Every finding on record at Majestic Care of Toledo SNF

Based on medical record review, review of self-reported incidents, staff interview, and review of facility policy, the facility failed to ensure injuries of unknown origin were thoroughly investigated and reported to the State Survey Agency. This affected one (Resident #59) of four residents reviewed for injuries of unknown origin. The facility census was 80.Findings include:Review of the medical record for Resident #59 revealed she was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, heart failure, anxiety, depression, type two diabetes mellitus, and dementia. The resident was discharged on 01/11/26.Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #59 revealed she was cognitively impaired and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a wheelchair and was dependent for transfers and mobilization. Resident #59 was dependent for activities of daily living.Review of progress notes for Resident #59 revealed notes on 12/25/25, at 10:42 A.M. and at 3:38 P.M., each indicating Resident #59 would not open her mouth to take her medications. Review of a progress note on 12/26/25 at 3:30 P.M. revealed Resident #56 was assessed for discoloration to each side of her face.Review of a skin assessment for Resident #59, completed by Registered Nurse (RN) #101 and dated 12/26/25 at 3:30 P.M., revealed new skin issues described as discoloration to bilateral sides of the resident's face. The assessment indicated the Director of Nursing (DON) was notified at 2:00 P.M., hospice was notified at 3:00 P.M., and Resident #59's family was notified at 3:50 P.M.Interview on 04/28/26 at 10:15 A.M. with RN #101 revealed the discoloration observed on Resident #59's bilateral face was located under the cheek bones, were red in color, equally midline between the ears and top corners of the mouth, and were symmetrical in shape the approximate size of a quarter.Review of facility self-reported incidents (SRIs) revealed no investigation or notification to the State Survey Agency was made regarding the identification of new discoloration on Resident #59's bilateral cheeks on 12/26/25.Interview on 04/28/26 at 3:30 P.M. with the DON regarding Resident #56's discoloration to her bilateral cheeks identified on 12/26/25, revealed she assumed, based on the resident's history of flailing herself, the discoloration was self-inflicted due to behaviors. The DON confirmed the discoloration to Resident #59's bilateral cheeks was not reported as an injury of unknown origin, nor investigated as such, by the facility.Review of a facility policy titled, Abuse Prevention Program, dated March 2021, revealed an injury of unknown origin was one that was not observed and suspicious due to nature, location, and/or quantity. Continued review revealed injuries of unknown origin would be reported and investigated by the facility.This deficiency represents non-compliance investigated under Complaint Number 2722375.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure accurate and descriptive wound assessments, timely treatment orders for an identified wound, and ensure wound interventions were in place for a resident with pressure ulcers. This affected one (#24) of two residents reviewed for pressure ulcers. The facility census was 67. Findings include:Review of the medical record revealed Resident #24 was admitted on [DATE]. Diagnoses included end stage renal failure, aphasia following cerebral infarction, dysphagia, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was severely cognitively impaired. Review of the Nursing Admission/readmission Evaluation dated 09/11/25 at 6:39 P.M. revealed Resident #24 was readmitted from the hospital and returned to the facility with no new bruises or wounds. Preexisting wounds on resident's buttocks and left heel were noted. There was no description or measurement of the wound on 09/11/25. Review of the Skin Condition Evaluation dated 09/12/25 revealed on (re)admission, there was a suspected deep tissue injury (DTI) to the left heel measuring 1.4 centimeters (cm) in length by (x) 3.2 cm in width x 0.0 cm in depth. There was no wound treatment ordered on 09/11/25 or 09/12/25. The first wound treatment to the left heel was initiated on 09/17/25. The physician order dated 09/16/25 revealed an order for bilateral heel protectors on at all times when in bed. The physician order, dated 09/17/25, revealed an order for the left heel, cleanse with wound cleanser/normal saline and leave open to air twice a day. The wound assessment report dated 09/17/25 revealed the DTI pressure ulcer to the left heel measuring 1.3 cm x 3.5 cm x 0.0 cm. The care plan dated 09/18/25 revealed Resident #24 had impaired skin integrity to the left heel pressure ulcer with interventions including bi-lateral heel protectors on at all times when in bed. The wound assessment report dated 09/24/25 revealed a DTI pressure ulcer to Resident #24's left heel measuring 1.6 cm x 2.9 cm x 0.0 cm and noted to be improving without complications. Observation on 09/24/25 at 8:46 A.M. revealed Resident #24 was lying in bed on his back with his eyes closed and heels on the mattress. There were no heel protectors in place. Interview on 09/24/25 at 8:50 A.M. with Licensed Practical Nurse (LPN) #376 verified Resident #24 was in bed and did not have heel protectors on. LPN #376 located the heel protectors in the closet. Interview on 09/24/25 at 10:09 A.M. with the Director of Nursing (DON) verified the Nursing Admission/readmission Evaluation was completed inaccurately. The resident had a new heel wound (not existing) and verified there was no descriptions of the wounds to the left heel and buttocks. Interview on 09/25/25 at 11:34 A.M. with Registered Nurse (RN) #360 verified completing the skin assessment report including wound description with measurements on 09/12/25 and no physician treatment orders for the left heel were in not implemented until five days later on 09/17/25. Review of the policy titled Wound Management Policy dated 05/20/24 revealed upon admission upon admission, resident specific categorical skin risk factors are assessed, documented, care planned, and care plan interventions are operationalized, monitored, and evaluated. Residents with impaired skin integrity are recognized by our care team, treated timely, and healing interventions are exhausted until the skin is healed. The facility will have a system in place to identify impaired skin integrity development early to prevent further damage and treat the condition as soon as it is identified.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure residents were assessed and monitored for complications before and after hemodialysis treatments and failed to implement physician orders to notify the physician for weight loss in a day or week. This affected one (#24) of one resident reviewed for dialysis. The facility census was 67. Findings include:Review of the medical record revealed Resident #24 was admitted on [DATE]. Diagnoses included end stage renal failure, dysphagia, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was severely cognitively impaired and received dialysis. Review of the care plan dated 08/19/25 revealed Resident #24 required hemodialysis. Interventions included to weigh daily Monday, Wednesday, and Friday with instructions to notify the physician if weight gain was greater than three pounds in a day of five pounds in a week. Review of the pre/post dialysis communication reports for Resident #24 from 08/18/25 to 09/22/25 revealed the reports were not completed on 08/22/25, 08/27/25, and 09/12/25. The physician orders dated 09/12/25 revealed an order to weigh daily Monday, Wednesday, and Friday. Notify the physician if weight gain was greater than three pounds in a day or five pounds in a week. The Medication Administration Record (MAR) dated September 2025 revealed on 09/17/25, Resident #24 weighed 114.5 pounds and on 09/22/25, Resident #24 weighed 104 pounds (10 pound loss in five days). There was no documentation in the medical record the physician was notified of Resident #24's weight loss of ten pounds in five days on 09/22/25. There was no reweight document on 09/22/25. Interview on 09/23/25 at 4:33 P.M. with the Director of Nursing (DON) verified the pre/post dialysis communication report was not completed on 08/22/25, 08/27/25, and 09/12/25. The DON also verified on 09/22/25, Resident #24 should have been reweighed and if the weight was accurate, the physician should have been notified. Follow-up from surveyor notification on 09/23/25 the facility reweighed Resident #24 with an updated weight of 113.6 pounds. Review of the policy titled Dialysis dated 01/02/24 revealed the facility will assure each resident receives the care and services for the provision of hemodialysis consistent with professional standards including ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

Based on record review and staff interview, the facility failed to ensure physician orders were transcribed accurately in the electronic medical record. This affected one (Resident #5) of 20 residents reviewed for medical record accuracy. The facility census was 67. Findings include: Review of Resident #5's medical record revealed an admission date of 02/01/23. Diagnoses included hypertensive heart failure, congestive heart failure, and atrial fibrillation. Review of Resident #5's Medication Administration Record (MAR) dated September 2025 revealed Losartan Potassium (antihypertensive) oral tablet 25 milligrams (mg) was to be administered by mouth one time daily for hypertension. Hold for heart rate greater than 60, systolic blood pressure greater than 110, and diastolic blood pressure greater than 60. The physician order was dated 08/05/25. There was an order for Furosemide (diuretic) 10 mg by mouth one time a day for fluid overload. Hold if heart rate was greater than 60. The physician order was dated 07/28/25. Review of Resident #5's September 2025 MAR revealed the medications were administered per nursing judgement and not as written in the order. Interview with the Director of Nursing (DON) on 09/25/25 at 10:43 A.M. verified Resident #5's medication orders were placed in the electronic medical record inaccurately. The orders should have read the Losartan Potassium should have been held if the heart rate was under (not over) 60, systolic blood pressure was under 110, and the diastolic blood pressure was under 60. The Furosemide should have been held if the heart rate was under 60. The DON revealed no written order was available for the medications and it may have been a verbal order from the physician. The nurses who placed the orders in the medical record inaccurately used the greater than and less than signs.

