the facility's policy, Care Plans- Comprehensive, dated September 2010, revealed an individualized comprehensive care plan is developed for each resident and care plans are revised as information about the resident and the resident's condition change.

Based on observation, record review, staff interview, and review of facility policy, the facility failed to provide a dependent resident with grooming needs. This affected one (Resident #74) of four residents reviewed for activities of daily living. The facility census was 100. Findings include: Review of the medical record revealed, Resident #74 was admitted on [DATE]. Diagnoses included Huntington's chorea, Alzheimer's dementia, Parkinson's disease, adult failure to thrive, aphasia, musculoskeletal impairment, gastrostomy tube, depression, and anxiety. Review of Resident #74's Minimum Data Set (MDS) assessment dated [DATE] revealed her cognitive skills for daily decision making was severely impaired with a Brief Interview for Mental Status (BIMS) score unable to be obtained. Resident #74 required total dependence of two staff for activities of daily living, dressing, toileting, personal hygiene, and bathing. Review of Resident #74's plan of care dated 02/18/23 revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit requiring total dependence on staff for all care needs. Interventions included to check nail length and to trim and clean on bath day and as necessary. Further review of Resident #74's medical record revealed no documentation showing the resident received nail care. Observation on 07/24/23 at 11:25 A.M. revealed Resident #74's fingernails on both hands were long, jagged, and dirty with dark discoloring underneath the nails. Observation on 07/25/23 at 3:57 P.M. revealed Resident #74's fingernails on both hands were long, jagged, and dirty with dark discoloring underneath the nails and red abraded like areas to thumb and first digit on the left hand. Interview 07/25/23 at 3:59 P.M. with State tested Nurse Aide (STNA) #256 revealed hospice provided Resident #74 with baths. STNA #256 verified Resident #74's nails were long and stated it appeared the nail length caused scratches to Resident #74's thumb and finger. Interview on 07/25/23 at 4:42 P.M. with Licensed Practical Nurse (LPN) #229 at Resident #74's bedside, verified Resident #74's fingernails were long and needed trimmed. LPN #229 verified the abrasions on the resident's hand were caused by nail length. Observation on 07/27/23 at 9:25 A.M. revealed Resident #74's fingernails on both hands were long, jagged, and dirty with dark discoloring underneath the nails and red abraded like areas to thumb and first digit on left hand. Review of the facility policy, Quality of Life- Accommodation of Needs, dated 08/2009, revealed the resident's individual needs and preferences shall be accommodated.

Based on observation, staff interview, and record review, the facility failed to follow fluid restrictions. This affected one (Resident #23) of one resident reviewed for fluid restrictions. The facility census was 100. Findings include: Review of the medical record for Resident #23 revealed an admitted [DATE]. Medical diagnoses included End Stage Renal Disease (ESRD), dependence on renal dialysis, diabetes mellitus, and non-compliance with medical regimen or treatment. Review of the physician's orders revealed Resident #23 had an order for a renal diet, with double portions. Additionally, a fluid restriction was ordered for Resident #23 on 06/14/22. The order stated Resident #23 was to be restricted to 1200 milliliters (ml) fluid intake daily. 720 ml total is to be provided by dietary each day, and 480 ml to be provided by nursing daily. The amount provided by nursing was further divided with 360 ml to be provided by nursing staff on the 7:00 A.M. to 7:00 P.M. day shift, and 120 ml to be provided by nursing staff on the 7:00 P.M. to 7:00 A.M. night shift. Observation on 07/26/23 at 12:04 P.M. of Resident #23's lunch tray revealed one cup of coffee, one carton of milk, and one smaller glass of fruit punch. Resident #23 stated he always received the same drinks from the kitchen with meals. The tray slip on Resident #23's tray reflected 8 ounces (equivalent to 240 ml) of coffee, 8 ounces of whole milk, and 4 ounces (equivalent to 120 ml) of sugar free fruit punch. The items listed on the tray ticket matched what appeared on Resident #23's lunch meal tray. Review of Resident #23's dietary tray cards for breakfast, lunch, and dinner on 07/24/23, 07/25/23, and 07/26/23 revealed the resident received 8 oz of coffee, 8 oz of whole milk, and 4 oz of sugar free fruit punch at each meal. Fluid intake provided by dietary at mealtimes totaled 600 ml per meal, and 1800 ml daily. Interview on 07/26/23 at 12:11 P.M. with Dietary Manager (DM) #245 revealed the orders listed in the electronic health record for residents did not transfer over to the dietary department's system used for tray cards. DM #245 stated she had to manually enter all diet orders, supplements, and fluid restrictions manually. Items listed on tray cards are what residents received at mealtimes. DM #245 stated she had no knowledge Resident #23 was on a fluid restriction, and verified the dietary department had no listed fluid restriction for Resident #23, or it would have been listed on the tray card. DM #245 verified Resident #23 received a total of 600 ml of fluid with each meal, and a total of 1800 ml per day from dietary.

