Every finding on record at Lutheran Home

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure their medication error rate was less than five percent (%). There were two medication errors out of 27 opportunities resulting in a 7.41% medication error rate. This affected two (Residents #11 and #37) of eight residents observed for medication administration. The facility census was 40.Findings include: 1. Record review for Resident #11 revealed an admission date of 12/14/21. Diagnosis included vitamin D deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was moderately cognitively impaired.Review of the physician orders dated 09/28/22 revealed Resident #11 had an order for vitamin D3 tablet 1,000 unit give two tablets by mouth one time a day for a supplement. Observation on 07/15/26 at 8:46 A.M. revealed Licensed Practical Nurse (LPN) #195 administered medications to Resident #11. LPN #195 administered vitamin D3 tablet 1,000 units, one tablet only.During an interview on 07/15/26 at 9:58 A.M., LPN #195 confirmed Resident #11's physician order for vitamin D3 was to receive two tablets of vitamin D3 1,000 units. LPN #195 confirmed he only administered Resident #11 one tablet of vitamin D3 1,000 unit, and not two according to the physician's order. 2. Record review for Resident #37 revealed an admission date of 06/26/10. Diagnosis included acute cystitis without hematuria, acute pyelonephritis, paraplegia, malignant neoplasm of floor of mouth, and long term use of antibiotics.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact. Review of the physician order for Resident #37 dated 06/04/26 revealed an order for acidophilus oral capsule give one capsule by mouth one time a day for gut maintenance. Observation on 07/15/26 at 10:02 A.M. revealed Licensed Practical Nurse (LPN) #165 administered acidophiles with pectin (100 milligrams (mg)) one tablet to Resident #37.Interview on 07/15/26 at 10:55 A.M. with the Director of Nursing (DON) confirmed acidophiles and acidophiles with pectin are two different medications.During an interview on 07/15/26 at 11:06 A.M., LPN #165 confirmed Resident #37's physician order was for acidophilus oral capsule give one capsule by mouth one time a day for gut maintenance. The order did not include pectin. LPN #165 confirmed she gave Resident #37 acidophiles with pectin.Review of the facility's undated policy titled Medication Administration revealed the purpose was to administer in a safe and effective manner. Follow the five rights of medication administration: Right patient, right drug, right dose, right route and the right time.

Based on observations, staff interviews, record reviews, and review of the facility policy, the facility failed to ensure infection control practices were maintained for two residents who required Enhanced Barrier Precautions (EBP) during high contact resident care activities. This affected two (Residents #31 and #48) of two residents observed for EBP. The facility identified there were a total of seven current residents who had EBP in place. The facility census was 40.Findings include:1. Record review for Resident #48 revealed an admission date of 06/24/26. Diagnoses included obstructive and reflux uropathy, retention of urine and nonrheumatic aortic valve stenosis.Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact. Resident #48 had indwelling catheter care and was dependent on staff for toileting hygiene, lower body dressing, chair/bed to chair transfer, and required substantial/maximum assistance for bed mobility. Review of the physician order dated 07/07/26 revealed an order for EBP in place for indwelling catheter every shift. Observations and interview on 07/13/26 at 11:53 A.M. revealed Resident #48 had an EBP sign outside his doorway. The sign revealed everyone must clean their hands before entering and when leaving the room. Providers and staff must also wear gloves and gown for the following high contact resident care activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, device care or use including urinary catheter. There was also a three-drawer container with multiple disposable isolation gowns and gloves inside near the sign. Certified Nursing Assistant (CNA) #150 dressed Resident #48's lower extremities and reposition Resident #48 in bed and CNA #150 was not wearing a gown. CNA #150 confirmed Resident #48 had an indwelling catheter in place, did not don an isolation gown during the care and stateded she also just completed incontinence care for Resident #48. CNA #150 then assisted Resident #48 to the side of the bed when CNA #184 entered the room. Observation revealed both CNA #150 and #184 transferred Resident #48 from his bed to his chair. Neither CNA donned an isolation gown. CNA #150 then straightened out Resident #150's sheets and pillow then exited the room with the soiled linen bag without washing her hands or using hand sanitizer. Observations and interview on 07/13/26 at 1:54 P.M. revealed CNA #150 drained the urine from Resident #48's indwelling catheter bag. CNA #150 never donned an isolation gown and revealed the staff would only need to don an isolation gown if they were changing the catheter, the gown was not required for any other personal care. CNA #150 confirmed she never donned the isolation gown while providing personal care. Review of the care plan dated 07/14/26 revealed Resident #48 was at risk for infection related to indwelling medical device (Foley catheter). Interventions included EBP. 2. Record review for Resident #31 revealed an admission date of 02/24/22. Diagnoses included cerebral palsy and gastrostomy status. Review of the care plan dated 07/01/25 revealed Resident #31 was at risk for infection related to indwelling medical device percutaneous endoscopic gastrostomy (PEG) tube. Interventions included Resident #31 was to receive EBP. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact. Resident #31 was always incontinent of bowel and bladder, had impairment to both sides of the upper extremities, required substantial to maximum assistance for bed mobility, was dependent on staff for toileting hygiene, dressing, personal hygiene, and chair/bed to chair transfer.Review of the physician orders for Resident #31 dated 05/21/26 revealed an order for EBP in place for PEG tube. There was also an order in place for water flushes through the PEG tube. Observation on 07/13/26 at 2:01 P.M. revealed Resident #31 had an EBP sign outside her doorway. There was also a three-drawer container with multiple disposable isolation gowns and gloves inside near the sign. Observation of incontinence care revealed CNA #184 never donned an isolation gown while providing the care for Resident #31. Resident #31's PEG tube was visible and CNA #184 repositioned Resident #31 multiple times during the care, applied cream to the buttocks, removed her gloves and exited the room without washing her hands. Interview on 07/13/26 at 2:19 P.M. with CNA #184 confirmed she did not don an isolation gown while providing incontinence care for Resident #31 and confirmed she left the room and did not wash her hands or use hand sanitizer.Review of the facility's undated policy titled Enhanced Barrier Precautions revealed the Centers for Disease Control and Prevention (CDC) guidelines as related to EBP to prevent the transmission of multidrug-resistant organisms (MDROs) will be adhered to while promoting resident quality of life by addressing the need for psychosocial well being of residents on EBP. EBP expand the use of personal protective equipment (PPE) and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP will be implemented for residents with open wounds requiring dressing and indwelling medical devices (which included urinary catheter and feeding tube). EBP will be used during high-contact resident care activities. High-contact care activities requiring gloves and a gown include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care (urinary catheter, feeding tube), or wound care.

Based on medical record review, review of facility policy, review of facility education in-service, review of a disciplinary action form, and staff interview, the facility failed to ensure care and services for a peripherally inserted central catheter (PICC) line site were completed as ordered. This affected one resident (#70) of three residents reviewed for intravenous (IV) access. The facility census was 66.Findings include: Review of the medical record for Resident #70 revealed an admission date of 08/21/25 and discharge date of 09/13/25. Diagnoses included Evan's syndrome (an autoimmune disorder where the immune system destroys its own blood cells), systemic lupus erythematosus, hereditary hemolytic anemia, long term use of antibiotics, and drug or chemical induced diabetes mellitus with hyperglycemia.Review of the admission assessment dated [DATE] revealed Resident #70 admitted to the facility from the hospital for urinary tract infection (UTI) and was being treated with antibiotics (ATB). It was noted Resident #70 had PICC line to right upper extremity (RUE).Review of Resident #70's physician order dated 08/23/25 revealed an order to change the RUE PICC line site dressing every week on Sundays. An additional order dated 08/23/25 noted Resident #70 had an upcoming follow-up appointment with a hematology center on 09/05/25 at 11:30 A.M. for a scheduled treatment. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2025 revealed Licensed Practical Nurse (LPN) #800 had signed off for the dressing change for Resident #70's PICC line site dressing on 08/24/25 and Agency LPN #801 had signed off the dressing change for Resident #70's PICC dressing on 08/31/25.Review of the MAR and TAR for September 2025 revealed no evidence of any dressing changes to Resident #70's RUE PICC line site. The order was discontinued on 09/07/25.Review of Resident #70's progress notes revealed a note dated 09/05/25 which indicated Resident #70's PICC site had been discontinued. Review of a progress note dated 09/08/25 revealed Resident #70 was seen by Nurse Practitioner (NP) #809. The note referenced Resident #70 had completed IV antibiotic treatment on 08/31/25. NP #809 noted Resident #70's PICC line was placed on 08/20/25. It was noted Resident #70 had a follow-up appointment with hematology on 09/05/25 and her PICC line was removed at the appointment. The note indicated the PICC line was removed as it was discovered the PICC line dressing was never changed since placement. Blood cultures were drawn and the PICC line was removed at the hematology appointment.Interview on 11/20/25 at 1:06 P.M. with Infusion Center Nurse #810 revealed on 09/05/25, Resident #70's PICC line dressing was noted to be very visibly soiled and was dated for 08/20/25. Infusion Center Nurse #810 stated Resident #70's PICC line was removed at the appointment on 09/05/25.Interview on 11/24/25 at 8:26 A.M. with the Director of Nursing (DON) revealed education was completed for all nurses on PICC line site care. The DON indicated LPN #800 was written up for signing off on Resident #70's PICC line dressing that she did not complete. The DON stated she was not working at this facility during this time.Interview on 11/24/25 at 9:49 A.M. with Assistant Director of Nursing (ADON) revealed she was the facility's infection preventionist. The ADON reported Resident #70 was admitted to the facility with IV access to administer IV ATB to treat a urinary tract infection. The ADON noted Resident #70 went to multiple infusion appointments during admission. The ADON stated she was notified by infusion clinic that Resident #70's PICC line dressing had not been changed at the facility. The ADON stated LPN #800 and Agency LPN #801 signed off on the treatments in Resident #70's MAR/TAR without actually completing the dressing change. The ADON indicated she was unable to recall the exact date on the dressing, however stated it was not changed for about two weeks. The ADON stated LPN #800 was written up and Agency LPN #801 was marked on the do not return (DNR) list. The ADON stated Resident #70 had no adverse effects of missing two dressing changes that she was aware of. The ADON indicated it was the policy of the facility to change IV site dressings every Sunday.Interview on 11/24/25 at 12:52 P.M. with Agency LPN #801 revealed it was the weekend when she picked up a shift at the facility. Agency LPN #801 stated she had requested dressing supplies for Resident #70's PICC line from the supervisor; however, the supervisor did not return with the dressing supplies. Agency LPN #801 did not recall or provide additional information related to Resident #70.Interview on 11/24/25 at 2:29 P.M. with LPN # 800 revealed the nurse confirmed she had received disciplinary action related to not completing Resident #70's PICC line dressing changes. LPN #800 stated she thought she had completed all the dressings on her assignment, including Resident #70's. LPN #800 also stated she had to do an in-service on PICC line site care. LPN #800 did not recall or provide additional information related to Resident #70.Review of Coaching/Counseling/Corrective Action Form dated 09/10/25 revealed LPN # was given a written warning for signing off the TAR that she changed a treatment however it was discovered the dressing had not been changed since 08/21/25. It was noted on the form that the dressing was to be changed weekly. Review of the facility policy Catheter Insertion and Care dated January 2019 revealed to assess the insertion site for complications at each dressing change. Care instructions included to apply a sterile transparent dressing over the insertion site and to label and date the dressing. There was no indication within the policy of frequency of dressing changes.This deficiency represents non-compliance investigated under Complaint Number 2650038.