Based on review of the medical record, observations, staff interview, policy review, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to assess newly identified skin breakdown, notify the physician of skin breakdown, and implement treatments to aid in the healing of skin breakdown. This resulted in Actual Harm when Resident #28 was found to have an open area that was not assessed or treated for two days and then was assessed as a stage three pressure ulcer to the coccyx. Additionally, the facility failed to assess a newly identified skin breakdown for Resident #7, which placed the resident at risk for more than minimal harm that did not result in actual harm. This affected two (#7 and #28) of two residents reviewed for pressure ulcers. The facility identified 11 residents with pressure ulcers. The facility census 80. Findings include: 1. Review of Resident #28's medical record revealed an admitted [DATE]. Diagnoses included malignant neoplasm of prostate, secondary malignant neoplasm of bone, major depressive disorder, type two diabetes mellitus, atrial fibrillation, chronic pain syndrome, and hypertensive heart disease with heart failure. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required the extensive assistance of two staff for bed mobility and transfers and required the extensive assistance of one staff for toileting. The resident was identified with one stage three pressure ulcer. Review of the skin care plan initiated 06/07/23 revealed the resident was at risk for skin breakdown. Interventions included routine turning and repositioning, routine toileting, pressure reducing cushion to chair, pressure reducing mattress on bed, weekly skin inspections, and treatments as ordered. The resident had refused placement of an air mattress. Review of a skin risk assessment dated [DATE] revealed the resident was at risk for skin breakdown. Review of a nurse's note dated 09/05/23 at 6:45 P.M., revealed the resident was observed with a pin sized hole on the sacrum that bleeds upon touch. The hospice nurse was notified and advised staff to place dry dressing to area until they assisted him in the morning. Review of the medical record revealed no wound assessment was completed and there was no documentation that the physician was notified. There were no physician orders for treatment. Review of a hospice handwritten note dated 09/06/23 revealed the resident had a coccyx pinhole wound and asked staff to let the facility skin team know. No wound assessment or physician notification was documented. Review of a skin and wound note dated 09/07/23 at 10:01 A.M., revealed the resident had a new stage three pressure ulcer to the coccyx. The wound measured 0.5 centimeter (cm) in length, 0.3 cm in width, and 0.4 cm in depth with 100% granulation tissue and scant amount of serosanguineous drainage. The wound edges were unattached. The resident was noted with blanchable erythema to the entire buttocks with scar tissue present. The nurse practitioner ordered to cleanse with wound cleanser, apply collagen to base of the wound and secure with hydrocolloid. Review of a physician order dated 09/09/23 revealed to cleanse wound to coccyx with wound cleanser, collagen, and hydrocolloid every Tuesday, Thursday, and Saturday. The order was discontinued on 09/18/23. Review of a physician order dated 09/19/23 revealed to cleanse wound with wound cleanser, apply calcium alginate with border foam daily. Review of the treatment administration record (TAR) dated 09/01/23 through 10/10/23 revealed there was no documentation that the initial treatment of a dry dressing was administered on 09/05/23 or 09/06/23. Also, there was no documentation of wound treatments being completed on 09/14/23, 09/21/23, 09/23/23, 09/30/23 and 10/05/23. Review of a skin and wound note dated 10/09/23 at 3:23 A.M., revealed the resident spent a good amount of time up in wheelchair during day and does not return to bed to offload as often as recommended. The resident's wound was stable. The wound measured 0.8 cm in length, 0.3 cm in width, 0.2 cm in depth with 100% granulation tissue and a small amount of serosanguineous drainage. The wound had unattached edges and the peri wound was macerated and intact. New orders to cleanse the wound with wound cleanser, apply triad paste to base of wound and leave open to air twice daily and as needed. Observation on 10/17/23 at 1:29 P.M., of wound care for Resident #28 with Registered Nurse (RN) #369 revealed Resident #28 had a pressure area to his coccyx. The area was round, less than one cm in length and width. The wound bed was 100% granulation tissue with no drainage and no odor. The surrounding skin was intact, red, and blanched. The resident had a pressure reducing cushion in his wheelchair and a pressure reducing mattress in place. Interview on 10/18/23 at 2:31 P.M., with the Director of Nursing (DON) and Unit Manager (UM) #401 revealed the resident had a pin size hole on the sacrum on 09/05/23. The DON and UM #401 revealed on 09/05/23 and 09/06/23 the wound was not assessed, and the physician was not notified. The DON and UM #401 revealed no treatment orders were in place until 09/07/23 when the wound was assessed as a stage three pressure ulcer to the coccyx. UM #401 also verified there was no documentation wound treatments were completed on 09/14/23, 09/21/23, 09/23/23, 09/30/23 and 10/05/23. 2. Review of Resident #7's medical record revealed an admitted [DATE]. Diagnoses included chronic kidney disease stage 3B, paraplegia, neuromuscular dysfunction of bladder, dementia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment completed 08/11/23 revealed the resident had intact cognition. The resident required the extensive assistance of one staff for bed mobility, transfers, and toileting. The resident was at risk for pressure ulcers. The resident had no unhealed pressure ulcers. Review of the skin care plan initiated 03/17/22 revealed the resident was at risk for skin breakdown. Interventions included routine turning and repositioning, low air loss mattress to bed, pressure reducing cushion to chair, weekly skin inspection, and preventative skin care as ordered. Review of a skin risk assessment dated [DATE] revealed the resident was at risk for skin breakdown. Review of a weekly nursing summary dated 10/14/23 at 4:32 P.M., revealed the resident had a new open area to the sacrum and a treatment was in place. Review of the medical record revealed no wound assessment was completed. Review of a physician order dated 10/14/23 revealed to cleanse the resident's sacrum with wound cleaner, apply silver alginate, and border foam daily. Review of a skin and wound note dated 10/16/23 revealed the resident had a stage three pressure ulcer to the coccyx. The wound measured seven centimeters (cm) in length by 7.5 cm in width by 0.2 cm in depth. The wound was 100% granulation tissue with a moderate amount of serosanguineous drainage. The wound edges were attached. The surrounding skin was fragile with erythema. The resident was noted with chronic skin discoloration to the buttocks. The resident received new orders to cleanse with wound cleanser, apply calcium alginate to the base of the wound, secure with bordered foam dressing, change daily and as needed. Review of a physician order dated 10/17/23 revealed the treatment to the sacrum was changed to cleanse with wound cleaner, apply calcium alginate and border foam daily. Review of the medication administration record (MAR) dated 10/14/23 through 10/18/23 revealed the treatment to the sacrum was completed on 10/14/23, 10/15/23, and 10/16/23. There was no documentation of the wound being assessed until 10/16/23. Review of the treatment administration record (TAR) dated 10/14/23 through 10/18/23 revealed the treatment to the sacrum was completed on 10/17/23 and 10/18/23. Interview on 10/16/23 at 3:35 P.M., Unit Manager (UM) #401 revealed the resident had a recently healed wound that reopened over the weekend. UM #401 verified the wound found on 10/14/23 was not assessed until the nurse practitioner was in the facility on 10/16/23. Observation on 10/18/23 at 10:10 A.M., of wound care with UM #401 revealed the resident had a large pressure ulcer on his sacrum extending to the upper right and upper left buttocks. The wound bed was approximately 75% granulation tissue and 25% slough with no odor. The surrounding skin was excoriated, macerated, and discolored. The resident had a pressure reducing cushion in place for the wheelchair and an air mattress on the bed. Interview on 10/17/23 at 4:40 P.M., Regional Nurse Consultant (RNS) #439 revealed wounds should be assessed when found. Review of the policy titled Pressure Injury Prevention and Management, dated 2022, revealed the facility would establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. Assessments of pressure injuries would be performed by a licensed nurse and documented in the medical record. The attending physician would be notified of the presence of a new pressure injury upon identification. Review of the policy titled, Wound Care, revised 10/2012, revealed the date, time and type of wound care given would be documented in the medical record. All assessment data including wound bed color, size, drainage, would also be documented in the medical record. Review of the NPUAP guidelines dated 2014 pages 70-71 at (https://npiap.com/general/custom.asp?page=2014Guidelines) revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment.