Based on record review, observation, staff interview, and facility policy review, the facility failed to properly administer medications via enteral gastrostomy tube. This affected one (Resident #74) of one resident reviewed for medication administration via gastrostomy tube. The facility census was 100. Findings include: Review of the medical record revealed Resident #74 was admitted on [DATE]. Diagnoses included Huntington's chorea, Alzheimer's dementia, Parkinson's disease, adult failure to thrive, aphasia, musculoskeletal impairment, gastrostomy tube, depression, and anxiety. Review of Resident #74's Minimum Data Set (MDS) assessment dated [DATE] revealed her cognitive skills for daily decision making were severely impaired with never or rarely making decisions. Further review revealed the resident required total dependence of two staff for activities of daily living including dressing, toileting, personal hygiene, bathing, with total dependence of one staff for intake of nourishment, and functional limitations of range of motion of upper and lower extremities. Observation on 07/26/23 at 11:27 A.M. revealed Licensed Practical Nurse (LPN) #229 preparing to administer medications to Resident #74's via gastrostomy tube. LPN #229 proceeded to push water mixed with crushed medication through the resident's gastrostomy tube with a syringe. Interview on 07/26/23 at approximately 11:35 A.M. LPN #229 verified during administration of medication to Resident #74, medications were pushed via syringe into the gastrostomy tube, rather than using the gravity method. Review of the facility's policy labeled, Administering Medications through an Enteral Tube, dated March 2015 revealed to attach the syringe without the plunger to the gastrostomy tube, administer medication by gravity flow and flush gastrostomy tubing after medication using gravity flow.

Based on medical record review, observation, and interview, the facility failed to implement fall interventions to potentially prevent falls. This affected one (Resident #90) of two residents reviewed for falls. The facility census was 100. Findings include: Review of the medical record for Resident #90 revealed an admitted [DATE]. Diagnoses included traumatic subarachnoid hemorrhage, syncope and collapse, hearing loss bilateral, dementia, dysphagia, Alzheimer's Disease with late onset, and fall. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #90 had severely impaired cognition. The resident required extensive assistance of one person for bed mobility, walk in room, and dressing. The resident required extensive assistance of two persons for transfers. The resident had one fall with no injury since admission, reentry, or prior assessment. Review of the nursing note dated 07/03/23 at 1:30 P.M. revealed Resident #90 was wandering in front of the building in the main common area. The resident slid out of her wheelchair. Resident #90 was unable to describe what happened. Neurological checks were initiated and the resident was assisted into her wheelchair. Maintenance to put anti-roll back devices on the resident's wheelchair for safety. Review of the plan of care dated 07/24/23 revealed Resident #90 had an actual fall with injury related to poor balance and unsteady gait with a goal to resume usual activities without further incident through the review date. Interventions included, anti-roll backs to wheelchair (added 07/07/23), educate resident on proper sitting while in wheelchair, fall mat to side of bed, and wear proper footwear while out of bed. Observation on 07/26/23 at 4:07 P.M. of Resident #90 in the common area revealed the resident did not have an anti-roll back device on her wheelchair. This was verified by Maintenance Staff #218, present at the time. Maintenance Staff #90 stated the resident's wheelchair had an anti-tip device and explained the difference in the modification. Observation on 07/26/23 at 4:51 P.M. Regional Director of Clinical Operations #241 verified Resident #90 did not have an anti-roll back device, as the wheelchair freely rolled backward. Regional Director of Clinical Operations #241 asked the nurse present to monitor the resident one on one until they had the situation figured out. Interview on 07/26/23 at 5:10 P.M. the Director of Nursing (DON) and Regional Director of Clinical Operations #241 reported the resident had been placed in the correct wheelchair. The facility did not provide a policy related to safety devices for resident mobility devices.

Based on observation, record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure a resident was free from physical restraints. This affected one (Resident #34) of one resident reviewed for physical restraints. The facility census was 100. Findings include: Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included convulsions, cerebrovascular disease, myoneural disorder, muscle weakness, dementia, epilepsy, cognitive communication deficit, convulsions, anxiety, and depression. Review of Resident #34's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident was cognitively impaired. Further review revealed the resident required extensive two-person assistance for bed mobility, dressing, personal hygiene, and toileting with incontinence of bowel and bladder. There was no documentation indicating the use of physical restraints. Review of Resident #34's care plan dated 05/21/22 revealed no goals or interventions in place for the use of physical restraints. Further review of Resident #34's medical record revealed no documentation, including physician orders and assessments, for use of physical restraints. Observation and interview on 7/24/23 at 11:32 A.M. revealed Resident #34 was observed in her room sitting in a broda chair with a large plastic tray in front of the resident's lap covering both arm rests. The tray was connected to the broda chair with a strap that wrapped around to the back of Resident 34's broda chair and fastened using a plastic buckle clip. Resident #34 stated she was unable to remove the tray, grabbing the tray and shaking the tray with the attempt to move the tray and was unable to remove tray from her lap. Interview on 07/24/23 at 11:43 A.M. with State tested Nurse Aide (STNA) #236 revealed Resident #34 was not able to remove the tray attached to her broda chair herself, and proceeded to show the plastic buckle clipped in the back of the broda chair, with Resident #34 was sitting in the chair. Interview on 07/26/23 at 11:27 A.M. with Licensed Practical Nurse (LPN) #229 revealed Resident #34 used the tray table all the time while up in the broda chair and was unable to remove the tray herself. Observation on 07/26/23 at 5:00 P.M. revealed Resident #34 sitting in her broda chair with the tray table across her lap and buckled behind the broda chair while in her room. Interview on 07/27/23 at 2:16 P.M. with the Director or Nursing (DON) confirmed there was no restraint assessment or physician order for for Resident #34. Review of the policy, Use of Restraints, dated December 2007, defined a restraint as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Further review revealed that prior to the placing a resident in a restraint, a pre-restraint assessment was to be performed, a physician order for the restraint usage, consent from the resident and or representative was to be obtained and a plan of care was to be reflective of the resident.