Based on observation, record review, interview, and policy review the facility failed to ensure Resident #64 was free from physical restraints. This affected one resident (#64) of one resident reviewed for restraints. The facility census was 104. Findings include: Review of the medical record for Resident #64 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, dementia, and type two diabetes. Review of the annual, Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had a short-and long-term memory problem, was severely impaired for tasks of daily life, and required two-person total dependence for activities of daily living (ADL). Further review of the MDS assessment, section P, revealed physical restraints were 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 normal access to one's body. Review of section P revealed Resident #64 did not use physical restraints. Review of the physician orders dated June, July, and August 2023 revealed no orders for physical restraints. Review of the standard assessments located in the electronic medical record revealed no assessments for use of restraints. Review of the care plan dated 07/28/23 revealed no care plan for physical restraints. Review of the progress note dated 08/07/23 at 2:31 P.M. revealed Licensed Practical Nurse (LPN) #800 gave State tested Nurse Assistant (STNA) #801 permission to lay Resident #64 down for a few hours due to being up early in the morning. LPN #800 revealed she was trying to avoid Resident #64 having a breakdown with his skin from being in a chair for a long period of time. Review of the progress note revealed STNA #801 was to lower the bed to the floor and place the tray table across Resident #64 so that he did not climb out of the bed. Review of the Witness Statement dated 08/10/23 at 11:30 A.M. revealed Unit Manager (UM) #501 asked Resident #64 to demonstrate his ability to move bedside table from in front of him. Review of the statement revealed Resident #64 demonstrated with no difficulty and physically moved the bedside table from in front of him. Review of the facility education record dated 08/10/23, three days after the documented incident of a restraint being used, revealed facility staff were in-serviced on restraints and interventions that included any intervention put in place for a resident must improve mobility and cannot prevent normal activities of daily living and residents had a right to fall. Interview on 08/22/23 at 4:30 P.M. with STNA #506 revealed Resident #64 could not remove a tray table if he was lying flat in the bed. Observation of demonstration of Resident #64, with STNA #506 present, revealed he was unable to follow commands or push the tray table away. Interview on 08/23/23 at 11:08 A.M. with STNA #504 revealed Resident #64 required total care and use of a Hoyer (mechanical) lift. STNA #504 revealed Resident #64 would not be able to remove a tray table from over him. Interview on 08/23/23 at 11:12 A.M. with LPN #505 revealed Resident #64 required total care and was unable to hold a conversation with staff or other residents. LPN #505 revealed Resident #64 had a lot of safety measures in place due to history of falls. LPN #505 revealed Resident #64 was non-weight bearing and if he attempted to get out of bed, he would end up on the floor. LPN #505 revealed Resident #64 did not have enough strength to remove a bedside table if he was lying in bed. LPN #505 revealed most of Resident #64's falls resulted from trying to get out of bed. Interview on 08/23/23 at 4:50 P.M. with LPN #808 revealed Resident #64 required total care for ADL and would not be able to move a tray table from over him while lying down. LPN #808 revealed Resident #64 was unable to follow commands or conversation. Interview with the Director of Nursing (DON) on 08/23/23 at 8:29 A.M. confirmed the above findings. Interview on 08/24/23 at 9:46 A.M. with UM #501 revealed Resident #64 was very confused and was only able to follow conversations and demonstrate moving the bedside table with her. UM #501 revealed she was not present during the use of the restraint. Random observations of Resident #64 throughout the survey period dated 08/21/23 to 08/24/23 revealed him up in his Broda (reclining) chair, unable to communicate with staff or other residents, requiring complete assistance with meals, and unable to ambulate, transfer, or be repositioned without the help of staff. Resident #64 was observed slowly pushing activity blocks across the table while seated in the dining room. Review of the undated facility document titled Physical Restraints revealed the facility had a policy in place to ensure physical restraints were used appropriately. Review of the document revealed residents had a right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Further review of the document revealed for a method, device, material, or equipment to be considered a physical restraint, it must be attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body. Review of the document revealed the facility did not implement the policy.

Based on medical record review, interview, review of the fall investigations, and facility policy review the facility failed to ensure fall prevention interventions were in place to prevent falls for Resident #78 and failed to ensure falls were thoroughly investigated. This affected one resident (#78) of three residents reviewed for accidents. The facility census was 104. Findings include: Review of the medical record for Resident #78 revealed an admitted [DATE]. Diagnoses included Alzheimer's, muscle weakness, repeated falls, anxiety, pain, and insomnia. Review of the fall risk assessment dated [DATE] revealed Resident #78 was at high risk for falls. Review of the fall risk plan of care dated 02/20/23 revealed Resident #78 was at risk for falls due to limited mobility, muscle weakness, and a history of a right hip fracture. Interventions included anti-rollbacks to her wheelchair, Dycem (non-skid material) under her wheelchair seat cushion, non-skid footwear when out of bed, a night light in her room, perimeter mattress for positioning, offering to toilet every two to three hours, a metal reacher, and toileting at the end of each evening shift. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had severe cognitive impairment and required extensive assistance of one person for bed mobility and transfers, limited assistance of one person to walk in her room and was frequently incontinent of bowel and bladder. Review of the physician's orders for March 2023 revealed an order for Eliquis (blood thinner) 5 milligrams (mg) twice per day (BID). Review of the nursing note dated 03/08/23 at 9:11 A.M. revealed Resident #78 was sitting on the floor in her room, dressed in a gown with non-slip socks on, and an incontinence brief. A large, dried area of blood and tracks on the floor mixed with fresh blood on the Resident's left hand were observed. Bruising was noted to her right eyebrow, right temple, side of her face and hair. The resident was holding her right elbow and shoulder, grimacing and making verbal statements of Oww!. Her right shoulder appeared visibly displaced with visible discoloration. Her bed was in the low position, call light was attached to the right side bed rail, in reach while in bed. A body pillow was on the right side of the bed. 911 was called, and the resident was taken to the local Emergency Department (ED) where she was treated for a clavicle fracture. Resident #78 reported she was attempting to go to the bathroom when she lost her balance. A new intervention was initiated to place her bed in a low position. Review of the fall investigation dated 03/08/23 did not indicate if the resident fell from the bed or the wheelchair and if the perimeter mattress and or Dycem were in place, anti-rollbacks were in place on the wheelchair or when she was last offered to be toileted. Observation and interview on 08/24/23 at 8:15 A.M. with State tested Nurse's Aide (STNA) #802 revealed Resident #78 did not have a perimeter mattress on her bed. She revealed it had deflated and the facility had not yet replaced it. Observation and interview on 08/24/23 at 9:46 A.M. with Licensed Practical Nurse (LPN) #809 revealed there was no night light in the resident's room. LPN #809 turned the over bed light on in Resident #78's room because she thought it was dark in the room. It is noteworthy to mention, it was storming outside at the time of the observation and notably dark outside. LPN #809 also confirmed there was no reacher available in the room, although there was a note taped to the resident's closet to remember to use her reacher. Interview on 08/24/23 at 12:57 P.M. with the Director of Nursing (DON) verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 03/08/23. Review of the nurses note dated 05/15/23 at 5:35 A.M. revealed Resident #78 was sitting on the floor in her bathroom, in front of the toilet with her walker tilted over, brief on the floor in front of the toilet. She was wearing nonskid socks. The bathroom floor was covered in a large amount of water with an excessive amount of tissue on the toilet. She could not explain how she fell . Her vital signs were checked and found to be stable and neurological checks were initiated. The resident was encouraged to use the call light when using the bathroom. Review of the fall investigation dated 05/15/23 did not indicate if the Dycem was in place, anti-rollbacks were in place on the wheelchair, or when she was last offered to be toileted. Interview on 08/24/23 at 12:57 P.M. with the DON confirmed there were no witness statements obtained as part of the investigation, the investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 05/15/23. Review of the nurses noted dated 07/03/23 at 7:30 A.M. revealed Resident #78 was found on the floor in her room lying near her wheelchair with her walker at her feet. She was wearing nonskid socks. A laceration was noted to her upper right arm which was cleaned and covered with antibiotic ointment and gauze. The resident said she was trying to get out of bed. She was assessed for other injuries and vital signs were obtained which were within normal limits. Review of the fall investigation dated 07/03/23 did not indicate if the resident fell from the bed or the wheelchair, and if the perimeter mattress and/or Dycem were in place, anti-rollbacks were in place on the wheelchair or when she was last offered to be toileted. Interview on 08/24/23 at 12:57 P.M. with the DON confirmed witness statements were not obtained from all staff as part of the investigation, the investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 07/03/23. Review of the nurses' note dated 08/02/23 at 9:44 A.M. revealed Resident #78 was found on the floor in her room trying to go to the bathroom without assistance. Her vital signs were obtained, and she was placed back into her wheelchair with her walker out of reach. No injuries were observed. Review of the fall investigation dated 08/03/23 did not indicate if the Dycem was in place, anti-rollbacks were in place on the wheelchair, or when she was last offered to be toileted. Interview on 08/24/23 at 12:57 P.M. with the DON verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 08/03/23. Review of the nurse's note dated 08/04/23 at 7:00 A.M. revealed Resident #78 was found on the floor in her room in front of her wheelchair. She stated she slid out of her wheelchair. The Dycem was then placed in the wheelchair. She sustained an injury to her right elbow. Interview on 08/24/23 at 12:57 P.M. with the DON verified the fall was not investigated, and the Dycem was not in use at the time of the fall on 08/04/23. Review of the undated facility policy titled Resident Falls revealed the facility would implement systems to minimize the likelihood of falls and falls would be reviewed to determine the potential cause.

Based on record review, interview, and facility policy review the facility failed to ensure a prescribed antibiotic was not given for more than 14 days without a rationale. This affected one resident (#15) of five residents reviewed for unnecessary medications. The facility census was 104. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included dry eye syndrome, anxiety, paraplegia, and corneal ulcer to the right eye. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact. She required extensive assistance of one person for transfers, bed mobility, dressing, toilet use, and hygiene. Review of the physician's orders for August 2023 revealed an order for Refresh Plus Solution one drop in both eyes four times a day (QID), Restasis 0.05 % one drop in both eyes one time a day (QD) and Moxifloxacin HCl ophthalmic drop (used to treat infections of the membrane that covers the outside of the eyeballs and the inside of the eyelids) in both eyes twice per day (BID) which began on 07/12/23. Review of the medical record revealed no evidence the physician provided a rationale for the continued use of the Moxifloxacin past 14 days. Review of the drug information located at drugs.com revealed Moxifloxacin should be used for a duration of seven days. Interview on 08/23/23 at 2:41 P.M. with the Director of Nursing (DON) confirmed there was no stop date listed or no rationale for the continued use of the Moxifloxacin. Review of the undated facility policy titled Antibiotic Stewardship-Prescribing Antibiotics revealed antibiotics would include frequency, duration and a stop date.

Based on record review, interview, and facility policy review the facility failed to ensure non-pharmacological interventions were utilized, failed to ensure anti-anxiety medications were used for the intended purpose and not used for longer than 14 days without a rationale. This affected three residents (#48, #71, and #94) of five residents reviewed for unnecessary medications. The facility census was 104. Findings include: 1. Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included Lupus, psychosis, anxiety, fibromyalgia, chronic kidney disease, and arthritis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact. She was totally dependent on two people for transfers, required extensive assistance of two people for bed mobility and toilet use and extensive assistance of one person for dressing and hygiene. Review of the physician's orders for August 2023 revealed Resident #48 was ordered Ativan 0.5 (antianxiety) milligrams (mg) one tablet by mouth (PO) two times a day (BID) for anxiety and Ativan 0.5 mg every eight hours as needed (PRN) for anxiety which began 03/03/23. Review of the Medication Administration Record (MAR) for May, June, and July 2023 revealed Resident #48 received PRN Ativan on 05/27/23, 06/21/22, 06/22/23, 07/07/23, 07/11/23, 07/13/23, 07/14/23 and 07/21/23. Review of the medical record revealed no documented evidence non-pharmacological interventions were attempted prior to the administration of PRN Ativan and no documented evidence the physician provided a rationale for the continued use of Ativan. Interview on 08/23/23 at 2:50 P.M. with the Director or Nursing (DON) confirmed non-pharmacological interventions would be documented in MAR or a nursing progress note. She confirmed there was no stop date for the PRN Ativan and the physician had not provided a rationale for its continued use. Review of the undated facility policy titled Psychotropic medications revealed residents receiving psychotropic medications would be reviewed for non-pharmacological interventions and PRN psychotropic medications were limited to 14 days, unless the physician documented a rationale for continued use and indicated the duration of time the medication would be used. 47568 2. Review of the medical record for Resident #94 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease with late onset, dementia, anxiety disorder, depression, and insomnia. Review of the admission MDS assessment dated [DATE] revealed Resident #94 had severe cognitive impairment. The MDS assessment also indicated Resident #94 received three days of antianxiety medications during the seven-day assessment reference period. Review of the physician's orders for August 2023 identified an order for Ativan 0.5 mg every four hours PRN for anxiety and agitation. The Ativan order was dated 06/09/23 and duration was marked as indefinite. Review of Resident #94's MAR for July 2023 revealed Resident #94 received PRN Ativan seven times during the month. Review of the MAR for August 2023 revealed Resident #94 received PRN Ativan ten times during the month. Review of Resident #94's progress notes from 07/01/23 to 08/24/23 revealed no documented evidence that non-pharmacological interventions were attempted prior to administering PRN Ativan. Review of the physician progress notes for Resident #94 dated 06/13/23, 07/26/23, and 08/10/23 revealed no rational or duration indication to extend PRN Ativan order past 14-day duration. Interview on 08/24/23 at 12:15 P.M. with Unit Manager #507 confirmed Resident #94's PRN Ativan had a duration marked indefinite with no physician documentation for indication for extended duration. Unit Manager #507 further confirmed there was no documented evidence that non-pharmacological interventions were attempted prior to administration of PRN Ativan. Review of the undated policy titled Psychotropic Medications revealed non-pharmacological interventions will be used in conjunction with the psychoactive medication. PRN orders for psychotropic drugs are limited to 14 days, unless the practitioner believes that it is appropriate to extend beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN orders. 3. Review of the medical record for Resident #71 revealed an admitted [DATE]. Diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, unspecified psychosis, and delusional orders. Review of the quarterly MDS assessment dated [DATE] revealed Resident #71 had severely impaired cognition and other behavioral symptoms not directed toward others. The resident received antipsychotic and antidepressant medications. Review of the physician orders for August 2023 revealed Resident #71 was ordered Ativan 0.5 mg PRN for anxiety. Give 20 minutes prior to nail cutting. The order began 09/16/22. No end date was specified. Review of the MARs June, July, and August 2023 revealed Ativan 0.5 mg was given to Resident #71 on 06/08/23, 06/09/23, 06/11/23, 06/29/23, 07/06/23, 07/07/23, 07/24/23, 08/01/23, 08/13/23, and 08/21/23. Review of the medication review from the psychiatric follow-up visits on 07/06/23, 03/16/23, and 12/15/22 revealed Ativan 0.5 mg was to be given 20 minutes prior to nail cutting. Review of the nursing progress notes dated 06/08/23, 06/09/23, 06/11/23, 06/29/23, 07/06/23, 07/07/23, 07/24/23, 08/01/23, 08/13/23, and 08/21/23 for Resident #71, the dates Ativan was given, revealed no documented evidence of nail cutting. Anxiety, yelling out, resident restless yelling and screaming, increased anxiety patient yelling out, anxious; screaming out, given for yelling out and agitation, and yelling out behavior were what was noted. Non-pharmacological interventions were only documented on 06/11/23 and 7/24/23. Interview on 08/24/23 at 3:19 P.M. with Unit Manager/Licensed Practical Nurse (LPN) #595 verified the Ativan was used PRN without an end date and non-pharmacological interventions were not consistently documented. 37097