Based on observation, medical record review, staff interview, review of the facility policy, and review of the manufacturer's guidelines, the facility failed to ensure proper hand hygiene was performed during food service on the third floor. This affected Resident #30 and had the potential to affect all residents on the third floor except Resident #44 who received no food from the kitchen. The facility identified 31 residents on the third floor. Additionally, the facility failed to ensure the dishwasher in the main kitchen washed dishes at the appropriate temperature. This had the potential to affect all residents in the facility except Resident #44 who received no food from the kitchen. The facility identified Resident #44 as the only resident in the facility who did not receive food from the kitchen. The facility census was 80. Findings include: 1. Observations beginning on 10/16/23 at 12:16 P.M., revealed Dietary Aide (DA) #321 with her bare hands taking food temperatures, using a pen to write food temperatures on a paper log, using a hot pad to place pans of food into the steamer, and then putting on food-safe gloves for meal service without washing her hands. DA #321 then touched the rolling cart, a coffee cup, a thickened coffee packet, and the coffee dispenser before returning to the tray line to wait to serve food. Upon returning to the tray line, DA #321 rested her hands on the biscuits in the tray while she waited to begin serving food. Interview on 10/16/23 at approximately 12:20 P.M., with DA #321 confirmed she touched several non-food items with her gloved hands before resting them on the biscuit. DA #321 proceeded to change her gloves without washing her hands. Continued observations during meal service revealed DA #321 serving chicken pot pie using the serving utensil, touching salad tongs, and picking up biscuits with a gloved hand to place on plates. Further observation revealed DA #321 wearing the same gloves and picking up a wrapped pack of hamburger buns, untwisting the tie holding the bag closed, reaching into the bag, taking out a bun, opening the bun with both gloved hands and placing it on a plate. DA #321 then picked up a hamburger patty with her gloved hand and placed it on the bun. DA #321 then walked to the refrigerator and placed her left hand on the frame of the refrigerator and used her right hand to pull open the handle. DA #321 picked up a plastic-wrapped block of sliced cheese and returned to the tray line where she opened the plastic and picked up a piece of cheese with her gloved hand and placed it on the burger patty. DA #321 continued to assemble the burger using a combination of her gloved hands and serving utensils. The burger was then given to Resident #30. Interview on 10/16/23 at 12:35 P.M., with DA #321 confirmed she touched multiple non-food items, including the refrigerator, and also touched ready-to-eat food (the hamburger) without changing her gloves and washing her hands. Interview on 10/16/23 at approximately 12:36 P.M., with Dietary Manager #325 confirmed DA #321 should wash her hands and change her gloves before touching ready-to-eat food. 2. Observation on 10/18/23 at approximately 10:25 A.M., revealed the dishwasher machine in the main kitchen in use and displaying a wash temperature of 142 degrees Fahrenheit (F) and a rinse temperature of 190 degrees F. Interview on 10/18/23 at approximately 10:26 A.M., with DA #320 confirmed she had just run several loads through the dish machine. Further, DA #320 stated she had previously noted the washing temperature less than 150 degrees F and had mentioned it more than once to the representative from the chemical/service company who assured DA #320 that as long as the rinse temperature was above 180 degrees F, DA #320 did not need to worry about the wash temperature below 150 degrees F. Interview on 10/18/23 at 10:30 A.M., with District Manager #440 confirmed the dish machine wash temperature read 142 degrees F and further confirmed the company policy was to maintain wash temperatures between 150-160 degrees F. Further, District Manager #440 confirmed the dish machine was a high temperature machine. Continued observations revealed staff put away dishes as they dried and did not rewash dishes in a properly functioning machine. Review of the policy titled, Ware washing, revised September 2017, revealed all dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature machines. Review of the manufacturer's guidelines for the dish machine, provided by District Manager #440, confirmed the minimum wash temperature should be 150 degrees F. Review of the policy titled Food: Preparation, revised September 2017, revealed all staff would use serving utensils appropriately to prevent cross contamination.

Based on staff interview, review of facility monitoring logs, Legionella Risk Assessment review, and review of the policy, the facility failed to ensure monitoring for Legionella was completed. This had the potential to affect all 80 residents in the facility. The facility census was 80. Findings include: Review of the facility's undated Legionella Risk Assessment revealed the facility identified the incoming water supply and the building's hot and cold-water distribution systems as areas at risk for Legionella growth. Review of the facility monitoring logs dated January 2023 through October 2023 revealed rooms throughout the facility were monitored weekly and vacant rooms were identified. The log did not identify whether the sink or shower faucets were tested . The log did not include water temperatures. Interview on 10/18/23 at 4:13 P.M., with the Maintenance Director (MD) #413 revealed the monitoring logs for Legionella documented the vacant rooms in which he ran water. Further interview revealed no additional monitoring for Legionella, including water temperatures, was completed. Review of an undated facility documented titled Procedure for Legionella revealed the facility's census was reviewed weekly for vacant rooms. Vacant rooms were monitored for Legionella by running the water for five to ten minutes once weekly until the room was occupied. No guidance was provided regarding the running of sink faucets or shower heads, and whether hot or cold water should be running for five to ten minutes.

Based on staff interview, review of monitoring logs, review of the medical record, and review of policy, the facility failed to ensure an antibiotic stewardship program was implemented to ensure infections and antibiotics were accurately being tracked. This had the potential to affect all 80 residents in the facility. The facility census was 80. Findings include: Review of the Infection Surveillance Monthly Report (ISMR) dated August 2023 revealed line items for 45 identified infections. Further review revealed the log did not include the type of infection for 30 infections and did not include the signs and symptoms of the infection for 37 infections. Review of the ISMR dated September 2023 revealed line items for 64 identified infections. Further review revealed the log did not include the type of infection for 29 infections and did not include the treatment for 20 infections. Further, review of a line item for Resident #67 revealed an infection onset date of 09/25/23 of a urinary tract infection (UTI). No signs and symptoms were included in the log. Review of a line item for Resident #69 revealed an infection onset date of 09/26/23 of a urinary tract infection with signs and symptoms of altered mental status. Interview and concurrent review of the ISMR and medical records for Resident #67 and Resident #69 on 10/17/23 at 2:31 P.M. with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional Clinical Support #439 revealed Resident #67's UTI symptoms began 09/23/23, two days earlier than indicated on the log. Additionally, Resident #69's UTI symptoms including burning and itching (symptoms not captured on the log) beginning 09/23/23, three days earlier than indicated on the log. An ongoing interview at that time revealed the ADON assumed responsibility as the Infection Preventionist in July 2023. The ADON confirmed she was still learning how to complete the log accurately. Further, the ADON confirmed she was not completing an electronic assessment of each infection, per the facility's standard of practice, to ensure each infection was reviewed for antibiotic use as part of the antibiotic stewardship program. An ongoing interview at that time with Regional Clinical Support #439 confirmed some line items on the August and September 2023 logs reflected resolved incidents of infections and those line items remained on the log in error. Further interview at that time with the DON, ADON, and Regional Clinical Support #439 confirmed the ISMR log was incomplete, and the facility was not following their process for antibiotic stewardship surveillance. Review of the policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised 02/01/22, revealed the antibiotic surveillance tracking form would include twelve specific line items, including the date symptoms appeared, the name of the antibiotic, the start date of the antibiotic, and the identified pathogen (type of infection).