Based on medical record review, staff interviews, and review of facility policy, the facility failed to complete an accurate assessment to reflect a resident's current status. This affected one (Resident #82) of one resident reviewed for accuracy of assessments. The facility census was 100. Findings include: Review of the medical record for Resident #82 revealed an admitted [DATE]. The resident was admitted with diagnoses including end stage renal disease, type two diabetes mellitus, hypertension, dependence on renal dialysis. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #82 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Further review revealed the resident required supervision for walking in his room and corridor. Interview on 07/25/23 at 8:50 A.M. with Resident #82 revealed he was unable to walk since he came to the facility. Interview on 07/26/23 at 8:12 A.M. with Therapy Manager #400 revealed Resident #82 was receiving therapy upon his admission to the facility and was discharged per his choice. The resident did not walk during therapy and utilized a wheelchair for locomotion. Interview on 07/27/23 at 12:36 with MDS Coordinator #272 verified Resident #82' MDS assessment was incorrect in reflecting the residents current status for locomotion. Review of the Resident Assessment Instrument revised 09/2010 revealed the purpose of the assessment was to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure the physician was notified when a resident experienced a decline in health status. This resulted in actual harm when Resident #21's experienced a delay in emergency treatment for [REDACTED]. This affected one (#21) of three residents reviewed for notification. The facility census was 95. Findings include: Review of Resident #21's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no impairment in cognition. The resident experienced no behaviors and no rejection of care. He was independent with bed mobility, dressing, toilet use, personal hygiene, and eating. He required limited assistance with one staff for transfers. Review of the resident's nursing notes revealed an entry on 05/20/19 at 1:00 A.M. with a summary of care documented from 05/19/19 at 8:15 P.M. through 05/20/19 at 12:30 A.M., from Licensed Practical Nurse (LPN) #54. On 05/19/19 at 8:15 P.M., LPN #54 documented the resident complained of not feeling well. His temperature was 100.3 orally. Blood pressure was 154/111. The resident requested and received an as needed medication ([MEDICATION NAME]) (narcotic pain medication) then went to his room and went to bed. At 9:30 P.M., the resident had a large emesis and no other complaints. At 10:20 P.M. the resident complained of pain in his left shoulder and around the diaphragm area on his chest. The resident had decreased urine output, so LPN #54 documented she changed his urinary catheter. Upon removal of the urinary catheter, she documented a big glob of slimy mucous came out of his penis and about 250-300 cubic centimeters (cc) of urine. The resident's urine was noted to be pink tinted with more mucous. The resident's urinary catheter was replaced, which he tolerated well. He continued to complain of pain in the left shoulder area. Blood pressure was 125/76 and pulse was 106. Temperature was 100.5. At 12:30 A.M., the resident again requested and received as needed [MEDICATION NAME] pain medication. LPN #54 then documented the resident was resting quietly, eyes closed, respirations even and unlabored. Call light was within reach. Will continue to monitor urine output throughout shift. Will get urinalysis with culture and sensitivity in the morning. Continued review of the resident's medical record revealed [REDACTED].#54 on 05/19/19 or 05/20/19. There was no further nursing note from LPN #54 after 05/20/19 at 1:00 A.M. There was no docuemntation of the physician being notifed of the change in condition. Continued review of the resident's nursing notes revealed no further entries until 05/20/19 at 8:50 A.M. from LPN #55. She documented the resident was sent to the emergency room with a temperature of 104.5. Report was called to the emergency room . The resident left the facility at 9:15 A.M. Review of the resident's hospital transfer form completed by LPN #55 on 05/20/19 at 8:30 A.M. revealed the resident had a temperature of 104.5, blood pressure 117/79, pulse 118, respirations 18, pain level of eight, which was generalized. Review of the resident's physician's orders [REDACTED]. Review of the resident's Treatment Administration Record (TAR) revealed the last set of vital signs obtained for the resident was on 05/01/19. The resident's blood pressure was 128/88 and pulse was 92. There was no documentation of respirations or temperature. Review of the resident's hospital discharge papers dated 05/27/19 revealed he was admitted to the intensive care unit with [DIAGNOSES REDACTED]. Urine culture was positive for Escherichia coli and Proteus mirabilis. The resident received intravenous and oral antibiotics daily while in the hospital. Review of emergency room documentation revealed he presented with a fever and body aches. He stated he was having pain to his upper back radiating up to his shoulders. He stated he was unable to keep anything down due to nausea and vomiting. His temperature was 103.1 degrees, blood pressure was 106/56 and pulse was 139. The resident's lactic acid (presence in elevated quantities is commonly associated [MEDICAL CONDITION]) level was elevated at 6.30 millimoles per liter (mmol/L) (normal 0.5-1 mmol/L). The resident's white blood cell count (cells in the body that fight infection) was elevated at 23.3 cells per liter (normal 4.5-11.0). The resident was started on [MEDICAL CONDITION] protocol in the emergency room . Interview with LPN Unit Manager #50 on 07/09/19 at 10:15 A.M. verified LPN #54 did not call the physician when Resident #21 had a change in condition. She verified the resident was directly admitted to the intensive care unit after evaluation in the emergency room . She stated he was treated for [REDACTED].