Based on record review and staff interview the facility failed to ensure its facility assessment contained necessary required information. This had the potential to affect all 104 residents residing in the facility. Findings include: Review of the facility assessment dated [DATE] with a cover letter reading for the year of 2023, revealed it did not contain the following required information: Information related to facility staffing level needs, evaluation of any contracts, memorandums of understanding including third party agreements for the provision of goods, services, or equipment to the facility during both normal operations and emergencies. An evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff available to meet each resident's needs. Information regarding the facility's resources which include supplies, equipment, or other services necessary to provide for the needs of residents. Information regarding a competency-based approach to determine the knowledge and skills required among staff to ensure residents were able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. On 08/24/23 at 2:06 P.M. interview with the Administrator verified the facility assessment did not contain all the required information as noted above.

Based on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assurance (QA) Committee. This had the potential to affect all residents. The facility census was 104. Findings include: Review of the facilities sign-in sheet for the QA meeting minutes for the meetings held on 10/19/22, 02/27/23, 04/09/23 revealed no documented evidence the medical director attended the meetings. Interview with the Administrator on 08/24/23 at 2:06 P.M. verified the medical director did not attend the QA meetings as required.

Based on observation, interview, record review and review of the facility policy, the facility failed to provide scheduled showers for three residents, Resident #301, #302, and #303 and the facility failed to provide personal hygiene, shaving and grooming, for two residents, Resident #301 and #302 of three residents reviewed. The facility census was 106. Findings include: 1. Record review for Resident #303 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #303 was rarely or never understood. Resident #303's long term memory was ok. Resident #303 had short term memory problems. Resident #303 required extensive assistance of two for bed mobility, dressing, and personal hygiene, extensive assistance of one for toilet use, total dependence for transfers, locomotion, and bathing, and supervision for eating with set up assistance. Resident #303 used a wheelchair for mobility and was always incontinent of bowel and bladder. Record review of the care plan dated 07/18/22 included Resident #303 had an activities of daily living self-care performance deficit related to impaired balance and musculoskeletal impairment. Interventions included Resident #303 required one staff participation with bathing and personal hygiene. Record review of the facility shower sheets for July and August 2022 revealed Resident #303 was to receive two showers/baths per week (Mondays and Thursdays). Record review reveled Resident #303 did not receive a shower or bed bath the week of 07/24/22 through 07/30/22 and only received one shower/bed bath the week of 07/31/22 through 08/06/22 and one shower/bed bath the week of 08/07/22 through 08/13/22. Review of the nurses notes dated 07/24/22 through 08/14/22 revealed no documentation revealing Resident #303 refused showers, or bed baths. Interview on 08/15/22 at 3:00 P.M. with DON verified the shower sheets for Resident #303 were accurate. 2. Record review for Resident #301 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS dated [DATE] revealed Resident #301 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 revealing Resident #301 was cognitively intact. Resident #301 required extensive assistance of one person for bed mobility, two persons for transfers, one-person physical assist for personal hygiene, and was total dependence for bathing. Record review of the care plan dated 07/02/22 revealed Resident #301 had an activity of daily living self-care performance deficit related to weakness. Record review of the facility shower sheets for July and August 2022 revealed Resident #301 received two showers/bed baths per week (Wednesdays and Saturdays). Resident #301 did not receive a shower or bed bath on 07/30/22 or 08/10/22. Record review of the shower sheet dated 08/13/22 had no State tested Nurse Aide (STNA) signature confirming a shower or bed bath was given. Review of the record revealed Agency Nurse, Licensed Practical Nurse (LPN) #307 signed the bottom of the sheet dated 08/13/22 under charge nurse. Review of the nurses notes dated 07/30/22 through 08/14/22 revealed no documentation revealing Resident #302 refusing showers, grooming or bed baths. Interview on 08/15/22 at 10:31 A.M. with Resident #301 revealed Resident #301 ' s hair was disheveled, and his face was unshaven. Resident revealed he preferred to be shaven daily, but the staff did not always assist him. Resident #301 revealed he had not received a shower in two weeks. Resident confirmed he never refused showers revealing the staff sometimes do not ask him and he did not want to be any trouble because he knew they were busy so he would not ask. Residents wife was also present and confirmed Resident #301 had not received a shower in two weeks. Observation on 08/15/22 at 12:10 P.M. of Resident #301 revealed Resident #301 ' s face was still unshaven. Interview on 08/15/22 at 12:15 P.M. with STNA #242 verified Resident #301 ' s face was unshaven and confirmed Resident #301 did not refuse to be shaven this A.M. Interview with DON on 08/15/22 at 3:00 P.M. revealed STNA's do the resident showers. The nurses sign the sheet at the bottom. DON confirmed she could not verify by the sheet Resident #301 received the shower on 08/13/22 because the STNA did not sign it and the sheet was incomplete. 3. Record review for Resident #302 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] revealed Resident #302 had a BIMS score of 8 revealing Resident #301 was moderately cognitively impaired. Resident required extensive assistance of two for bed mobility, extensive assistance of one for transfers, one-person physical assist for personal hygiene, and total dependence for bathing. Record review of the care plan dated 06/22/22 revealed Resident #302 had an activity of daily living self-care performance deficit related to fatigue and weakness. Interventions included Resident #302 required one staff participation for personal hygiene and bathing. Record review of the facility shower sheets for July and August 2022 revealed Resident #302 was to receive showers two days a week, Tuesdays and Fridays. Record review revealed Resident #302 did not receive a shower or bed bath on 07/12/22 or 08/02/22. Review of the nurses notes dated 07/12/22 through 08/02/22 revealed no documentation revealing Resident #302 refusing showers, grooming or bed baths. Observation and interview on 08/15/22 at 12:13 P.M. revealed Resident #302 had facial hair appearing as a full beard and mustache grown out and her hair was disheveled. Resident #302 revealed she wanted to be shaved. Resident revealed if she does not get shaved her facial hair grows. Resident revealed the staff tell her they don ' t like to shave her, occasionally an STNA will shave her but most will not. Resident revealed it had been a long time since she was shaved. DON verified Resident #302 had facial hair appearing as a full beard and mustache and confirmed Resident #302 should have been shaved. Interview on 08/15/22 at 12:20 P.M. with STNA #242 revealed she must have overlooked the facial hair on Resident #302 revealing Resident #302 was a woman and she did not want to offend her. Interview on 08/15/22 at 12:28 P.M. with STNA #229 revealed Resident #302 allowed staff to shave her. STNA #229 revealed Resident #302 should be shaved daily and when she worked her hall, she was able to shave her with no trouble. Resident #302 never refused to be shaved. Interview on 08/15/22 at 3:00 P.M. with the DON confirmed Resident #302's shower sheets were accurate. Review of facility policy titled Activities of Daily Living, undated, revealed it is the policy of the Community to ensure activities of daily living are provided in accordance with acceptable standards of practice, the care plan, karex, and resident choices and preferences. This deficiency substantiates complaint number OH 678.

Based on record review and interview, the facility failed to answer call lights for residents requiring assistance in a timely manner. This had the potential to affect all residents who activated their call lights for assistants. The facility census was 106. Findings include: Interviews on 08/15/22 from 10:10 A.M. through 12:43 P.M. with Resident #301, #302, #304, #305, #308, #309, #311, and #312 revealed call lights were not answered timely and at times took one to two hours to answer. Interviews on 08/15/22 between 10:28 A.M. and 08/17/22 at 12:46 P.M. with State tested Nurse Aide (STNA) #255, #138, Registered Nurse (RN) #148, and Nurse Manager #183 confirmed call lights were not answered timely either due to the system failure or agency staff moving slowly to respond. Interview on 08/15/22 at 11:37 A.M. with RN #148 revealed the new call light system no longer blinked above the resident ' s door when activated. The call light signal went to a phone each nurse and STNA carried with them. RN #148 revealed at times it was difficult to know when the signal went off because the phone did not always work. The phones needed charged. The chargers were located at each nurses station and many times they disappeared so there was no way to charge the phone. RN #148 revealed at times staff brought their own phone charger in, otherwise they would not know when a resident activated their call light. Observation and interview on 08/15/22 at 12:46 P.M. with Nurse Manager #183 revealed there was enough staff to complete tasks but at times it took an hour to answer call lights due to issues with the phones used for the call light system. Observation with Nurse Manager #183 of the charging station in the nursing office (one of three) revealed there was one charger to charge the phones used for the call light system. Nurse Manager #183 revealed there were two nurses and three STNA ' s who would need to charge their phones. Nurse Manager #183 revealed there were originally five charges at the station, but they disappeared, and the phone would not work if they were not kept charged. Observation and interview on 08/15/22 at 12:55 P.M. with RN #148 at Nursing Station two of three revealed there were only two end plugs with no cords attached for staff to charge the phones used for the call light system. RN #148 verified there were two nurses and three STNA ' s assigned to this area, and this was where they would charge their phones for the call lights. RN #148 revealed the cords and chargers disappear and are not available for staff to charge the phone and the phone dies. Interview on 08/15/22 at 3:15 P.M. with Administrator revealed with the current call system the call light goes to a phone provided by the facility that each nurse and STNA carried during their shift. When a resident activated their call light, that would alert the staff of the room number and time the call light was activated. Administrator confirmed the above the door signals were disconnected with the new system and the only way to alert staff the call light was activated, was through the phone. Interview on 08/17/22 at 4:50 P.M. with DON revealed the response time for a call light would be different depending on each situation and the resident's safety would be forefront. DON confirmed her response on 08/15/22 at 3:00 P.M. was call lights should be answered within 15 minutes. DON confirmed she has had family and resident concerns who brought to her attention of the long call light times. Record review dated 08/10/22 through 08/15/22 of the electronic call light response times provided by the Administrator revealed of the total 590 call lights activated from 08/10/22 through 08/15/22; 87 took 30 minutes to one hour to respond (throughout each shift), 29 took one hour up to two hours to respond (throughout each shift), four took two to three hours to respond and two were greater than three hours. Review of facility policy titled, Resident Call System, undated, revealed when activated, an alert is sent to the Associates ' receiving device, e.g. phone or pager, and the residents room number will be displayed. If the STNA is unable to respond to the alert, then the nurses ' device will be activated. If nurse does not respond to the alert, then the supervisor ' s alert will be activated. Resident call system must be canceled in the resident ' s room, bathroom or the pendant. The deficiency substantiates complaint number OH 678