Based on observation, medical record review, resident interview, staff interview, and review of policy, the facility failed to maintain comfortable room temperatures in resident rooms. This affected one resident (#67) of three residents reviewed on the 100 hallway. The facility census was 80. Findings include: Review of the medical record for Resident #67 revealed an admitted [DATE]. Diagnoses included protein calorie malnutrition, chronic kidney disease, adjustment disorder, osteoarthritis, and prostate cancer. Review of Resident #67's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #67 was cognitively intact. Resident #67 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #67 displayed no behavior during the review period. Review of Resident #67's care plan revised 08/09/23 revealed supports and interventions for assistance with activities of daily living, risk for falls, and chronic pain. Observation on 10/16/23 at 9:41 A.M., of Resident #67 found him in bed in his room. The temperature of the room felt uncomfortably hot. Observation of the thermostat on the wall found the room temperature was 87 degrees Fahrenheit. Coinciding interview with Resident #67 found him to be alert and aware. Resident #67 stated it was way too hot in his room and he wanted it to be around 76 degrees. Resident #67 reported he had complained to the staff, and no one had been able to fix it. Resident #67 had been wanting it fixed since he got to the facility. Observation on 10/16/23 at 12:15 P.M., of Resident #67 found State tested Nursing Assistant (STNA) #371 in Resident #67's room. STNA #371 asked Resident #67 if he wanted the temperature that warm. Resident #67 said it was too hot and he wanted the temperature turned down to 76 degrees. STNA #371 was observed going to the thermostat and attempting to turn the temperature down. STNA #371 stated the temperature was actually set at 77 degrees, but it was malfunctioning because the room temperature was 86 degrees. STNA #371 said she would let maintenance know. Interview on 10/16/23 at 12:19 P.M., with STNA #371 verified Resident #67 complained of it being too hot in his room and the current temperature was 86 degrees. Observation on 10/17/23 at 8:48 A.M. of Resident #67's room temperature found it to be 85 degrees. Coinciding interview with Resident #67 verified it was still too warm in his room. Review of the facility policy titled, Safe and Homelike Environment, revised February 2023 revealed the facility would maintain comfortable and safe temperature levels. The facility should strive to keep the temperatures in common areas between 71- and 81-degrees Fahrenheit. If a resident preferred to keep their room below 71 degrees or above 81 degrees, the facility would assess the safety of this practice on the resident.

Based on observation, medical record review, resident interview, staff interview and review of the policy, the facility failed to ensure residents who required staff assistance with activities of daily living, received adequate and timely care to maintain good personal hygiene including nail care and shaving. This affected two residents (#67 and #10) of three residents reviewed for activities of daily living. The facility census was 80: Findings include: 1. Review of the medical record for Resident #67 revealed an admitted [DATE]. Diagnoses included protein calorie malnutrition, chronic kidney disease, adjustment disorder, osteoarthritis, and prostate cancer. Review of Resident #67's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #67 was cognitively intact. Resident #67 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #67 was totally dependent on staff for bathing. Resident #67 displayed no behavior during the review period. Review of Resident #67's care plan revised 08/09/23 revealed supports and interventions for the need for assistance with activities of daily living, and chronic pain. Resident #67 was to have nail care provided on his bath days and as necessary. Review of Resident #67's shower sheets revealed Resident #67's received revealed Resident #67 refused all showers. Resident #67 received a bed bath on 09/21/23, 09/23/23, 09/27/23, 09/30/23, 10/11/23, and 10/14/23. Resident #67's nails were not documented as trimmed on any of the days he was bathed. Observation on 10/16/23 at 9:41 A.M., found Resident #67's fingernails to be long and untrimmed. Interview on 10/16/23 at 9:52 A.M., with Resident #67 found him to be alert and aware. Resident #67 reported he had been asking for his fingernails to be clipped and no one had done it. He said he felt like they just ignored him when he asked. He stated they were way too long, and he wanted them trimmed. Interview on 10/17/23 at 9:00 A.M., with State tested Nursing Assistant (STNA) #388 verified Resident #67's fingernails were to be trimmed on his bathing days. STNA #388 verified Resident #67's fingernails had not been trimmed. Review of the policy titled, Fingernails/Toenails, Care of, revised 02/18 revealed the purpose of the policy was to keep nail beds clean and nails trimmed. Nail care included daily cleaning and regular trimming. 2. Review of Resident #10's medical record revealed an admitted [DATE]. Diagnoses included history of COVID-19, type II diabetes, dysphagia, generalized anxiety disorder, major depressive disorder, and spinal stenosis. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven indicating Resident #10 was severely cognitively impaired. Resident #10 required extensive assistance with bed mobility, toilet use and personal hygiene. Resident #10 had delusions and displayed wandering behaviors one to three days during the review period. Review of Resident #10's care plan revised 09/25/23 revealed supports and interventions for the need for assistance with activities of daily living, behavioral symptoms, and risk for falls. Resident #10 required extensive assistance with personal hygiene and was dependent on staff for bathing and or showering. Observation on 10/16/23 at 10:31 A.M., found Resident #10 sitting up in her bed trying to feed herself breakfast. Resident #10 was observed to have a brown substance under the fingernails of both her hands and hair on her upper lip and chin approximately a quarter of an inch long. An interview was attempted with Resident #10, and it was found she was unable to be interviewed. Observation on 10/16/23 at 2:46 P.M., of Resident #10 found her fingernails continued to have a brown substance around them and she continued to have facial hair. Observation on 10/17/23 at 9:15 A.M., of Resident #10 found her fingernails continued to have a brown substance around them and she continued to have facial hair. Interview on 10/17/23 at 9:24 A.M., with State tested Nursing Assistant (STNA) #360 verified Resident #10's fingernails were dirty and she had facial hair. STNA #360 reported she had been off but Resident #10 should have been shaven on her shower days and her nails cleaned whenever needed as Resident #10 would allow. STNA #360 stated she would make sure Resident #10 was cleaned up and shaven today. Observation on 10/17/23 at 2:28 P.M., of Resident #10 found her nails were cleaned and she had been shaven. Resident #10 nodded her head yes when she was asked if she was happy, she was cleaned up and shaven. Review of the policy titled, Fingernails/Toenails, Care of, revised 02/18 revealed the purpose of the policy was to keep nail beds clean and nails trimmed. Nail care included daily cleaning and regular trimming. Review of the policy titled, Activities of Daily Living, revised 10/22 revealed a resident who was unable to carry out activities of daily living will receive the necessary care and services to maintain good grooming and personal hygiene.

Based on observation, medical record review, resident interview, staff interview, and review of policy, the facility failed to ensure resident's smoking materials were kept in a secured area by staff. This affected one resident (#36) of two residents reviewed for smoking. The facility census was 80. Findings include: Review of Resident #36's medical record revealed an admitted [DATE]. Diagnoses included paraplegia, osteomyelitis, major depressive disorder, seizures, adjustment disorder with anxiety, mild intellectual disabilities, and sleep disorder. Review of Resident #36's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #36 was cognitively intact. Resident #36 was totally dependent on staff for transfer. Resident #36 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #36 displayed verbal behavioral symptoms directed toward others and behavioral symptoms not directed toward others one to three days during the review period. Review of Resident #36's care plan revised 08/18/23 revealed supports and interventions for self-care deficit, behaviors of noncompliance, and smoking. Interventions for smoking included to complete smoking assessment quarterly and as needed, instruct resident about smoking risks and hazards about smoking cessation aides, instruct resident regarding the facility policy on smoking including designated locations, times, and safety concerns, notify nurse of any violations of smoking policy, and smoking materials to be kept with facility staff. Review of Resident #36's Behavioral Contract dated 03/07/23 revealed there was absolutely no smoking in rooms or the facility. Resident #36 was permitted to smoke outside per the facility policy. Resident #36 signed the agreement indicating he would be complaint with the smoking policy of the facility and would not smoke in his room and would not carry or smoke any illegal substances on the facility property. Review of Resident #36's Quarterly Smoking Review dated 07/05/23 revealed Resident #36 had his memory intact, had fine motor skills needed to securely hold a cigarette, was able to communicate the risks to smoking, able to light a cigarette safely, utilized an ashtray safely, was able to extinguish a cigarette safely, and smoked safely. Interview on 10/16/23 at 4:15 P.M., with Resident #36 revealed he was alert and aware. Resident #36 reported he smoked and went out to smoke whenever he wanted. Resident #36 reported he kept his smoking materials in his room, so they were always available to him. Resident #36 stated he did not have any designated smoking times. He reported he would take himself out to the smoking area whenever he wanted to smoke and would ring the bell to be let back in when he was done. Interview on 10/17/23 at 9:21 A.M., with State tested Nursing Assistant (STNA) #360 verified Resident #36 smoked when he wanted to and kept his own cigarettes and lighter. Interview on 10/17/23 at 12:48 P.M., with Licensed Practical Nurse (LPN) #405 verified Resident #36 kept his own smoking materials and would take himself out to smoke whenever he wanted. LPN #405 reported Resident #36 would ring the bell when he was done smoking, and they would let him back into the facility. Interview on 10/18/23 at 11:30 A.M., with Resident #36 revealed he had his cigarettes and lighter in the front pocket of his sweatshirt at the time of the interview. Resident #36 reported when he did not have his smoking materials on his person, he would store them in the drawer next to his bed or in an empty tissue box on his bedside table which was up against the wall. Resident #36 demonstrated how he would put his cigarettes in the tissue box so one end was sticking up. Resident #36 again reported he did not have scheduled smoking times and would just go outside whenever he wanted to smoke. Review of the policy titled, Smoking Policy - Residents, revised 06/22 revealed all residents would be supervised during smoking. All smoking materials will be kept in a secure area by staff. Residents were not permitted to have any smoking related materials.