#54. She verified the resident had an order for [REDACTED]. Interview with LPN #55 on 07/09/19 at 10:23 A.M. revealed she worked day shift on 05/20/19 on Resident #21's unit. She stated LPN #54 told her in report the resident had a rough night and might have a urinary tract infection. She stated she was not aware he had an emesis, elevated pulse and blood pressure, or shoulder/chest pain. She stated she went in to check on Resident #21 on 05/20/19 and he looked washed out and had a temperature of 104.5. She stated she called the physician and stated she had already called for an ambulance to send him to the emergency room . Interview with LPN #54 on 07/09/19 at 10:46 A.M. verified she should have notified the physician when she noted the resident's elevated blood pressure on 05/19/19 at 8:15 P.M. She verified she did not obtain a complete set of vital signs at 8:15 P.M. She verified 154/111 was not a normal blood pressure for the resident. She stated she checked on him throughout the night, but verified she did not document any further assessment after 05/20/19 at 1:00 A.M. Interview with the Director of Nursing DON on 07/09/19 at 11:40 A.M. verified the facility had not identified a concern regarding nursing assessments or physician notification. Interview with Resident #21's Physician #100 on 07/09/19 at 1:58 P.M. revealed she would have expected a phone call or for the nurse to have called the physician on call with the symptoms exhibited by Resident #21. She stated she would have been concerned the resident was septic due to his decreasing blood pressure, elevated pulse, and complicated medical history. Review of an undated facility policy titled Change in a Resident's Condition or Status revealed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a decline or improvement in the resident's status that (includes) a.) Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions; b.) impacts more than one area of the resident's health status; c) requires interdisciplinary review and/or revision to the care plan; and d.) ultimately is based on the judgment of the clinical staff. This deficiency substantiates complaint number OH 624.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to provide a timely and thorough nursing assessment for a resident with a change in health status. This resulted in actual harm when Resident #21's deteriorating health status was not thoroughly assessed and monitored and resulted in hospitalization in the intensive care unit for spesis (a life-threatening condition in which the body is fighting a severe infection that has spread via the bloodstream). This affected one (#21) of three residents reviewed for infection control concerns. The facility census was 95. Findings include: Review of Resident #21's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no impairment in cognition. The resident experienced no behaviors and no rejection of care. He was independent with bed mobility, dressing, toilet use, personal hygiene, and eating. He required limited assistance with one staff for transfers. Review of the resident's nursing notes revealed an entry on 05/20/19 at 1:00 A.M., with a summary of care documented from 05/19/19 at 8:15 P.M. through 05/20/19 at 12:30 A.M., from Licensed Practical Nurse (LPN) #54. On 05/19/19 at 8:15 P.M., LPN #54 documented the resident complained of not feeling well. His temperature was 100.3 degrees Fahrenheit orally and blood pressure was 154/111. The resident requested and received an as needed medication ([MEDICATION NAME]) (narcotic pain medication) then went to his room and went to bed. At 9:30 P.M., the resident had a large emesis and no other complaints. At 10:20 P.M., the resident complained of pain in his left shoulder and around the diaphragm area on his chest. The resident had decreased urine output, so LPN #54 documented she changed his urinary catheter. Upon removal of the urinary catheter, she documented a big glob of slimy mucous came out of his penis and about 250-300 cubic centimeters (cc) of urine. The resident's urine was noted to be pink tinted with more mucous. The resident's urinary catheter was replaced, which he tolerated well. He continued to complain of pain in the left shoulder area. Blood pressure was 125/76 and pulse was 106, temperature was 100.5. At 12:30 A.M., the resident again requested and received as needed [MEDICATION NAME] pain medication. LPN #54 then documented the resident was resting quietly, eyes closed, respirations even and unlabored. Call light was within reach. Will continue to monitor urine output throughout shift. Will get urinalysis with culture and sensitivity in the morning. Continued review of the resident's medical record revealed [REDACTED].#54 on 05/19/19 or 05/20/19. There was no further nursing note from LPN #54 after 05/20/19 at 1:00 A.M. Continued review of the resident's nursing notes revealed no further entries until 05/20/19 at 8:50 A.M. from LPN #55. She documented the resident was sent to the emergency room with a temperature of 104.5. Report was called to the emergency room . The resident left the facility at 9:15 A.M. Review of the resident's hospital transfer form completed by LPN #55 on 05/20/19 at 8:30 A.M., revealed the resident had a temperature of 104.5, blood pressure 117/79, pulse 118, respirations 18, pain level of eight, which was generalized. Review of the resident's physician's orders [REDACTED]. Review of the resident's Treatment Administration Record (TAR) revealed the last set of vital signs obtained for the resident was on 05/01/19. The resident's blood pressure was 128/88 and pulse was 92. There was no documentation of respirations or temperature. Review