Based on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate care and services were provided and physicians orders were followed to ensure one resident's (Resident #89) pain was addressed. Actual Harm occurred on 12/31/21 at 6:00 P.M. when Resident #89 was admitted to the facility from the hospital following surgery of a right above the knee amputation, the physician orders were not followed for pain medication, and Resident #89 had to be transported back to the hospital emergency department on 12/31/21 at 10:10 P.M. by Emergency Medical Services (EMS) for control of severe pain. This affected one out of three residents reviewed for pain. The facility census was 98. Findings include: Review of Resident #89's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #89's Hospital Discharge Instructions printed by the facility on 12/31/21 at 2:42 P.M. revealed Oxycodone ([MEDICATION(S)]) IR (immediate release) 5 milligram (mg), take one to two tablets every four hours as needed for pain. Last time oxycodone was given to Resident #89 at the hospital was 12/31/21 at 8:04 A.M. Review of the After Hours On-Call schedule for 12/31/21 revealed MD #570 was on-call for Admission Notifications. Review of Resident #89's progress notes written on 12/31/21 at 9:12 P.M. by an unidentified staffing agency nurse revealed Resident #89 arrived at the facility from the hospital at approximately 6:00 P.M., had surgery on 12/29/21 for an above the knee amputation of her right leg, shrinker (dressing) was in place covering surgical area, resident was alert and oriented to time, place, and person. Resident #89 stated she had a pain score of 10 out of 10 (10 being the worst pain) and required total assistance with all activities of daily living. Resident #89 was given Tylenol. Resident #89 arrived without proper paperwork and a call was placed to the medical doctor (name not specified) for further instructions. Review of Resident #89's medical record revealed no evidence Resident #89's physician was reached regarding further instructions for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record contained no evidence of the time Tylenol was administered or the effectiveness of the medication. Review of Resident #89's progress notes on 12/31/21 at 9:56 P.M. revealed Resident #89 requested to be transferred to the Emergency Department due to uncontrolled pain. Resident #89 was sent via 911 to the local hospital Emergency Department. Review of Resident #89's Prehospital Care Report Summary, dated 12/31/21, from the local fire department included a 911 call was received from the facility at 9:40 P.M., Emergency Medical Services (EMS) were dispatched and arrived at the facility at 9:47 P.M. The report stated Resident #89 arrived at the facility at 6:00 P.M. and the facility did not get a report from the hospital and had no orders for Resident #89. Calls to Resident #89's physician were not returned, Resident #89 complained of pain and tightness in the right leg and had a right above the knee amputation two days ago at the local hospital. Resident #89 was transported to a local hospital emergency department and arrived at 10:10 P.M. Review of Resident #89's Minimum Data Set (MDS) 3.0 assessment, dated 01/05/22, revealed Resident #89 required the extensive assistance of one staff member for bed mobility and personal hygiene, and required the extensive assistance of two staff members for transfers and toilet use. Resident #89 was always incontinent of urine and bowel. Observation on 01/19/22 at 11:57 A.M. revealed Resident #89 was lying in bed watching television. Resident #89 had a right above the knee amputation, staples intact, skin slightly reddened with a small amount of swelling around staples, and scabbing was noted. Interview on 01/19/22 at 11:57 A.M. with Resident #89 revealed she had an infection and her leg was amputated late in the day on 12/29/21 at a local hospital, she was transported to the facility on [DATE], and the hospital did not send a prescription for pain. Resident #89 stated she was in so much pain, she had to be transported to the local emergency department. Resident #89 stated she was really upset because her leg hurt and she needed the pain medication. Interview on 01/19/22 at 2:19 P.M. with Interim Director of Nursing (IDON) #568 revealed she tested positive for COVID-19 on 12/29/21 and was out of the facility for eleven days. IDON #568 stated she did not receive calls regarding residents, including Resident #89, during the time she was out with COVID-19, and Infection Preventionist (IP) #523, Corporate Nurse #571, and the Administrator received calls from staff regarding residents. Interview on 01/20/22 at 10:44 A.M. with Nurse Practitioner (NP) #566 revealed she worked with Medical Doctor (MD) #567. NP #566 stated she did not receive calls regarding residents when they were admitted to the facility, and the call regarding Resident #89 would be to MD #567 because the physician orders upon admission would be verified by the primary physician. NP #566 confirmed she did not receive calls regarding Resident #89 on 12/31/21. Interview on 01/20/22 at 10:50 A.M. with MD #567 revealed she tested positive for COVID-19 at the end of 12/2021 and was not working 12/31/21 and was not on-call that weekend. MD #567 stated MD #570 was on-call for long term care on 12/31/21. Interview on 01/20/22 at 1:18 P.M. with Interim Director of Nursing (IDON) #568 revealed she was unable to provide staff assignment sheets for 12/31/21 due to Scheduler #569 recently quit working at the facility and IDON #568 was not able to find the staff assignment sheets for 12/31/21. Interview on 01/20/22 at 1:39 P.M. with IDON #568 and Infection Preventionist (IP) #523 revealed the facility would accept a resident if they did not arrive with discharge instructions from the hospital, that did not happen often, and they would call the hospital to have the paperwork faxed to the facility. If a resident was in pain, the resident's primary physician would be notified, the physician would call pharmacy, and the pharmacy would give a code to the nurse, allowing the nurse to take a controlled medication for pain out of the contingency cupboard at the facility and administer it to the resident. IDON #568 and IP #523 stated they did not receive a phone call on 12/31/21 regarding Resident #89. Interview on 01/20/22 at 2:12 P.M. with Admissions Manager (AM) #531 revealed on 12/31/21 she placed Resident #89's admission notification on the front of her clinical information, definitely had the hospital information, and took it back to the unit Resident #89 would be residing on. Resident #89 did not want to transition from the skilled nursing unit to the long term care unit she would be residing on, and requested to be admitted to her long term care room. AM #531 stated she went to Resident #89's long term care unit, spoke to an unidentified day shift nurse from a staffing agency to inform her she had Resident #89's paperwork, and asked the day shift nurse if she would like to review the paperwork with her. The day shift nurse stated she was too busy to review the paperwork. AM #531 stated she went back to Resident #89's long term care unit around 3:30 P.M. to speak with the nurse who would be admitting Resident #89 to the facility, because she wanted to make sure everything would go smoothly with the admission. AM #531 stated she found the nurse who would be admitting Resident #89, she was a nurse from a staffing agency, AM #531 did not know her name, and the nurse told her she was too busy to review Resident #89's paperwork. AM #531 told the nurse she left the admission paperwork on the counter at the nurse's station. Interview on 01/24/22 at 1:10 P.M. with AM #531 revealed she printed Resident #89's discharge instructions from the hospital on 12/31/21 at 2:42 P.M. and took them to the agency nurse who would admitting Resident #89 to the facility, the nurse was too busy to review the paperwork, and AM #531 left the paperwork on the counter at the nurse's station. AM #531 stated if there were any questions she could have been called, but she did not receive a call from the admitting nurse or the house charge nurse (HCN) regarding Resident #89's hospital discharge instructions. Interview on 01/24/22 at 1:40 P.M. with MD #570 revealed he was on-call 12/31/21 for the facility and did not remember a call regarding Resident #89. MD #570 stated he did not receive any text messages or phone calls from the facility regarding Resident #89's hospital paperwork. MD #570 stated if he was called because a resident had no paperwork he would advise them to call the hospital to have it faxed to the facility, and if he was called because a resident was in pain he would have the pharmacy call him for a pain medication order. MD #570 stated if he received this information he would have signed it out to the team, but checking his records for 12/31/21 and the only message he received was Resident #89 arrived to the facility and he signed Resident #89's arrival out to the team. MD #570 stated he saved all his text messages, double checked them and was not texted regarding Resident #89 having no discharge instructions or needing pain medication. Interview on 01/25/22 at 11:15 A.M. with State tested Nursing Assistant (STNA) #470 revealed on 01/01/22 she worked 7:00 A.M. through 3:30 P.M., and after introducing herself to Resident #89, she found Resident #89's hospital discharge instructions in a big white envelope on the night-stand underneath Resident #89's tablet personal computer. Interview on 01/27/22 at 10:11 A.M. with Administrator revealed he did not remember meeting with LPN #561 regarding Resident #89's discharge instructions, but it was discussed in the management morning meeting. There were no notes from the morning meetings, but the discharge instructions were left at Resident #89's bedside table by an ambulance driver. Interview on 01/27/22 at 10:43 A.M. with DON revealed if an on-call nurse practitioner for MD #567 received a call regarding Resident #89's admission to the facility, the nurse practitioner would contact the facility to inform the nurse of the need to call a physician regarding Resident #89's admission. Review of the facility policy titled, Pain, undated, revealed the purpose was to ensure resident's pain was addressed in a timely manner. The report included to complete a pain assessment on admission and readmission, incorporate a resident interview in the pain assessment as well as observations regarding pain characteristics, notify the physician and as appropriate obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] This deficiency substantiates Complaint Number OH 009.

Based on observation, interview, record review, and facility policy review, the facility failed to consistently provide a functioning call light system to ensure care and services were provided for the residents. This had the potential to affect all the residents residing in the facility. The facility census was 98. Findings include: Interview on 01/25/22 at 11:39 A.M. with Resident #31 revealed the call light system did not work correctly. Resident #31 stated she would activate her call light and no staff would come to assist her. Observation of Resident #31 revealed she pressed her call light for staff assistance and no nurse or State tested Nursing Assistant (STNA) entered the room to answer the call light. Observation on 01/25/22 at 11:50 A.M. of STNA #575 revealed she entered Resident #31's room carrying a meal tray. STNA #575 stated she was assigned to care for Resident #31 today, and when asked if Resident #31's call light registered on the call light cell phone, STNA #575 looked at her phone, stated Resident #31's call light did not register on her phone, and showed the surveyor the call was not displayed on the phone screen. STNA #575 stated she did not know Resident #31 activated her call light until the surveyor mentioned it. STNA #575 revealed sometimes when resident's activated their call lights it did not show up on the phone, and she would have to exit out of the call light app on her phone, clear the phone, then tap on the icon to re-open the call light application, and most of the time when she did this it would work. STNA #575 stated often when she tapped on the call light icon, the phone screen would show the app was loading for a while, and the phone screen would return to the app without loading into the system. STNA #575 stated she told the facility management there was a problem with the call light cell phones, but did not remember the name of the staff she talked to. Interview on 01/25/22 at 12:01 P.M. with Resident #31 revealed she put her call light on sometimes and the staff would tell her it did not register on their phones. Resident #31 stated this happened one to two days ago. Observation on 01/25/22 at 12:39 P.M. of Resident #57's call light revealed the call light was pressed at 12:39 P.M. and STNA #476 entered Resident #57's room at 1:03 P.M. to provide assistance to Resident #57. STNA #476 confirmed Resident #57's call light was activated at 12:39 P.M. on her cell phone. Review of the facility Alarm Average Response Time Report for 01/25/22 did not reveal Resident #57's call light was activated at 12:39 P.M. and it took 24 minutes for staff to turn the call light off and provide care for Resident #57. The report did not have any documentation on 01/25/22 Resident #57 activated her call light. Interview on 01/26/22 at 1:30 P.M. of the Administrator and Director of Nursing (DON) confirmed there was no documentation on the Alarm Average Response Time Report on 01/25/22 Resident #57's call light was activated at 12:39 P.M. or response time noted. Interview on 01/25/22 at 1:18 P.M. with Licensed Practical Nurse (LPN) #580 revealed she did not receive a call light cell phone when she arrived for work at 7:00 A.M., she usually worked on the second floor skilled nursing unit, and stated she never provided with a call light cell phone when she worked at the facility. LPN #580 stated the State tested Nursing Assistants (STNA)'s carried the phones. Interview on 01/25/22 at 1:29 P.M. with LPN #561 confirmed she heard LPN #580 state she did not have a call light cell phone and never carried one. LPN #580 stated all nurse's should have call light cell phones, it really helped, because the nurse's could monitor the call lights, and notify the STNA's a resident's call light was activated. LPN #561 stated the facility recently ordered more phones, and there were enough call light cell phones for all the nurse's and STNA's to carry them. Interview on 01/25/22 at 1:39 P.M. with Family Member (FM) #578 revealed Resident #26's call light often did not get answered. FM #578 stated there were a lot of staffing agency nurse's and STNA's who worked in the facility and they did not know how to use the cell phones they were given for the call light system. FM #578 stated the agency staff told her they did not know how to log-in to the system, and were so busy they did not take the time to figure it out. FM #578 stated the call light phones did not always work and would kick the staff out of the system, and the staff would not be able to see which resident call lights were on. FM #578 stated on 01/10/22 the system was down, and she was not sure if the system was only down on the nursing unit Resident #26 resided on or the entire facility. FM #578 stated she talked to Interim Director of Nursing (IDON) #568 around 5:00 P.M. on 01/10/22 and told her Resident #26's call light had been on all day and no staff answered the light. IDON #568 checked the call lights, found there was a problem and re-booted the system. Interview on 01/25/22 at 2:02 P.M. with Facilities Manager #534 revealed the facility upgraded the resident call light system about a year ago, and lights no longer lit up above resident doorways or showed up on a panel at the nurse's station when they were activated. Facilities Manager #534 stated residents pressed their call light, the signal was activated on cell phones all staff carried to alert them a resident needed assistance. Each unit had call light cell phones assigned specifically to that unit and should not be carried to other units. Facilities Manager #534 revealed if a call light remained unanswered the signal was activated on a manager's phone, and would travel up the chain of command depending on how long the call light remained unanswered. Interview on 01/25/22 at 2:34 P.M. with Informational Technologist Manager (IT) #532 revealed he was not aware of any situations where the call light system was not working and no staff had informed him the call light system was not working properly. IT #532 stated there was a scheduled call light system update on 12/08/21, and the system was down for a very short time until the update was completed. IT #532 stated he did not re-boot the system in January or know of any issues with the call lights. IT #532 stated he did not contact the vendor for call light problems. IT #532 stated he did not run reports on the system or check on a routine basis to make sure the call light system was functioning appropriately. Interview on 01/25/22 at 3:00 P.M. with State tested Nursing Assistant (STNA) #481 revealed every once in a while there was a glitch in the call light system. STNA #481 stated sometimes when she checked her call light phone it would show that she was not logged onto the server and there was no way to tell how long her phone wasn't connected to the server. STNA #481 stated another problem with call light phone was when the call light icon was tapped, the phone would show the icon was loading, it would load for awhile then go back to the original screen without loading the call light information. This happened at least once per shift and usually more, and she had to keep tapping the icon and fiddling with the phone to get the system to work. STNA #481 stated it took different amounts of time before the call light system worked on her phone. When this happened STNA #481 made rounds on the residents to make sure everyone was alright. Observation on 01/25/22 at 3:00 P.M. of STNA #481's call light phone revealed she tapped the call light icon, the phone would show the application loaded for five to ten seconds, then the phone would show the icon again without entering the system, and this continued for three cycles before the call light phone showed which resident call lights were activated. Interview on 01/25/22 at 3:15 P.M. with Licensed Practical Nurse (LPN) #579 revealed he usually worked on the second floor skilled nursing unit. LPN #579 stated residents complained to him about their call lights not being answered. LPN #579 stated sometimes the STNA's working for a staffing agency did not know how the call light phones worked and took phones from one nursing unit to another, did not properly log-on and the phones did not work appropriately. Interview on 01/25/22 at 3:20 P.M. with Registered Nurse (RN) #526 revealed in the past month or so she worked without a cell phone because there were not enough to go around. RN #526 stated the facility ordered more phones and now there enough for all the staff. RN #526 revealed residents told her their call lights were not being answered, and when she checked her phone the activated resident call light did not register on the phone, and she did not know a resident needed assistance. RN #526 revealed she could not remember which residents were affected, or if there were any negative affects from call lights not getting answered. Interview on 01/25/22 at 3:40 P.M. with IDON #568 revealed she spoke with FM #578 regarding Resident #26's call light not being answered. IDON #568 stated she could not remember the date she spoke with FM #578, but she spoke to her two or three times during the day regarding the call light system. IDON #568 stated she checked the system and the call lights were activated in three resident rooms, but did not show up on the call light pagers. IDON #568 stated she could not remember what residents were affected or the room numbers but three residents on the second floor skilled nursing unit were immediately provided with one-to-one care by the staff until the system was working. IDON #568 stated she kept the residents on one-to-one care until at least the next day and had to justify to the Administrator why she felt it was necessary to provide the one-to-one care. IDON #568 stated she notified the Administrator and IT #532 of the call light issues. IDON #568 stated this was not the first time there was an issue with call lights, but could not give dates when the call light system was not working. Interview on 01/26/22 at 12:07 P.M. with Administrator revealed some of the call light cell phones were not syncing with the system and needed re-booted. The Administrator stated he could not remember the date this happened, but it was not a big problem and was handled quickly. The Administrator revealed when the call lights were activated by the residents, it was not showing up on the phones, the phones were turned off, restarted and then the call lights registered on the call light phones. The Administrator stated he could not remember what units, or which residents were affected, and did not have any records or documentation regarding the call light cell phones needing rebooted. The Administrator stated he could not remember a day any residents needed one-to-one care because the call lights were not working. Although the Administrator was unaware of resident's needing one-to-one care because the call lights were not working he walked around the facility and checked every STNA's and nurse's call light cell phones to make sure they were working. The Administrator stated there was no written documentation regarding checking the phones. The Administrator stated the vendor was not contacted to check the system because the problem was identified and fixed. The Administrator revealed the only way the facility would know there was a problem with the system is if a resident stated they activated their call light, it was not answered, and staff could not find the call light on their phones. Review of Resident Council Minutes on 12/20/21 revealed one resident indicated they were not sure the call system was always working and requested IDON #568 to check to see if it was. IDON #568 indicated that she would work with the IT department to resolve any issues. Review of the facility policy titled, Resident Call System, undated, revealed the resident call system could be activated in the resident room, resident bathroom, or pendant for resident's who have been assigned one. When activated, an alert was sent to the Associates' receiving device, e.g. phone or pager, and the resident room number would be displayed. If the STNA was unable to respond to the alert, then the nurses' device would be activated. If nurse did not respond to the alert, then the supervisor's alert would be activated. Resident call system must be canceled in the resident's room, bathroom or the pendant.