Based on observation, medical record review, staff interview, resident interview, review of physician orders, and policy review, the facility failed to ensure a urinary catheter anchor was in place for prevention of urinary catheter dislodgement. This affected one (#67) of one resident reviewed for urinary catheters. The facility identified five residents with urinary catheters. The facility census was 80. Findings include: Review of the medical record revealed Resident #67 had an admitted [DATE]. Diagnoses included benign prostatic hyperplasia, chronic kidney disease stage three, obstructive and reflux uropathy, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and malignant neoplasm of the prostate. Review of Resident #67's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #67 was cognitively intact. Resident #67 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #67 had an indwelling catheter at the time of the review. Review of the care plan last revised 06/29/23 revealed no interventions for a urinary catheter anchor. Review of a physician order dated 06/30/23 revealed the resident had orders for a Foley catheter for obstruction uropathy. Review of a physician order dated 06/30/23 revealed the resident had an order to secure Foley catheter tubing with Foley catheter anchor to resident's leg; change weekly on Sundays on nightshift and as needed to prevent dislodgement. Observation on 10/18/23 at 9:03 A.M., of Foley catheter care for Resident #67 with State tested Nursing Assistant (STNA) #388 revealed a catheter anchor was not in place to secure the resident's urinary catheter tubing. Interview on 10/18/23 at 9:08 A.M., STNA #388 verified the resident's urinary catheter anchor was not in place and she would notify the nurse. STNA #388 revealed she was unaware of where the urinary catheter anchors were located. Interview on 10/18/23 at 9:09 A.M., Resident #67 revealed the urinary catheter anchor came off and staff had not replaced the anchor. Review of the policy titled, Catheter Care, Urinary, revised 09/2014, revealed for staff to ensure the catheter remained secured with a leg strap to reduce friction and movement at insertion site. Catheter tubing should be strapped to the resident's inner thigh.

Based on observation, medical record review, resident interview, staff interview and policy review, the facility failed to ensure a resident received nutritional supplements as ordered. This affected one resident (#67) of three residents reviewed for nutrition. The facility census was 80. Findings include: Review of the medical record for Resident #67 revealed an admitted [DATE]. Diagnoses included protein calorie malnutrition, chronic kidney disease, adjustment disorder, osteoarthritis, and prostate cancer. Review of Resident #67's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #67 was cognitively intact. Resident #67 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #67 was totally dependent on staff for bathing. Resident #67 displayed no behavior during the review period. Resident #67 was independent with eating and was on a physician prescribed weight gain regimen. Review of Resident #67's care plan revised 08/09/23 revealed support and interventions for assistance with activities of daily living, and nutritional risk. Interventions for nutritional risk included honoring food preferences as much as possible and providing supplements as ordered. Review of Resident #67's physician orders revealed an order dated 08/10/23 for Ensure Clear three times a day. Review of Resident #67's Medication Administration Record (MAR) for August 2023, September 2023, and October 2023 revealed Resident #67's Ensure Clear was not provided for all three meals on 09/10/23, 09/11/23, 09/12/23, 09/13/23, 09/14/23, 09/16/23, 09/18/23, 09/20/23, 10/02/23, 10/03/23, 10/04/23, or 10/05/23. The missed supplements were not documented as refused. The documentation indicated the nurses notes should be reviewed for information. Corresponding nurses notes were not found for refusals. Interview on 10/16/23 at 9:44 A.M., with Resident #67 found him to be alert and aware. Resident #67 reported he was supposed to be receiving a nutritional supplement with every meal and he was not getting it all the time. Resident #67 reported due to his beliefs he had dietary restrictions and his supplement needed to be Kosher. He was prescribed Ensure Clear with all meals. Resident #67 reported he often did not get the supplement with his meals. Observation on 10/16/23 at 12:20 P.M., of Resident #67's meal tray delivery found no nutritional supplement provided. Interview on 10/16/23 at 12:25 P.M., with Resident #67 verified he was supposed to get his nutritional supplement with his meal, but he had not been provided one. Resident #67 reiterated his need for a dairy free supplement and his preference for mixed berry clear flavor. Interview on 10/16/23 at 12:31 P.M., with Unit Manager (UM) #401 verified Resident #67 had an order to receive Ensure clear three times a day and had not been provided one. UM #401 looked throughout the unit searching in cupboards and refrigerators at the two nurses stations. No Ensure clear was found. Interview on 10/16/23 at 12:34 P.M., with UM #401 verified there was not any of Resident #67's nutritional supplement available on the unit. On 10/16/23 at 12:37 P.M., three unopened boxes of Boost Breeze were found in the large storage closet on the opposite end of the facility. A box was transported back to Resident #67's unit. On 10/16/23 at 12:40 P.M., Resident #67 was provided with his nutritional supplement. Interview on 10/19/23 at 10:50 A.M., with the Director of Nursing (DON) verified there was no corresponding notations as to why Resident #67 had not been provided his nutritional supplement as ordered in September and October of 2023. There were two notations in October 2023 indicating the supplement was on order. Review of the policy titled, Supplement Use, revised July 2020 revealed supplement use had the purpose to provide additional nutrition support to residents with identified risk conditions.

Based on record review, staff interview, and review of the policy, the facility failed to ensure pneumococcal vaccines were offered to residents. This affected one (#1) of five residents reviewed for pneumococcal vaccines. The facility census was 80. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE], with diagnoses of hemiplegia and hemiparesis affecting the right dominant side and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. Review of the Informed Consent for Pneumococcal Vaccine form signed 09/02/22 revealed Resident #1 gave permission to receive the pneumococcal vaccine and had not received a pneumococcal vaccine in the past five years. Interview on 10/17/23 at 12:12 P.M., with the Director of Nursing (DON) confirmed Resident #1 was eligible to receive a pneumococcal vaccine and the facility did not offer her one. Review of the policy titled, Pneumococcal Vaccine, revised February 2018, revealed all residents will be offered the pneumococcal vaccine within 30 days of admission to the facility unless medically contraindicated.

Based on record review, staff interview, review of the Centers for Disease Control Prevention (CDC) guidelines, and review of the policy, the facility failed to ensure COVID-19 vaccines were offered to residents. This affected two (#1 and #44) of five residents reviewed for COVID-19 vaccination. The facility census was 80. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE], with diagnoses of hemiplegia and hemiparesis and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. Review of a form titled Coronavirus (COVID-19) Vaccination Acceptance Waiver revealed Resident #1 signed on 09/02/22 to accept the COVID-19 vaccine/booster. Review of Resident #1's vaccine record revealed no evidence of receiving a COVID -19 booster. 2. Review of the medical record for Resident #44 revealed an admitted [DATE], with diagnoses of dementia and transient ischemic attack (stroke). Review of the quarterly MDS assessment dated [DATE] revealed Resident #44 had impaired cognition. Review of a form titled Coronavirus (COVID-19) Vaccination Acceptance Waiver revealed Resident #44 signed on 05/20/22 to accept the COVID-19 vaccine/booster. Review of Resident #44's vaccine record revealed no evidence of receiving a COVID -19 booster. Interview on 10/17/23 at 12:12 P.M., with the Director of Nursing (DON) confirmed Resident #1 and Resident #44 were eligible to receive a COVID-19 booster and were not offered one by the facility. Review of the Centers for Disease Control Prevention (CDC) guidelines for COVID-19 booster revealed the bivalent booster (for COVID-19 vaccination and to protect against variants Omicron BA.4 and BA.5) was available and recommended from 09/01/22 until 09/11/23. Websites accessed 10/12/23: https://www.cdc.gov/media/releases/2022/s0901-covid-19-booster.html and https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html. Review of the undated policy titled, SARS-CoV-2 Resident Vaccine revealed the facility would offer the COVID-19 vaccine and eligible booster doses to all residents who had no medical contraindications.