of the resident's hospital discharge papers dated 05/27/19 revealed he was admitted to the intensive care unit with [DIAGNOSES REDACTED]. Urine culture was positive for Escherichia coli and Proteus mirabilis. The resident received intravenous and oral antibiotics daily while in the hospital. Review of emergency room documentation revealed he presented with a fever and body aches. He stated he was having pain to his upper back radiating up to his shoulders. He stated he was unable to keep anything down due to nausea and vomiting. His temperature was 103.1 degrees, blood pressure was 106/56 and pulse was 139. The resident's lactic acid (presence in elevated quantities is commonly associated [MEDICAL CONDITION]) level was elevated at 6.30 millimoles per liter (mmol/L) (normal 0.5-1 mmol/L). The resident's white blood cell count (cells in the body that fight infection) was elevated at 23.3 cells per liter (normal 4.5-11.0). The resident was started on [MEDICAL CONDITION] protocol in the emergency room . Interview with LPN Unit Manager #50 on 07/09/19 at 10:15 A.M., verified LPN #54 did not call the physician when Resident #21 had a change in condition. She verified the resident was directly admitted to the intensive care unit after evaluation in the emergency room . She stated he was treated for [REDACTED].#54. She verified the resident had an order for [REDACTED]. Interview with LPN #55 on 07/09/19 at 10:23 A.M., revealed she worked day shift on 05/20/19 on Resident #21's unit. She stated LPN #54 told her in report the resident had a rough night and might have a urinary tract infection. She stated she was not aware he had an emesis, elevated pulse and blood pressure, or shoulder/chest pain. She stated she went in to check on Resident #21 on 05/20/19 and he looked washed out and had a temperature of 104.5. She stated she called the physician and stated she had already called for an ambulance to send him to the emergency room . Interview with LPN #54 on 07/09/19 at 10:46 A.M., verified she should have notified the physician when she noted the resident's elevated blood pressure on 05/19/19 at 8:15 P.M. She verified she did not obtain a complete set of vital signs at 8:15 P.M. She verified 154/111 was not a normal blood pressure for the resident. She stated she checked on him throughout the night, but verified she did not document any further assessment after 05/20/19 at 1:00 A.M. Interview with the Director of Nursing DON on 07/09/19 at 11:40 A.M., verified the facility had not identified a concern regarding nursing assessments or physician notification. Interview with Resident #21's Physician #100 on 07/09/19 at 1:58 P.M., revealed she would have expected a phone call or for the nurse to have called the physician on call with the symptoms exhibited by Resident #21. She stated she would have been concerned the resident was septic due to his decreasing blood pressure, elevated pulse, and complicated medical history. Review of an undated facility policy titled Change in a Resident's Condition or Status revealed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a decline or improvement in the resident's status that (includes) a.) Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions; b.) impacts more than one area of the resident's health status; c.) requires interdisciplinary review and/or revision to the care plan; and d.) ultimately is based on the judgment of the clinical staff. This deficiency substantiates complaint number OH 624.

Based on medical record review, staff and resident interview and policy review the facility failed to ensure residents were free from significant medication errors. This affected one Resident (#1) of three reviewed for timely medication administration. This resulted in actual harm to Resident #1 when he missed two doses of his [MEDICAL CONDITION] medication and had a [MEDICAL CONDITION]. The facility census was 94. Findings include: Review of the medical record for Resident #1 revealed he was admitted to the facility on [DATE] from a local hospital. His [DIAGNOSES REDACTED]. Review of the Admission assessment dated [DATE] at 5:10 P.M revealed the resident arrived at 5:10 P.M. prior to receiving his bedtime medications for 09/15/16. Review of the After Visit Summary from the hospital revealed the residents primary [DIAGNOSES REDACTED]. Review of the hospital medication list for home dated 09/15/16 revealed the medications were ordered to resume after his discharge to the facility including: [MEDICATION NAME] (for [MEDICAL CONDITION]) 10 milligram (mg) per PE[DEVICE] at 8:00 P.M. and three times daily thereafter; [MEDICATION NAME] (for hypertension) 6.25 mg per PE[DEVICE] twice daily; Lacosimide (for [MEDICAL CONDITION]) 20 mg per PE[DEVICE] at 9:00 P.M. and three times daily thereafter; Levetiracetam (for [MEDICAL CONDITION]) 100 mg/ml solution, give 15 mls per PE[DEVICE] at 9:00 P.M. and twice daily thereafter; [MEDICATION NAME] (for [MEDICAL CONDITION]) 125 mg/ml give 8 mls per PE[DEVICE] at 9:00 P.M. and three times daily thereafter; Rifaximin (anti diarrheal) 550 mg per PE[DEVICE] at 9:00 P.M. and twice daily thereafter Additionally [MEDICATION NAME] (for depression) 25 mg per PE[DEVICE] to be given in the morning and daily; [MEDICATION NAME] (vitamin) 100 mg to be given in the morning and daily; Spirolactone (diuretic) 25 mg to be given in the morning and daily; Multivitamin liquid 5 mls to be given in the morning and daily; Lactobacillus (supplement) 1 capsule to be given in the morning and daily; Folic acid (vitamin) 1 mg to be given in the morning and daily; and [MEDICATION NAME] (used for heart conditions) 125 mcg to be given in the morning and daily. The order was electronically signed by the hospital physician. The residents diet order was nothing by mouth (NPO), PE[DEVICE] feeding was 2-Cal HN at 45 ml per hour continuous