Based on observation, interview, record review, facility policy review, the facility failed to ensure one resident's (Resident #99) responsible party was informed of a significant change in her condition. This affected one resident (Resident #99) out of three residents reviewed for notification regarding a change in condition. Findings include: Review of Resident #99's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #99 passed away at the facility on 11/07/21. Review of the Minimum Data Set (MDS) assessment, dated 09/12/21, revealed the resident had moderate cognitive impairment. Resident #99 required the extensive assistance of one person for bed mobility, transfers, toilet use, and was frequently incontinent of urine and bowel. Review of Resident #99's progress notes on 11/01/21 revealed Resident #99's evening medications were not administered because Resident #99 was too lethargic to swallow them. Routine [MEDICATION(S)] was administered. Review of Resident #99's progress notes on 11/02/21 revealed Resident #99 was not awake or alert enough to drink and swallow fluids. Resident #99 was not consuming food, and was not responding to verbal and tactile stimulation. A hospice nurse was in Resident #99's room and stated she would contact her daughter with an update. Review of Resident #99's progress notes on 11/01/21 did not reveal documentation the facility notified Resident #99's Family Member/Power of Attorney (FM/POA) #583 of Resident #99's change of condition. Review of Resident #99's hospice progress notes on 11/01/21 written by Licensed Social Worker #584 revealed Resident #99 was very tired and lethargic, would not eat lunch, aide assisted Resident #99 to lay down, and daughter (FM/POA #583) was notified. Interview on 01/26/22 at 2:53 P.M. with FM/POA #583 revealed on 11/01/21 Resident #99 was very lethargic and unresponsive to staff. FM/POA #583 stated she lived twelve minutes away from the facility and was not notified on 11/01/21 Resident #99 had a change in condition, and she was very upset no one called to notify her Resident #99 was lethargic and not responding. FM/POA #583 stated if she had been notified she would have immediately gone to the facility to visit Resident #99. Interview on 01/31/22 at 9:08 A.M. with Licensed Practical Nurse (LPN) #555 revealed she cared for Resident #99 on 11/02/21, had not cared for her for a few days, and she was more lethargic and non-responsive than she had been previously. LPN #555 stated an unidentified staffing agency nurse told her hospice contacted the daughter regarding Resident #99's condition, but LPN #555 did not know for sure if the daughter was notified. Review of the facility policy titled Notification And Reporting of changes in Health Status, Illness, Injury And Death Of A Resident revealed appropriate associates will promptly inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) regarding a significant change in the resident's physical, mental, or psychosocial status such as a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. This deficiency substantiates Master Complaint Number OH 356 and Complaint Number OH 009.