Based on observation, medical record review, resident interview, staff interview, and review of policy, the facility failed to ensure a resident's room was maintained in a clean, homelike environment. This affected one (#44) of two residents reviewed for a clean, homelike environment. The facility census was 80. Findings include: Review of the medical record for Resident #44 revealed an admitted [DATE] with diagnoses of dementia and transient ischemic attack (stroke). Review of the quarterly MDS assessment dated [DATE] revealed Resident #44 had impaired cognition. Review of the physician orders for Resident #44 revealed he received no food by mouth and received nutrition via gastrostomy tube since 04/06/22. Observations on 10/16/23 at 9:23 A.M., on 10/17/23 at 8:37 A.M., and on 10/18/23 at 8:17 A.M., revealed Resident #44 lying in bed with a tube feeding bottle hanging on a pole next to his bed. The pump dispensing the tube feeding was running. The color of the tube feeding was tan. Resident #44's head of the bed was placed against a wall. The wall at the head of the bed had droplets and spots of dried tan/brown liquid covering approximately three feet wide and approximately three and a half feet high. Interview on 10/18/23 at 8:17 A.M., with Housekeeper #302 revealed she worked at the facility for approximately six months and was assigned to the third floor. Continued interview with Housekeeper #302 with concurrent observation of Resident #44's room confirmed dried brown spots and droplets were on the wall at the head of his bed. Housekeeper #302 stated the wall was like that since she began working at the facility and stated she had tried to clean it several times without success. Observation at that time, revealed Housekeeper #302 scrubbed the spots with routine cleaner and her rag and the spots remained on the wall. Housekeeper #302 stated she never tried a different cleaner or a more aggressive rag or sponge. Additionally, Housekeeper #302 stated she never reported her concerns with the spots to her supervisor or maintenance. Housekeeper #302 also stated Resident #44's family complained about the spots recently. Observation on 10/18/23 at 11:33 A.M., in Resident #44's room revealed the wall at the head of his bed was noticeably cleaner with only a few dried stained spots visible. Interview at that time with Resident #44 revealed no concerns regarding the spots in his room, he stated he could not see them when he was in bed. Further, Resident #44 was not aware of any concerns from his family about the wall. A subsequent interview on 10/18/23 at approximately 11:40 A.M., with Housekeeper #302 revealed she was unaware anyone entered Resident #44's room to clean the wall and was unaware the wall was noticeably cleaner. Interview on 10/19/23 at 3:28 P.M., with Maintenance Director #414 verified the dried spots and drips on Resident #44's wall were food based and not chemical. Review of the policy titled Safe and Homelike Environment, revised February 2023, revealed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review and staff interview, the facility failed to provide care and services in a timely manner to treat a Urinary Tract Infection ([CONDITION(S)]). This resulted in actual harm for Resident #34 who displayed symptoms of a [CONDITION(S)] for fifteen days prior to a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (Resident #34) of three residents reviewed for UTIs. The facility census was 66. Findings include: Review of Resident #34's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 03/31/22, revealed the resident was rarely understood and was always incontinent of bowel and bladder. Review of nurse's progress note dated 03/04/22, revealed Resident #34's urine was dark and smelled strong. Further review revealed a urinalysis would be collected. Review of nurse's progress note dated 03/17/22, revealed an aide reported Resident #34 had dark tinted urine. Further review revealed the information would be passed along to the next shift with directions to collect a urine sample. Review of nurse's progress note dated 03/19/22, revealed a new order for laboratory work including a urinalysis. Review of nurse's progress note dated 03/19/22, revealed Resident #34 had a temperature of 100.4 degrees Fahrenheit and Tylenol was provided. Review of nurse's progress note dated 03/19/22, revealed the laboratory was contacted and asked for an estimated time of arrival for the short turn around immediate (STAT) laboratory and urinalysis. The laboratory reported they were unable to draw until the morning. Review of nurse's progress note dated 03/20/22, revealed Resident #34 was sent to the hospital via emergency services at 11:40 A.M. Resident #34 was sent to the hospital for evaluation due to having blood like urine. The nurse took a urine sample and called the nurse practitioner for results. Resident #34 was not taking in any input and the output was poor. Review of nurse's progress notes dated 03/29/22, revealed Resident #34 returned to the facility. Review of nurse practitioner's progress note dated 04/05/22, revealed Resident #34 was hospitalized due to a severe [CONDITION(S)] and hypovolemic shock. Review of nurse practitioner's progress note, dated 04/10/22, revealed Resident #34 was recently hospitalized with urosepsis. Interview on 04/14/22 at 12:36 P.M. the Director of Nursing (DON) verified nurse's progress notes documented concerns related to possible urinary tract infection symptoms on 03/04/22 and 03/17/22 with no order for a urinalysis until 03/19/22. Resident #34 was hospitalized for a [CONDITION(S)] on 03/20/22. Interview on 04/14/22 at 3:45 P.M., the Director of Nursing (DON) verified the facility had identified the concern of not responding timely to Resident #34's symptoms and stated the facility had completed a quality improvement plan. As a result of the incident, the facility took the following corrective actions completed on 04/07/22: · Audits were to be conducted one time per week of urinalysis/culture and sensitivity orders. · Staff education involving processes for laboratory/x-ray services, shift report, charting/progress notes, and notifications. Staff interviews conducted on 04/25/22 at 4:28 P.M. and 4:37 P.M. LPN #200 and LPN #214 verified staff education was completed regarding the process for laboratory/x-ray services, shift report, charting/progress notes, and notifications. Review of medical records for Resident #14 and Resident #58 reviewed for UTIs, revealed no concerns. Additional medical record review for Resident #66 and Resident #67 reviewed for timely physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility policy tiled, Assessment and Management Urinary Continence and Incontinence, revised September 2010 revealed the identification and management of UTIs will follow relevant clinical guidelines. This deficiency substantiates Complaint Number OH 813.

Based on observation, record review and interview, the facility failed to ensure a resident with limited mobility was consistently provided with a lower extremity abduction brace. This affected one (Resident #1) of three residents reviewed for the application of assitive devices. The census was 76. Findings include; Resident #1 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE] the resident was cognitively intact, dependent on one staff for the completion of activities of daily living, limited impairment to one lower extremity, utilizes a walker and wheelchair for mobility and frequently incontinent of bowel and bladder. On 06/07/21 a plan of care was implemented to address the resident's impaired mobility related to dislocation of left hip prosthesis as evidenced by need for spica brace when out of bed, need for assistance with activities of daily living(ADL), and transfers. Interventions included assist to reposition frequently, encourage and facilitate early ambulation and other ADL's as appropriate to condition, and assist with initial changes such as dangling, and sitting. Review of nursing notes dated 05/29/21 at 6:06 P.M. documented the resident had a spica splint (left lower extremity abduction brace) for his hip to be in place for all transfers and ambulation. No further documentation contained in the medical record indicated the brace was applied or attempts to contact the physician for order clarification. On 06/07/21 the resident was evaluated by the orthopedic physician. The physician noted the resident was nine week status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Immobilization orders included the use of an abduction pillow at all tome when non-ambulatory for three months and the use of a hip abduction brace when ambulatory. There was no documentation in the medical record indicating the abduction pillow or hip abduction brace was being applied as ordered. On 06/28/21 a therapy home evaluation noted training provided during or after the home assessment included education to the resident's responsible party regarding safety with steps, tub transfer, hip precautions, and donning and doffing brace. On 07/19/21, a follow-up appointment with the orthopedic physician indicated the risk of dislocation and the possibility of revision surgery in the future. The physician noted the choice to continue the abduction brace was desired by the resident. The resident and responsible party requested to avoid a revision surgery and continue with conservative management. According to Occupational Therapy (OT) discharge documentation dated 07/19/21 caregiver education included staff demonstration with assisting Resident #1 with donning brace and with ADL's. According to Physical Therapy (PT) discharge recommendations dated 07/19/21 noted donning of left lower extremity abduction brace in accordance with orthopedic recommendations to reduce the risk for dislocation, supervision for all transfers and ambulation. During observation on 09/13/21 at 7:28 A.M., State tested Nursing Assistant (STNA) #200 entered Resident #1's room and gave the resident verbal direction to adjust and sit at the side of the bed. The left lower extremity abduction brace was not applied. STNA #200 positioned a walker at the bedside and placed a gait belt onto the resident. STNA #200 gave a verbal prompt for Resident #1 to stand at the bedside and the resident proceeded to stand with STNA #200 providing stand by assistance. The resident took small steps and transferred to the wheelchair. STNA #200 propelled the resident to the restroom and provided verbal and standby assistance with standing using the walker and gait belt as the resident sat himself to the toilet. Once again the resident utilized the walker and small steps to transfer to the toilet. During interview on 09/13/21 at 8:50 A.M., Resident #1 stated the left lower extremity abduction brace was not applied. The resident was seated in a wheelchair. The brace was located inside the resident's closet. During interview On 09/13/21 at 8:54 A.M., STNA #200 stated she had cared for the resident during the past week and was unaware the resident was to have a left lower extremity abduction brace applied. During interview on 09/13/21 a 10:04 A.M., STNA #201 stated she had worked with the resident the prior week and placed the left lower extremity abduction brace on resident as shown by another STNA. STNA #200 and #201 were unable to find instruction or direction related to the application of the left lower extremity abduction brace. On 09/13/21 at 10:10 A.M. review of the medical record with Registered Nurse #500 revealed no current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 09/13/21 at 12:25 P.M., the Director of Therapy (DOT) #1 confirmed the resident was provided OT/PT and the left lower extremity abduction brace was applied during treatments until discharge from therapy on 07/19/21. During telephone interview on 09/14/21 at 11:06 A.M., Orthopedic Physician Registered Nurse (OPRN) #501 via stated the abduction brace was to be applied when the resident was up and out of bed. During interview on 09/14/21 at 11:18 A.M., the Director of Nursing verified no documentation was contained in the medical record indicating the abduction brace was applied as ordered by the orthopedic physician. This deficiency substantiates Complaint Number OH 322.