with 100 ml free water flush every six hours. Review of the admission physician orders [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED].M. medications on 09/16/16. Review of the Interdisciplinary Progress Note (IPN) note dated 09/16/16 with no identifying time revealed Resident#1 had a [MEDICAL CONDITION] and was given his [MEDICAL CONDITION] medications. He was resting and doing better and postictal now. Plan was to do labs, continue his medications and see him again in one week. The note was signed by the facility physician. The IPN dated 09/15/16 at 9:50 P.M. revealed at 12:28 P.M. a State tested Nurse Aide (STNA) reported Resident #1 was unresponsive. The nurse and unit manager went to his room and his eyes were opened, he was staring ahead and unable to verbally respond. His vital signs (VS) were normal and he was in no distress. Investigation by the nurse revealed his 6:00 A.M. medications were not given. The physician was called and after several attempts an order was obtained to give all 6:00 A.M. medications at that time. The medications were administered by 1:00 P.M. Within 45 minutes Resident #1's facial response began to return. The facility physician arrived to the facility and ordered suctioning to prevent choking on phlegm. Bright red bleeding was noted due to resident had bit his tongue during the [MEDICAL CONDITION]. Resident #1 was talking with staff and family prior to the [MEDICAL CONDITION] in the morning. At 9:50 P.M. Resident #1 was quietly resting in bed with his mother and sister at bedside. Suctioning was used as needed throughout the day and there were no further concerns or signs of distress. VS were normal. Interview with Licensed Practical Nurse (LPN) #30 on 09/26/16 at 3:25 P.M. indicated staff are to obtain medications for a newly admitted resident. Usually a fax is received from the admitting facility in order to get the residents medication orders prior to their admission to the facility. The nurses send the order to the pharmacy and order them to be drop shipped. The pharmacy is supposed to deliver the medications within four hours. If the medications are not obtained the nurse will call to get the medications or the nurse will get the medications from contingency and the medications are administered. She verified the medications are always supposed to be given and not held. Interview with the Administrator on 09/26/16 at 3:31 P.M. indicated she was unaware Resident #1 did not receive his 9:00 P.M scheduled medications on 09/15/16. She verified Resident #1 did not received his 6:00 A.M. scheduled medications on 09/16/16. The Administrator verified Resident #1 had a [MEDICAL CONDITION] on 09/16/15 at around noon. When the medication error was discovered, the physician was called immediately and the medications were administered. She verified Resident #1 did not get his medications as ordered on [DATE] at 9:00 P.M. or on 09/16/16 at 6:00 A.M. Interview by phone with the Director of Nursing (DON) on 09/26/16 at 3:39 P.M. indicated she was unable to verify the 9:00 P.M. medications were given on 09/15/16. The DON verified Resident #1 did have a [MEDICAL CONDITION] on 09/16/16 at around noon. She verified the facility policy was for medications to be obtained and given as ordered for new admissions. If medications are not obtained for some reason the physician should be notified. The DON verified Resident #1's medications did not arrive until 6:02 A.M. on 09/16/16 and they were not available to be given on 09/15/16 at 9:00 P.M. The DON verified Resident #1 also did not get his medications on 09/16/16 at 6:00 A.M. even though they arrived to the facility at 6:02 A.M. Interview by phone with LPN #31 on 09/26/16 at 5:17 P.M. verified Resident #1's medications arrived on 09/16/16 about 6:00 A.M. He verified did not give the medications. This deficiency substantiates Complaint Number OH 056 and Complaint Number OH 003.

Based on observations, medical record review, staff interviews, review of facility policy, and review of a medication package insert, the facility failed to ensure treatments were provided appropriately to promote healing of pressure ulcers. This resulted in actual harm for Resident #65 who developed four Stage II pressure ulcers to left and right buttocks. This deficient practice affected three (#65, #77 and #18) of three residents reviewed for pressure ulcers. The facility identified 12 residents residing in the facility with pressure ulcers. The total facility census was 110. Findings include: 1. Review of Resident #65's medical record revealed an admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of the "Pressure Ulcer Record" initiated on 02/26/13 revealed the resident had a Stage II pressure ulcer on her right buttock that was last measured on 03/05/13 as 1.0 centimeter (cm) in length by 0.6 cm in width by less than 0.1 cm in depth with improvement noted. Review of Resident #65's physician's orders [REDACTED]. On 03/06/13 at 11:05 A.M., Licensed Practical Nurse (LPN) #20 and State tested Nurse Aide (STNA) #11 were observed completing a dressing change to Resident #65's pressure ulcer. LPN #20 washed her hands and donned gloves. STNA #11 rolled Resident #65 onto her right side and LPN #20 removed her brief which revealed incontinence of a large bowel movement. LPN #20 used the dirty brief to wipe off the rest of the bowel movement, placed the brief in trash, and removed her gloves. LPN #20 applied new gloves without washing her hands. LPN #20 then removed Resident #65's dressing from the wound which revealed four Stage II pressure ulcers on the left and right buttocks. LPN #20 did not change gloves or wash her hands and then measured the wounds. The Stage II pressure ulcer on left buttock measured 2.0 cm in length by 1.0 cm in width by 0.1 cm in depth. The Stage II pressure ulcer on the right upper buttock measured 