Based on observation, interview, record review, and facility policy review, the facility failed to provide care and services, follow physician orders and ensure care planned interventions were implemented for Resident's #31, #82 and #95. This affected three residents (Resident's #31, #82 and #95) out of three residents reviewed for care of dependent residents. Findings include: 1. Review of Resident #31's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #31's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed resident was cognitively intact and required extensive assistance of one staff member for bed mobility, transfers, personal hygiene and toilet use. Resident #31 was frequently incontinent of urine and bowel. Review of Resident #31's care plan. dated and revised 12/28/21, included Resident #31 had an activity of daily living (ADL) self care performance deficit related to dementia, fatigue, impaired balance, musculoskeletal impairment, [CONDITION(S)], history of [CONDITION(S)] with [CONDITION(S)]. Resident #31 would be able to participate in ADL tasks through the review date. Interventions included Resident #31 required one staff participation to use toilet. Resident #31 was at risk for falls related to confusion, deconditioning, gait and balance problems, [CONDITION(S)], incontinence, psychoactive drug use, unaware of safety needs. Resident #31 would have a reduced risk for falls through the review date. Interventions included to be sure Resident #31's call light was within reach and encourage to use it for assistance as needed, and alter or remove any potential causes of falls if possible. Observation on 01/24/22 at 11:26 A.M. of Resident #31 sitting in a wheelchair in the doorway to her room. Observation of Licensed Practical Nurse (LPN) #574 standing in the hall next to Resident #31's room near a medication cart. Resident #31 asked LPN #574 to help her because she needed to use the bathroom. LPN #574 stated I will tell an aide,, did not assist Resident #31, continued to stand near the medication cart and made no attempt to find an aide to assist Resident #31. After a few minutes LPN #574 walked down the hall, turned a corner and could no longer be seen. Observation on 01/24/22 at 11:29 A.M. of Resident #31 revealed she turned her wheelchair around in the doorway very slowly, with quite a bit of difficulty and began to move toward the bathroom. Observation on 01/24/22 at 11:35 A.M. of Resident #31 opening the bathroom door in her room with difficulty and maneuvering her wheelchair into the bathroom. Observation of Resident #31 attempting to transfer onto the toilet without assistance. Observation on 01/24/22 at 11:39 A.M. of LPN #574 revealed she was walking in the hallway toward the medication cart. When asked if she found assistance for Resident #31, LPN #574 stated she did not tell a State tested Nursing Assistant (STNA) Resident #31 needed assistance to the bathroom. Observation on 01/24/22 at 11:40 A.M. of STNA #575 walking in the hall toward Resident #31's room. After surveyor intervention LPN #574 called to STNA #575 and asked her to assist Resident #31 in the bathroom. STNA #575 stated Resident #31 did not need her help in the bathroom, and 100 percent could take herself to the bathroom. LPN #574 insisted STNA #575 help Resident #31 and she entered Resident #31's bathroom and assisted her. Interview on 01/24/22 at 11:48 A.M. with Resident #31 revealed she often took herself to the bathroom, because when she needed to use the bathroom she could not wait a long time for assistance. Resident #31 stated she often waited a long time when she was in the bathroom, put the call light on, and needed staff to assist her back to her wheelchair and out of the bathroom. 2. Review of Resident #82's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #82's care plan, dated 08/02/21, revealed Resident #82 had an ADL self-care performance deficit related to [CONDITION(S)] and general muscle weakness. Resident #82 would maintain current level of function in ADL's through the review date. Interventions included Resident #82 required extensive staff participation of one person with bathing and showering. Review of Resident #82's MDS 3.0 assessment, dated 10/20/21, revealed the resident was cognitively intact and required extensive assistance of one staff member for bathing, and supervision with assistance of one staff member for dressing. Review of Resident #82's progress notes on 01/07/22 revealed resident tested positive for COVID-19 and was transferred to the COVID-19 nursing unit. Review of Resident #82's progress notes on 01/18/22 revealed resident was transferred from the COVID-19 nursing unit back to her room on the long term care nursing unit. Review of the STNA Report Sheet for the long-term care nursing unit Resident #82 resided on revealed she was scheduled for bathing/showers on Tuesdays and Fridays and required extensive assistance of one staff person. Review of Resident #82's medical record from 01/07/22 through 01/18/22 did not reveal documentation resident was offered or refused to have a shower. Observation on 01/19/22 at 9:19 A.M. with LPN #555 of Resident #82 revealed she was laying in her bed with the television on. Resident #82 stated she was so happy to be back in her room on the long-term care nursing unit where the staff was so friendly and helpful. Resident #82 stated she just returned from the COVID-19 nursing unit and had not had a shower for ten days. Resident #82 stated she wore the same pajamas for four days because no one would bring clothes for her to wear. Resident #82 revealed she washed herself in her room with minimal assistance of the STNA's on the COVID-19 unit, and when she asked if she could have a shower they said they would look into it and did not return to give her a shower. Resident #82 did not know the names of the STNA's who did not come back to give her a shower. Interview on 01/19/22 at 3:11 P.M. with STNA #476 revealed she often worked on the COVID-19 nursing unit and residents received showers unless they refused, but most residents wanted to stay in bed and have a bed bath. STNA #476 did not remember if Resident #82 received a shower or bed bath. Interview on 01/20/22 at 4:15 P.M. with Director of Nursing (DON) and Interim Director of Nursing (IDON) #568 revealed they were not aware Resident #82 did not receive a shower for ten days and would investigate the matter. No documentation was provided by the facility regarding Resident #82's showers. 3. Review of Resident #95's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #95's care plan, dated 10/01/21, included Resident #95 had an ADL self-care performance deficit. ADLs fluctuate at times related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #95 would maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the review date. Interventions included to check nail length and trim and clean on bath day and as necessary, report any changes to the nurse, and Resident #95 was dependent on one staff member with personal hygiene and oral care. Resident #95 was non-compliant with personal care; would make statements to nurse that he would allow care from STNA then when approached by STNA would refuse care, declined shaving at times (states he'll wait for daughter to come in to shave him). Interventions included Resident #95 would make well informed choices about accepting care after adequate staff education, and offer choice of alternate treatment or medication. Review of Resident #95's physician orders on 07/27/21 revealed nursing to monitor that Resident #95's fingernails were trimmed every day shift for skin integrity. Review of Resident #95's MDS 3.0 assessment, dated 12/07/21, revealed resident was cognitively intact and required extensive assistance of two persons for bed mobility, was totally dependent on two staff members for transfers, toilet use and bathing and required extensive assistance of one person for personal hygiene. Resident #95 was always incontinent of urine and bowel. Review of Resident #95's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #95's STNA task documentation in the medical record revealed a task to shave residents face every day shift. Review of Resident #95's medical record revealed no evidence Resident #95 was shaved on 01/02/22, 01/04/22, 01/07/22, 01/09/22, 01/10/22, 01/14/22, 01/15/22, 01/16/22, 01/17/22, 01/19/22, and 01/24/22. Review of Resident #95's medical record from 01/01/22 through 01/28/22 did not reveal documentation resident refused to be shaved and there were no refusal of trimming fingernails trimmed documented. Observation on 01/19/22 at 12:20 P.M. of Resident #95 revealed the resident was lying on his back with the head of his bed slightly elevated and had a slight stubble on his face, stated he was not shaved today but was shaved 01/18/22. Observation of Resident #95's fingernails revealed they were approximately one-quarter inch to one-half inch long, yellow in color, and had a brown gunky looking material underneath them. Resident #95 stated the nurse's cut his fingernails sometimes. Interview on 01/21/22 at 8:10 A.M. with Family Member (FM) #577 revealed she talked to the facility management staff many times regarding her fathers care. FM #577 stated he was not regularly shaved and his fingernails were not trimmed and cleaned often. Observation on 01/24/22 at 11:00 A.M. of Resident #95 revealed he had a quarter-inch stubble on his face and stated the staff shaved his face, but he could not remember the last day he was shaved. Observation of Resident #95's fingernails revealed they were approximately one-half inch long, yellow, and had brown material underneath the nails. Observation on 01/24/22 at 11:52 A.M. of Resident #95 revealed after intervention of the surveyor, STNA #576 shaved Resident #95, but his fingernails were still long, yellow and dirty. Interview on 01/24/22 at 2:12 P.M. the DON confirmed Resident #95's fingernails were long, yellow, and had a brown gunky substance underneath them. DON told LPN #555 to clean and trim Resident #95's fingernails. Review of the facility policy titled Activity of Daily Living, undated, included it was the policy of the community to ensure ADLs were provided in accordance with accepted standards of practice, the care plan and Kardex, and the resident's choices and preferences. Associates should refer to resident's care plan and Kardex for assistance required for ADLs, and resident's preferences and choices. Associates should report changes from baseline ADL status to nurse, including if resident chooses not to have ADLs performed. If resident chooses to not have ADLs performed, Associate should re-approach at a later time or discuss alternative times with the Resident. This violation substantiates Master Complaint Number OH 356, Complaint Number, OH 009, and Complaint Number OH 909.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure Resident #89 was free from significant medication error. This affected one resident (Resident #89) out of three residents reviewed for medications administered per physician orders. Findings include: Review of Resident #89's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #89's progress notes written at 9:12 P.M. on 12/31/21 by an unidentified staffing agency nurse revealed Resident #89 arrived at the facility from the hospital at approximately 6:00 P.M., had surgery on 12/29/21 for an above the knee amputation of her right leg, shrinker (dressing) was in place covering surgical area, resident was alert and oriented to time, place, and person. Resident #89 arrived without proper paperwork and a call was placed to the Medical Doctor (name not specified) for further instructions. Review of the After Hours On-Call schedule for 12/31/21 revealed MD #570 was on-call for admission notifications. Review of Resident #89's medical record revealed no evidence Resident #89's physician was reached regarding further instructions for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #89's medical record revealed she was sent to the hospital on 12/31/21 at 9:47 P.M. due to unrelieved pain, and returned to the facility on [DATE] at 4:00 A.M., again without discharge instructions. Review of Resident #89's progress notes on 01/01/22 at 6:51 A.M. written by House Charge Nurse/Licensed Practical Nurse (HCN/LPN) #564 revealed HCN assisted the unit nurse to try to obtain Resident #89's hospital discharge instructions. The hospital was unsuccessfully called two times for the discharge instructions to be faxed to the facility. After hours service for Medical Doctor (MD) #567 contacted, and no return call was received. A message was sent to MD #567 and the Director of Nursing (DON) to update regarding the situation. Awaiting further instruction on how to proceed with Resident #89's admission process. Review of Resident #89's progress notes on 01/01/22 at 9:30 A.M. written by LPN #561 revealed the hospital was called, admission paperwork was obtained, and MD #570 covering for MD #567 verified Resident #89's orders. Pharmacy was notified, and medications were obtained. Review of Resident #89's Hospital Discharge Instructions revealed the following orders: [MEDICATION(S)] ([MEDICATION(S)]) (anticoagulant) 40 mg per 0.4 milliliters (ml), start taking on 01/01/22, inject 0.4 ml subcutaneously every twenty four hours for four days; [MEDICATION(S)] ([MEDICATION(S)]) (hypertension) 40 mg tablet, take one tablet by mouth once daily, and the last time Resident #89 received [MEDICATION(S)] was 12/31/21 at 8:05 A.M.; [MEDICATION(S)] (antibiotic) 100 mg tablet, take one tablet by mouth twice daily for fourteen days; [MEDICATION(S)] (anticonvulsant) 100 mg tablet, take two tablets by mouth daily at bedtime; trazadone (antidepressant) 100 mg tablet, take one tablet by mouth daily at bedtime; [MEDICATION(S)] (antiparkinson agent) (Requip) 0.25 mg tablet, take 0.25 mg by mouth twice daily. On 01/06/22, Resident #89 was to start [MEDICATION(S)] ([MEDICATION(S)]) (anticoagulant) 5 mg tablet, take one tablet by mouth twice daily. Review of Resident #89's Medication Administration Audit Report, dated 12/31/21 through 01/01/22 revealed [MEDICATION(S)] [MEDICATION(S)] (antibiotic) 100 mg tablet, due 12/31/21 at 9:00 P.M. was not administered; [MEDICATION(S)] [MEDICATION(S)] (antibiotic) 100 mg tablet was due on 01/01/22 at 9:00 A.M. and not administered until 2:33 P.M.; trazadone [MEDICATION(S)] tablet 100 mg was due on 12/31/21 at 9:00 P.M. and not administered; [MEDICATION(S)] (Requip) tablet 0.25 mg was due on 12/31/21 at 9:00 P.M. and not administered; [MEDICATION(S)] 0.25 mg tablet was due on 01/01/22 at 9:00 A.M. and not administered; [MEDICATION(S)] 0.25 mg was due on 01/01/22 at 9:00 P.M. and not administered until 10:26 P.M. Review of Resident #89's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #89's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Resident #89 was not administered [MEDICATION(S)] 40 mg for three days. Review of Resident #89's progress notes from 12/31/21 through 01/03/21 did not reveal documentation pharmacy was contacted to have Resident #89's [MEDICATION(S)] delivered to the facility or a physician was notified medication not administered to the resident. Review of Resident #89's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #89's Medication Administration Audit Report dated 01/01/22 revealed [MEDICATION(S)] Tablet 5 mg ([MEDICATION(S)]), give 5 mg two times a day for right above the knee amputation was due at 9:00 A.M. and not administered until 2:34 P.M. Further review of the report revealed [MEDICATION(S)] Tablet ([MEDICATION(S)]) 5 mg was due on 01/01/22 at 9:00 P.M. and administered at 10:26 P.M. Review of Resident #89's Minimum Data Set (MDS) 3.0 assessment, dated 01/05/22, revealed Resident #89 required the extensive assistance of one staff member for bed mobility and personal hygiene, and required extensive assistance of two staff members for transfers and toilet use. Resident #89 was always incontinent of urine and bowel. Review of Resident #89's care plan, dated 01/24/22, revealed the resident had hypertension related to medications and Resident #89 would remain free of complications related to hypertension through review date. Interventions included to give anti hypertensive medications as ordered. Monitor for side effects such as [CONDITION(S)] and increased heart rate and effectiveness. Resident #89 used antidepressant medication related to depression and would be free from adverse reactions related to antidepressant therapy through the review date. Interventions included to give antidepressant medications ordered by physician and monitor and document side effects and effectiveness. Resident #89 received anticoagulant therapy related to [CONDITION(S)] and would be free from discomfort or adverse reactions related to anticoagulant use through the review date. Interventions included daily skin inspection and report abnormalities to the nurse, and monitor and document, and report to the physician signs and symptoms of anticoagulant complications. Resident #89 had [CONDITION(S)] and was at risk for complications and would remain free of further signs and symptoms of discomfort or complications related to [CONDITION(S)] through review date. Interventions included to give medications as ordered by the physician and monitor and document side effects and effectiveness. Observation on 01/19/22 at 11:57 A.M. revealed Resident #89 was lying in bed watching television. The resident had a right above the knee amputation, staples intact, skin slightly reddened with a small amount of swelling around staples, and scabbing noted. Interview on 01/19/22 at 11:57 A.M. with Resident #89 revealed she had an infection in her right leg for the last two years, and her leg was amputated late in the day on 12/29/21 at a local hospital. Resident #89 was transported to the facility on [DATE], and the hospital did not send her report and she was not given any medications after she was admitted to the facility. Interview on 01/19/22 at 2:19 P.M. with Interim Director of Nursing (IDON) #568 revealed she tested positive for COVID-19 on 12/29/21 and was out of the facility for eleven days. IDON #568 stated she did not receive calls regarding residents during the time she was out with COVID-19, and Infection Preventionist (IP) #523, Corporate Nurse #571, and the Administrator received calls from staff regarding residents. Interview on 01/20/22 at 10:44 A.M. with Nurse Practitioner (NP) #566 revealed she worked with Medical Doctor (MD) #567. NP #566 stated she did not receive calls regarding residents when they were admitted to the facility, and the call regarding Resident #89 would be to MD #567 because the physician orders upon admission would be verified by the primary physician. NP #566 confirmed she did not receive calls regarding Resident #89 on 12/31/21 and 01/01/22. Interview on 01/20/22 at 10:50 A.M. with MD #567 revealed she tested positive for COVID-19 at the end of 12/2021 and was not working 12/31/21 or 01/01/22 and was not on-call that weekend. MD #567 stated MD #570 was on-call for long term care on 12/31/21 and 01/01/22. Interview on 01/20/22 at 1:18 P.M. with Interim Director of Nursing (IDON) #568 revealed she was unable to provide staff assignment sheets for 12/31/21 or 01/01/21 due to Scheduler #569 recently quit working at the facility and IDON #568 was not able to find the staff assignment sheets for those days. Interview on 01/20/22 at 1:39 P.M. of IDON #568 and Infection Preventionist (IP) #523 revealed the facility would accept a resident if they did not arrive with discharge instructions from the hospital, that did not happen often, and they would call the hospital to have the paperwork faxed to the facility. IDON #568 and IP #523 stated they did not receive a phone call on 12/31/21 or 01/01/22 regarding Resident #89. Interview on 01/20/22 at 2:12 P.M. with Admissions Manager (AM) #531 revealed on 12/31/21 she placed Resident #89's admission notification on the front of her clinical information, definitely had the hospital information, and took it back to the unit Resident #89 would be residing on. Resident #89 did not want to transition from the skilled nursing unit to the long term care unit she would be residing on, and requested to be admitted to her long term care room. AM #531 stated she went to Resident #89's long term care unit, spoke to an unidentified day shift nurse from a staffing agency to inform her she had Resident #89's paperwork, and asked the day shift nurse if she would like to review the paperwork with her. The day shift nurse stated she was too busy to review the paperwork. AM #531 stated she went back to Resident #89's long term care unit around 3:30 P.M. to speak with the nurse who would be admitting Resident #89 to the facility, because she wanted to make sure everything would go smoothly with the admission. AM #531 stated she found the nurse who would definitely be admitting Resident #89, she was a nurse from a staffing agency, AM #531 did not know her name, and the nurse told her she was too busy to review Resident #89's paperwork. AM #531 told the nurse she left the admission paperwork on the counter at the nurse's station. Interview on 01/24/22 at 1:10 P.M. with AM #531 revealed she printed Resident #89's discharge instructions from the hospital on 12/31/21 at 2:42 P.M. and took them to the agency nurse who would admitting Resident #89 to the facility, the nurse was too busy to review the paperwork, and AM #531 left the paperwork on the counter at the nurse's station. AM #531 stated if there were any questions she could have been called, but she did not receive a call from the admitting nurse or the house charge nurse (HCN) regarding Resident #89's hospital discharge instructions. Interview on 01/24/22 at 1:40 P.M. with MD #570 revealed he was on-call 12/31/21 and 01/01/22 for the facility and did not remember a call regarding Resident #89. MD #570 stated he did not receive any text messages or phone calls from the facility regarding Resident #89's hospital paperwork. MD #570 stated if he was called because a resident had no paperwork he would advise them to call the hospital to have it faxed to the facility, and if he was called because a resident was in pain he would have the pharmacy call him for a pain medication order. MD #570 stated if he received this information he would have signed it out to the team, but checking his records for 12/31/21 and 01/01/21 the only message he received was Resident #89 arrived to the facility and he signed Resident #89's arrival out to the team. MD #570 stated he saved all his text messages, double checked them and was not texted regarding Resident #89 having no discharge instructions or needing pain medication. Interview on 01/25/22 at 10:24 A.M. with Licensed Practical Nurse (LPN) #564 revealed she worked at the facility on 12/31/21 from 11:00 P.M. through 7:30 A.M., was the house charge nurse (HCN) during those hours, and she also was assigned a nursing unit. LPN #564 stated she was briefly informed Resident #89 had pain and was sent to the local hospital Emergency Department. LPN #564 stated the nurse assigned to the unit (LPN #572) called her when Resident #89 returned from the emergency department and told her she did not arrive with discharge instructions. LPN #564 revealed she made a call to the hospital to have the discharge instructions sent to the facility, and texted MD #567 to let her know there were no orders. LPN #564 stated after she made the call to the hospital and texted MD #567 she went back to her assigned floor, and thought LPN #572 would receive the orders and a phone call from MD #567. LPN #564 stated after Resident #89 arrived at the facility on 01/01/22 around 4:00 A.M. she was told by LPN #572 there were no discharge instructions and again tried to have the hospital discharge instructions faxed to the facility. LPN #564 stated she did not remember if she contacted MD #567's answering service, and if MD #567 was not available an on-call physician or nurse practitioner would contact the facility. LPN #564 stated it was a very busy night, LPN #572 was stressed and told her Resident #89 had no discharge instructions, LPN #564 did not look on the unit for discharge instructions because she had her own unit and had a lot of things she had to address. Interview on 01/25/22 at 11:15 A.M. with State tested Nursing Assistant (STNA) #470 revealed on 01/01/22 she worked 7:00 A.M. through 3:30 P.M., and after introducing herself to Resident #89, she found Resident #89's hospital discharge instructions in a big white envelope on the night-stand underneath Resident #89's tablet personal computer. STNA #470 stated she immediately took the envelope and gave it to the LPN #573, the day shift nurse. LPN #573 gave the discharge instructions to the LPN #561. Interview on 01/25/22 at 11:29 A.M. with LPN #561 confirmed Resident #89's medications per hospital discharge instructions and physician orders were not administered timely. LPN #561 revealed she worked on 01/01/22 and was the HCN for day shift. LPN #561 revealed she was told by night shift LPN #564 the facility was trying to locate Resident #89's hospital discharge instructions, and asked if anyone looked in Resident #89's room, but she did not get an answer. LPN #561 called the hospital and had Resident #89's discharge instructions faxed to the facility, and while waiting for the fax from the hospital, the discharge instructions were found by STNA #470 in Resident #89's room under her tablet personal computer. LPN #561 stated she was assigned a nursing unit, and she needed to make sure all the nursing units were staffed appropriately and her unit was alright, before she took care of Resident #89's discharge instruction orders. LPN #561 indicated it was around 10:00 A.M. when she notified the on-call physician (she did not remember the name) and verified the orders. LPN #561 revealed STNA #470 wrote a statement, but she didn't turn it in to the Administrator because the situation was taken care of. LPN #561 stated she met with the Administrator a few days later regarding the situation and could not remember if IDON #568 or IP #523 were notified of the situation. Interview on 01/27/22 at 10:11 A.M. of the Administrator revealed he did not remember meeting with LPN #561 regarding Resident #89's discharge instructions, but it was discussed in the management morning meeting. There were no notes from the morning meetings, but the discharge instructions were left at Resident #89's bedside table by an ambulance driver. Interview on 01/27/22 at 10:43 A.M. with DON revealed if an on-call nurse practitioner for MD #567 received a call regarding Resident #89's admission to the facility, the nurse practitioner would contact the facility to inform the nurse of the need to call a physician regarding Resident #89's admission. Interview on 01/27/22 at 3:59 P.M. with Director of Nursing (DON) verified Resident #89's Discharge Instructions dated 12/31/21, from the hospital stated [MEDICATION(S)] 5 mg ([MEDICATION(S)]) tablet, start taking on 01/06/22, take one tablet by mouth twice daily. DON stated Medical Doctor (MD) #570 verified the orders with the nurse and might have wanted Resident #89's [MEDICATION(S)] to start on 01/01/22, and she would check with MD #570 to see if he changed the orders. Interview on 01/27/22 at 5:37 P.M. with MD #570 revealed he did not remember Resident #89, and would get 30 resident admissions during a weekend. MD #570 stated he relied on the nurse's to give accurate information when verifying orders. MD #570 stated the hospital Discharge Instructions were the orders used to verify resident orders, if the instructions stated to start [MEDICATION(S)] on 01/06/22 that is what he would have verified, and he would not change the dates stated on the Discharge Instructions for the [MEDICATION(S)] was to be administered. MD #570 stated it would be unusual to give [MEDICATION(S)] and [MEDICATION(S)] together at the same time, and he could not think of a reason why it would be ordered that way. MD #570 stated it could be harmful for Resident #89 because it could cause increased bleeding. Review of the facility policy titled, Medication Administration, undated, included it was the policy of this community to administer medications safely and effectively following the 5 rights of medication administration. Follow 5 rights of medication administration: ensure right patient, right drug, right dose, right route, and right time. This deficiency substantiates Complaint Number OH 009.