Based on observation, staff interviews, and review of facility policies, the facility failed to ensure the walk-in refrigerator was clean; food items in the upright kitchen refrigerator were properly covered, labeled, and dated; and failed to cover food during transportation and distribution to residents. This had the potential to affect 71 of 72 residents who receive food from the kitchen. The facility identified one resident (#19) who did not receive food from the kitchen and directly affected six residents (#6, #21, #42, #45, #53, and #69) who received a lunch meal tray in their resident room. The facility census was 72. Findings include: 1. Observation on 05/24/21 at 9:23 A.M., revealed the upright kitchen refrigerator in the Labuhn Rehabilitation Center with seven grilled cheese sandwiches not labeled or dated, seventeen berry fruit cups with whipped topping not covered, labeled or dated, and egg salad like food not labeled or dated. Interview on 05/24/21 at 9:25 A.M., with Dietary Manager #175 verified the grilled cheese sandwiches were not labeled or dated, the fruit with whipped topping was not covered, labeled, or dated, and the egg salad was not labeled or dated. 2. Observation on 05/25/21 at 11:15 A.M., revealed the walk-in kitchen refrigerator had two storage shelves with thick dark green and black mold like substances on the shelves ranging in size from approximately half an inch to three inches. Interview on 05/25/21 at 11:35 A.M., with Dietary Manager #175 verified the substance on the kitchen shelving unit appeared to be mold. Dietary Manager #175 revealed she had cleaned one of the other shelves the previous week and reported there is a kitchen cleaning schedule but does not have information of the last time the walk-in refrigerator was cleaned. 3. Observation on 05/24/21 at 12:13 P.M., revealed an open meal cart with lunch meal trays which included uncovered berries with whipped cream topping served to six (#6, #21, #42, #45, #53, and #69) residents in their resident rooms. Interview on 05/24/21 at 12:17 P.M., with State tested Nursing Assistant (STNA) #150 verified the berry fruit cup with whipped cream was uncovered during transportation and distribution to residents receiving meal trays. Review of the policy titled, Food Storage, revised 11/01/20, revealed food is stored, prepared, and transported by methods designed to prevent contamination or cross contamination. The food is stored in an area that is clean, dry, and free from contaminants. All foods should be covered, dated, and labeled. Review of the policy titled, Dietary Cleaning Policy, revised 11/01/20, revealed the food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas.