2.0 cm in length by 1.0 cm in width by 0.1 cm in depth. The Stage II pressure ulcer on right middle buttock measured 3.0 cm in length by 3.5 cm in width by 0.1 cm in depth. The Stage II pressure ulcer on the right lower buttock measured 2.0 cm in length by 1.5 cm in width by 0.1 cm in depth. All pressure ulcers were noted to have redness around the wounds. LPN #20 applied skin prep around the wound and cleansed the wound with Simply Saline. LPN #20 patted the wound dry, applied a large amount of Santyl to a four by four gauze, and covered all three wounds and surrounding healthy skin tissue on the right buttock. LPN #20 then placed a large amount of Santyl to gauze and covered the wound and surrounding healthy tissue to the left buttock. LPN #20 did not change gloves or wash her hands after cleansing the wounds. She placed three pieces of tape around the edges of both areas of the gauze except for the bottom part of the gauze which remained open. There was still a moderate amount of bowel movement observed on Resident #65's buttocks near the wound. LPN #20 then cleaned up the items on the table, removed her gloves, and washed her hands. Interview with LPN #20 on 03/06/13 at 11:15 A.M. verified Resident #65 had four Stage II pressure ulcers on her right and left buttocks. She stated she was not aware of the open area on the left buttock prior to this dressing change. LPN #20 felt the open areas on the right had been there but she didn't know if Unit Manager #5 had been measuring them all as one or separate. LPN #20 further verified she did not completely clean Resident #65 of the bowel movement, but this is why she had not finished taping the dressing as she was going to do that after she finished washing her. LPN #20 stated she usually changes gloves when soiled, but only washes her hands before the procedure and at the end. LPN #20 further verified she did not wash her hands after cleaning Resident #65's bowel movement, prior to cleaning the wounds, and after cleaning the wounds. Interview with Unit Manager #5 on 03/06/13 at 1:30 P.M. verified she measured Resident #65's wounds on 03/04/13 and there was only one small, healing open area on her right buttock at that time. Unit Manager #5 further verified the nurses change the dressing and provide the treatment twice daily. She further stated she was instructed the amount of Santyl to be used was a "healthy" amount which meant enough to cover the wound and the surrounding area. Review of the Santyl package insert, provided by the facility, noted precautions that a slight transient [DIAGNOSES REDACTED] has been noted occasionally in the surrounding tissue particularly when the ointment was not confined to the wound. Therefore, the ointment should be applied carefully within the area of the wound. Interview with Unit Manager #5 on 03/06/13 at 1:45 P.M. verified that after reading the Santyl package insert, the Santyl being applied to healthy tissue may have caused Resident #65's additional areas of breakdown. Review of the facility's policy entitled "Dressing Changes" dated 01/01/07 indicated nurses are to remove and dispose soiled dressings, remove gloves, wash hands, and apply new disposable gloves. 2. Review of Resident #77's medical record revealed the resident has Stage II pressure ulcer to the coccyx, between the gluteal folds. The ulcer measured 0.5 cm in length by 0.5 cm in width by less than 0.2 cm in depth. The resident had a physician's orders [REDACTED]. Apply Santyl and [MEDICATION NAME] powder to a four by four and place on the area. Cover with a second four by four and secure with paper tape. On 03/06/13 at 11:55 A.M., LPN #22 and LPN #24 were observed to do a dressing change to Resident #77's coccyx wound. LPN #22 used proper technique, hand washing, and use of gloves. However, when she prepared the Santyl, she squeezed a large glob of the Santyl on the four by four gauze and pressed it onto the wound and surrounding healthy skin and then secured the dressing with tape. Interview with Unit Manager #5 on 03/06/13 at 1:30 P.M. indicated nurses complete the dressing changes and that she has been instructed the amount of Santyl to be used was a "healthy" amount which meant enough to cover the wound and the surrounding area. Review of the Santyl package insert, provided by the facility, noted precautions that a slight transient [DIAGNOSES REDACTED] has been noted occasionally in the surrounding tissue particularly when the ointment was not confined to the wound. Therefore, the ointment should be applied carefully within the area of the wound. 3. Review of Resident #18's medical record revealed an admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of the "Pressure Ulcer Record" dated 01/01/13 revealed the resident has a Stage II pressure ulcer on the coccyx. Review of Resident #18's physician's orders [REDACTED]. On 03/06/13 at 1:17 P.M., Registered Nurse (RN) #2 was observed to complete a dressing change to Resident #18's pressure ulcer. She washed her hands and donned gloves. RN #2 removed Resident #18's dirty dressing, but did not change gloves or wash her hands after she removed the dirty dressing. RN #2 then measured the wound and placed the treatment to the wound with a cotton tipped applicator. RN #2 cleansed around the wound with sure prep, applied gauze, and secured with paper tape. RN #2 then placed a gauze with an adhesive pad on top of the dressing, removed her gloves, and washed her hands. Interview with RN #2 on 03/06/13 at 1:25 P.M. verified she did not remove her gloves or wash her hands after removing the old dressing. She stated she should have. Review of the facility's policy entitled "Dressing Changes" dated 01/01/07 indicated nurses are to remove and dispose soiled dressings, remove gloves, wash hands, and apply new disposable gloves. "This deficiency substantiates Complaint Number OH 180."