Based on observation, interview, and review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP), and review of the CDC Covid Tracker data, the facility failed to maintain proper infection control procedures to prevent the potential spread of Covid-19. This had the potential to affect all residents residing in the facility. The census was 91. Findings include: Observation on 10/07/21 at 5:06 A.M. revealed Licensed Practical Nurse (LPN) #201 exiting a resident's room without a face mask or eye protection. LPN #201 quickly began looking for a mask and eye protection and stated she had misplaced her face mask and eye protection and was unable to locate it. LPN #201 stated she was aware she was required to wear a face mask and eye protection. Observation on 10/07/21 at 5:19 A.M. revealed Dietary Aide #400's face mask was pulled down below her chin. Interview with Dietary Aide #400 at time of observation revealed her mask should have been covering her nose and mouth. Interview with the Director of Nursing (DON) on 10/07/21 at 6:29 A.M. revealed she was notified by the evening charge nurse that staff had not been wearing proper Personal Protective Equipment (PPE). The DON indicated the facility did not have active Covid in the building and stated staff had been instructed on the PPE required while in the facility regardless of Covid cases. She further stated she was working as the Infection Preventionist and was working to train a new employee on infection control policies and procedures. Observation on 10/09/21 at 6:17 A.M. revealed STNA #310 wearing a face mask; however, the face mask was pulled down below her chin. Interview with STNA #310 at time of observation revealed she did not realize her face mask was pulled down below her chin and stated it was supposed to be covering her nose and mouth. Review of the Centers for Disease Control Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 09/10/21 revealed the following. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic Establish a Process to Identify and Manage Individuals with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection Ensure everyone is aware of recommended IPC practices in the facility. Implement Source Control Measures Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control options for HCP include: A NIOSH-approved N95 or equivalent or higher-level respirator OR A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators (note: these should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated) OR A well-fitting facemask. When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator during the care of a patient with [CONDITION(S)]-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned. Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have: Not been fully vaccinated; or Suspected or confirmed [CONDITION(S)]-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with [CONDITION(S)]-CoV-2 infection for 14 days after their exposure, including those residing or working in areas of a healthcare facility experiencing [CONDITION(S)]-CoV-2 transmission (i.e., outbreak); or Moderate to severe immunocompromise; or Otherwise had source control and physical distancing recommended by public health authorities While it is generally safest to implement universal use of source control for everyone in a healthcare setting, the following allowances could be considered for fully vaccinated individuals (who do not otherwise meet the criteria described above) in healthcare facilities located in counties with low to moderate community transmission. Fully vaccinated people might choose to continuing using source control if they or someone in their household is immunocompromised or at increased risk for severe disease, or if someone in their household is unvaccinated. Fully vaccinated HCP: Consistent with guidance for the community could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms, kitchen). They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors). If [CONDITION(S)]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: NIOSH-approved N95 or equivalent or higher-level respirators should be used for: All aerosol-generating procedures (refer to Which procedures are considered aerosol generating procedures in healthcare settings? ) All surgical procedures that might pose higher risk for transmission if the patient has COVID-19 (e.g., that generate potentially infectious aerosols or involving anatomic regions where [CONDITION(S)] loads might be higher, such as the nose and throat, oropharynx, respiratory tract) Facilities could consider use of NIOSH-approved N95 or equivalent or higher-level respirators for HCP working in other situations where multiple risk factors for transmission are present. One example might be if the patient is unvaccinated, unable to use source control, and the area is poorly ventilated. Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. Review of the CDC Covid Tracker data dated 10/09/21 revealed the county where the facility was located had a high transmission rate. This deficiency substantiates Complaint Number OH 106.