Based on observation, staff interview, resident record review, and review of the facility's policies, the facility failed to complete weekly wound assessments and failed to complete wound treatments as physician ordered. This affected four (#8, #53, #57, and #69) of six residents reviewed for pressure ulcers. The facility identified eight residents with pressure ulcers. The facility census was 72. Findings include: 1. Review of medical record for Resident #69 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 04/20/21, revealed the resident had significant cognitively impairment. Resident #69 had one Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed). Review of the physician orders, dated 04/29/21, revealed orders for dressing changes to the resident right and left buttocks. Dressing change orders included, apply calcium alginate to wounds on left and right buttocks and cover with [MEDICATION(S)]. The orders were to change the dressing every other day and as needed if soiled. Review of the wound evaluation, dated 05/05/21, revealed Resident #69 had a full thickness pressure wound assessed as a Stage III. The wound measured 1.0 centimeters (cm.) long by 0.9 cm. wide by 0.1 cm. deep. The assessment indicated the wound was draining a moderate amount serosanguinous exudate. Review of the Treatment Administration Record (TAR) revealed Resident #69 received a dressing change on 05/23/21. Review of Resident #69's wound assessments revealed there were no wound assessments completed between the dates of 02/19/21 to 03/16/21 and 05/06/21 to 05/24/21. Observation and interview on 05/25/21 at 2:02 P.M. revealed Licensed Practical Nurse (LPN) #140 administering a wound treatment to Resident #69. The resident was undressed and turned to his left side. There was no dressing observed to be in place on the resident's buttocks/coccyx region. The resident's wounds were not visible at the time of observation due to the amount of dried cream in the area. LPN #140 attempted to cleanse the area but stopped due to the resident's discomfort. LPN #140 proceeded to complete the dressing change using [MEDICATION(S)] was applied to two small areas near the coccyx which LPN #140 described as the open areas. A foam dressing was placed over the area. LPN #140 verified a dressing should have been in place and was not. LPN #140 stated she had not been informed by any of the aide staff that Resident #69's dressing was no longer applied or needed changed. Interview on 05/25/21 at 2:16 P.M. with State tested Nursing Assistant (STNA) #150 revealed she had been caring for Resident #69 on day shift. STNA #150 stated she changed Resident #69's brief when she first arrived around 7:00 A.M., around 12:00 P.M., and around 1:45 P.M. STNA #150 stated there were not any dressings in place on the resident's buttock area at the time she changed his brief. STNA #150 stated she cared for Resident #69 in the past and that he had dressings in place during her previous encounters. STNA #150 further explained that upon her first care with the resident at 7:00 A.M., she noted there was not a dressing in place, had assumed he was no longer requiring dressing changes, and completed incontinence care by applying barrier cream to the area. STNA #150 confirmed she did not report to the nurse that there was not a dressing in place because she thought the treatment had been discontinued. Interview on 05/26/21 at 9:03 A.M. with Director of Nursing (DON) verified there were no weekly wound assessments completed between the dates of 02/19/21 to 03/16/21 and 05/06/21 to 05/24/21. 2. Review of the medical record for Resident #53 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed Resident #53 was at risk for skin breakdown due to incontinence and needed help for bed mobility. Interventions included reposition frequently during the day when in bed or chair. Reposition as tolerated during the night. Monitor skin during baths and weekly and treatments as ordered. Review of the significant change Minimum Data Set (MDS) assessment, dated 04/26/21, revealed Resident #53 was severely cognitively impaired, required extensive two person assist with bed mobility, total dependence of two persons for transfers, personal hygiene, and toilet use. Resident #53 did not have a pressure ulcer and was under hospice care. Review of the skin assessment, dated 04/29/21, revealed Resident #53 had a stage three coccyx pressure ulcer. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR), dated April 2021, revealed Resident #53 did not receive the following treatments as ordered: observe wounds daily for signs and symptoms of infection, increased redness, swelling, pain, drainage or warm to touch or increased temperature on 04/15/21 and 04/25/21 on the day shift and 04/06/21, 04/13/21, and 04/23/21 on the evening shift. Resident #53 also did not receive house barrier cream on 04/15/21 and 04/25/21 on the day shift and 04/06/21, 04/13/21 and 04/23/21 on the evening shift. Review of the TAR, dated May 2021, revealed the following ordered treatments were not administered: weekly skin assessment on 05/03/21, 05/17/21 and 05/24/21; observe wound(s) daily for signs/symptoms of infection on 05/01/21, 05/02/21, 05/03/21, 05/05/21 and 05/21/21 on the day shift and on 05/01/21 on the evening shift; wash sacral/coccyx with soap and water, dry completely, and cover with foam dressing every three days on 05/06/21 and 05/12/21; and house barrier cream on 05/01/21, 05/02/21, 05/21/21 on the day shift and 05/01/21 on the evening shift. Interview on 05/27/21 at 8:04 A.M. with the Director of Nursing (DON) verified the TARs did not reflect treatments were provided as ordered. 3. Review of the medical record for Resident #57 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 04/19/21, revealed Resident #57 was severely cognitively impaired, required two-person extensive assistance with transfers, dressing, toilet use, personal hygiene and had a stage three pressure ulcer upon admission. Review of the care plan revealed Resident #57 had a stage three pressure ulcer due to poor bed mobility. Interventions included treatments as ordered, follow with wound care, and monitor skin during care, baths, weekly skin, and treatments. Review of the physician orders, dated 05/12/21, revealed Resident #57 had a treatment order to apply Triad paste (used to promote wound healing) to cover wound twice daily. Review of the TAR, dated May 2021, revealed Resident #57 did not receive Triad paste to cover wound at breakfast on 05/13/21 and 05/19/21. Interview on 05/27/21 at 7:54 A.M. with the Director of Nursing (DON) verified the TAR did not reflect Resident #57 received Triad paste to cover wound at breakfast on 05/13/21 and 05/19/21 as ordered. 4. Review of Resident #8's closed medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 was discharged from the facility on 05/17/21. Review of an admission nursing assessment, dated 01/26/21, revealed Resident #8 was alert and oriented to person, place, and time and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no measurements of the DTI on the admission nursing assessment and no documentation of Resident #8 with any other pressure ulcers on admission. Review of an admission baseline care plan, dated 01/26/21, revealed Resident #8 had a care plan in place for pressure ulcers with interventions to follow wound care protocol, report skin breakdown and redness, measure open wounds at least weekly, and administer treatment as ordered. Review of Resident #8's comprehensive care plan, dated 02/09/21, revealed pressure ulcer interventions including wound care and dressing changes as ordered. Review of an admission Minimum Data Set (MDS) assessment, dated 02/05/21, revealed Resident #8 was cognitively intact, required extensive two-plus persons physical assistance with bed mobility, had no days in the look back period with care rejected, and was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 05/07/21, revealed Resident #8 was assessed as rejecting care on a daily basis and remained with two unstageable pressure ulcers. Review of the physician orders, dated between 01/26/21 and 01/28/21, revealed no wound dressing were ordered for Resident #8's bilateral leg wounds. The physician order, dated 01/29/21, revealed Resident #8 was ordered to have wraps applied to bilateral lower extremities during daytime and off at night daily. This order was discontinued on 02/08/21. Review of facility and wound care clinic wound assessments revealed Resident #8's wounds were not assessed again until 02/05/21. At this time Resident #8 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] .) long by 13.5 cm. wide by 0.1 cm. deep, a DTI to the left heel measuring 10.0 cm. long by 3.4 cm. wide by 0.1 cm. deep, a DTI to the left anterior ankle measuring 1.0 cm. long by 5.3 cm. wide by 0.1 cm. deep, a DTI cluster to the right anterior ankle measuring 4.2 cm. long by 6.2 cm. wide by 0.1 cm. deep, a DTI to the right medial foot measuring 5.3 cm. long by 1.4 cm. wide by 0.1 cm. deep, and a right lateral foot DTI measuring 8.0 cm. long by 2.5 cm. wide by 0.1 cm. deep. Further review of weekly wound assessments revealed Resident #8's wounds were not assessed weekly between 02/12/21 and 02/26/21 or between 02/26/21 and 03/12/21. Review of a physician order, dated 02/05/21, revealed Resident #8 was ordered to have her left posterior ankle covered with a gauze pad and wrapped with a bandage daily and have the right calf cleaned with normal saline, apply a medication ointment, cover with gauze, and wrap with a bandage daily. These orders were discontinued on 02/19/21. The physician order, dated 02/19/21, revealed Resident #8 was ordered to have the right and left lower extremity wounds cleaned with [MEDICATION(S)] soaked gauze, apply an absorbent pad to the wounds, and wrapped with a bandage daily. This order was continued until 03/29/21. On 03/26/21, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February, March, April, and [NAME] 2021 TARs revealed no documentation of Resident #8's wound being treated on 02/07/21, between 02/12/21 and 02/17/21, 02/28/21, 03/03/21, between 03/10/21 and 03/15/21, 03/17/21, 03/20/21, 03/25/21, 03/28/21, 03/30/21, 04/01/21, 04/08/21, 04/10/21, 04/12/21, 04/26/21, between 04/28/21 and 04/30/21, between 05/02/21 and 05/05/21, and 05/13/21. Review of the nursing progress notes and skilled nursing notes dated between 01/26/21 and 05/17/21 revealed no documentation of wound care provided for Resident #8 for the missing dates on the TARs. Review of a vascular surgeon assessment, dated 04/26/21, revealed Resident #8 stated the nursing home she was in did not change her dressings routinely. A telephone interview was completed on 05/26/21 at 12:58 P.M. with Assistant Director of Nursing (ADON) #1 verified Resident #8 was admitted to the facility with wounds to both her right and left legs. ADON #1 stated she assisted with making appointments for Resident #8's wound care clinic, and stated all of the documentation of Resident #8's wound care should be in the electronic health record. ADON #1 stated the documentation of Resident #8's wound care treatments should be in the TARs but may also be in the nursing progress notes. Interview on 05/27/21 at 12:48 P.M. with Director of Nursing (DON) #1 verified Resident #8's missing weekly wound assessments in February and March 2021 as well as the missing documentation of Resident #8's wound care being provided in February, March, April, and May 2021. Review of a facility policy titled, Skin Care and Wound Treatment Protocol, revised August 2019, revealed the facility will ensure the resident's skin and/or wound area(s) are treated and cared for in an attempt to keep area(s) from becoming open or worsening in the facility's care, and will monitor and document interventions and outcomes. Review of a facility policy titled, Dressing Change, revised October 2020, revealed dressing changes will occur according to physician or nurse practitioner order and as needed including documentation of wound measurements, discomfort with dressing change, and drainage. This deficiency substantiates Complaint Number OH 585.

Based on medical record review, staff interview and review of a facility policy, the facility failed to ensure a resident was provided adequate assistance during transfers. This resulted in actual harm when Resident #30 whom suffered a laceration to her left lower extremity while she was transferred by one staff member from her bed to her wheelchair. This affected one (Resident #30) of three residents reviewed for transfers. The facility census was 76. Findings include: Review of the medical record for Resident #30 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment, dated 05/09/19, revealed the resident had severely impaired cognition. Further review revealed the resident required extensive assistance from two staff for transfers. Review of the resident's plan of care dated 05/19/19, for basic care needs, revealed the resident required two people to assist with all transfers. Review of a skin assessment dated [DATE], revealed the resident had a wound to her left lower extremity measuring 2.3 centimeters (cm) long, 2.1 cm wide and 1.3 cm deep. Review of a hospital discharge summary, dated 05/23/19, revealed Resident #30 was treated in the emergency room (ER) for a laceration repair with sutures. Review of an Incident Note, dated 05/22/19 at 7:15 A.M. and authored by Licensed Practical Nurse (LPN) #203, revealed State tested Nursing Assistant (STNA) #105 (an agency STNA) brought Resident #30 to LPN #203. Resident #30's left lower leg was wrapped with a wash cloth and tape due to bleeding. LPN #203 took off the washcloth, cleaned the area, and applied an ABD pad (highly absorbent sterile dressing) to the wound, and wrapped the area with a gauze. Review of a progress note dated 05/23/19 revealed, ADON #300 spoke with a hospice nurse regarding the resident's open area to her left leg. The hospice nurse informed ADON #300 the injury was significant and the resident was sent to the ER for evaluation and treatment. ADON #300 informed the hospice nurse and family she would educate the agency staff on the resident's care planned need for two staff to assist the resident for all transfers. Review of an undated witness statement, signed by STNA #105, revealed she transferred the resident into her wheelchair and during the process the resident's leg started bleeding and STNA #105 wrapped a towel around it and informed the nurse. During interview on 06/14/19 at 9:38 A.M., ADON #300 confirmed on 05/22/19, STNA #105 transferred Resident #30 from her bed to her wheelchair without getting a second staff member to help with the transfer. During this transfer, the resident's leg was injured and required seven stitches to close the wound. During interview on 06/14/19 at 12:03 P.M., LPN #203 revealed the morning of 05/22/19 she was made aware of Resident #30 suffered an injury to her left lower leg while she was transferred from her bed to her wheelchair by STNA #105. During interview on 06/14/19 at 1:58 P.M., STNA #105 confirmed while transferring the Resident #30 from her bed to her wheelchair, she heard a pop sound and the resident's left lower leg was injured and bleeding. STNA #105 confirmed she transferred the resident alone and did not ask another staff member to help her. Review of facility policy titled, Body Mechanics, dated (MONTH) 2012, revealed the purpose was to prevent injury to residents and staff. Staff were to ask another staff member for assistance if needed.