This deficiency represents an incident of past non-compliance. Based on medical record review, staff interview, review of facility policy, surveyor observation and review of a facility investigation, it was determined that the facility failed to ensure one resident was transferred properly to prevent an avoidable fracture. This resulted in actual harm for Resident #1 who sustained a right tibia/fibula fracture after being transferred without the use of a mechanical lift. This affected one (#1) of three residents reviewed for mechanical lift transfers of a total of 16 residents who require mechanical lifts for transfers. Findings include. Review of Resident #1's medical record revealed she was readmitted to the facility on [DATE]. She had current [DIAGNOSES REDACTED]. The most current annual minimum data set (MDS) assessment dated [DATE] indicated the resident had short-term and long-term memory problems, no recall ability, she never/rarely made decisions, was easily distracted, had periods of altered perception, episodes of disorganized speech, periods of lethargy and her mental function varied over the course of the day. The assessment noted the resident was totally dependent on two staff persons and physical assistance for transfers. She had full loss of limitation on both sides of her neck, arms, hands, legs and feet. Review of the activities of daily living (ADL) resident assessment protocol (RAP) dated 08/05/10 revealed the resident was completely dependent on staff for all ADL needs except for eating. She required a mechanical (Hoyer) lift for transfers and required two staff members at all times for bed mobility and transfers. She did not have good balance while sitting and could not stand at all. Review of the plan of care for at risk for falls, initiated on 08/01/07, revealed an intervention for a mechanical lift with two assistance. Review of the nurse's notes dated 10/22/10 at 2:15 P.M. revealed a state tested nurse aide (STNA) noted bruising to the resident's right ankle area. The nurse noted a large blue bruise on Resident #1's right ankle and up her leg with 2+ edema. Her pedal pulse was palpable and regular. She notified the physician and received an order for [REDACTED]. Review of the x-ray results dated 10/22/10 at 5:06 P.M. revealed transverse fractures of the right distal tibia and fibula. During interview on 11/09/10 at 12:55 P.M., with the Director of Clinical Services (DCS), she stated on 10/22/10, two STNAs on the day shift noted bruising on Resident #1's right lower leg when her sock slipped down past her ankle. They notified her (DCS) immediately and she started an investigation. She said she called in the night shift staff, Licensed Practical Nurse (LPN) #4 and STNAs #2 and #3, for questioning regarding the bruising on Resident #1's right lower leg and informed them they were suspended during the investigation. STNA #2 told her it was more efficient, easier and quicker not to use the Hoyer lift and STNA #3 told her they did not want to bump the roommate's bed with the Hoyer lift and wake her. LPN #4, STNA #2 and STNA #3 were terminated following the findings of the investigation. Review of the facility's investigation, dated 10/25/10, of the bruising on Resident #1's right ankle/leg revealed the DCS was summoned to the resident's room to assess the resident. She observed significant bruising on Resident #1's right lower leg and the resident displayed overt signs and symptoms of an underlying injury to a boney structure. The resident did not wince or cry out with range of motion of the right foot. She did attempt to withdraw the limb with gentle manipulation of the limb. The unit manager informed the DCS that there was no report of injury prior to the discovery of the bruising. The investigation noted the evident bruising was certainly many hours old as it had spread from the lateral aspect of the distal right leg all the way to her knee. The bruising was from an injury that had occurred much earlier in the day or the night prior to discovery. STNA #2 and STNA #3, who worked third shift on 10/21/10 from 11:00 P.M. to 7:00 A.M. on 10/22/10 were interviewed independently. The STNAs informed the DCS that they had transferred Resident #1 without the full body/Hoyer lift and both stated they were well aware that the resident required the use of the full body/Hoyer lift and two people at all times for transfers. The investigation noted the STNAs reported that during the transfer, they each placed an arm under the resident's armpit and lifted her arm and leg style from a lying to a sitting position at the edge of the bed. Both of the STNAs stated they sat the resident at the edge of the bed, heard something make a sound and realized her right foot was lodged under her left leg. STNA #3 stated she observed the resident's foot/lower extremity throughout the night and her skin became discolored and bruised. She stated she reported the incident to the nurse on her hall. On 11/09/10 between 1:55 P.M. and 2:05 P.M., Resident #1 was observed with a soft cast wrapped with an ace wrap on her right lower leg. She was noted with flexion contractures of the right knee and hip. There was yellow/green bruising noted above the soft cast on the right lower leg. She was observed being transferred from her wheelchair to the bed with the use of a Hoyer lift and two STNAs. No concerns were identified with the transfer of Resident #1. On 11/09/10 at 3:37 P.M., telephone interview with STNA #2 revealed he and STNA #3 transferred Resident #1 from a shower chair to the bed on the morning of 10/22/10 between approximately 1:30 A.M. and 2:00 A.M. He stated he observed her right foot twisted under her and heard a "crunch" sound. He went to answer call lights and STNA #3 went to tell the nurse. He verified he knew Resident #1 required a Hoyer lift for transfers. STNA #2 further stated, "It was just more convenient to transfer the resident without the Hoyer lift." He indicated he had not heard anything about the resident and thought everything was okay until he got a call from the Director of Clinical Services later that afternoon on 10/22/10. Review of the facility's policy entitled "Lifting and Moving Residents" with an effective date of January 2007, revealed staff are to use a mechanical lift to transfer a resident who cannot stand from the bed to the wheelchair. This deficient practice that involved Resident #1 represents an incident of past non-compliance as the facility took immediate corrective action. The three staff members involved were terminated and the facility also provided documentation of formal inservices for staff that began on 10/22/10 and concluded on 10/27/10 when all nursing staff were trained. The staff inservices included the proper lifting and transferring of residents. There have been no other incidents of improper transfers of residents since 10/22/10 and there were no observations of improper transfers during the survey on 11/09/10. "This deficiency substantiates Control Number OH 192."