Based on observation, record review and interview the facility failed to develop a comprehensive infection control program to decrease the risk of infections and ensure adequate monitoring of infections was completed. The facility failed to maintain consistent use of isolation precautions for Resident #9 and failed to ensure dressing changes were completed to reduce the risk of infection for Resident #40 and #110. This affected three residents (#9, #40 and #110) and had the potential to affect all 126 residents residing in the facility. Finding include: 1. Review of the facility monthly infection control logs and quarterly infection control summaries revealed the total numbers of residents marked as positive for infections for the last four quarters had increased. The number of residents marked as positive for the first quarter (January to March) of 2019 was 20, the second quarter (April to June) number was 35, and the third quarter (July to September) for 2019 was 37. There was no totaled number for the fourth quarter (October to December) of 2019 at the time of the survey. Review of information provided by the facility revealed an inservice was completed for nurses and state tested nursing assistants on 09/24/19 and 09/25/19. The outline for the inservice indicated thepaper training and quiz portion of the inservice had a 30 minute section on infection control-tb ([MEDICAL CONDITION]), thirty minutes for Legionnaires and fifteen minutes dedicated to Needle stick-OSHA (Occupational Safety and Health Administration). The outline indicated competencies were observed for handwashing and perineal care for both males and females. An interview with the infection control nurse, Registered Nurse (RN) #500 and the corporate risk management nurse/RN #501 on 01/15/20 at 2:10 P.M. revealed RN #500 had just started her duties in her position within the last three weeks. RN #500 stated she had not had time to review the logs and trends of the facility infection control tracking. She stated she had not yet completed any inservices for staff, but had been attempting to review residents and had inventoried infection control supplies at the bedside/doorways for residents. An interview with RN #501 on 01/16/20 at 10:30 [NAME]M. revealed she had reviewed the logs and tracking for the facility. She stated she was unsure of the meaning of the numbers obtained on the quarterly infection control antibiotic tracking forms. She stated she could not be sure what the former infection control nurse had counted when obtaining the numbers, which she verified indicated an increase in infections for residents in the facility. She stated she was also not sure if the census had increased dramatically or if the infections included in the counts also encompassed hospital acquired infections, facility acquired infections, residents with colonized infections or all of these categories. An interview with medical doctor, (MD) #600, by telephone on 01/16/20 at 3:10 P.M. revealed she was a consultant at the facility with a speciality in infection control. She stated she had been in frequent contact with the infection control nurse (RN #505) at the facility in the past but had not received much information for the last several months. An interview with the director of nursing on 01/16/20 at 4:06 P.M. verified RN #505 had retired at the end of (MONTH) 2019. She stated another nurse, RN #510 started as the the new infection control nurse soon after but had resigned her position at the end of (MONTH) 2019. She stated RN #500 started in the position approximately three weeks ago. She indicated the facility had been unable to verify some of the tracking processes used in the past by the nurses who had previously held the position, so could not verify if numbers had increased or not. The director of nursing verified the summary of the infections had last been totaled at the end of (MONTH) 2019, and although infection control logs existed for the rest of 2019, the monthly numbers had not been calculated or were not accessible at the time of the survey to indicate if infections had continued to increase or had declined. The director of nursing also verified the facility had conducted an inservice in (MONTH) 2019, which included teaching and competencies on infection control subjects. She was unable to state if all nursing staff had completed the inservice or if any audits had been conducted to ensure nursing staff were adhering to infection control standards. 2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was admitted to Hospice services on 11/01/18. Review of the most recent annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was severely cognitively impaired, was dependent of staff for activities of daily living and had a pressure area. Review of the medical record revealed a pressure area to the resident's right foot. A wound note dated 01/10/20 revealed the area was a State IV (impaired skin area with exposed bone) to the right proximal medial first toe which measured 0.5 centimeters by 0.3 centimeters with a depth unable to be determined. The treatment ordered 10/05/19 revealed the area should be cleaned with normal saline, patted dry and a [MEDICATION NAME] moistened gauze applied. The area should be covered with a pad and wrapped with gauze wrap. An observation of the resident with the wound nurse, RN #407 on 01/16/20 at 8:40 [NAME]M. revealed the resident was in bed at the time of the observation. RN #407 assembled all equipment on the night stand and after washing her hands and applying gloves, she used a scissors to cut away the old dressing. She used a saline moistened gauze to cleanse the area and then applied a gauze pad that had [MEDICATION NAME] on it. She covered the area with a pad and wrapped it with a gauze wrap. RN #300 did not change her gloves or wash her hands during the procedure. An interview with RN #407 on 01/16/20 at 10:50 [NAME]M. confirmed she did not change gloves during the procedure. She verified she should have removed her gloves, washed her hands and put on new gloves after removing the old dressing and cleaning the wound, before applying the new treatment, which she applied to the area with the same gloved hands with which she had cleaned the area. Review of the facility undated clean dressing change policy revealed a clean pair of gloves should be applied then changed after removing the soiled dressing, with a clean pair of gloves put on to clean the wound and apply the clean dressing. 3. Record review revealed Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 12/20/19 included a potential for impaired skin integrity related poor tissue integrity. The care plan included Resident #110 had a sacrum pressure ulcer, Stage II. The care plan also included to provide treatment orders per physician orders. Record review of physician's orders [REDACTED]. Observation on 01/16/20 at 9:30 [NAME]M. of sacral wound care for Resident #110 revealed RN #407 entered Resident #110's room. RN #407 washed her hands then explained the procedure to Resident #110. RN #407 placed a barrier on the bedside table and placed clean wound dressing supplies on the barrier. RN #407 then put her gloves on and assisted STNA #408 to position the resident on her left side to provide wound care. RN #407 removed the old dressing from the sacral wound, laid the old dressing down then cleansed the wound using a dry gauze and saline solution. RN #407 then took off her gloves and exited the room. RN #407 gathered supplies from the treatment cart located outside the doorway in the hall. RN #407 then laid the additional supplies on the barrier located on the bedside table. RN #407 put new gloves on then applied the [MEDICATION NAME] blue to the wound bed then applied the foam dressing. Interview with RN #407 on 01/16/20 at 9:40 [NAME]M. confirmed she did not dispose of the gloves after removing the soiled dressing and apply new gloves before cleansing the wound. Review of the procedure for a clean dressing change, dated 2012 revealed to put on the first pair of disposable gloves, remove the soiled dressing and discard in a plastic bag, dispose of the gloves in a plastic bag, put on a second pair of disposable gloves, cleanse the wound. 4. Record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had adequate hearing and vision, her speech had been clear and had been able to understand verbal content. Review of the nursing progress notes dated 01/03/20 at 1:00 P.M. revealed Resident #9 had cluster of filled blisters to the left side of her face/chin and behind her left ear. A call had been placed to Resident #9's physician and an order was obtained for medication for seven days and Resident #9 was to be placed on contact precautions. Review of the written physician's orders [REDACTED]. The definition of shingles, according to the Mayo Clinic, revealed shingles was a [MEDICAL CONDITION] infection that causes a painful rash. Although shingles can occur anywhere on your body, it most often appears as a single stripe of blisters that wraps around the left side or the right side of the torso. Shingles is caused by the [MEDICATION NAME]-[MEDICATION NAME] virus, the [MEDICAL CONDITION] that causes chicken pox. The [MEDICATION NAME]-[MEDICATION NAME] virus is contagious, and if you have shingles, you can spread [MEDICAL CONDITION] to another person, which could then, cause them the chicken pox. Contact precautions refer to infection prevention and control interventions to be used in addition to routine practices and were intended to prevent transmission of infectious agents which are spread by direct or indirect contact. Healthcare workers should wear a gown and gloves while in the patient's room. Review of the care plan for Resident #9 dated 01/06/20 revealed Resident #9 had shingles to the left side of her face/chin and behind left ear. The intervention for Resident #9 included use contact precautions to prevent infection. Observation on 01/13/20 at 11:25 [NAME]M. revealed an isolation cart including isolation gowns and gloves was located at the entrance of Resident #9's room. Observation on 01/13/20 at 11:30 [NAME]M. revealed Resident #9 was sitting in a chair in the dining room with multiple residents and staff members present. Interview on 01/13/20 at 11:30 [NAME]M. with Licensed Practical Nurse (LPN) #403 revealed if a resident was in contact precautions, they would be in their room on isolation. LPN #403 verified Resident #9 had been in the dining room during the interview. LPN #403 verified Resident #9 had been out to the dining room daily with other residents and staff during the month of (MONTH) 2020. LPN #9 verified contact precautions had been ordered by the physician for Resident #9 due to a [DIAGNOSES REDACTED]. Interview on 01/13/20 with State tested Nursing Assistant (STNA) #404 revealed Resident #9 has eaten her meals in the dining room every day and had not eaten anywhere but the dining room with other residents and staff present for the month of (MONTH) 2020. Observation on 01/13/19 at 1:57 P.M. revealed Resident #9 had been sitting in a chair in the dining room. Interview on 01/16/20 between 1:05 P.M. and 1:10 P.M. with LPN's #405 and #406 confirmed Resident #9 had consumed her meals in the dining room daily with multiple residents and staff present during the month of (MONTH) 2020 and while on contact precautions.

Based on record review and interview, the facility failed to ensure posted nurse staffing information was accurate. This had the potential to affect all 129 residents currently residing in the facility. Findings include: Review of the daily schedule and assignment logs, daily roster reports, and the nurse staffing information postings dated 02/01/19, 02/05/19, 02/08/19, 02/11/19, 02/14/19, 02/15/19, and 02/16/19 revealed the nurse staffing information postings were inaccurate. The number of Registered Nurses, Licensed Practical Nurses, and State tested Nurse Aides recorded as working the first shift were incorrect and the daily resident census was not included for those dates. On 02/25/19 at 4:00 P.M. Staffing Coordinator #210 verified the nurse staffing information postings inaccurately reflected the numbers of nursing staff working the first shift and the resident census was not included for the above reviewed dates.

Based on observation, record review and interview the facility failed to maintain sufficient levels of nursing staff to ensure call lights were answered timely and to meet the total care needs of all residents. This affected 13 residents (Resident #12, #13, #25, #33, #40, #71, #73, #74, #77, #84, #85, #118 and #120) and had the potential to affect all 134 residents residing in the facility. Findings include: 1. During the annual survey, the following residents identified concerns related to staffing: Interview on 11/26/18 at 10:36 A.M. with Resident #71 revealed the resident felt the facility needed more staff because she had incidents in which she had to to sit on the toilet too long. Interview on 11/26/18 at 10:50 A.M. with Resident #74 revealed sometimes she has to wait 40 minutes for her call light to get answered, more on second shift, and she had been left on the bed pan for two hours a couple months ago. Interview on 11/26/18 at 2:40 P.M. with Resident #84 revealed the facility was short on staff in the evening and call light response was delayed due to staffing. Interview on 11/26/18 at 2:48 P.M. with Resident #77 revealed there was a delay in call response and that it could take 45 minutes to an hour for staff to respond on second and third shift. Interview on 11/26/18 at 2:50 P.M. with Resident #85 revealed in the morning and night she waits a half hour or all day to go to the bathroom, resulting in sometimes having to go out of her room and get some help. Interview on 11/27/18 at 9:21 A.M. with Resident #33 revealed sometimes he has to wait 20 to 25 minutes on night shift to get help. Interview on 11/27/18 at 11:55 A.M. with Resident #118's family member revealed the resident has had to wait one hour at night for help and he has had to use his electronic wireless calling system to call his family to contact the facility to go and help him. 2. Observation on 11/26/18 at 11:43 A.M. revealed Resident #120's call light had been activated. It was unclear when it was initially activated. The call light was answered at 12:07 P.M., 24 minutes later. Review of Resident #120's Device Activity Report for 11/26/18 revealed his call light was activated at 11:30 A.M. and cleared at 12:10 P.M., 39 minutes later. Interview on 11/27/18 at 10:59 A.M. with Resident #120 revealed when he pushed his call light it took staff a little while to answer it, like when he needed rinks. Resident #120 revealed sometimes he has to wait an hour for staff to respond to his needs. The resident stated this didn't happen often but could happen at any time. 3. Observation on 11/26/18 at 11:51 A.M. revealed Resident #40's call light had been activated. It was unclear when it was first activated. The call light was answered at 12:06 P.M., 15 minutes later. Five facility employees were observed assisting residents with eating in the dining room, and one employee was passing trays in the halls at the time the call light was activated. Review of Resident #40's Device Activity Report for 11/26/18 revealed her call light was activated at 11:38 A.M. and was cleared at 12:09 P.M., 30 minutes later. 4. Review of the resident council minutes, dated 11/19/18 revealed the resident's present at the meeting spoke with the Director of Nursing regarding concerns they has related to call light response times. The residents were informed that call light response time would be audited. On 11/28/18 beginning at 1:59 P.M. a resident group meeting was held. During the meeting, Resident #71, Resident #12, Resident #13, Resident #84, Resident #73 and Resident #25 revealed their call lights were not answered timely. Resident #71 provided a specific example that she almost transferred herself from her wheelchair to her chair on 11/28/18 because the call light response was so delayed. Resident #84 provided a specific example that her call light response time was delayed and she sustained a fall because of it recently (actual date not provided). Review of Resident 71's Device Activity Report for 11/28/18 revealed her call light was activated at 12:42 P.M. and was cleared at 11/28/18, 76 minutes later. Review of Resident #84's Device Activity Report for 11/24/18, the day she last fell , revealed her call light was activated at 10:11 A.M. and cleared at 10:39 A.M., 28 minutes later. Interview on 11/29/18 at 2:11 P.M. with the Administrator confirmed the delayed call light response times on the Device Activity tracker as noted above.

Based on interview, closed record review and review of facility fall investigation the facility failed to ensure the proper amount of staff were provided to Resident #8 during personal care as care planned resulting in a fall with injury. Actual harm occurred when State tested Nurse Aide (STNA) #4 attempted to provide personal care for Resident #8 by himself, instead of waiting for a second STNA to help as care planned. This resulted in Resident #8 rolling out of bed and onto the floor during care. Resident #8 required hospitalization and returned to the facility with a large hematoma to her left forehead, a laceration with four steri strips below her left temple and multiple discolorations to her face. This affected one of three residents reviewed for falls. The facility census was 124. Findings Include: Closed record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 assessment ((MDS) dated [DATE] revealed Resident #17 was severely cognitively impaired with limited range of motion of the upper and lower extremities, and required the assistance of two persons for bed mobility, toileting, transfers and personal hygiene. Review of the care plan for Resident #8 revealed the resident was at risk for falls and had deficits in self care. Interventions included extensive assist with personal hygiene with two staff and extensive assist of two with toileting. Resident #8 expired at the facility on [DATE]. Review of the nursing progress note dated [DATE] at 6:33 A.M. revealed Resident #8's assigned STNA, (STNA #4), reported to the charge nurse that Resident #8 threw her legs over the edge of the bed and rolled herself out of bed during care. Upon entering the room Resident #8 was on the floor between the bed and the wall, face down, her head was bleeding and Resident #8 stated everything hurts. No other care providers were in the room at the time of fall. Resident #8 was sent out to a local hospital for an evaluation. Resident #8 returned on the evening of [DATE] with a large hematoma to her left forehead, a laceration with four steri strips below the left temple and multiple discolorations to her face. Review of the fall investigation dated [DATE] revealed STNA #4 provided a statement that he was the only person in the room at the time of the fall providing incontinence care to Resident #8. The facility investigation noted STNA #4 was disciplined by the facility for failing to ensure proper staff were present to assist with patient care. Interview with the facility's Director of Nursing on [DATE] at 8:07 A.M. verified that STNA #4 provided care without the assistance of another STNA as care planned on [DATE]. Review of the facilities fall prevention program policy revised (MONTH) (YEAR) revealed The Licensed Nurse will monitor to assure fall prevention interventions are in place. The Clinical Nurse Manager will routinely review compliance with the Plan of Care interventions. This deficiency substantiates Complaint Number OH 061